Prevention and curative management of hypertrophic scar formation

Inflammation and cutaneous nervous system involvement in hypertrophic scarring

This study aimed to use a mouse model of hypertrophic scarring by mechanical loading on the dorsum of mice to determine whether the nervous system of the skin and inflammation participates in hypertrophic scarring. Results of hematoxylin-eosin and immunohistochemical staining demonstrated that inflammation contributed to the formation of a hypertrophic scar and increased the nerve density in scar tissue.Western blot assay verified that interleukin-13 expression was increased in scar tissue. These findings suggest that inflammation and the cutaneous nervous system play a role in hypertrophic scar formation.

Guidelines for burn rehabilitation in China

Quality of life and functional recovery after burn injury is the final goal of burn care, especially as most of burn patients survive the injury due to advanced medical science. However, dysfunction, disfigurement, contractures, psychological problems and other discomforts due to burns and the consequent scars are common, and physical therapy and occupational therapy provide alternative treatments for these problems of burn patients. This guideline, organized by the Chinese Burn Association and Chinese Association of Burn Surgeons aims to emphasize the importance of team work in burn care and provide a brief introduction of the outlines of physical and occupational therapies during burn treatment, which is suitable for the current medical circumstances of China. It can be used as the start of the tools for burn rehabilitation.

Role of verapamil in preventing and treating hypertrophic scars and keloids

Keloid and hypertrophic scars are difficult to manage and remain a therapeutic challenge. Verapamil has shown a great potential in the management of keloid and hypertrophic scars. Comparing with conventional corticosteroid injections, verapamil could improve the appearance of keloid and hypertrophic scars, and is associated with a lower incidence of adverse effects. Is verapamil an effective alternative modality in the prevention and treatment of keloid and hypertrophic scars? The aim of this study was to assess the effectiveness of verapamil in preventing and treating keloid and hypertrophic scars. Searches were conducted in Medline, EMbase and Cochrane databases from 1974 to January 2015. The selection of articles was limited to human subjects. Five randomised controlled trials (RCTs) or cluster-randomised trials or controlled clinical trials (CCTs) comparing the efficacy of verapamil with conventional treatments were identified. The results showed that verapamil could improve keloid and hypertrophic scars, and was not significantly different from conventional corticosteroid injections. Few adverse effects were observed. However, this result should be considered carefully, as most of the included studies have a high risk of bias because of issues with randomization, allocation concealment, blinding, incomplete outcomes and selective reporting. In conclusion, verapamil could act as an effective alternative modality in the prevention and treatment of keloid and hypertrophic scars. More high-quality, multiple-centre, large-sample (RCTs) are required to define the role of verapamil in preventing and treating keloid and hypertrophic scars.

High-efficiency expression of TAT-bFGF fusion protein in Escherichia coli and the effect on hypertrophic scar tissue

Background

Basic fibroblast growth factor (bFGF) is a member of the fibroblast growth factor family that has effects on wounding healing and neuro-protection. However, it is difficult to use bFGF to treat diseases that are separated by physiological barriers, such as the dermal barrier and blood brain barrier.

Methodology/Principal Findings

To improve bFGF’s penetration ability, we fused the recombinant human fibroblast growth factor (rhbFGF) gene with TAT. We constructed a pET3c vector that contained the recombinant bFGF gene and successfully expressed this gene in the E. coli strain BL21 (DE3) pLsS. The fusion protein was purified using CM Sepharose FF and heparin affinity chromatography. The purity of the TAT-rhbFGF was greater than 95%, as detected by SDS-PAGE. An in vitro MTT trial revealed that the modified bFGF significantly promoted the proliferation of NIH3T3 cells. The cell penetration trial and the mouse skin penetration trial demonstrated that the fusion protein had certain penetration abilities. The animal experiments confirmed that TAT-rhbFGF was effective in the treatment of the hypertrophic scars.

Conclusions/Significance

We have successfully expressed and purified a TAT-rhbFGF fusion protein in this study. Our results have shown that the fusion protein had a greater ability to penetrate the dermal skin layer. TAT-rhbFGF improved the physical appearance of hypertrophic scars. TAT-rhbFGF may be a potential fusion protein in the treatment of dermal disorders, including hypertrophic scar.

Emerging drugs for the treatment of wound healing

INTRODUCTION

Wound healing can be characterized as underhealing, as in the setting of chronic wounds, or overhealing, occurring with hypertrophic scar formation after burn injury. Topical therapies targeting specific biochemical and molecular pathways represent a promising avenue for improving and, in some cases normalizing, the healing process.

AREAS COVERED

A brief overview of both normal and pathological wound healing has been provided, along with a review of the current clinical guidelines and treatment modalities for chronic wounds, burn wounds and scar formation. Next, the major avenues for wound healing drugs, along with drugs currently in development, are discussed. Finally, potential challenges to further drug development, and future research directions are discussed.

EXPERT OPINION

The large body of research concerning wound healing pathophysiology has provided multiple targets for topical therapies. Growth factor therapies with the ability to be targeted for localized release in the wound microenvironment are most promising, particularly when they modulate processes in the proliferative phase of wound healing.

