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Yuan W, Sun H, Yu L. Long non-coding RNA LINC01116 accelerates the progression of keloid formation by regulating miR-203/SMAD5 axis. Burns 2020; 47:665-675. [PMID: 32883538 DOI: 10.1016/j.burns.2020.07.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/15/2020] [Accepted: 07/30/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Emerging evidence reveals the importance of long non-coding RNAs (lncRNAs) in the development and progression of keloid formation. However, the roles and molecular mechanism of lncRNA LINC01116 in the progression of keloid formation remain largely unknown. METHODS The expression levels of LINC01116, microRNA-203 (miR-203) and SMAD family member 5 (SMAD5) were measured by quantitative real-time polymerase chain reaction (qRT-PCR) and western blot. Cell proliferation, migration and invasion were detected by Cell counting Kit-8 (CCK-8) assay and transwell assay. Flow cytometry and western blot assay were used to examine cell apoptosis and extracellular matrix (ECM) production. The interaction between miR-203 and LINC01116 or SMAD5 was predicted by bioinformatics analysis and verified by dual-luciferase reporter and RNA Immunoprecipitation (RIP) and RNA pull-down assays. RESULTS LINC01116 and SMAD5 were upregulated while miR-203 was downregulated in keloid tissues and keloid fibroblasts. LINC01116 knockdown suppressed the proliferation, migration, invasion, and ECM production but induced apoptosis in keloid fibroblasts through enhancing miR-203 and inhibiting SMAD5. Moreover, SMAD5 was identified as a direct target of miR-203 and miR-203 could directly bind to LINC01116. Besides, LINC01116 regulated SMAD5 expression by targeting miR-203. CONCLUSION Downregulation of LINC01116 inhibited the progression of keloid formation by regulating miR-203/SMAD5 axis, which might provide a novel target for keloid therapy.
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Affiliation(s)
- Weiwei Yuan
- Department of Plastic and Cosmetic Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, 518020, China
| | - Hui Sun
- Department of Plastic and Cosmetic Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, 518020, China
| | - Li Yu
- Department of Plastic and Cosmetic Surgery, Shenzhen People's Hospital, Shenzhen, Guangdong, 518020, China.
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Delgado-Vargas B, Sanz López L, Acle Cervera L, Mata Castro N. Corticosteroid Injection for Treatment of Idiopathic Subglottic Stenosis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2020. [DOI: 10.1016/j.otoeng.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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53
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Kim DH, Han SH, Suh HS, Choi YS. Benefits of extracorporeal shock waves for keloid treatment: A pilot study. Dermatol Ther 2020; 33:e13653. [DOI: 10.1111/dth.13653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/12/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Dong Hee Kim
- Department of Dermatology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
| | - Seok Hyun Han
- Department of Dermatology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
| | - Ho Seok Suh
- Department of Dermatology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
| | - Yu Sung Choi
- Department of Dermatology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
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Inyección intralesional de corticoide como tratamiento para la estenosis subglótica idiopática. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2020; 71:256-259. [DOI: 10.1016/j.otorri.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/14/2019] [Accepted: 07/20/2019] [Indexed: 11/24/2022]
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Pérez-Wilson J, Whittle C, García V, Norris F, Castro A, Hitschfeld M. Ulcerated Keloid Secondary to a Coexisting Complicated Epidermal Inclusion Cyst: A Sonographic Diagnosis. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2020. [DOI: 10.1177/8756479320914517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Keloid is a benign fibroblastic tumor that is most often secondary to tissue injury. The clinical presentation is a hard red or purple tumor, mostly itchy or painful. The clinical objectives are to report an ulcerated keloid secondary to a central or inner complicated epidermal inclusion cyst histologically proven and to describe the sonographic findings that permitted the diagnosis. A 29-year-old man with multiple large keloids on the chest wall presented with a two-day pain history, increased volume, and ulceration on one side. Physical examination showed a keloid with edema, peripheral erythema, and a 1-cm central ulcer with purulent discharge. On the sonogram, multiple solid dermal hypodermal pseudotumors were visualized. The lesions were well-defined hypoechogenic heterogeneous solid masses that were hypovascular with color Doppler, concordant with keloids. Within the ulcerated enlarged mass, a complicated epidermal inclusion cyst was discovered with inflammatory changes. The significance of this case lies in the very low frequency of ulceration of a keloid and the high diagnostic value of sonography to demonstrate the presence of a coexisting epidermal inclusion cyst. In the differential diagnosis of an ulcerated keloid, sonography can assist in achieving a better presurgical approach.
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Affiliation(s)
- Jaime Pérez-Wilson
- Department of Dermatology, Clínica Alemana de Santiago de Chile, Vitacura, Metropolitan Region, Chile
| | - Carolina Whittle
- Associate Professor, Facultad de Medicina. Universidad del Desarrollo, Radiology Department, Clínica Alemana de Santiago, Chile
| | - Viviana García
- Department of Dermatology, Clínica Indisa, Santiago, Metropolitana, Chile
| | - Frances Norris
- Resident of Dermatology, Universidad del Desarrollo - Clínica Alemana de Santiago, Chile
| | - Alex Castro
- Pathology Department, Clínica Alemana de Santiago, Chile
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Moreno Pizarro E, Morales Valencia E, Pérez Cuéllar A, Acuña Pinzon C, Serrano Padilla AE. Monoclonal Antibodies Addressed to Factors of Signalization in Keloid Scars: Opportunities and Areas of Action. Cureus 2020; 12:e8894. [PMID: 32742861 PMCID: PMC7389189 DOI: 10.7759/cureus.8894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The advance of technology has made possible the use of new techniques within medicine for the treatment of diseases; monoclonal antibodies are a clear example of this. Keloid scars are one of the most difficult pathologies to treat due to the high percentage of recidivism, formed by the growth of a scar with benign fibrous tissue in genetically predisposed individuals, resulting from a process of inflammation and abnormal scarring. Monoclonal antibodies, being a line of treatment that has increased over the years, can show a new frontier in the treatment of them by focusing on the signaling that causes it. We review the literature on the signaling mechanisms of keloid scars and the possible monoclonal approach.
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Affiliation(s)
| | | | - Arturo Pérez Cuéllar
- Orthopedics and Traumatology, General Hospital of León, León, MEX.,Orthopedics and Traumatology, Medica Campestre Hospital, León, MEX
| | - Camilo Acuña Pinzon
- General Surgery, Hospital Regional de Alta Especialidad del Bajío, León, MEX
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Current potential therapeutic strategies targeting the TGF-β/Smad signaling pathway to attenuate keloid and hypertrophic scar formation. Biomed Pharmacother 2020; 129:110287. [PMID: 32540643 DOI: 10.1016/j.biopha.2020.110287] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/08/2020] [Accepted: 05/16/2020] [Indexed: 12/12/2022] Open
Abstract
Aberrant scar formation, which includes keloid and hypertrophic scars, is associated with a pathological disorganized wound healing process with chronic inflammation. The TGF-β/Smad signaling pathway is the most canonical pathway through which the formation of collagen in the fibroblasts and myofibroblasts is regulated. Sustained activation of the TGF-β/Smad signaling pathway results in the long-term overactivation of fibroblasts and myofibroblasts, which is necessary for the excessive collagen formation in aberrant scars. There are two categories of therapeutic strategies that aim to target the TGF-β/Smad signaling pathway in fibroblasts and myofibroblasts to interfere with their cellular functions and reduce cell proliferation. The first therapeutic strategy includes medications, and the second strategy is composed of genetic and cellular therapeutics. Therefore, the focus of this review is to critically evaluate these two main therapeutic strategies that target the TGF-β/Smad pathway to attenuate abnormal skin scar formation.
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SAKTHİVEL S, BABU GS, CASTELİNO R, AJİLA V, BİSWAS A. Bir Auriküler Keloid Olgusu Sunumu. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2020. [DOI: 10.30934/kusbed.658867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Chang OH. Care of the Post-vaginoplasty Patient: Management of Complications and Common Gynecologic Issues. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00290-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Limandjaja GC, Niessen FB, Scheper RJ, Gibbs S. The Keloid Disorder: Heterogeneity, Histopathology, Mechanisms and Models. Front Cell Dev Biol 2020; 8:360. [PMID: 32528951 PMCID: PMC7264387 DOI: 10.3389/fcell.2020.00360] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/22/2020] [Indexed: 12/22/2022] Open
Abstract
Keloids constitute an abnormal fibroproliferative wound healing response in which raised scar tissue grows excessively and invasively beyond the original wound borders. This review provides a comprehensive overview of several important themes in keloid research: namely keloid histopathology, heterogeneity, pathogenesis, and model systems. Although keloidal collagen versus nodules and α-SMA-immunoreactivity have been considered pathognomonic for keloids versus hypertrophic scars, conflicting results have been reported which will be discussed together with other histopathological keloid characteristics. Importantly, histopathological keloid abnormalities are also present in the keloid epidermis. Heterogeneity between and within keloids exists which is often not considered when interpreting results and may explain discrepancies between studies. At least two distinct keloid phenotypes exist, the superficial-spreading/flat keloids and the bulging/raised keloids. Within keloids, the periphery is often seen as the actively growing margin compared to the more quiescent center, although the opposite has also been reported. Interestingly, the normal skin directly surrounding keloids also shows partial keloid characteristics. Keloids are most likely to occur after an inciting stimulus such as (minor and disproportionate) dermal injury or an inflammatory process (environmental factors) at a keloid-prone anatomical site (topological factors) in a genetically predisposed individual (patient-related factors). The specific cellular abnormalities these various patient, topological and environmental factors generate to ultimately result in keloid scar formation are discussed. Existing keloid models can largely be divided into in vivo and in vitro systems including a number of subdivisions: human/animal, explant/culture, homotypic/heterotypic culture, direct/indirect co-culture, and 3D/monolayer culture. As skin physiology, immunology and wound healing is markedly different in animals and since keloids are exclusive to humans, there is a need for relevant human in vitro models. Of these, the direct co-culture systems that generate full thickness keloid equivalents appear the most promising and will be key to further advance keloid research on its pathogenesis and thereby ultimately advance keloid treatment. Finally, the recent change in keloid nomenclature will be discussed, which has moved away from identifying keloids solely as abnormal scars with a purely cosmetic association toward understanding keloids for the fibroproliferative disorder that they are.
