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Pomegranate as a cosmeceutical source: Pomegranate fractions promote


proliferation and procollagen synthesis and inhibit matrix
metalloproteinase-1 production in human skin cells

Article  in  Journal of Ethnopharmacology · March 2006


DOI: 10.1016/j.jep.2005.07.027 · Source: PubMed

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Journal of Ethnopharmacology 103 (2006) 311–318

Pomegranate as a cosmeceutical source: Pomegranate fractions promote


proliferation and procollagen synthesis and inhibit matrix
metalloproteinase-1 production in human skin cells
Muhammad Nadeem Aslam a , Ephraim Philip Lansky b , James Varani a,∗
a Department of Pathology, The University of Michigan Medical School, 1301 Catherine Road/Box 0602, Ann Arbor, MI 48109, USA
b Rimonest Ltd., Haifa, Israel

Received 10 May 2005; received in revised form 23 June 2005; accepted 28 July 2005
Available online 10 October 2005

Abstract
Pomegranate (Punica granatum) is an ancient fruit with exceptionally rich ethnomedical applications. The peel (pericarp) is well regarded for
its astringent properties; the seeds for conferring invulnerability in combat and stimulating beauty and fertility. Here, aqueous fractions prepared
from the fruit’s peel and fermented juice and lipophilic fractions prepared from pomegranate seeds were examined for effects on human epidermal
keratinocyte and human dermal fibroblast function. Pomegranate seed oil, but not aqueous extracts of fermented juice, peel or seed cake, was
shown to stimulate keratinocyte proliferation in monolayer culture. In parallel, a mild thickening of the epidermis (without the loss of ordered
differentiation) was observed in skin organ culture. The same pomegranate seed oil that stimulated keratinocyte proliferation was without effect
on fibroblast function. In contrast, pomegranate peel extract (and to a lesser extent, both the fermented juice and seed cake extracts) stimulated
type I procollagen synthesis and inhibited matrix metalloproteinase-1 (MMP-1; interstitial collagenase) production by dermal fibroblasts, but had
no growth-supporting effect on keratinocytes. These results suggest heuristic potential of pomegranate fractions for facilitating skin repair in a
polar manner, namely aqueous extracts (especially of pomegranate peel) promoting regeneration of dermis, and pomegranate seed oil promoting
regeneration of epidermis.
© 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Pomegranate (Punica granatum); Type I procollagen; Matrix metalloproteinase-1 (interstitial collagenase); Skin repair; Photodamaged/aged skin;
Epidermal hyperplasia

1. Introduction Lavker, 1995). Skin damage is also seen as a consequence of dia-


betes (Prakash et al., 1974; Klenerman et al., 1996; Laing, 1998;
Damage to the skin occurs as a consequence of the natural Reiber, 1998), in other diseases that compromise the vasculature
aging process and damage is exacerbated in chronically sun- of the skin (Strigini and Ryan, 1996; Mendez et al., 1998; Stadel-
exposed skin (photoaging) (Smith et al., 1962; Lavker, 1979; mann et al., 1998) and following long-term corticosteroid use
Lovell et al., 1987; Kligman and Balin, 1989; Oikrinen and (McMichael et al., 1996). Skin damage is a cosmetic issue, but
Kallioinen, 1989; Schwartz et al., 1989; Schwartz et al., 1993; it is also a medical problem. Severely damaged skin is prone
to bruising, and often the bruises go on to form non-healing
ulcers. Ulcer formation in the lower limbs of diabetic patients,
for example, is the major cause of limb amputations (Reiber,
Abbreviations: ANOVA, analysis of variance; DMEM-FBS, Dulbecco’s
modified minimal essential medium supplemented with 10% fetal bovine serum; 1998; Margolis et al., 1999; Margolis and Hoffstad, 2002).
EA, ethyl acetate; EDTA, ethylenediamine tetraacetic acid; ELISA, enzyme- Topical treatment of skin with biologically active retinoids
linked immunosorbant assay; KBM, keratinocyte basal medium; KGM, ker- including all-trans retinoic acid (RA) and its parent compound,
atinocyte growth medium; MMP-1, matrix metalloproteinase-1; RA, retinoic all-trans retinol (Vitamin A) has been shown to repair dam-
acid; SDS-PAGE, sodium dodecyl sulfate polyacrylamide gel electrophoresis;
age in aged/photoaged skin (Kligman et al., 1986; Weiss et
TDS, total dissolved solids
∗ Corresponding author. Tel.: +1 734 615 0298; fax: +1 734 763 6476. al., 1988). RA-induced repair is presumed to reflect retinoid
E-mail address: varani@umich.edu (J. Varani). capacity to influence connective tissue metabolism, i.e., sup-

