Intralesional botulinum toxin type A equally effective and better tolerated than intralesional steroid in the treatment of keloids: a randomized controlled trial

Recent Understandings of Biology, Prophylaxis and Treatment Strategies for Hypertrophic Scars and Keloids

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.

Botulinum Toxin in the Field of Dermatology: Novel Indications

Since its approval by the US Food and Drug Administration in 2002 for glabellar wrinkles, botulinum toxin (BTX) has been widely used to correct facial wrinkles. As a result, many consider BTX synonymous with cosmetic dermatology. Recent studies indicate that BTX elicits biological effects on various skin cell types via the modulation of neurotransmitter release, and it seems that BTX has a wider zone of dermatologic influence than originally understood. Clinicians and researchers are now beginning to explore the potential of BTX beyond the amelioration of facial lines and encouraging results are seen with BTX in a variety of skin conditions. In this paper, we review novel dermatological indications of BTX which includes (but not limited to) scar prevention, facial flushing, post-herpetic neuralgia and itch. These areas show great promise, but there is definite need for larger, double-blinded, randomized control trials against established treatments before BTX becomes a clinical reality.

Recent developments in clinical trials of botulinum neurotoxins

Botulinum neurotoxins (BoNTs) are increasingly used in clinical practice for several indications. Following the pioneering years of discoveries, the recent years have witnessed an increase of new indications and new toxin brands. We review here the clinical trials on BoNTs performed since 2014 and put them into perspective. We also review the ongoing trials listed by the National Institutes of Health registry (Clinicaltrials.gov). The following indications are reviewed here: blepharospasm, cervical dystonia, spasticity, cerebral palsy, urinary incontinence, headache, topical formulations, postoperative cardiac arrhythmia, keloids and scars. For each of these indications the latest trials are reviewed and commented.

Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies

The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.

Homeobox B9 facilitates hypertrophic scar formation via activating the mitogen-activated protein kinase signaling pathway

The functions and underlying mechanisms of homeobox B9 (HOXB9) in scar formation remain unclear; therefore, the present study aimed to investigate whether HOXB9 is highly expressed in hypertrophic scar formation. Immunohistochemistry was performed to examine the expression levels of laminin, fibronectin (FN), collagen type I (Col1) and HOXB9 in hypertrophic scar and healthy skin tissues, and in lentivirus‑constructed HOXB9‑overexpressed or ‑silenced fibroblasts (FBs). Reverse transcription‑quantitative polymerase chain reaction and western blotting were performed to evaluate the mRNA and protein expression levels of HOXB9, laminin, FN, Col1, extracellular signal‑regulated kinase (ERK), c‑Jun N‑terminal kinase (JNK), p38, p‑c‑Jun N‑terminal kinase (JNK), p‑ERK and p‑p38. A gel contraction assay was used to evaluate the effect of HOXB9 on FB contraction. Co‑immunoprecipitation assays were performed to verify the reciprocal interactions between HOXB9 and ERK, JNK and p38. It was demonstrated that HOXB9, laminin, FN and Col1 were upregulated in hypertrophic scar tissues, and HOXB9 upregulated laminin, FN, Col1, p‑ERK, p‑JNK and p38, potentially by interacting directly with p38. Furthermore, FBs overexpressing HOXB9 exhibited enhanced contractile capacity. In conclusion, the present study demonstrated that HOXB9 may facilitate hypertrophic scar formation via activating the mitogen‑activated protein kinase signaling pathway.

New Uses of AbobotulinumtoxinA in Aesthetics

BotulinumtoxinA (BoNT-A) is now widely established for the main approved indication of reducing glabellar lines, and is also widely used off-label to improve the appearance of wrinkles and lines in other parts of the face. The number of aesthetic procedures continues to increase as the patient population becomes more diverse, in particular with increasing numbers of people of color and men. Further developments in treatment may continue to expand the audience for BoNT-A by making procedures more comfortable and by delivering a more natural, less static appearance. These may be achieved through use of combinations of BoNT-A with other aesthetic procedures, tailoring the dose of toxin to the patient's muscle mass or by using novel injection and application techniques. Beyond amelioration of facial lines, encouraging results have been seen with the use of BoNT-A to improve the appearance of hypertrophic and keloid scars and even to prevent them. Studies have been conducted with scars in various parts of the body and further research is ongoing. Dermatological and other medical uses for BoNT-A are also active areas of research. Injections of BoNT-A have been shown to reduce signs and symptoms of acne, rosacea, and psoriasis, to reduce neuromuscular pain, and to bring about significant improvements in a number of rare diseases that are caused or exacerbated by hyperhidrosis. This paper reviews these new uses for BoNT-A, looking at the rationale for their use and discussing the results of published case studies and clinical trials. These areas have shown great promise to date, but more and larger clinical studies will be required before these treatments become a clinical reality. To this end details are also provided of clinical trials currently listed in the main clinical trials database to highlight research areas of particular interest.

Botulinum Toxin Off-Label Use in Dermatology: A Review

BACKGROUND

Botulinum toxin is a neurotoxin produced by the bacterium Clostridium botulinum which causes a flaccid muscle paralysis. It is currently used for aesthetic treatments and in the focal hyperhidrosis. Recently, botulinum toxin has also been used experimentally in many other dermatological conditions with good results.

OBJECTIVE

To review and analyze the possible botulinum toxin off-label applications published.

METHODS

A retrospective review of the published data was conducted.

CONCLUSIONS

this potent drug can lead to several off-label indications of interest for dermatologists. Further clinical trials are still needed to better understand the real efficacy and safety of these applications and to standardize injection and dose protocols.

