Treatment of Keloids and Hypertrophic Scars

Can single use negative pressure wound therapy be an alternative method to manage keloid scarring? A preliminary report of a clinical and ultrasound/colour-power-doppler study

Keloid scarring represents a pathological healing where primary healing phenomenon is deviated from normal. Pico is a single use negative pressure wound therapy system originally introduced to manage open or just closed wounds. Pico dressing is made of silicone, and distributes an 80 mmHg negative pressure across wound bed. Combination of silicon layer and continuous compression could be a valid method to manage keloid scarring. Since November 2011, three patients were enrolled and evaluated before negative pressure treatment, at end of treatment (1 month) and 2 months later, through Vancouver Scar Scale (VSS), Visual Analog Scale (VAS) and a scoring system for itching. Ultrasound (US) and colour-power-doppler (CPD) examination was performed to evaluate thickness and vascularisation of the scar. One patient was discharged from study after 1 week. In last two patients, VSS, VAS and itching significantly improved after 1 month therapy and the results were stable after 2 months without any therapy. At end of therapy, the 'appearance of palisade vessels' disappeared in both cases at CPD exam; US showed a thickness reduction (average 43·8%). We propose a well-tolerated, non invasive treatment to manage keloid scarring. Prospective studies are necessary to investigate whether these preliminary observations are confirmed.

Topical modalities for treatment and prevention of postsurgical hypertrophic scars

There is no universally accepted treatment regimen and no evidence-based literature to guide management of hypertrophic scars. This article summarizes the existing literature regarding topical treatments such as silicone gel sheeting and ointment, onion extract, vitamin E, pressure garment therapy, massage therapy, and topical imiquimod 5% cream in the management of hypertrophic scars.

Proper care of early wounds to optimize healing and prevent complications

Proper wound care has broad applications for all clinicians. Much of the future direction for enhancing wound repair focuses on key cells and growth factors, which is why possessing a strong understanding of the basic physiology of wound healing is imperative. This article first provides a thorough review of the phases of wound healing followed by a discussion on the latest wound management strategies. Wound conditions and surgical techniques are important components for optimizing wound healing and preventing complications. Special consideration has been given to the unique settings of contaminated wounds, open wounds, or avulsed tissue.

Effects of the cyclin-dependent kinase 10 (CDK10) on the tamoxifen sensitivity of keloid samples

Cyclin-dependent kinase 10 (CDK10) is a cell cycle regulating protein kinase, which has just been discriminated in recent years. In this paper, mRNA and protein expression of CDK10 were first investigated by a comparative study between 23 human keloid tissue samples and their adjacent normal skin. To further address its potential as a therapeutic target in the treatment of keloid, a plasmid expressing the CDK10 gene was transfected into keloid fibroblast. The effects on tamoxifen-induced apoptosis were then investigated using Western blot assay and flow cytometry. Results showed that there is a generally down-regulated expression of CDK10 in keloid compared to normal skin samples. Transfection with the recombinant CDK10 plasmid significantly decreased the viability of cells and increased the apoptosis rates. Tamoxifen sensitivity in keloid fibroblasts was observed after treatment with the recombinant CDK10 plasmid. The results suggested that CDK10 may play an important role in enhancement of tamoxifen efficiency, and its expression may have a synergistic effect on keloid treatments.

Keloid formation after syndactyly release in patients with associated macrodactyly: management with methotrexate therapy

We present a series of cases of keloid formation after release of syndactyly in the hands and feet of children with associated digital overgrowth. The use of methotrexate to suppress keloid formation after release of syndactyly and for control of recurrence after surgery for keloid is effective.

Tracheostomaplasty: A surgical method for improving retention of an intraluminal stoma button for hands-free tracheoesophageal speech

BACKGROUND

We describe a minimally invasive surgical technique, tracheostomaplasty, to overcome anatomical deformities of the stoma that preclude successful retention of a stoma button for hands free tracheoesophageal (TE) speech.

METHODS

We conducted a retrospective analysis of 21 patients who underwent tracheostomaplasty after laryngectomy to accommodate an intraluminal valve attachment for hands-free TE speech.