0378-8741/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.jep.2005.07.027
312 M.N. Aslam et al. / Journal of Ethnopharmacology 103 (2006) 311–318

press matrix metalloproteinase (MMP) generation (Fisher et Table 1


al., 1996, 1997) and stimulate matrix synthesis (Griffiths et al., Major chemical constituents of pomegranate seed oil and aqueous peel extract
1993; Talwar et al., 1995). In addition to its dermal effect, the Seed oil
same biologically active retinoids also stimulate proliferation Fatty acids (as triglycerides ∼88%)
in the epidermis, leading to epidermal thickening. The epider- Fatty acids (as diacylglycersols ∼7%)
Fatty acids (as phospholipids ∼3%)
mal effects of retinoids may contribute to improved appearance.
Retinoid effects in the epidermis may also be important for Punicic acid (∼65%)
improved wound repair since closure of superficial wounds relies Linoleic acid (7%)
on migration and proliferation of keratinocytes at the wound 22:0 Docosanoic acid (1.3%)
margin (Pilcher et al., 1997). In addition to potentially bene- 24:0 Tetracosanoic acid (1.4%)
Campesterol (0.1%)
ficial effects, retinoid epidermal hyperplasia with concomitant Stigmasterol (0.1%)
disruption of skin barrier function is also tied to the irritation ␤-Sitosterol (1%)
response that occurs in many individuals on topical retinoid ther- ␥-Tocopherol (1%)
apy (Griffiths et al., 1995; Varani et al., 2001). 17-␣-estradiol (0.3%)
It is difficult to separate the relative importance of dermal
Peel extract
versus epidermal effects of retinoids since these agents have Punicalagin
broad activity in both compartments of the skin. As a way to Punicalin
address this issue, we have examined a number of natural com- Ellagic acid
pounds for “partial” retinoid activities. In a recent study (Aslam Gallic acid
et al., 2005), we demonstrated that PADMA 28, a mixture of Quercetin
Luteolin
herbs formulated according to an ancient Tibetan recipe, had Kaempferol
similar effects as RA in the dermis but was without epidermal Naringennin
effects. The present study continues efforts to identify natural
products with skin repair potential. Here, we describe potentially
useful dermal and epidermal activities in different fractions of (about 2 weeks). The alcohol was then removed by distillation,
pomegranate fruit (Punica granatum). and the remaining liquor concentrated over an open fire to 50%
The pomegranate is a highly celebrated medicinal food plant total dissolved solids (TDS). The concentrate was layered upon
chosen as the symbol of medicine for the 2000 UK Millennial ethyl acetate (EA) for 15 h, after which the extract was removed
Festival of Medicine (Langley, 2000). Current interest focuses from the EA phase by evaporating the EA with nitrogen gas. To
largely on the pomegranate’s anti-oxidant and anti-inflammatory obtain the peel extract, dried pomegranate peels from the same
activities (Schubert et al., 1999; Aviram et al., 2000; Gil et al., pomegranate source noted above were combined with an equal
2000; Singh et al., 2002) and on growth-inhibiting activities amount of water and boiled in a covered steel vessel for1 h. The
(Murthy et al., 2002; Hora et al., 2003; Albrecht et al., 2004; liquor was then strained, concentrated to 50% TDS and extracted
Lansky et al., 2005). Pomegranate fruit has wide-ranging with EA as described above.
heuristic applications against (for example) erectile dysfunc- Three different fractions were prepared from pomegranate
tion (Azadzoi et al., 2005; Loren et al., 2005), carotid occlu- seeds, i.e., from the remaining small dried white pithy kernels
sion (Aviram et al., 2004) and neonatal ischemia (Loren et following juice extraction and removal of the pulp. To pre-
al., 2005). In the present study, we show that seed oil from pare cold-pressed pomegranate seed oil, the seeds were forced
pomegranate has a stimulatory effect on keratinocyte prolifera- through a mechanical extrusion device according to the method
tion but does not stimulate dermal fibroblast function. In con- previously reported (Schubert et al., 1999) generating an oil
trast, an aqueous extract of pomegranate peel has a potent dermal (approximately 10% of the seed product) and the remaining
effect—stimulating dermal fibroblast proliferation and collagen pomegranate seed “cake” (90% of the initial seed). This cake
synthesis while inhibiting the major collagen-degrading enzyme was then exhaustively extracted with 95% food-grade ethanol to
in skin—but does not stimulate keratinocyte proliferation. yield an oily phase (75%) that was discarded, and a dark heavier
tarry phase (25%). An additional sample of cold-pressed seed
2. Materials and methods oil was prepared according to the method described above from
a different seed source, specifically “Mixed Wildcrafted Culti-
2.1. Pomegranate fractions vars” obtained from the southeastern region (Adana) of Turkey.
Major constituents of seed oil and peel extract from (Wonderful)
For these studies, we examined aqueous extracts of pomegranate are presented in Table 1.
pomegranate juice, peel and seed. The extract of pomegranate
juice was prepared according to the method previously described 2.2. Human skin organ cultures
(Schubert et al., 1999). Briefly, fresh pomegranate juice
obtained by pressing the arils of organically grown “Wonder- Organ cultures of human skin were prepared as described pre-
ful” pomegranates from Kibbutz Sde Eliahu, Israel (2000) was viously (Varani et al., 1993, 1994). Briefly, replicate 2 mm full-
combined with wine yeast (Lalvin EC-1118, Lallemand, Mon- thickness punch biopsies of sun-protected hip skin were obtained
treal, Canada, 18,000:1) and allowed to ferment to completion from young adult volunteers. The participation of human sub-
M.N. Aslam et al. / Journal of Ethnopharmacology 103 (2006) 311–318 313