A facilely fabricated in vivo hypertrophic scar model through continuous gradient elastic tension

In this study, a facile, reproducible, and economical rat HScs model was successfully fabricated, driven through elastic tension.

Mesenchymal stem cell-mediated suppression of hypertrophic scarring is p53 dependent in a rabbit ear model

Introduction

Mesenchymal stem cells (MSCs) are considered to play important roles in wound repair and tissue remodeling. Hypertrophic scar (HTS) is a cutaneous condition characterized by deposits of excessive amount of collagen after an acute skin injury. However, currently there is little knowledge about the direct relationship between MSCs and HTS.

Methods

The hypertrophic scar model was established on rabbit ears. MSCs were isolated from rabbit femur bone marrow and transplanted through ear artery injection. Hypertrophic scar formation was examined using frozen-section analysis, hematoxylin and eosin (HE) staining, Masson’s trichrome staining, and scar elevation index. The role of p53 in the MSCs-mediated anti-scarring effect was examined by gene knockdown using p53 shRNA.

Results

In this study, MSCs engraftment through ear artery injection significantly inhibited the hypertrophic scarring in a rabbit ear hypertrophic scar model, while this anti-scarring function could be abrogated by p53 gene knockdown in MSCs. Additionally, we found that MSCs down-regulated the expression of TGF-β receptor I (TβRI) and alpha-smooth muscle actin (α-SMA) at both mRNA and protein levels in a paracrine manner, and this down-regulation was rescued by p53 gene knockdown. Moreover, our results showed that MSCs with p53 gene knockdown promoted the proliferation of fibroblasts through increasing nitric oxide (NO) production.

Conclusions

These results suggest that MSCs inhibit the formation of HTS in a p53 dependent manner through at least two mechanisms: inhibition of the transformation of HTS fibroblast to myofibroblast; and inhibition of the proliferation of fibroblasts through inhibition of NO production.

New insights on keloids, hypertrophic scars, and striae

This article presents an overview of the literature regarding treatments for keloid disease, hypertrophic scars, and striae distensae in dark pigmented skin. Striae, keloid, and hypertrophic scarring present a challenging problem for both the clinician and patient. No single therapy is advocated for hypertrophic scars, keloid scars, or striae distensae. New therapies have shown promise in the treatment of hypertrophic and keloid scars, and in patients with dark pigmented skin. This article provides guidance on the assessment and determination of patients' suitability for certain treatment options, as well as advice on the follow-up of patients affected with problematic scarring and striae.

Reliability of Repeated Measurements on Post-Burn Scars with Corneometer CM 825(®)

BACKGROUND/PURPOSE

The water content in burn scars, the parameter of stratum corneum water holding capacity, is an important feature in evaluation of biophysical properties of scars. Nevertheless, quantifiying this parameter is a challenge. In this study, the reliability of repeated water content measurements with Corneometer CM825(®) on (burn) scars was investigated.

METHODS

Intra-observer reliability, inter-observer reliability and day-by-day variability were examined on 30 scars by means of intra-class correlation coefficient (ICC) and within-subject coefficient of variation (WSCV). Bland-Altman plots with '95% limits of agreement' were constructed.

RESULTS

Results revealed excellent ICC values (ICCintra  = 0.985; ICCinter  = 0.984) with relatively low WSCV (WSCVintra  = 6.3%; WSCVinter  = 10.6%) for respectively intra- and inter-observer reliability. However, the Bland-Altman plot showed that more than 5% of differences were expected to exceed 4 a.u., the limit of what has been defined as a clinically acceptable difference. Results for day-by-day variability showed good ICC value (ICCday-by-day  = 0.849) and higher WSCV (WSCVday-by-day  = 20.5%).

CONCLUSION

The Corneometer CM825(®) is an objective and sensitive instrument for water content measurements. On the basis of our results, we concluded that the instrument can be used in clinical trials, but only under very strict conditions with standardized test protocol, preferably in combination with the evaluation of other physiological parameters.

Mechanical tension promotes skin nerve regeneration by upregulating nerve growth factor expression

This study aimed to explore the role of mechanical tension in hypertrophic scars and the change in nerve density using hematoxylin-eosin staining and S100 immunohistochemistry, and to observe the expression of nerve growth factor by western blot analysis. The results demonstrated that mechanical tension contributed to the formation of a hyperplastic scar in the back skin of rats, in conjunction with increases in both nerve density and nerve growth factor expression in the scar tissue. These experimental findings indicate that the cutaneous nervous system plays a role in hypertrophic scar formation caused by mechanical tension.

Update on hypertrophic scar treatment

Scar formation is a consequence of the wound healing process that occurs when body tissues are damaged by a physical injury. Hypertrophic scars and keloids are pathological scars resulting from abnormal responses to trauma and can be itchy and painful, causing serious functional and cosmetic disability. The current review will focus on the definition of hypertrophic scars, distinguishing them from keloids and on the various methods for treating hypertrophic scarring that have been described in the literature, including treatments with clearly proven efficiency and therapies with doubtful benefits. Numerous methods have been described for the treatment of abnormal scars, but to date, the optimal treatment method has not been established. This review will explore the differences between different types of nonsurgical management of hypertrophic scars, focusing on the indications, uses, mechanisms of action, associations and efficacies of the following therapies: silicone, pressure garments, onion extract, intralesional corticoid injections and bleomycin.