RESULTS

Sixteen men and 5 women (median age, 65 years; median follow-up, 27.7 months) underwent tracheostomaplasty; 6 patients developed a mild cellulitis that required therapy and 5 patients required a minor revision surgery. At last follow-up, 15 (71%) patients successfully achieved hands-free TE speech using an intraluminal stoma button. Three patients only retained the intraluminal device to facilitate digital occlusion. Tracheostomaplasty failed in 3 patients because of granulation tissue formation or stomal stenosis.

CONCLUSIONS

Tracheostomaplasty is a successful technique to improve intraluminal retention of a stoma button for hands-free TE speech in laryngectomy patients.

Beyond the Borders of Keloid Formation: A Case Report

The keloid scar is a cutaneous mass characterized by nodular fibroblastic proliferation of dermis and a predilection for distinctive anatomical locations. However, keloid extension to neighbouring tissue as a nonsyndromic entity has not been described. In the present report, a case involving a 48-year-old woman with extensive bilateral keloids of the ear lobules and neck following ear piercing is presented.

Therapeutic hotline: An alternative adjuvant treatment after ear keloid excision using a custom-made methyl methacrylate stent

The efficacy of most pressure devices developed for treatment of ear keloids is limited by the insufficient control of the applied pressure, sometimes causing pain and repeated bleeding with a subsequently increased risk of infections and cosmetic problems. The present study aims to describe the efficacy of the custom-made methyl methacrylate stent in patients that were surgically treated for ear keloids and afterward underwent pressure therapy. The recurrence rate of the ear keloids was evaluated after at least 12 months. Adjuvant treatment with the methyl methacrylate stent resulted in an 83% success rate in our experience with 23 patients that completed the intended therapeutic duration of 18 months. No cases of severe complications were seen during or after the treatment. Furthermore, all the items of the Patient and Observer Scar Assessment Scale resulted in a statistically significant improvement of the scar (p < 0.05). Postoperative pressure therapy with the custom-made methyl methacrylate stent seems efficacious, safe, and is usable for keloids of both the helix and the earlobe.

Giant keloid of left buttock treated with post-excisional radiotherapy

Keloids are defined as excessive scar tissue formation extending beyond the area of the original skin injury and occurring in predisposed individuals. While no single treatment has proven widely effective, several series report excellent outcomes for keloids with post-surgery radiation therapy as described in the literature. We present a patient with recurrent giant keloid of left buttock after several surgical removals, that at physical examination shows the size of 40×22×10 cm in the largest dimension. Patient underwent a surgical excision of gluteal lesion and postoperative radiotherapy using photons at 8 MV of linear accelerator: the total dose delivered was 22 Gy in 11 days, with a daily fraction of 2 Gy. No relapse was showed at 36 months post-therapy. Several methods seem unsatisfactory for preventing keloid recurrence. The combination of surgery and adjuvant radiotherapy seems an excellent strategy to prevent recurrent disease.

Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies

Excessive scars form as a result of aberrations of physiologic wound healing and may arise following any insult to the deep dermis. By causing pain, pruritus and contractures, excessive scarring significantly affects the patient's quality of life, both physically and psychologically. Multiple studies on hypertrophic scar and keloid formation have been conducted for decades and have led to a plethora of therapeutic strategies to prevent or attenuate excessive scar formation. However, most therapeutic approaches remain clinically unsatisfactory, most likely owing to poor understanding of the complex mechanisms underlying the processes of scarring and wound contraction. In this review we summarize the current understanding of the pathophysiology underlying keloid and hypertrophic scar formation and discuss established treatments and novel therapeutic strategies.