jects in this project was approved by the University of Michigan Vera Corp., Madison, WI) as described previously (Varani et al.,
Institutional Review Board, and all subjects provided written 2000). The procollagen assay uses an antibody to the C-terminal
informed-consent prior to their inclusion in the study. Immedi- propeptide region that is part of the collagen molecule as it is
ately upon biopsy, the tissue was immersed in culture medium synthesized and secreted (before being proteolytically cleaved).
consisting of Keratinocyte Basal Medium (KBM) (Cambrex As such, this assay is a measure of newly synthesized collagen.
Bioscience, Walkersville, MD). KBM is a low Ca2+ (0.15 mM)
serum-free modification of MCDB-153 medium optimized for 2.6. MMP assays
high-density keratinocyte growth. For use in organ culture, it
was supplemented with CaCl2 to bring the final Ca2+ concen- The same fibroblast-conditioned medium was assayed for
tration to 1.4 mM. This was done because previous studies had MMP-1 (interstitial collagenase) and MMP-2 (72-kDa gelati-
demonstrated that survival of both the epidermis and dermis nase) by casein and gelatin zymography, respectively. Assays
in organ-cultured skin required conditions optimized for fibrob- were carried out as described in a previous report (Gibbs et al.,
lasts (Varani et al., 1993, 1994). After transport to the laboratory 1999). Briefly, SDS-PAGE gels were prepared from 30:1 acry-
on ice, the biopsies were incubated in a 24-well dish contain- lamide/bis with the incorporation of either (3-casein or gelatin
ing 0.5 ml of Ca2+ supplemented KBM with varying amounts (1 mg/ml) before casting. The gels were routinely 7.5% acry-
of the different pomegranate fractions. Cultures were incubated lamide. Culture fluid samples and molecular weight standards
at 37 ◦ C in an atmosphere of 95% air and 5% CO2 . Other than were electrophoresed at constant voltage of 150 V under non-
incubating the tissue in a minimal volume of medium, nothing reducing conditions. After electrophoresis, gels were removed
further was done to maintain a strict air–liquid interface. Incu- and washed twice for 15 min in 50 mM Tris buffer containing
bation was for 8 days, with change of medium every second or 1 mM Ca2+ and 0.5 mM Zn2+ with 2.5% Triton X-100. The gels
third day. At the end of the incubation period, tissue was fixed in were then incubated overnight in Tris buffer with 1% Triton
10% buffered formalin and examined histologically after stain- X-100 and stained with Brilliant Blue R Concentrate the fol-
ing with hematoxylin and eosin. lowing day. After destaining, zones of hydrolysis were detected
as clear areas against a dark background. Zymographic images
2.3. Human epidermal keratinocytes and dermal fibroblasts were digitized. Negative images were created and quantified by
in monolayer culture scanning densitometry. Using the digitized images, quantitative
values for MMP-1 and MMP-2 were obtained.
Normal human epidermal keratinocytes and dermal fibrob-
lasts were isolated from skin as described previously (Varani 2.7. Statistical analysis
et al., 1994). Keratinocytes were maintained in Keratinocyte
Growth Medium (KGM) (Cambrex Bioscience) and fibrob- Differences between groups in experiments with multiple
lasts were maintained in Dulbecco’s modified minimal essential groups were analyzed for statistical significance by ANOVA
medium supplemented with non-essential amino acids and 10% followed by paired-group comparisons. Where there were only
fetal bovine serum (DMEM-FBS). In some experiments, the two groups, the Student t-test was used. Data were analyzed
HaCaT line of immortalized human epidermal keratinocytes as paired or unpaired as appropriate. P < 0.05 was considered
(Boukamp et al., 1988) was used in place of normal ker- significant.
atinocytes. Both keratinocytes and fibroblasts were maintained
at 37 ◦ C in an atmosphere of 95% air and 5% CO2 . Cells were 3. Results
sub-cultured by exposure to trypsin/ethylenediamine tetraacetic
acid (EDTA) and used at passage 2–3. 3.1. Effects of pomegranate seed oil and extracts of
pomegranate peel, fermented juice and seed cake on
2.4. Survival and proliferation assays epidermal proliferation