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Affiliation(s)
- Grace C Limandjaja
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Center (location VUmc), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Frank B Niessen
- Department of Plastic Surgery, Amsterdam University Medical Center (location VUmc), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rik J Scheper
- Department of Pathology, Amsterdam University Medical Center (location VUmc), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Susan Gibbs
- Department of Molecular Cell Biology and Immunology, Amsterdam University Medical Center (location VUmc), Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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61
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Pediatric earlobe keloids: Outcomes and patterns of recurrence. J Pediatr Surg 2020; 55:461-464. [PMID: 31383580 DOI: 10.1016/j.jpedsurg.2019.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 06/23/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE Keloids occur as a result of abnormal wound healing and as many as 70% of keloids and hypertrophic scars affect the pediatric population. Earlobe keloids, similar to lesions elsewhere in the body, remain a challenging problem given the high rates of recurrence and lack of consensus regarding treatment strategy. This study aims to evaluate the outcomes and patterns of recurrences following treatment of earlobe keloids in a large cohort of pediatric patients to facilitate identification of the optimal treatment strategy. METHODS All pediatric patients who underwent surgical therapy for earlobe keloids over a 10-year period (2004-2015) were identified and demographic, clinical and outcomes data were collected. A follow-up phone survey was administered to assess rates of long-term recurrence and overall satisfaction with the treatment strategy. Data analysis was performed using Student's t-test and Fisher's exact as appropriate. RESULTS A total of 94 patients with 135 keloids were identified. Mean age was 14 years with slight preponderance of females (52%) and a majority (75%) of the patients were African American (AA). Mean keloid size was 2.4 cm (0.25-11 cm) with ear piercing being the most common inciting etiology. Excision with steroid injection (59%) was the most frequent treatment approach followed by excision alone (25%). During a median follow up of 2 years, keloid recurrence occurred in 27 (28.7%) patients, 19 (70.4%) underwent additional therapy with 10 (52.6%) re-recurrences noted. Median time to recurrence was 23 months, with a slightly higher recurrence rate in AA patients (32%; p = 0.26) and in those age < 10 years (50%; p = 0.11). CONCLUSION This represents the largest series of earlobe keloids treatment in children. Our data suggest that recurrence rates are unaffected by the age at excision and race of the patient. Moreover, adjuncts to excisional therapy such as steroid injection, compression therapy and radiation also did not appear to influence recurrence. Given the pattern of recurrences studies with longer term follow-up are needed to assess the efficacy of treatment strategies. TYPE OF STUDY Case series. LEVEL OF EVIDENCE IV.
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Evdokiou A, Kanisicak O, Gierek S, Barry A, Ivey MJ, Zhang X, Bodnar RJ, Satish L. Characterization of Burn Eschar Pericytes. J Clin Med 2020; 9:jcm9020606. [PMID: 32102389 PMCID: PMC7074206 DOI: 10.3390/jcm9020606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/19/2020] [Indexed: 12/31/2022] Open
Abstract
Pericytes are cells that reside adjacent to microvasculature and regulate vascular function. Pericytes gained great interest in the field of wound healing and regenerative medicine due to their multipotential fate and ability to enhance angiogenesis. In burn wounds, scarring and scar contractures are the major pathologic feature and cause loss of mobility. The present study investigated the influence of burn wound environment on pericytes during wound healing. Pericytes isolated from normal skin and tangentially excised burn eschar tissues were analyzed for differences in gene and protein expression using RNA-seq., immunocytochemistry, and ELISA analyses. RNA-seq identified 443 differentially expressed genes between normal- and burn eschar-derived pericytes. Whereas, comparing normal skin pericytes to normal skin fibroblasts identified 1021 distinct genes and comparing burn eschar pericytes to normal skin fibroblasts identified 2449 differential genes. Altogether, forkhead box E1 (FOXE1), a transcription factor, was identified as a unique marker for skin pericytes. Interestingly, FOXE1 levels were significantly elevated in burn eschar pericytes compared to normal. Additionally, burn wound pericytes showed increased expression of profibrotic genes periostin, fibronectin, and endosialin and a gain in contractile function, suggesting a contribution to scarring and fibrosis. Our findings suggest that the burn wound environment promotes pericytes to differentiate into a myofibroblast-like phenotype promoting scar formation and fibrosis.
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Affiliation(s)
- Alexander Evdokiou
- Shriners Hospitals for Children, Research Department, Cincinnati, OH 45229, USA; (A.E.); (S.G.); (A.B.)
| | - Onur Kanisicak
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH 45267-0529, USA; (O.K.); (M.J.I.)
| | - Stephanie Gierek
- Shriners Hospitals for Children, Research Department, Cincinnati, OH 45229, USA; (A.E.); (S.G.); (A.B.)
| | - Amanda Barry
- Shriners Hospitals for Children, Research Department, Cincinnati, OH 45229, USA; (A.E.); (S.G.); (A.B.)
| | - Malina J. Ivey
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH 45267-0529, USA; (O.K.); (M.J.I.)
| | - Xiang Zhang
- Genomics, Epigenomics and Sequencing Core, University of Cincinnati, Cincinnati, OH 45267, USA;
| | - Richard J. Bodnar
- Veterans Affairs Medical Center, University Dr. C, Pittsburgh, PA 15240, USA;
| | - Latha Satish
- Shriners Hospitals for Children, Research Department, Cincinnati, OH 45229, USA; (A.E.); (S.G.); (A.B.)
- Department of Pathology and Laboratory Medicine, University of Cincinnati, Cincinnati, OH 45267-0529, USA; (O.K.); (M.J.I.)
- Correspondence: or ; Tel.: +1-513-872-6278
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Bao Y, Xu S, Pan Z, Deng J, Li X, Pan F, Li X. Comparative Efficacy and Safety of Common Therapies in Keloids and Hypertrophic Scars: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2020; 44:207-218. [PMID: 31637502 DOI: 10.1007/s00266-019-01518-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES At present, there are many therapies for treating keloids and hypertrophic scars, but there is still a lack of treatments that are relatively balanced in efficacy and safety. The study aims to evaluate comprehensively efficacy and safety of common therapies in keloids and hypertrophic scars. METHODS The literature search was conducted up to May 2019. The traditional meta-analysis was performed on 17 therapies. Bayesian network meta-analysis was conducted on the four most common treatments. The outcome indicators were the numbers of patients with good-to-excellent effect, Vancouver Scar Scale (VSS) and adverse events. RESULTS There was no significant difference in the efficacy of triamcinolone acetonide (TAC) compared with other monotherapies except for silicone gel sheet and neodymium-yttrium-aluminum-garnet in primary indicator. The combination therapies were superior to TAC, and the results were consistent after the pooled analysis (RR = 0.522, 95% CI 0.332-0.823). The level of VSS in TAC group was higher than that in 5-flurouracil (5-FU) and TAC + 5-FU group, but lower than that in verapamil (VER) group. And the patients treated with TAC were less safe than those treated with verapamil (P = 0.013). Surface under cumulative ranking ranked verapamil and TAC + 5-FU as the favorable efficacy therapies in terms of primary indicator and ranked TAC + 5-FU as the best therapy for VSS, while VER was ranked as the worst. CONCLUSION This meta-analysis showed that TAC + 5-FU may be the most effective therapy, while verapamil may be a better therapeutic strategy for safety. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Cui J, Jin S, Jin C, Jin Z. Syndecan-1 regulates extracellular matrix expression in keloid fibroblasts via TGF-β1/Smad and MAPK signaling pathways. Life Sci 2020; 254:117326. [PMID: 31954164 DOI: 10.1016/j.lfs.2020.117326] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 01/05/2020] [Accepted: 01/13/2020] [Indexed: 12/13/2022]
Abstract
AIMS The present study aimed to explore the effect of syndecan-1 on keloid fibroblasts. MAIN METHODS Immunohistochemistry and Western blot were employed to assess the expression of syndecan-1. Primary cultured keloid fibroblasts were transfected with syndecan-1 siRNA. The function of syndecan-1 on the proliferation of keloid fibroblasts was investigated through Cell Counting Kit-8 (CCK-8) and flow cytometry. Extracellular matrix, TGF-β1/Smad, and MAPK related proteins were evaluated by Western blot. KEY FINDINGS Syndecan-1 was significantly overexpressed in both keloid tissues and fibroblasts. Moreover, the knockdown of syndecan-1 remarkably attenuated the proliferation of keloid fibroblasts and reduced the content of the extracellular matrix. Importantly, syndecan-1 regulates the expression of the extracellular matrix in keloid fibroblasts via TGF-β1/Smad and mitogen-activated protein kinase (MAPK) signaling pathways. SIGNIFICANCE The current results revealed a crucial function for syndecan-1 in regulating the expression of extracellular matrix and cell proliferation, thereby designating syndecan-1 as a novel target for keloid.
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Affiliation(s)
- Jing Cui
- Klebs Research Center, Department of Dermatology, Yanbian University Hospital, Yanji 133000, China
| | - Shan Jin
- Klebs Research Center, Department of Dermatology, Yanbian University Hospital, Yanji 133000, China
| | - Chenglong Jin
- Klebs Research Center, Department of Dermatology, Yanbian University Hospital, Yanji 133000, China.
| | - Zhehu Jin
- Klebs Research Center, Department of Dermatology, Yanbian University Hospital, Yanji 133000, China.