COL1A1 oligodeoxynucleotides decoy: biochemical and morphologic effects in an acute wound repair model

Type I collagen is an integral component of granulation tissue and scar, that is highly dependent on TGFβ1, a member of a pro-fibrotic family of cytokines, for its promotion and deposition. Blocking COL1A1 gene transcription obstructs type I collagen synthesis, hindering the progress of granulation tissue deposition and fibrosis. Local injections of a double stranded oligodeoxynucleotide (dsODN) decoy, containing the TGFβ1 regulatory element that is located in the distal promoter of the COL1A1 gene, were investigated in a rat polyvinyl alcohol (PVA) sponge granulation tissue implant model. The effects on the granulation tissue deposition by dsODN decoy therapy were evaluated by the synthesis of types I and III collagens as well as ED-A (cellular) fibronectin. Fluorescently labeled dsODN was used to identify the distribution of the decoy molecules in the sponge implant relative to the observed histological effects. Morphological alterations in cells and changes in the organization of connective tissue were documented and evaluated. Collagen levels were reduced by half in implants treated with 10 nM dsODN decoy compared to scrambled dsODN-treated implants. Histologically, dsODN decoy treated implants had an increased cellular density without a corresponding increase in deposited connective tissue. Polarized light birefringence pattern of Sirius red-stained sections showed less collagen fibers accumulating between fibroblasts. The highest concentration of fluorescently labeled dsODN was identified within the interior margin of sponge implants, correlating to increased cellular density and an altered birefringence patterns. In conclusion, 10 nM dsODN decoy therapy reduced collagen deposition and altered the organization of granulation tissue, supporting its potential as a localized anti-fibrotic therapy for limiting fibrotic conditions.

The emerging role of antineoplastic agents in the treatment of keloids and hypertrophic scars: a review

The management of keloids and hypertrophic scars continues to challenge health-care providers. Though both forms of pathologic scarring are distinct entities at the macro and microscopic level, their etiologies and treatment are often similar. Potential treatment approaches are progressing, and combinations of treatment options have been proposed in the literature with promising outcomes. The treatment evolution has reached a level where molecular therapeutic modalities are being investigated. Currently, no gold standard treatment exists. Overall success rates and patient satisfaction seem to be slowly climbing, but additional investigational studies must continue to be performed. Several studies have investigated antineoplastic agents, and there seems to be a marked improvement in rates of recurrence, patient satisfaction, and overall quality of scar when these agents are used. Intralesional injection and/or wound irrigation with interferon-a2b, interferon-g, mitomycin-C, bleomycin, or 5-fluorouracil seems to have a positive effect on the reduction of pathologic scars. There is mounting evidence that these drugs used alone or in combination therapy, have the potential to be an integral part of the treatment paradigm for hypertrophic scars and keloids.

A radiobiological analysis of multicenter data for postoperative keloid radiotherapy

PURPOSE

To identify factors significantly affecting recurrence rates after postoperative external beam radiotherapy (XRT) of keloids, and to delineate any radiation dose response and effects of radiation dose per fraction.

METHODS AND MATERIALS

A comprehensive literature review was performed to compile a database of 2,515 resected keloids (36.9% earlobe). Postoperative XRT was 45- to 100-kV X-rays in 27.0% or 120- to 250-kV X-rays in 11.1%, Co-60 in 1.9%, Sr-90 in 4.7%, 1.5- to 9-MeV electrons in 26.5%, and no XRT in 28.8%. In the 1,791 irradiated patients, the median radiation parameters were as follows: total dose, 15 Gy (range, 6-30 Gy); dose per fraction, 5.0 Gy (range, 2-15 Gy); fractions, 3 (range, 1-10); and time, 7 days (range, 0-33 days).

RESULTS

Multivariate stepwise logistic regression correlated decreased keloid recurrence with earlobe location (p = 1.98E-10; odds ratio, 0.34), biologically effective dose (p = 1.01E-27), and treatment with electron beam or Co-60 vs. other techniques (p = 0.0014; odds ratio, 0.72). Different radiobiological models calculated values of α/β = 1.12 to 2.86 (mean, 2.08) and time (repopulation) correction factors for biologically effective dose from 0.98 to 2.13 Gy per day (mean, 1.34) starting 10 days after surgery. Different models (with α/β = 2.08) predicted that doses needed for 90% and 95% control with 3 fractions of postoperative electron beam were 16.0 to 16.2 Gy and 18.3 to 19.2 Gy, respectively, in less than 10 days for earlobe keloids and 21.5 to 22.2 Gy and 23.4 to 24.8 Gy, respectively, in less than 10 days for other sites.