Keratinocytes and fibroblasts were seeded at 4 × 104 cells per In the first series of experiments, various pomegranate
well in 24-well plates using their respective growth media. The fractions were examined for ability to influence keratinocyte
cells were allowed to attach overnight. The next day, they were proliferation in monolayer culture. As seen in Fig. 1, cold-
washed and then incubated in KBM with or without Ca2+ sup- pressed pomegranate seed oil stimulated keratinocyte prolifer-
plementation and with different concentrations of the various ation in a concentration-dependent manner. Under conditions
pomegranate fractions as indicated in Section 3. Cell num- in which optimal stimulatory activity was observed (0.5 ␮l of
bers were determined 3 days later by releasing the cells with pomegranate seed oil in 1 ml of serum-free, growth factor-free
trypsin/EDTA and enumerating them using a particle counter culture medium), keratinocyte proliferation was increased by
(Coulter Electronics, Hialeah, FL). 60% (proliferation index = 1.56 for no seed oil versus 2.04 in
the presence of seed oil (0.5 ␮l/ml; n = 6; P < 0.05). A second
2.5. Type I procollagen assay seed oil preparation (from a different pomegranate source) also
stimulated keratinocyte proliferation under the same conditions
Fibroblast-conditioned medium was assayed for type I pro- (data not shown). In contrast to the effects observed with the seed
collagen by enzyme-linked immunosorbant assay (ELISA) (Pan oil preparations, there was no stimulation with water-soluble
314 M.N. Aslam et al. / Journal of Ethnopharmacology 103 (2006) 311–318

Fig. 1. Effects of pomegranate seed oil on keratinocyte proliferation. Prolifera-


tion assays were carried out as described in Section 2. Values shown represent
the arithmetical means ± standard errors based on triplicate experiments with
duplicate data points in each. Statistical significance of the differences between
control and pomegranate-treated groups was determined using ANOVA followed
by paired-group comparisons. Asterisk (*) indicates significance at the P < 0.05
level.

extracts of pomegranate peel, fermented juice or seed cake.


