Topical Donepezil for Cholinergic Modulation in Chronic Wound Repair

Chronic wounds result from combined defects in vascular perfusion, inflammatory resolution, and epithelial repair. The skin's non-neuronal cholinergic system (NNCS), formed by keratinocytes, endothelial cells, fibroblasts, and immune cells that synthesise and respond to acetylcholine (ACh), helps coordinate these processes through muscarinic and nicotinic receptors. Inhibition of acetylcholinesterase (AChE) increases local ACh concentrations and may engage two key pathways supported by preclinical data: M3 muscarinic receptor (M3 mAChR)-endothelial nitric oxide synthase (eNOS)-nitric oxide (NO)-mediated vasodilation, and α7 nicotinic acetylcholine receptor (α7-nAChR)-mediated suppression of pro-inflammatory cytokines. Donepezil is a reversible, selective AChE inhibitor with physicochemical properties compatible with dermal administration. Low-dose or microneedle dermal delivery has produced dermal exposure with limited systemic uptake in animal and ex vivo skin studies. In preclinical diabetic wound models, nicotinic receptor activation accelerated healing, reduced inflammatory signalling, and improved control of bacterial burden. We hypothesise that topical donepezil formulated for localised dermal delivery could restore cholinergic signalling within the wound microenvironment by increasing local ACh concentrations. This approach may complement metabolic therapies that support arginine-NO coupling and redox balance. Controlled pilot studies should assess local cutaneous pharmacodynamics, perfusion responses, and wound-closure outcomes.