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65
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Disease Severity and Quality of Life Outcome Measurements in Patients With Keloids. Dermatol Surg 2019; 45:1477-1483. [DOI: 10.1097/dss.0000000000002172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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66
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Kilmister EJ, Paterson C, Brasch HD, Davis PF, Tan ST. The Role of the Renin-Angiotensin System and Vitamin D in Keloid Disorder-A Review. Front Surg 2019; 6:67. [PMID: 32039229 PMCID: PMC6988818 DOI: 10.3389/fsurg.2019.00067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 11/13/2019] [Indexed: 12/20/2022] Open
Abstract
Keloid disorder (KD) is a fibroproliferative condition characterized by excessive dermal collagen deposition in response to wounding and/or inflammation of the skin. Despite intensive research, treatment for KD remains empirical and unsatisfactory. Activation of the renin-angiotensin system (RAS) leads to fibrosis in various organs through its direct effect and the resultant hypertension, and activation of the immune system. The observation of an increased incidence of KD in dark-skinned individuals who are predisposed to vitamin D deficiency (VDD) and hypertension, and the association of KD with hypertension and VDD, all of which are associated with an elevated activity of the RAS, provides clues to the pathogenesis of KD. There is increasing evidence implicating embryonic-like stem (ESC) cells that express ESC markers within keloid-associated lymphoid tissues (KALTs) in keloid lesions. These primitive cells express components of the RAS, cathepsins B, D, and G that constitute bypass loops of the RAS, and vitamin D receptor (VDR). This suggests that the RAS directly, and through signaling pathways that converge on the RAS, including VDR-mediated mechanisms and the immune system, may play a critical role in regulating the primitive population within the KALTs. This review discusses the role of the RAS, its relationship with hypertension, vitamin D, VDR, VDD, and the immune system that provide a microenvironmental niche in regulating the ESC-like cells within the KALTs. These ESC-like cells may be a novel therapeutic target for the treatment of this enigmatic and challenging condition, by modulating the RAS using inhibitors of the RAS and its bypass loops and convergent signaling pathways.
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Affiliation(s)
| | | | - Helen D Brasch
- Gillies McIndoe Research Institute, Wellington, New Zealand
| | - Paul F Davis
- Gillies McIndoe Research Institute, Wellington, New Zealand
| | - Swee T Tan
- Gillies McIndoe Research Institute, Wellington, New Zealand.,Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Wellington, New Zealand
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Maymone MBC, Watchmaker JD, Dubiel M, Wirya SA, Shen LY, Vashi NA. Common Skin Disorders in Pediatric Skin of Color. J Pediatr Health Care 2019; 33:727-737. [PMID: 31655787 DOI: 10.1016/j.pedhc.2019.04.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 12/12/2022]
Abstract
Children with skin of color represent a large proportion of the pediatric population. There are numerous skin conditions that commonly occur in this population, including but not limited to acne, atopic dermatitis, pityriasis alba, tinea versicolor, progressive macular hypomelanosis, traction alopecia, and confluent and reticulated papillomatosis. This article highlights the clinical presentations of these conditions in skin of color and briefly addresses pathophysiology and treatment modalities.
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Kaufmann J, Bode K, Puder C, Laschat M, Engelhardt T, Wappler F. Transglottic corticosteroid injection for treatment of soft post-intubation subglottic stenosis: a retrospective analysis of 26 children. Eur Arch Otorhinolaryngol 2019; 276:3419-3424. [PMID: 31531776 DOI: 10.1007/s00405-019-05642-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/10/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Surgical treatment is generally recommended for severe subglottic lesions following traumatic endotracheal intubation in children. An alternative approach is early transglottic corticosteroid administration to reduce scar formation and prevent the need for subsequent surgical intervention. This technique has been practiced successfully for several decades at the Children's Hospital of Cologne and the outcomes of 26 subsequent patients reviewed in this analysis. METHODS All patients who underwent transglottic corticosteroid injection for treatment of post-intubation stridor and dyspnoea between 2012 and 2018 were identified and their records and endoscopy images analysed. Severity of the endoscopic findings was assessed using the Myer-Cotton classification (MCC) and an Expected Need for Surgical Intervention (ENSI) score (1 = inevitable; 2 = very likely necessary; 3 = probably avoidable and 4 = most likely not necessary) was recorded. Treatment was considered successful if the children had a complete resolution of clinical symptoms. RESULTS A total of 26 patients with a median (range) age of 1.9 (0.02-7.2) years and weight of 9.8 (1.8-25) kg were identified and included into the analysis. Endoscopic images were available for 22 children. All children underwent transglottic corticosteroid injection prior to any potential surgical treatment. A total of 22 patients (85%) improved following transglottic corticosteroid injection including 4 of 5 patients with a MCC = 3 and ENSI = 1 avoiding surgical intervention. None of the patients experienced a deterioration of clinical symptoms or endoscopic findings. CONCLUSION Transglottic corticosteroid injections as first-line treatment in children with severe post-endotracheal intubation trauma can successfully resolve symptoms and prevent invasive surgery.
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Affiliation(s)
- Jost Kaufmann
- Department for Paediatric Anaesthesia, Children's Hospital, Amsterdamer Str. 59, 50735, Cologne, Germany. .,Faculty for Health, University Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
| | - Katrin Bode
- Department for Paediatric Anaesthesia, Children's Hospital, Amsterdamer Str. 59, 50735, Cologne, Germany
| | - Christian Puder
- ENT Specialist in Private Practice and attending ENT Surgeon Children's Hospital, Amsterdamer Str. 59, 50735, Cologne, Germany
| | - Michael Laschat
- Department for Paediatric Anaesthesia, Children's Hospital, Amsterdamer Str. 59, 50735, Cologne, Germany
| | - Thomas Engelhardt
- Department for Anaesthesia, Royal Children's Hospital, Westburn Road, Foresterhill, Aberdeen, AB25 2ZG, UK
| | - Frank Wappler
- Department for Paediatric Anaesthesia, Children's Hospital, Amsterdamer Str. 59, 50735, Cologne, Germany.,Faculty for Health, University Witten/Herdecke, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
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69
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Expression Profiles of lncRNAs and circRNAs in Keloid. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2265. [PMID: 31624676 PMCID: PMC6635192 DOI: 10.1097/gox.0000000000002265] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
Abstract
Supplemental Digital Content is available in the text. Background: We hypothesized that crosstalk between noncoding RNAs, including microRNA (miRNA), lncRNA, and circRNA, might play a critical role in keloids development and physiology. To reveal the molecular mechanisms involved in the pathogenesis of keloids, we compared their gene expression profiles and differential expressions in keloid and normal skin tissues. Methods: Expression profiles of mRNAs and lncRNAs and circRNAs in 2 pairs (identification set) of keloid and matched normal skin tissues were analyzed through sequencing. Real-time quantitative PCR was performed to validate the sequencing results using 5 pairs (validation set) of keloid and matched normal skin tissues. Presumed targets of differentially expressed lncRNAs and circRNAs were functionally annotated by bioinformatics approaches. Results: The differential expression of mRNAs in keloid and normal skin by high-throughput sequencing was 2,528, of which 1,271 were downregulated, whereas 1,257 were upregulated. In the meantime, sequencing identified 2,227 differentially expressed lncRNAs, including 1,224 upregulated and 1,003 downregulated in keloid tissue compared with normal skin tissue. Additionally, 154 differentially expressed circRNAs were identified, including 81 upregulated and 73 downregulated in keloid tissue compared with normal skin tissue. Functional annotations of differentially expressed circRNA targets revealed their enrichment in several signaling pathways important for scar wound healing. Conclusions: Expression profiles of mRNAs, lncRNAs, and circRNAs were altered in keloid tissue, which may partly contribute to the etiology of keloids by affecting several signaling pathways relevant to scar wound healing. A better understanding of keloids pathogenesis may identify new therapeutic targets for keloids.
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70
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Limandjaja GC, Waaijman T, Roffel S, Niessen FB, Gibbs S. Monocytes co-cultured with reconstructed keloid and normal skin models skew towards M2 macrophage phenotype. Arch Dermatol Res 2019; 311:615-627. [PMID: 31187196 PMCID: PMC6736899 DOI: 10.1007/s00403-019-01942-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/28/2019] [Accepted: 06/04/2019] [Indexed: 01/15/2023]
Abstract
Several abnormalities have been reported in the peripheral blood mononuclear cells of keloid-forming patients and particularly in the monocyte cell fraction. The goal of this in vitro study was to determine whether monocytes from keloid-prone patients contribute to the keloid phenotype in early developing keloids, and whether monocyte differentiation is affected by the keloid microenvironment. Therefore, keloid-derived keratinocytes and fibroblasts were used to reconstruct a full thickness, human, in vitro keloid scar model. The reconstructed keloid was co-cultured with monocytes from keloid-forming patients and compared to reconstructed normal skin co-cultured with monocytes from non-keloid-formers. The reconstructed keloid showed increased contraction, dermal thickness (trend) and α-SMA+ staining, but co-culture with monocytes did not further enhance the keloid phenotype. After 2-week culture, all monocytes switched from a CD11chigh/CD14high/CD68low to a CD11chigh/CD14low/CD68high phenotype. However, only monocytes co-cultured with either reconstructed keloid scar or normal skin models skewed towards the more fibrotic M2-macrophage phenotype. There was negligible fibroblast and fibrocyte differentiation in mono- and co-cultured monocytes. These results indicate that monocytes differentiate into M2 macrophages when in the vicinity of early regenerating and repairing tissue, independent of whether the individual is prone to normal or keloid scar formation.