Rather, at high concentrations, these three fractions were all
slightly inhibitory (Fig. 2).
Fig. 3 demonstrates histological features of human skin
in organ culture in the absence and presence of cold-pressed
pomegranate seed oil. Consistent with findings in monolayer
cell culture, treatment of human skin with pomegranate seed oil
(0.5 ␮l/ml) induced a mild thickening of the epidermis (panel B)
as compared to control conditions (panel A). It can be seen from
panel B that normal epidermal differentiation was maintained in
the pomegranate seed oil-treated skin with basal, suprabasal and
granular layers represented. In regard to these features of differ-
entiation, the activity of pomegranate seed oil is significantly
different from that of RA, which induces a much more intense
hyperplasia but also interferes with normal differentiation (Elias Fig. 2. Effects of pomegranate peel, juice and seed cake extract on keratinocyte
et al., 1981; Jetten et al., 1989; Floyd and Jetten, 1989). proliferation. Proliferation assays were carried out as described in Section 2.
Values shown represent the arithmetical means ± standard errors based on trip-
3.2. Effects of pomegranate seed oil and extracts of licate experiments with duplicate data points in each. Statistical significance of
the differences between control and pomegranate-treated groups was determined
pomegranate peel, juice and seed cake on dermal function
using ANOVA followed by paired-group comparisons. Asterisk (*) indicates
significance at the P < 0.05 level.
Human dermal fibroblasts were incubated in KBM and
treated with various amounts of pomegranate peel extract. In the
absence of the extract, there was no growth in this serum-free,
growth factor-free medium and approximately half of the cells Ability of pomegranate peel extract to alter type I procol-
died over the 3 day incubation period. As shown in the upper lagen production by dermal fibroblasts was assessed next. The
panel of Fig. 4, pomegranate peel extracts prevented cell death middle panel of Fig. 4 demonstrates that type I procollagen syn-
and allowed proliferation to occur. Concentrations between 0.05 thesis was increased in the presence of pomegranate peel extract.
and 0.5 ␮l of extract per ml of culture medium were effective. Interestingly, dose–response studies indicated that type I procol-
Consistent with past reports (Varani et al., 1990a,b), when KBM lagen production was stimulated at concentrations below those
was supplemented with extracellular Ca2+ to a final concentra- optimal for proliferation, with procollagen elaboration declin-
tion of 1.4 mM, fibroblast survival and growth also occurred ing at higher concentrations. When KBM was supplemented
(Fig. 4; upper panel). Two other extracts (i.e., fermented juice with Ca2+ (1.4 mM final concentration), there was also a stim-
and seed cake) were also protective, but were less effective than ulation of procollagen synthesis. However, the level of increase
peel extract. In contrast, no protective activity was observed with Ca2+ stimulation was not as great as that achieved with
when pomegranate seed oil was examined (data not shown). pomegranate peel extract.
M.N. Aslam et al. / Journal of Ethnopharmacology 103 (2006) 311–318 315

Fig. 3. Histological features of human skin after incubation for 8 days in organ culture in the absence or presence of pomegranate seed oil. A: control and B: 1 ␮l/ml
pomegranate seed oil. Both sections are from organ-cultured skin after 8 days in culture (hematoxylin and eosin-stained; XI80).