CONCLUSIONS

Postoperative keloid radiotherapy requires moderately high doses and optimal technique to be effective. The relatively low α/β ratio indicates that radiotherapy with a limited number of fractions and high doses per fraction is the best strategy.

Adenovirus-mediated METH1 gene expression inhibits hypertrophic scarring in a rabbit ear model

Hypertrophic scarring remains a major problem for patients who have suffered from surgeries or burns. Vascularization plays an important role in the early phase of hypertrophic scarring. Therefore, the inhibition of angiogenesis might be used as a preventive strategy. In this study, we assessed the effect of anti-angiogenesis resulting from adenovirus-mediated METH1 (metalloprotease and thrombospondin1) gene expression on the hypertrophic scar formation in a rabbit ear model of hypertrophic scarring. We first investigated the number of microvessel and microcirculatory perfusion in untreated scars on days 10, 30, 60, and 90 after epithelialization. Then, we examined the effect of anti-angiogenesis by adenovirus-mediated METH1 expression on hypertrophic scar formation by calculating the scar elevation index, counting the microvessel and argyrophilic nucleolar organizer region particle, and detecting the amount of collagen on days 30 and 60 after treatment. We found that untreated scar tissues at the proliferative phase (days 10-60 after epithelialization) had a significantly higher density of microvessel and microcirculatory perfusion than those at the mature phase (day 90 after epithelization) (both p<0.05). On days 30 and 60 after treatment, the hypertrophic scar formation was significantly inhibited in the treatment group. There was significantly reduced scar elevation index, microvessel count, number of argyrophilic nucleolar organizer region, and total collagen content for treated scars. Our results demonstrate that METH1 has a markedly inhibitive effect on the formation of hypertrophic scar, and may thus have a promising application in the prevention of human hyperthropic scars.

New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group

The Global Alliance to Improve Outcomes in Acne published recommendations for the management of acne as a supplement to the Journal of the American Academy of Dermatology in 2003. The recommendations incorporated evidence-based strategies when possible and the collective clinical experience of the group when evidence was lacking. This update reviews new information about acne pathophysiology and treatment-such as lasers and light therapy-and relevant topics where published data were sparse in 2003 but are now available including combination therapy, revision of acne scarring, and maintenance therapy. The update also includes a new way of looking at acne as a chronic disease, a discussion of the changing role of antibiotics in acne management as a result of concerns about microbial resistance, and factors that affect adherence to acne treatments. Summary statements and recommendations are provided throughout the update along with an indication of the level of evidence that currently supports each finding. As in the original supplement, the authors have based recommendations on published evidence as much as possible.

Matrix metalloproteinase-2 and -9 activities in human keloids, hypertrophic and atrophic scars: a pilot study

Proteolytic degradation of extracellular matrix is one of the principal features of cutaneous wound healing but little is known about the activities of gelatinases; matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) on abnormal scar formation. The aim of this study is to determine collagen levels and the gelatinase activities in tissue from hypertrophic scars, atrophic scars, keloids and donor skin in 36 patients and 14 donors. Gelatinase levels (proenzyme + active enzyme) were determined by ELISA and their activities by gelatin zymography. MMP-9 activity was undetectable in gelatin zymography analysis. Pro-MMP-2 levels (median) were highest in normal skin group 53.58 (36.40-75.11) OD microg(-1) protein, while active MMP-2 levels were highest in keloid group 52.53 (42.47-61.51) OD microg(-1) protein. The active/pro ratio was the highest in keloid group 0.97 followed by hypertrophic scar, normal skin and atrophic scar groups 0.69 > 0.54 > 0.48, respectively. According to results of our study, the two-phase theory of the duration of hypertrophic scar and keloid formation can be supported by the data of tissue collagen and gelatinase analysis. This study is the first to relate scar formation relationship in regard to gelatinase activation ratio in a keloid, hypertrophic and atrophic scar patient group which is chosen appropriate in age and sex.