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Affiliation(s)
- Grace C Limandjaja
- Department of Molecular Cell Biology and Immunology, O|2 Lab Building Room 11E05, Amsterdam University Medical Centre (UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, De Boelelaan, 1108, Amsterdam, The Netherlands
| | - Taco Waaijman
- Department of Molecular Cell Biology and Immunology, O|2 Lab Building Room 11E05, Amsterdam University Medical Centre (UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, De Boelelaan, 1108, Amsterdam, The Netherlands
| | - Sanne Roffel
- Department of Molecular Cell Biology and Immunology, O|2 Lab Building Room 11E05, Amsterdam University Medical Centre (UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, De Boelelaan, 1108, Amsterdam, The Netherlands
| | - Frank B Niessen
- Department of Plastic Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Susan Gibbs
- Department of Molecular Cell Biology and Immunology, O|2 Lab Building Room 11E05, Amsterdam University Medical Centre (UMC), Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, De Boelelaan, 1108, Amsterdam, The Netherlands.
- Department of Oral Cell Biology, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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71
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Jones RE, Foster DS, Hu MS, Longaker MT. Wound healing and fibrosis: current stem cell therapies. Transfusion 2019; 59:884-892. [PMID: 30737822 DOI: 10.1111/trf.14836] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/01/2018] [Indexed: 12/20/2022]
Abstract
Scarring is a result of the wound healing response and causes tissue dysfunction after injury. This process is readily evident in the skin, but also occurs internally across organ systems in the form of fibrosis. Stem cells are crucial to the innate tissue healing response and, as such, present a possible modality to therapeutically promote regenerative healing while minimizing scaring. In this review, the cellular basis of scaring and fibrosis is examined. Current stem cell therapies under exploration for skin wound healing and internal organ fibrosis are discussed. While most therapeutic approaches rely on the direct application of progenitor-type cells to injured tissue to promote healing, novel strategies to manipulate the scarring response are also presented. As our understanding of developmental and stem cell biology continues to increase, therapies to encourage regeneration of healthy functional tissue after damage secondary to injury or disease will continue to expand.
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Affiliation(s)
- Ruth Ellen Jones
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Deshka S Foster
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael S Hu
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael T Longaker
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
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72
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Khattab FM, Nasr M, Khashaba SA, Bessar H. Combination of pulsed dye laser and verapamil in comparison with verapamil alone in the treatment of keloid. J DERMATOL TREAT 2019; 31:186-190. [DOI: 10.1080/09546634.2019.1610550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Fathia M. Khattab
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamad Nasr
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Shrook A. Khashaba
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Hagar Bessar
- Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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73
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Li K, Nicoli F, Xi WJ, Zhang Z, Cui C, Al-Mousawi A, Balzani A, Tong Y, Zhang Y. The 1470 nm diode laser with an intralesional fiber device: a proposed solution for the treatment of inflamed and infected keloids. BURNS & TRAUMA 2019; 7:5. [PMID: 30783604 PMCID: PMC6376646 DOI: 10.1186/s41038-019-0143-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/21/2019] [Indexed: 01/08/2023]
Abstract
Background Keloids are the result of abnormal wound healing and often are subject to infections and recurrent inflammation. We present a study conducted with a 1470 nm diode laser using an intralesional optical fiber device for the treatment of inflamed keloid scars. We evaluate its efficacy as a novel alternative method to decrease keloid infection and inflammation. Methods The patients who underwent 1470 nm laser treatment from February 2016 to February 2018 at the plastic and reconstructive surgery department of the Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University with keloid accompanying serious local infection and fester were included. Patients took curative effect evaluation before and 1 year after the treatment. The test items included infection frequency in each year; pain, by visual analogue scale (VAS); itch, using VAS; quality of life (QOL), using QOL scale; and blood supply, using PeriCam PSI. Results A total of 19 patients (mean age 35.21 years, range 11–66) with history of inflamed keloids with episodes of infection or abscess were enrolled. Patients underwent to a 1470 nm laser therapy for average of 1.16 times. After treatment, infection frequency and blood supply in keloids were reduced (p < 0.001). Pain, itching, and QOL were improved (p < 0.001). Conclusion The present study shows that 1470 nm fiber laser treatment could improve inflamed keloids fairly well by decreasing inflammation, and a relative stabilization of collagen composition. Therefore, it is an effective minimally invasive scar therapy, but further studies are essential to confirm the present results.
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Affiliation(s)
- Ke Li
- 1Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhi Zao Ju Road, Shanghai, 200011 China
| | - Fabio Nicoli
- 2Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy.,3Department of Plastic and Reconstructive Surgery, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Wen Jing Xi
- 1Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhi Zao Ju Road, Shanghai, 200011 China
| | - Zheng Zhang
- 1Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhi Zao Ju Road, Shanghai, 200011 China
| | - Chunxiao Cui
- 1Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhi Zao Ju Road, Shanghai, 200011 China
| | - Ahmed Al-Mousawi
- 3Department of Plastic and Reconstructive Surgery, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alberto Balzani
- 2Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy
| | - Yun Tong
- Department of Medical Cosmetology Surgery, Jinhua People's Hospital, Jinhua, China
| | - Yixin Zhang
- 1Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 639 Zhi Zao Ju Road, Shanghai, 200011 China
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74
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Fujita M, Yamamoto Y, Jiang JJ, Atsumi T, Tanaka Y, Ohki T, Murao N, Funayama E, Hayashi T, Osawa M, Maeda T, Kamimura D, Murakami M. NEDD4 Is Involved in Inflammation Development during Keloid Formation. J Invest Dermatol 2019; 139:333-341. [DOI: 10.1016/j.jid.2018.07.044] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 07/22/2018] [Accepted: 07/27/2018] [Indexed: 12/19/2022]
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75
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Khalid FA, Mehrose MY, Saleem M, Yousaf MA, Mujahid AM, Rehman SU, Ahmad S, Tarar MN. Comparison of efficacy and safety of intralesional triamcinolone and combination of triamcinolone with 5-fluorouracil in the treatment of keloids and hypertrophic scars: Randomised control trial. Burns 2019; 45:69-75. [DOI: 10.1016/j.burns.2018.08.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/20/2018] [Accepted: 08/07/2018] [Indexed: 11/25/2022]
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76
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Saki N, Mokhtari R, Nozari F. Comparing the Efficacy of Intralesional Triamcinolone Acetonide With Verapamil in Treatment of Keloids: A Randomized Controlled Trial. Dermatol Pract Concept 2019; 9:4-9. [PMID: 30775139 PMCID: PMC6368080 DOI: 10.5826/dpc.0901a02] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Background Keloid management remains a challenging clinical problem despite numerous therapies reported until now. The efficacy of corticosteroids in the treatment of keloids has been well established. The most commonly used corticosteroid is intralesional triamcinolone. Sporadic reports on the use of intralesional verapamil suggest its efficacy. Aim Since there is not sufficient evidence to support the role of intralesional verapamil as an effective alternative modality, it was decided to undertake a randomized study to determine its efficacy as a treatment for keloids. Methods A randomized, single-blind, single-group comparison with 15 patients (30 scars) was carried out to compare the effects of intralesional triamcinolone with verapamil injections. Injections were scheduled every 3 weeks accompanied by cryotherapy until complete flattening of the scar or maximum 8 sessions, whichever came earlier. Scar evaluation at each stage was done by serial photographic records as well as by Vancouver scar scale. Statistical analysis was done by Wilcoxon and Mann-Whitney U tests using SPSS version 19. Results In both study groups there was a reduction in height and pliability at the end of the study. Better improvement in height and pliability was seen with triamcinolone in comparison with verapamil. However, a desired change in vascularity and pigmentation was not seen with either of the drugs. Conclusion Verapamil is not as effective as triamcinolone in the treatment of keloids.
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Affiliation(s)
- Nasrin Saki
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Dermatology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Raya Mokhtari
- Dermatology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farnoosh Nozari
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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77
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Rasaii S, Sohrabian N, Gianfaldoni S, Hadibarhaghtalab M, Pazyar N, Bakhshaeekia A, Lotti T, Ramirez-Pacheco LA, Lange CS, Matta J, Seifi V, Ramirez-Fort MK, Feily A. Intralesional triamcinolone alone or in combination with botulinium toxin A is ineffective for the treatment of formed keloid scar: A double blind controlled pilot study. Dermatol Ther 2019; 32:e12781. [PMID: 30422367 DOI: 10.1111/dth.12781] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/24/2018] [Accepted: 10/16/2018] [Indexed: 11/29/2022]
Abstract
Cutaneous injury can ignite excessive fibroproliferative growth that results in keloid formation. Keloids are associated with significant morbidity related to disfigurement and/or symptoms (e.g., pain and pruritus). First-line treatment of formed keloids involves topical or intralesional steroids. Recurrent or resistant keloids are managed by surgical excision or cryotherapy, followed by steroidal application or adjuvant irradiation. Although adjuvant irradiation appears to be most efficacious, alternative therapeutic options are needed for patients without access to radiation centers. Botulinum Toxin A (BTA) appears to have similar inhibitory effects to irradiation on the cell cycle via downregulation of pathogenic cytokines. Herein, we conducted a study to compare the efficacy of intralesional triamcinolone used alone, or in combination with BTA, in the treatment of formed keloid scars. Twenty patients with a cumulative of 40 keloids completed the study. There was no significant difference between treatment arms with respect to height vascularization, pliability, and pigmentation scores. The addition of BTA resulted in significant symptomatic improvement of pain and pruritus as compared to intralesional triamcinolone alone (p < 0.001). Irradiation is only effective when administered in the adjuvant setting where inhibitory effects on cell cycle and migration are optimized. Future studies with intralesional triamcinolone and BTA should be performed adjuvantly.