Novel Insights on Understanding of Keloid Scar: Article Review

Keloid scar, dermal benign fibro-proliferative growth that extends outside the original wound and invades adjacent dermal tissue due to extensive production of extracellular matrix, especially collagen, which caused by over expression of cytokines and growth factors. Although many attempts were made to understand the exact pathophysiology and the molecular abnormalities, the pathogenesis of keloid scar is yet to be determined. Even though there are several treatment options for keloid scars include combination of medical and surgical therapies like combination of surgical removal followed by cryotherapy or intralesional steroid therapy, the reoccurrence rate is still high despite the present treatment. In this review, PubMed, clinical key and Wright State Library web site have been used to investigate any update regarding Keloid disease. We used Keloid, scar formation, hypertrophic scar and collagen as key words. More than 40 articles have been reviewed. This paper reviews literature about keloid scar formation mechanism, the most recent therapeutic options including the ones under research.

Botulinum Toxin Type A and the Prevention of Hypertrophic Scars on the Maxillofacial Area and Neck: A Meta-Analysis of Randomized Controlled Trials

Background

The purpose of the meta-analysis was to evaluate the efficiency of therapeutic botulinum toxin type A (BTX-A) in the prevention of maxillofacial and neck scars.

Methods and Findings

Information came from the following electronic databases: Medline, PubMed, Cochrane Library, and EMBASE (time was ended by August 31, 2015) to retrieve RCTs evaluating the effect of the BTX-A for hypertrophic scar on the maxillofacial or neck. All languages were included as long as they met the inclusion criteria. Here the effects of BTX-A were evaluated by comparing the width of the scar, patient satisfaction, and the visual analysis scores (VAS), respectively. Pooled weighted mean differences (WMDs), pooled odds ratios (ORs), and 95% confidence intervals (CI) were calculated. Nine RCTs covering a total of 539 patients were included. A statistically significant difference in scar width was identified between the BTX-A group and control group (non-BTX-A used) (WMD = -0.41, 95% CI = -0.68 to -0.14, P = 0.003). A statistically significant difference in patient satisfaction was observed between the BTX-A group and control group (OR = 25.76, 95% CI = 2.58 to 256.67, P = 0.006). And in patients regarding visual analysis scores (VAS), a statistically significant difference was also observed between the BTX-A group and control group (WMD = 1.30, 95% CI = 1.00 to 1.60, P < 0.00001).

Conclusions

This meta-analysis evaluates the efficacy of the BTX-A and confirms that BTX-A is a suitable potential therapy for the prevention of hypertrophic scars in patients in the maxillofacial and neck areas.

Combined Treatment with Botulinum Toxin and 595-nm Pulsed Dye Laser for Traumatic Scarring

Traumatic scars on skin covering areas of high movement, especially areas on the face, can be stressful for patients. We report two cases of traumatic scars that occurred on the chin, and that were successfully treated with a combined therapy of 595-nm pulsed dye laser (PDL) and intramuscular injection of botulinum toxin. After the treatment, good cosmetic results were achieved in both patients. The only adverse effect during and after the treatments was mild pain, which resolved within several days without any additional treatment. In conclusion, the combination of 595-nm PDL and intramuscular botulinum toxin injection was shown to be a safe and effective treatment for traumatic scars on the mobile chin area in Korean patients.

Foreign body reactions may not influence the keloid recurrence

PURPOSE

The foreign body reactions are comprised of macrophages and foreign body giant cells and are considered possible risk factors for recurrence in several conditions. The purpose of this study was to determine the effect of pathologically proven foreign body reactions on the recurrence of the auricular keloids.

METHODS

This study was carried out in 76 cases in 70 patients reaching the pathologic diagnosis of auricular keloids from March 2006 to February 2012. Patients with auricular keloids were included in the study according to the following criteria: The keloid scar was caused by ear piercing and confirmed pathologically; surgical excision with primary closure was performed; and female patients who have not underwent any previous treatments. To compare any differences of recurrence rate between categorical variables (the presence/absence of foreign body reactions), Fisher's exact tests were used. All patients completed the treatment protocol with a follow-up interval of 18 months.

RESULTS

Of these patients, 90.9% (69 keloids) had successful irradication of their auricular keloids, whereas 9.2% (seven keloids) had recurrences. Of the seven recurrent cases, two exhibited foreign body reactions at pathology, while five revealed no foreign body reactions (28.6% vs. 71.4%, P = 0.092).

CONCLUSIONS

Detection of foreign body reactions in keloid tissue may not predict recurrence in auricular keloids.

Botulinum neurotoxin type A: Actions beyond SNAP-25?

Botulinum neurotoxin type A (BoNT/A), the most potent toxin known in nature which causes botulism, is a commonly used therapeutic protein. It prevents synaptic vesicle neuroexocytosis by proteolytic cleavage of synaptosomal-associated protein of 25 kDa (SNAP-25). It is widely believed that BoNT/A therapeutic or toxic actions are exclusively mediated by SNAP-25 cleavage. On the other hand, in vitro and in vivo findings suggest that several BoNT/A actions related to neuroexocytosis, cell cycle and apoptosis, neuritogenesis and gene expression are not necessarily mediated by this widely accepted mechanism of action. In present review we summarize the literature evidence which point to the existence of unknown BoNT/A molecular target(s) and modulation of unknown signaling pathways. The effects of BoNT/A apparently independent of SNAP-25 occur at similar doses/concentrations known to induce SNAP-25 cleavage and prevention of neurotransmitter release. Accordingly, these effects might be pharmacologically significant. Potentially the most interesting are observations of antimitotic and antitumor activity of BoNT/A. However, the exact mechanisms require further studies.