The lower panel of Fig. 4 demonstrates the effects of compounds originating in pomegranate seed oil, juice and peel
pomegranate peel extract on MMP production. It can be seen have anti-oxidant activity and inhibit pro-inflammatory enzymes
that MMP-1 accumulation in the fibroblast-conditioned medium including the cyclooxygenases and lipoxygenases (Schubert et
was dramatically reduced in the presence of the pomegranate al., 1999; Gil et al., 2000; Aviram et al., 2000; Murthy et al.,
peel extract. The dose–response for MMP-1 inhibition mirrored 2002; Singh et al., 2002). As a result, pomegranate preparations
(inversely) the dose–response for proliferation, i.e., the same containing these components are being evaluated for potential
extract concentrations that stimulated proliferation inhibited anti-inflammatory activity. Pomegranate seed oil has also been
MMP-1 accumulation. It can also be observed from this figure shown in experimental studies to suppress proliferation of sev-
that the level of MMP-1 in Ca2+ supplemented KBM was similar eral different tumor cell types (Kim et al., 2002; Albrecht et
to the level in non-supplemented KBM. When pomegranate peel al., 2004; Kawaii and Lansky, 2004; Lansky et al., 2005) and
extract was included in Ca2+ supplemented KBM, inhibition to reduce skin carcinogenesis in mice (Hora et al., 2003) and
of MMP-1 elaboration was observed over the same dose-range mammary carcinogenesis in a mouse mammary organ culture
as was seen in the non-Ca2+ supplemented medium (data not model (Mehta and Lansky, 2004).
shown). In contrast to these results, when we assessed MMP- While most of the current interest in the pomegranate relates
2 (72-kDa gelatinase A) production in the pomegranate peel to its anti-oxidant, anti-inflammatory and anti-carcinogenic
extract-treated fibroblasts, there was no effect (data not shown). potential, the focus of the present work is on the potential for one
This is of interest since our past studies have shown that unlike or more pomegranate fractions to promote skin repair. Aging
MMP-1, MMP-2 is not subject to regulation by agents that act of the skin is accompanied by thinning of the epidermis and
through AP-1-mediated gene transcription (Fisher et al., 1996). a concomitant loss of dermal connective tissue (Smith et al.,
In a final set of experiments, skin organ cultures were 1962; Lavker, 1979; Lovell et al., 1987; Kligman and Balin,
incubated for 3 days in KBM in the presence or absence of 1989; Schwartz et al., 1989; Oikrinen and Kallioinen, 1989;
pomegranate peel extract (0.1–1.0 ␮l/ml). At the end of the incu- Schwartz et al., 1993; Lavker, 1995). The loss of connective
bation period, the culture medium was collected and assayed tissue elements including types I and III collagen in aged skin
for MMP-1. At 1 ␮l/ml, virtually complete inhibition of MMP- reflects progressive MMP-mediated connective tissue destruc-
1 production was observed. Approximately 50% inhibition was tion (occurring over decades) (Fisher et al., 1996, 1997; Varani et
observed in the presence of 0.5 ␮l of pomegranate peel extract al., 2000) and a late-stage sharp decline in synthesis of replace-
per ml while at 0.1 ␮l/ml, there was no observable inhibition ment collagen (Griffiths et al., 1993; Talwar et al., 1995; Varani
(data not shown). et al., 2001). Skin damage is a cosmetic problem, but it is also
a cause of significant morbidity. Aged/photo-aged skin bruises
4. Discussion easily (e.g., senile purpura) and the chronic bruises often go on to
form slow-healing ulcers. Similar detrimental changes are also
The pomegranate (Punica granatum) is a small tree culti- observed in diabetic skin (Loots et al., 1999; Hehenberger et al.,
vated in various parts of the world for its fruit. In addition to its 1999) and in other conditions where the vasculature of the skin
value as a table fruit, pomegranate preparations have been used is compromised (Strigini and Ryan, 1996; Stadelmann et al.,
for ages in various folk remedies (reviewed in Ayensu, 1981; 1998; Mendez et al., 1998) as well as following long-term corti-
Boulos, 1983; Duke and Ayensu, 1985). In recent years, efforts costeroid use (McMichael et al., 1996). If the connective tissue
have been made to identify bioactive moieties in pomegranate of damaged skin can be repaired, it might be possible to delay
preparations and to characterize their effects at the cellular and or prevent the serious consequences that occur in the damaged
biochemical levels. Pomegranate seed oil is a rich source of tissue (Lateef et al., 2005).
conjugated fatty acids (of which punicic acid is the most com- Various bioactive pomegranate fractions might well find
mon) mainly in the form of mono-, di- and triglycerols (Hora et use as skin repair agents. A water-soluble extract made from
al., 2003). Polyphenolic compounds are also present in the seed pomegranate peel was found in the present study to inhibit
oil of the pomegranate (Schubert et al., 1999). Polyphenolic elaboration of the major enzyme (MMP-1) responsible for col-
316 M.N. Aslam et al. / Journal of Ethnopharmacology 103 (2006) 311–318

ties of the pomegranate resemble activities associated with the


biologically active retinoids. The biologically active retinoids
including RA and its parent compound, all-trans retinol have
proven skin repair capacity (Kligman et al., 1986; Weiss et al.,
1988). It is generally believed that rebuilding damaged colla-
gen is essential for skin repair (Griffiths et al., 1993; Talwar et
al., 1995), but epidermal effects are also likely to be important.
While it is difficult to separate epidermal and dermal effects with
retinoids, it appears from the present studies that the epidermal
and dermal regenerative activities of the pomegranate reside in
different fractions. Thus, it might be possible to use these frac-
tions singly or in combination to identify and manipulate the
biological events most important for specific skin repair activity.

Acknowledgment

This study was supported in part by grant DK59169 from the


USPHS.

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