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Affiliation(s)
- Sima Rasaii
- Dermatology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nasibe Sohrabian
- Dermatology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | | | - Nader Pazyar
- Dermatology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Torello Lotti
- Dermatology, University G. Marconi of Rome, Rome, Italy
| | | | - Christopher S Lange
- Radiation Oncology, State University Hospital of New York at Downstate, Brooklyn, New York
| | - Jaime Matta
- Division of Pharmacology and Toxicology, Department of Basic Sciences, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Vahid Seifi
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Amir Feily
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
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78
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Rodrigues M, Kosaric N, Bonham CA, Gurtner GC. Wound Healing: A Cellular Perspective. Physiol Rev 2019; 99:665-706. [PMID: 30475656 PMCID: PMC6442927 DOI: 10.1152/physrev.00067.2017] [Citation(s) in RCA: 1152] [Impact Index Per Article: 230.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 02/08/2023] Open
Abstract
Wound healing is one of the most complex processes in the human body. It involves the spatial and temporal synchronization of a variety of cell types with distinct roles in the phases of hemostasis, inflammation, growth, re-epithelialization, and remodeling. With the evolution of single cell technologies, it has been possible to uncover phenotypic and functional heterogeneity within several of these cell types. There have also been discoveries of rare, stem cell subsets within the skin, which are unipotent in the uninjured state, but become multipotent following skin injury. Unraveling the roles of each of these cell types and their interactions with each other is important in understanding the mechanisms of normal wound closure. Changes in the microenvironment including alterations in mechanical forces, oxygen levels, chemokines, extracellular matrix and growth factor synthesis directly impact cellular recruitment and activation, leading to impaired states of wound healing. Single cell technologies can be used to decipher these cellular alterations in diseased states such as in chronic wounds and hypertrophic scarring so that effective therapeutic solutions for healing wounds can be developed.
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Affiliation(s)
- Melanie Rodrigues
- Department of Surgery, Stanford University School of Medicine , Stanford, California
| | - Nina Kosaric
- Department of Surgery, Stanford University School of Medicine , Stanford, California
| | - Clark A Bonham
- Department of Surgery, Stanford University School of Medicine , Stanford, California
| | - Geoffrey C Gurtner
- Department of Surgery, Stanford University School of Medicine , Stanford, California
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79
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Reconstructed human keloid models show heterogeneity within keloid scars. Arch Dermatol Res 2018; 310:815-826. [PMID: 30370495 PMCID: PMC6244653 DOI: 10.1007/s00403-018-1873-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/03/2018] [Accepted: 10/21/2018] [Indexed: 11/17/2022]
Abstract
Keloid scars are often described as having an actively growing peripheral margin with a regressing centre. The aim of this study was to examine the possible heterogeneity within keloids and the involvement of different regions within and around keloid scars in the pathogenesis, using an in vitro keloid scar model. In vitro skin models were constructed from keratinocytes and fibroblasts from normal skin and different regions within and around keloid scars: periphery, centre, and (adjacent) surrounding-normal-skin regions. Additionally, fibroblasts were isolated from the superficial-central and deep-central regions of the keloid and combined with central keratinocytes. All keloid regions showed increased contraction compared to normal skin models, particularly in central regions. Myofibroblasts were present in all keloid regions but were more abundant in models containing central-deep keloid fibroblasts. Secretion of anti-fibrotic HGF and extracellular matrix collagen IV gene expression was reduced in the central deep keloid compared to normal skin. No significant differences between peripheral and central regions within keloids were observed for inflammatory cytokine CCL20, CCL27, CXCL8, IL-6 and IL-18 secretion. Parameters for surrounding-normal-skin showed similarities to both non-lesional normal skin and keloids. In conclusion, a simple but elegant method of culturing keloid-derived keratinocytes and fibroblasts in an organotypic 3D scar model was developed, for the dual purpose of studying the underlying pathology and ultimately testing new therapeutics. In this study, these tissue engineered scar models show that the central keloid region shows a more aggressive keloid scar phenotype than the periphery and that the surrounding-normal-skin also shares certain abnormalities characteristic for keloids.
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80
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Morelli Coppola M, Salzillo R, Segreto F, Persichetti P. Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives. Clin Cosmet Investig Dermatol 2018; 11:387-396. [PMID: 30087573 PMCID: PMC6063260 DOI: 10.2147/ccid.s133672] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Keloids are pathological scars presenting as nodular lesions that extend beyond the area of injury. They do not spontaneously regress, often continuing to grow over time. The abnormal wound-healing process underlying keloid formation results from the lack of control mechanisms self-regulating cell proliferation and tissue repair. Keloids may lead to cosmetic disfigurement and functional impairment and affect the quality of life. Although several treatments were reported in the literature, no universally effective therapy was found to date. The most common approach is intralesional corticosteroid injection alone or in combination with other treatment modalities. Triamcinolone acetonide (TAC) is the most commonly used intralesional corticosteroid. The aim of this article was to review the use of TAC, alone or in combination, in the treatment of keloid scars. The response to corticosteroid injection alone is variable with 50-100% regression and a recurrence rate of 33% and 50% after 1 and 5 years, respectively. Compared to verapamil, TAC showed a faster and more effective response even though with a higher complication rate. TAC combined with verapamil was proved to be effective with statistically significant overall improvements of scars over time and long-term stable results. TAC and 5-fluorouracil (5-FU) intralesional injections were found to achieve comparable outcomes when administered alone, although 5-FU was more frequently associated with side effects. Conversely, the combination of 5-FU and TAC was more effective and showed fewer undesirable effects compared to TAC or 5-FU alone. Several kinds of laser treatments were reported to address keloids; however, laser therapy alone was burdened with a high recurrence rate. Better results were described by combining CO2, pulsed-dye or Nd: YAG lasers with TAC intralesional injections. Further options such as needle-less intraepidermal drug delivery are being explored, but more studies are needed to establish safety, feasibility and effectiveness of this approach.
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Affiliation(s)
- Marco Morelli Coppola
- Department of Plastic, Reconstructive and Aesthetic Surgery, "Campus Bio-Medico" University of Rome, Rome, Italy,
| | - Rosa Salzillo
- Department of Plastic, Reconstructive and Aesthetic Surgery, "Campus Bio-Medico" University of Rome, Rome, Italy,
| | - Francesco Segreto
- Department of Plastic, Reconstructive and Aesthetic Surgery, "Campus Bio-Medico" University of Rome, Rome, Italy,
| | - Paolo Persichetti
- Department of Plastic, Reconstructive and Aesthetic Surgery, "Campus Bio-Medico" University of Rome, Rome, Italy,
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Li Y, Liang X, Wang P, Long X, Wang X, Meng Z. Long non-coding RNA CACNA1G-AS1 promotes calcium channel protein expression and positively affects human keloid fibroblast migration. Oncol Lett 2018; 16:891-897. [PMID: 29963160 PMCID: PMC6019917 DOI: 10.3892/ol.2018.8717] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 11/20/2017] [Indexed: 11/06/2022] Open
Abstract
Keloids are a type of benign hyperplasia that cause dermatologic dysfunction and esthetic deformity by invading adjacent normal tissues. Little is known about their etiology, therefore, they are a challenge to treat using plastic surgery. In a previous study, it was demonstrated that the expression of the long non-coding RNA CACNA1G-AS1 (CAS1) is high in keloid tissue, suggesting that CAS1 is involved in keloid formation. In the present study, the aim was to identify potential keloid target proteins by exploring CAS1 biological function during cell proliferation and migration, cytokine secretion, collagen secretion and the control of calcium channel protein expression in human keloid fibroblasts. Three biopsy samples were collected from each patient with keloids at The Peking Union Medical College Hospital, which were then used to investigate the role of CAS1 in cell proliferation and migration. CAS1 silencing was also carried out using small interfering RNA; cell factors, collagen and calcium channel protein levels were compared with control cells. The interference of CAS1 expression reached 50% compared with the control group. CACNA1G and type I collagen expression was significantly downregulated by CAS1 knockdown, while the expression of transforming growth factor-β and type III collagen was not affected. Wound healing time was longer in the CAS1-knockdown group, but there was no visible change in cell proliferation. In conclusion, CAS1 appeared to promote calcium channel protein and type I collagen expression, and to have a positive effect on cell migration in human keloid fibroblasts. Therefore it has potential as a novel therapeutic target for keloids.
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Affiliation(s)
- Ye Li
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China
| | - Xuebing Liang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
| | - Peng Wang
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
| | - Xiaojun Wang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, P.R. China
| | - Zhiqiang Meng
- Department of Integrative Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China
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82
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Limandjaja GC, van den Broek LJ, Breetveld M, Waaijman T, Monstrey S, de Boer EM, Scheper RJ, Niessen FB, Gibbs S. Characterization of In Vitro Reconstructed Human Normotrophic, Hypertrophic, and Keloid Scar Models. Tissue Eng Part C Methods 2018; 24:242-253. [PMID: 29490604 DOI: 10.1089/ten.tec.2017.0464] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To understand scar pathology, develop new drugs, and provide a platform for personalized medicine, physiologically relevant human scar models are required, which are characteristic of different scar pathologies. Hypertrophic scars and keloids are two types of abnormal scar resulting from unknown abnormalities in the wound healing process. While they display different clinical behavior, differentiation between the two can be difficult-which in turn means that it is difficult to develop optimal therapeutic strategies. The aim of this study was to develop in vitro reconstructed human hypertrophic and keloid scar models and compare these to normotrophic scar and normal skin models to identify distinguishing biomarkers. Keratinocytes and fibroblasts from normal skin and scar types (normotrophic, hypertrophic, keloid) were used to reconstruct skin models. All skin models showed a reconstructed differentiated epidermis on a fibroblast populated collagen-elastin matrix. Both abnormal scar types showed increased contraction, dermal thickness, and myofibroblast staining compared to normal skin and normotrophic scar. Notably, the expression of extracellular matrix associated genes showed distinguishing profiles between all scar types and normal skin (hyaluronan synthase-1, matrix-metalloprotease-3), between keloid and normal skin (collagen type IV), between normal scar and keloid (laminin α1), and between keloid and hypertrophic scar (matrix-metalloprotease-1, integrin α5). Also, inflammatory cytokine and growth factor secretion (CCL5, CXCL1, CXCL8, CCL27, IL-6, HGF) showed differential secretion between scar types. Our results strongly suggest that abnormal scars arise from different pathologies rather than simply being on different ends of the scarring spectrum. Furthermore, such normal skin and scar models together with biomarkers, which distinguish the different scar types, would provide an animal free, physiologically relevant scar diagnostic and drug testing platform for the future.
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Affiliation(s)
- Grace C Limandjaja
- 1 Department of Dermatology, VU Medical Centre (VUMC) , Amsterdam, The Netherlands
| | | | - Melanie Breetveld
- 1 Department of Dermatology, VU Medical Centre (VUMC) , Amsterdam, The Netherlands
| | - Taco Waaijman
- 1 Department of Dermatology, VU Medical Centre (VUMC) , Amsterdam, The Netherlands
| | - Stan Monstrey
- 2 Department of Plastic Surgery, University of Ghent , Ghent, Belgium
| | - Edith M de Boer
- 1 Department of Dermatology, VU Medical Centre (VUMC) , Amsterdam, The Netherlands
| | - Rik J Scheper
- 3 Department of Pathology, VU Medical Centre (VUMC) , Amsterdam, The Netherlands
| | - Frank B Niessen
- 4 Department of Plastic Surgery, VU Medical Centre (VUMC) , Amsterdam, The Netherlands
| | - Susan Gibbs
- 1 Department of Dermatology, VU Medical Centre (VUMC) , Amsterdam, The Netherlands .,5 Department of Oral Cell Biology, Academic Centre for Dentistry (ACTA) , Amsterdam, The Netherlands
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83
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Lee HJ, Jang YJ. Recent Understandings of Biology, Prophylaxis and Treatment Strategies for Hypertrophic Scars and Keloids. Int J Mol Sci 2018; 19:ijms19030711. [PMID: 29498630 PMCID: PMC5877572 DOI: 10.3390/ijms19030711] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/07/2018] [Accepted: 01/08/2018] [Indexed: 02/06/2023] Open
Abstract
Hypertrophic scars and keloids are fibroproliferative disorders that may arise after any deep cutaneous injury caused by trauma, burns, surgery, etc. Hypertrophic scars and keloids are cosmetically problematic, and in combination with functional problems such as contractures and subjective symptoms including pruritus, these significantly affect patients’ quality of life. There have been many studies on hypertrophic scars and keloids; but the mechanisms underlying scar formation have not yet been well established, and prophylactic and treatment strategies remain unsatisfactory. In this review, the authors introduce and summarize classical concepts surrounding wound healing and review recent understandings of the biology, prevention and treatment strategies for hypertrophic scars and keloids.
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Affiliation(s)
- Ho Jun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon 24253, Korea.
| | - Yong Ju Jang
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
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84
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Saki N, Dorostkar A, Heiran A, Aslani FS. Satisfactory treatment of a large connective tissue nevus with intralesional steroid injection. Dermatol Pract Concept 2018; 8:12-14. [PMID: 29445568 PMCID: PMC5808365 DOI: 10.5826/dpc.0801a03] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/08/2017] [Indexed: 12/02/2022] Open
Abstract
Collagenoma is a type of connective tissue nevi, a rare hamartomatous malformation characterized by the predominant proliferation of normal collagen fibers and normal, decreased, or increased elastic fibers. Collagenomas present as multiple or solitary, hereditary or sporadic, asymptomatic, skin-colored papules, nodules, and plaques with variable sizes, and are usually located on the trunk, arm, and back. Here, we report on a 14-year-old boy who presented with an isolated giant collagenoma of the frontal area that dramatically responded to intralesional triamcinolone acetonide.
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Affiliation(s)
- Nasrin Saki
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Dermatology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Azadeh Dorostkar
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Dermatology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Heiran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Sari Aslani
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Pathology Department, Shiraz University of Medical Sciences, Shiraz, Iran
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85
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Optimizing Postsurgical Scars: A Systematic Review on Best Practices in Preventative Scar Management. Plast Reconstr Surg 2017; 140:782e-793e. [PMID: 28806293 DOI: 10.1097/prs.0000000000003894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Scar management is critical for every plastic surgeon's practice and, ultimately, the patient's satisfaction with his or her aesthetic result. Despite the critical nature of this component of routine postoperative care, there has yet to be a comprehensive analysis of the available literature over the past decade to assess the best algorithmic approach to scar care. To this end, a systematic review of best practices in preventative scar management was conducted to elucidate the highest level of evidence available on this subject to date. METHODS A computerized MEDLINE search was performed for clinical studies addressing scar management. The resulting publications were screened randomized clinical trials that met the authors' specified inclusion/exclusion criteria. RESULTS This systematic review was performed in May of 2016. The initial search for the Medical Subject Headings term "cicatrix" and modifiers "therapy, radiotherapy, surgery, drug therapy, prevention, and control" yielded 13,101 initial articles. Applying the authors' inclusion/exclusion criteria resulted in 12 relevant articles. All included articles are randomized, controlled, clinical trials. CONCLUSIONS Optimal scar care requires taking into account factors such as incisional tension, anatomical location, and Fitzpatrick skin type. The authors present a streamlined algorithm for scar prophylaxis based on contemporary level I and II evidence to guide clinical practice.
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86
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Franco RA, Husain I, Reder L, Paddle P. Awake serial intralesional steroid injections without surgery as a novel targeted treatment for idiopathic subglottic stenosis. Laryngoscope 2017; 128:610-617. [DOI: 10.1002/lary.26874] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 07/15/2017] [Accepted: 07/26/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Ramon A. Franco
- Division of Laryngology, Department of Otolaryngology; Harvard Medical School and Massachusetts Eye and Ear Infirmary; Boston Massachusetts U.S.A
| | - Inna Husain
- Department of Otolaryngology; Rush University Medical Center; Chicago Illinois U.S.A
| | - Lindsay Reder
- Department of Otolaryngology; University of Southern California; Los Angeles California U.S.A
| | - Paul Paddle
- Monash Health and Alfred Health; Victoria Melbourne Australia
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87
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Treatment of ear keloids: algorithm for a multimodal therapy regimen. Eur Arch Otorhinolaryngol 2017; 274:3859-3866. [DOI: 10.1007/s00405-017-4714-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/10/2017] [Indexed: 10/19/2022]
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88
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Kant SB, van den Kerckhove E, Colla C, Tuinder S, van der Hulst RRWJ, Piatkowski de Grzymala AA. A new treatment of hypertrophic and keloid scars with combined triamcinolone and verapamil: a retrospective study. EUROPEAN JOURNAL OF PLASTIC SURGERY 2017; 41:69-80. [PMID: 29398785 PMCID: PMC5780547 DOI: 10.1007/s00238-017-1322-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 05/01/2017] [Indexed: 11/13/2022]
Abstract
Background Since the management of keloid and hypertrophic scars still remains a difficult clinical problem, there is need for adequate, effective therapy. In this study, we explored for the first time the efficacy and the potential synergetic effect of combined triamcinolone and verapamil for the treatment of hypertrophic and keloid scars. The objective was to assess the efficacy of combined intralesional triamcinolone and verapamil therapy for hypertrophic and keloid scars. Methods Fifty-eight patients with hypertrophic scars (n = 31) and keloid scars (n = 27) were included. A specific injection therapy scheme was applied. Five follow-up moments were chosen, with a maximum follow-up of nearly 2 years. The effects of combination therapy on scar pliability, thickness, relief, vascularization, surface area, pain, and pruritus were examined by means of the Patient and Observer Scar Assessment Scale (POSAS). Results Our results reveal a fast and abiding improvement of both keloid and hypertrophic scars after treatment with the combination therapy. All POSAS components showed a reduction in scar score, while scar relief, pain, itchiness, and surface area improved significantly (P < 0.05) in keloids. Significant improvement in hypertrophic scars was found in scar pigmentation, vascularization, pliability, thickness, pain, and surface area. Overall POSAS scores revealed statistically significant decreases between baseline and 3–4 months, 4–6 months, and >12 months after start of therapy in both keloids and hypertrophic scars. Conclusions This study reveals that combined therapy of triamcinolone and verapamil results in overall significant scar improvement with a long-term stable result. Level of evidence: Level IV, therapeutic study.
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Affiliation(s)
- S B Kant
- 1Department of Plastic Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229HX Maastricht, The Netherlands
| | - E van den Kerckhove
- 1Department of Plastic Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229HX Maastricht, The Netherlands.,2KU Leuven, Department of Rehabilitation Sciences, Faber, Universitaire Ziekenhuizen Leuven, Leuven, Belgium.,3Department of Physical Medicine and Rehabilitation and Burns Center, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - C Colla
- 1Department of Plastic Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229HX Maastricht, The Netherlands
| | - S Tuinder
- 1Department of Plastic Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229HX Maastricht, The Netherlands
| | - R R W J van der Hulst
- 1Department of Plastic Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229HX Maastricht, The Netherlands
| | - A A Piatkowski de Grzymala
- 1Department of Plastic Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229HX Maastricht, The Netherlands
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89
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Keloid occurring in a tattoo. Ann Dermatol Venereol 2017; 144:455. [DOI: 10.1016/j.annder.2017.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 07/30/2016] [Accepted: 01/12/2017] [Indexed: 11/23/2022]
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90
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Wong TS, Li JZH, Chen S, Chan JYW, Gao W. The Efficacy of Triamcinolone Acetonide in Keloid Treatment: A Systematic Review and Meta-analysis. Front Med (Lausanne) 2016; 3:71. [PMID: 28083534 PMCID: PMC5186775 DOI: 10.3389/fmed.2016.00071] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 12/14/2016] [Indexed: 11/18/2022] Open
Abstract
Keloid is a cutaneous dermal outgrowth resulting from uncontrolled deposition of collagen and glycosaminoglycan around the wound. The uncontrolled and persistent growth of keloids scar will result in cosmetic disfigurement, functional impairment, and affect the quality of life. Triamcinolone acetonide (TAC) is traditionally employed in treating keloid scars. In this study, we aim to evaluate the effectiveness of TAC and compare it with other common therapy employed in keloid treatment. Only randomized controlled trial (RCT) and controlled trial were included. Inverse variance risk ratio, weighted mean difference, and corresponding 95% confidence intervals were calculated to evaluate the effect of intervention. Meta-analysis indicated that TAC treatment significantly reduced the size of keloid compared to untreated control. Reduction in size was statistically different in favor of TAC compared to silicone gel sheet. Significant difference in favor of TAC was observed compared with verapamil in term of vascularity and scar pliability. TAC treatment was more effective in reducing scar thickness in comparison with cryotherapy. However, the current meta-analysis has several limitations. Only a limited number of trials with the same comparison are available. Most trials recruited a small number of patients and used inconsistent outcome assessment. Most trials did not provide detail information on allocation concealment and blinding. Therefore, further evaluation in multi-center RCTs with consistent comparisons and outcome measurements are warrant to reach a consensus on the selection between TAC and different treatment modalities.
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Affiliation(s)
- Thian-Sze Wong
- Department of Surgery, The University of Hong Kong , Pokfulam , Hong Kong
| | - John Zeng-Hong Li
- Department of Surgery, The University of Hong Kong, Pokfulam, Hong Kong; Department of Otolaryngology, The First People's Hospital of Foshan, Foshan, Guangdong, China
| | - Siqi Chen
- Department of Surgery, The University of Hong Kong , Pokfulam , Hong Kong
| | - Jimmy Yu-Wai Chan
- Department of Surgery, The University of Hong Kong , Pokfulam , Hong Kong
| | - Wei Gao
- Department of Surgery, The University of Hong Kong , Pokfulam , Hong Kong
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91
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Comparing Two Methods of Cryotherapy and Intense Pulsed Light with Triamcinolone Injection in the Treatment of Keloid and Hypertrophic Scars: A Clinical Trial. Osong Public Health Res Perspect 2016; 7:313-319. [PMID: 27812490 PMCID: PMC5079190 DOI: 10.1016/j.phrp.2016.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/18/2016] [Indexed: 11/22/2022] Open
Abstract
Objectives Keloid and hypertrophic scars are abnormal manifestations of wounds that occur following skin injuries in the form of local proliferation of fibroblasts and increased production of collagen. There are several ways to cure these scars; treatment must be selected based on the nature of the scars. In this clinical trial, two methods—cryotherapy and intense pulsed light (IPL)—are compared in the treatment of scars, and the results are presented in terms of improvement level, complications, and patient satisfaction. Methods This clinical trial was conducted in southeastern Iran. The intervention group included scars that underwent the IPL method and the control group, which consisted of scars that were subjected to cryotherapy. In both methods, intralesional corticosteroid injection was administered. To select samples, the easy sampling method was used. To determine the expected outcomes, the criteria determined in the Vancouver scar scale were used. Data were analyzed using the Mix Model, chi-square test, and t test. Results In this study, 166 samples of keloid and hypertrophic scars were cured using two methods (Cryotherapy, 83; IPL, 83). The recovery rate was higher in the Cryotherapy group than in the IPL group (p > 0.05), and the incidence of complications was also higher in the Cryotherapy group (14.5% vs. 12%). Moreover, patients were more satisfied, although not significantly so, with the cryotherapy method (p = 0.09). Conclusion Both methods were highly successful in curing scars; participants were totally satisfied with both methods.
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92
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Trace AP, Enos CW, Mantel A, Harvey VM. Keloids and Hypertrophic Scars: A Spectrum of Clinical Challenges. Am J Clin Dermatol 2016; 17:201-23. [PMID: 26894654 DOI: 10.1007/s40257-016-0175-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Since their earliest description, keloids and hypertrophic scars have beleaguered patients and clinicians alike. These scars can be aesthetically disfiguring, functionally debilitating, emotionally distressing, and psychologically damaging, culminating in a significant burden for patients. Our current understanding of keloid pathophysiology has grown and continues to advance while molecular biology, genetics, and technology provide ever-deepening insight into the nature of wound healing and the pathologic perturbations thereof. Greater understanding will lead to the development and application of refined therapeutic modalities. This article provides an overview of our current understanding of keloids, highlighting clinical characteristics and diagnostic criteria while providing a comprehensive summary of the many therapeutic modalities available. The proposed mechanism, application, adverse events, and reported efficacy of each modality is evaluated, and current recommendations are summarized.
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Affiliation(s)
- Anthony P Trace
- Department of Radiology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Clinton W Enos
- The School of Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Alon Mantel
- Hampton University Skin of Color Research Institute, Hampton University, Hampton, VA, USA
| | - Valerie M Harvey
- Hampton University Skin of Color Research Institute, Hampton University, Hampton, VA, USA.
- Department of Dermatology, Eastern Virginia Medical School, 721 Fairfax Ave., Norfolk, VA, 23507, USA.
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93
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Krakowski AC, Totri CR, Donelan MB, Shumaker PR. Scar Management in the Pediatric and Adolescent Populations. Pediatrics 2016; 137:e20142065. [PMID: 26743819 DOI: 10.1542/peds.2014-2065] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 11/24/2022] Open
Abstract
For most children and adolescents who have developed symptomatic scars, cosmetic concerns are only a portion of the motivation that drives them and their caregivers to obtain treatment. In addition to the potential for cosmetic disfigurement, scars may be associated with a number of physical comorbidities including hypertrichosis, dyshidrosis, tenderness/pain, pruritus, dysesthesias, and functional impairments such as contractures, all of which may be compounded by psychosocial factors. Although a plethora of options for treating scars exists, specific management guidelines for the pediatric and adolescent populations do not, and evidence must be extrapolated from adult studies. New modalities such as the scar team approach, autologous fat transfer, and ablative fractional laser resurfacing suggest a promising future for children who suffer symptomatically from their scars. In this state-of-the-art review, we summarize cutting-edge scar treatment strategies as they relate to the pediatric and adolescent populations.
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Affiliation(s)
- Andrew C Krakowski
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital, San Diego, California;
| | - Christine R Totri
- Department of Dermatology, SUNY Downstate Medical Center, Brooklyn, New York
| | - Matthias B Donelan
- Department of Plastic Surgery, Shriner's Hospital for Children, Boston, Massachusetts; and
| | - Peter R Shumaker
- Department of Dermatology, Naval Medical Center, San Diego, California
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94
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Mishra PJ, Mishra PJ, Banerjee D. Keratinocyte Induced Differentiation of Mesenchymal Stem Cells into Dermal Myofibroblasts: A Role in Effective Wound Healing. ACTA ACUST UNITED AC 2016; 2016:5-32. [PMID: 27294075 DOI: 10.13052/ijts2246-8765.2016.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We have previously demonstrated that human mesenchymal stem cells (hMSCs) migrate toward human keratinocytes as well as toward conditioned medium from cultured human keratinocytes (KCM) indicating that the hMSCs respond to signals from keratinocytes [1]. Using fluorescently labeled cells we now show that in vitro hMSCs appear to surround keratinocytes, and this organization is recapitulated in vivo. Incubation of hMSCs with KCM induced dermal myofibroblast like differentiation characterized by expression of cytoskeletal markers and increased expression of cytokines including SDF-1, IL-8, IL-6 and CXCL5. Interaction of keratinocytes with hMSCs appears to be important in the wound healing process. Therapeutic efficacy of hMSCs in wound healing was examined in two animal models representing normal and chronic wound healing. Accelerated wound healing was observed when hMSCs and KCM exposed hMSCs (KCMSCs) were injected near wound site in nude and NOD/SCID mice. Long term follow up of wound healing revealed that in the hMSC treated wounds there was little evidence of residual scarring. These dermal myofibroblast like hMSCs add to the wound healing process. Together, the keratinocyte and hMSCs morphed dermal myofibroblast like cells as well as the factors secreted by these cells support wound healing with minimal scarring. The ability of hMSCs to support wound healing process represents another striking example of the importance of keratinocyte and hMSCs interplay in the wound microenvironment resulting in effective wound healing with minimal scarring.
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Affiliation(s)
- Pravin J Mishra
- Intermountain Precision Genomics, Intermountain Healthcare, Dixie Regional Medical Center 292 South 1470 East, Suite 201 & 301, St. George, UT 84770, USA
| | - Prasun J Mishra
- Department of Biochemical and Cellular Pharmacology, Genentech, 1, DNA Way, South San Francisco, California 94080, USA
| | - Debabrata Banerjee
- Department of Pharmacology, Robert Wood Johnson Medical School, Graduate School of Biomedical Sciences, New Brunswick-Piscataway, Rutgers University, 675 Hoes Lane West, Piscataway, NJ 08854. USA
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95
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Adotama P, Rutherford A, Glass DA. Association of keloids with systemic medical conditions: a retrospective analysis. Int J Dermatol 2015; 55:e38-40. [PMID: 26517298 DOI: 10.1111/ijd.12969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 12/26/2014] [Accepted: 01/13/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Prince Adotama
- Dermatology, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Donald A Glass
- Dermatology, UT Southwestern Medical Center, Dallas, TX, USA.
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96
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Mantel A, Newsome A, Thekkudan T, Frazier R, Katdare M. The role of aldo-keto reductase 1C3 (AKR1C3)-mediated prostaglandin D2 (PGD2) metabolism in keloids. Exp Dermatol 2015; 25:38-43. [PMID: 26308156 DOI: 10.1111/exd.12854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2015] [Indexed: 01/12/2023]
Abstract
Keloids are progressively expanding scars, mostly prevalent in individuals of African descent. Previous data identified increased mast cell number and activation state in keloids suggesting a role in disease progression. The major eicosanoid secreted by mast cells is prostaglandin D2 (PGD2), a relatively unstable pro-inflammatory mediator which can be spontaneously converted to 15-deoxy-(Delta12,14)-prostaglandin J2(15d-PGJ2) or enzymatically metabolized to 9α,11β-PGF2 by aldo-keto reductase 1C3 (AKR1C3). In this work, we investigated the possible role of PGD2 and its metabolites in keloids using CRL1762 keloid fibroblasts (KF) and immunohistochemical staining. Our data suggested approximately 3-fold increase of tryptase-positive mast cell count in keloids compared with normal skin. Furthermore, AKR1C3 was overexpressed in the fibrotic area of keloids while relatively weak staining detected in normal skin. Metabolism of PGD2 to 9α,11β-PGF2 by both, KF and normal fibroblasts, was dependent on AKR1C3 as this reaction was attenuated in the presence of the AKR1C3 inhibitor, 2'-hydroxyflavanone, or in cells with decreased AKR1C3 expression. 15d-PGJ2, but not the other tested PGs, inhibited KF proliferation, attenuated KF-mediated collagen gel contraction and increased caspase-3 activation. In addition, treatment with 15d-PGJ2 activated P38-MAPK, induced reactive oxygen species and upregulated superoxide dismutase-1 (SOD-1). Finally, inhibition of P38-MAPK further augmented 15d-PGJ2-induced caspase-3 cleavage and attenuated its effect on SOD-1 transcription. This work suggests that localized dual inhibition of AKR1C3 and P38-MAPK may inhibit keloid progression. Inhibiting AKR1C3 activity may generate oxidative environment due to redirection of PGD2 metabolism towards 15d-PGJ2 while inhibition of P38-MAPK will sensitize keloid cells to ROS-induced apoptosis.
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Affiliation(s)
- Alon Mantel
- Hampton University Skin of Color Research Institute (HUSCRI), Hampton, VA, USA
| | - Austin Newsome
- Hampton University Skin of Color Research Institute (HUSCRI), Hampton, VA, USA
| | - Theresa Thekkudan
- Hampton University Skin of Color Research Institute (HUSCRI), Hampton, VA, USA
| | - Robert Frazier
- Leroy T. Canoles Jr. Cancer Research Center, Eastern Virginia Medical School (EVMS), Norfolk, VA, USA
| | - Meena Katdare
- Hampton University Skin of Color Research Institute (HUSCRI), Hampton, VA, USA.,Department of Dermatology, Eastern Virginia Medical School (EVMS), Norfolk, VA, USA
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Ziyrek M, Şahin S, Acar Z, Şen O. The Relationship between Proliferative Scars and Endothelial Function in Surgically Revascularized Patients. Balkan Med J 2015; 32:377-81. [PMID: 26740897 DOI: 10.5152/balkanmedj.2015.15707] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 03/02/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Proliferative scars are benign fibrotic proliferations which demonstrate abnormal wound healing in response to skin injuries. As postulated in the "response to injury hypothesis", atherosclerosis is also triggered by an endothelial injury. Keloid and atherosclerotic processes have many pathophysiological and cytological features in common. AIMS In this study, we investigated the relationship between proliferative scars and endothelial function in surgically revascularized patients. We aimed to test the hypothesis that atherosclerosis is a wound healing abnormality. STUDY DESIGN Cross-sectional study. METHODS Consecutive patients who were admitted to the cardiology outpatient clinic with a history of coronary artery bypass grafting operation were evaluated. Thirty-three patients with proliferative scars at the median sternotomy site formed the keloid group, and 36 age- and sex-matched patients with no proliferative scar at the median sternotomy site formed the control group. Endothelial function was evaluated by flow-mediated vasodilatation of the brachial artery via ultrasonograhic examination. RESULTS There is no signicant difference according to the demographic data, biochemical parameters, clinical parameters and number of grafts between keloid and control groups. Endothelial-dependent vasodila-tory response was lower in the keloid group than the control group (9.30±3.5 and 18.68±8.2, respectively; p=0.001). CONCLUSION This study showed that endothalial dysfunction, which is strongly correlated with atherosclerosis, was more prominent in patients with proliferative scars. As proliferative scars and atherosclerosis have many features in common, we might conclude that atherosclerosis is a wound healing abnormality.
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Affiliation(s)
- Murat Ziyrek
- Department of Cardiology, Karadeniz Hospital, Trabzon, Turkey
| | - Sinan Şahin
- Department of Cardiology, Kanuni Training and Research Hospital, Trabzon, Turkey
| | - Zeydin Acar
- Department of Cardiology, Karadeniz Hospital, Trabzon, Turkey
| | - Onur Şen
- Department of Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
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Walliczek U, Engel S, Weiss C, Aderhold C, Lippert C, Wenzel A, Hörmann K, Schultz JD. Clinical Outcome and Quality of Life After a Multimodal Therapy Approach to Ear Keloids. JAMA FACIAL PLAST SU 2015; 17:333-9. [DOI: 10.1001/jamafacial.2015.0881] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Ute Walliczek
- Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Marburg, University of Giessen, Marburg, Germany
- Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stephan Engel
- Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, University of Heidelberg, Mannheim, Germany
| | - Christoph Aderhold
- Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christiane Lippert
- Department of Pathology, University Hospital of Mannheim, University of Heidelberg, Mannheim, Germany
| | - Angela Wenzel
- Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Mannheim, University of Heidelberg, Mannheim, Germany
| | - Karl Hörmann
- Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Mannheim, University of Heidelberg, Mannheim, Germany
| | - Johannes David Schultz
- Department of Otorhinolaryngology–Head and Neck Surgery, University Hospital of Mannheim, University of Heidelberg, Mannheim, Germany
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99
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Schneider D, Wickström SA. Force generation and transmission in keloid fibroblasts: dissecting the role of mechanosensitive molecules in cell function. Exp Dermatol 2015; 24:574-5. [DOI: 10.1111/exd.12753] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2015] [Indexed: 01/13/2023]
Affiliation(s)
- David Schneider
- Paul Gerson Unna Group ‘Skin Homeostasis and Ageing’; Max Planck Institute for Biology of Ageing; Cologne Germany
| | - Sara A. Wickström
- Paul Gerson Unna Group ‘Skin Homeostasis and Ageing’; Max Planck Institute for Biology of Ageing; Cologne Germany
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Lee DE, Trowbridge RM, Ayoub NT, Agrawal DK. High-mobility Group Box Protein-1, Matrix Metalloproteinases, and Vitamin D in Keloids and Hypertrophic Scars. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e425. [PMID: 26180726 PMCID: PMC4494495 DOI: 10.1097/gox.0000000000000391] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/23/2015] [Indexed: 01/16/2023]
Abstract
Keloids and hypertrophic scars represent excessive wound healing involving high production of collagen by skin fibroblasts. This review focuses on the role of high-mobility group box protein-1 (HMGB-1), matrix metalloproteinases (MMPs), and vitamin D in these conditions. Although the role of HMGB-1 in keloids and hypertrophic scars is unclear, the effect of HMGB-1 on fibroblasts suggests a profibrotic role and a potential contribution to excessive scarring. MMPs contribute extensively to wound healing and characteristically degrade the extracellular matrix. MMP-1 is decreased in keloids and hypertrophic scars. However, other MMPs, including MMP-2, have been found to be increased and are thought to possibly contribute to keloid expansion through peripheral extracellular matrix catabolism. Many novel therapeutic approaches to keloids and hypertrophic scars target MMPs and aim to increase their levels and catabolic activity. The higher prevalence of keloids in darker skin types may partially be due to a tendency for lower vitamin D levels. The physiologically active form of vitamin D, 1,25(OH)2D3, inhibits the proliferation of keloid fibroblasts, and correlations between vitamin D receptor polymorphisms, such as the TaqI CC genotype, and keloid formation have been reported. Additionally, vitamin D may exert an antifibrotic effect partially mediated by MMPs. Here, we critically discuss whether keloid and hypertrophic scar formation could be predicted based on vitamin D status and vitamin D receptor polymorphisms. Specifically, the findings identified HMGB-1, MMPs, and vitamin D as potential avenues for further clinical investigation and potentially novel therapeutic approaches to prevent the development of keloids and hypertrophic scars.
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Affiliation(s)
- Dylan E. Lee
- From the Center for Clinical and Translational Science, Creighton University School of Medicine, Omaha, Neb.; Brigham and Women’s Hospital, Boston, Mass.; and Westfield Plastic Surgery Center, Omaha, Neb
| | - Ryan M. Trowbridge
- From the Center for Clinical and Translational Science, Creighton University School of Medicine, Omaha, Neb.; Brigham and Women’s Hospital, Boston, Mass.; and Westfield Plastic Surgery Center, Omaha, Neb
| | - Nagi T. Ayoub
- From the Center for Clinical and Translational Science, Creighton University School of Medicine, Omaha, Neb.; Brigham and Women’s Hospital, Boston, Mass.; and Westfield Plastic Surgery Center, Omaha, Neb
| | - Devendra K. Agrawal
- From the Center for Clinical and Translational Science, Creighton University School of Medicine, Omaha, Neb.; Brigham and Women’s Hospital, Boston, Mass.; and Westfield Plastic Surgery Center, Omaha, Neb
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