Strategic management of keloid disease in ethnic skin: a structured approach supported by the emerging literature

Keloid disease (KD) is a common, benign, dermal fibroproliferative growth of unknown aetiology. Lesions tend to grow over time; they often recur following therapy and do not regress spontaneously. KD causes considerable discomfort due to pain, pruritus and inflammation, and a significant psychosocial impact with reduced quality of life. It is unique to humans and occurrence is higher in individuals with dark, pigmented, ethnic skin. There is a strong familial heritability, with a high ethnic predisposition in individuals of African, Asian and Hispanic descent. High recurrence rates and unknown resolution rates present a major problem for both the patient and clinician. Many treatment modalities exist; however, there is no single advocated therapy. Therefore, the aim of this review was to explore the most current literature regarding the range of treatment options for KD and to offer a structured approach in the management of KD, based on evidence and experience, to aid clinicians in their current practice. A focused history involving careful evaluation of the patient's symptoms, signs, quality of life and psychosocial well-being should direct targeted therapy, complemented with regular follow-up and re-evaluation. Many treatment modalities, such as intralesional steroid injection, silicone gel application, cryotherapy, lasers, 5-fluorouracil and, relatively recently, photodynamic therapy, are currently being used in clinical practice for the management of KD. Combination therapies have also been shown to be beneficial. However, there is a lack of robust, randomized, level-one, evidence-controlled trials evaluating these treatment options. Management of KD in ethnic pigmented skin remains a clinical challenge. Thus, a strategic approach with structured assessment, targeted therapy and focus on prevention of recurrence is highly recommended. Quality evidence is essential in order to tailor treatment effectively for the ethnic patient presenting with KD.

Updated scar management practical guidelines: non-invasive and invasive measures

Hypertrophic scars and keloids can be aesthetically displeasing and lead to severe psychosocial impairment. Many invasive and non-invasive options are available for the plastic (and any other) surgeon both to prevent and to treat abnormal scar formation. Recently, an updated set of practical evidence-based guidelines for the management of hypertrophic scars and keloids was developed by an international group of 24 experts from a wide range of specialities. An initial set of strategies to minimize the risk of scar formation is applicable to all types of scars and is indicated before, during and immediately after surgery. In addition to optimal surgical management, this includes measures to reduce skin tension, and to provide taping, hydration and ultraviolet (UV) protection of the early scar tissue. Silicone sheeting or gel is universally considered as the first-line prophylactic and treatment option for hypertrophic scars and keloids. The efficacy and safety of this gold-standard, non-invasive therapy has been demonstrated in many clinical studies. Other (more specialized) scar treatment options are available for high-risk patients and/or scars. Pressure garments may be indicated for more widespread scarring, especially after burns. At a later stage, more invasive or surgical procedures may be necessary for the correction of permanent unaesthetic scars and can be combined with adjuvant measures to achieve optimal outcomes. The choice of scar management measures for a particular patient should be based on the newly updated evidence-based recommendations taking individual patient and wound characteristics into consideration.

Recombinant nAG (a salamander-derived protein) decreases the formation of hypertrophic scarring in the rabbit ear model

nAG (newt-Anterrior Gradient) protein is the key mediator of regrowth of amputated limbs in salamanders. In a previous work in our lab, a new nAG gene (suitable for humans) was designed and cloned. The cloned vector was transfected into primary human fibroblasts. The expression of nAG in human primary fibroblasts was found to suppress collagen expression. The current study shows that local injection of recombinant nAG reduces scar hypertrophy in the rabbit ear model. This is associated with lower scar elevation index (SEI), lower levels of collagen I & III, higher levels of MMP1, and a higher degree of scar maturation in experimental wounds compared to controls.

Studying intense pulsed light method along with corticosteroid injection in treating keloid scars

BACKGROUND

Results of various studies suggest that the hypertrophic and keloid scars are highly prevalent in the general population and are irritating both physically and mentally.

OBJECTIVE

Considering the variety of existing therapies, intense pulsed light (IPL) method along with corticosteroid injection was evaluated in treating these scars.

MATERIALS AND METHODS

86 subjects were included in this clinical trial. Eight sessions of therapeutic intervention were done with IPL along with corticosteroid intralesional injection using 450 to 1200 NM filter, Fluence 30-40 J/cm2, pulse duration of 2.1-10 ms and palsed delay 10-40 ms with an interval of three weeks. To specify the recovery consequences and complication rate and to determine features of the lesion, the criteria specified in the study of Eroll and Vancouver scar scale were used.

RESULTS

The level of clinical improvement, color improvement and scar height was 89.1%, 88.8% and 89.1% respectively. The incidence of complications (1 telangiectasia case, 7 hyperpigmentation cases and 2 atrophy cases) following treatment with IPL was 11.6%. Moreover, the participants' satisfaction with IPL method was 88.8%.

CONCLUSIONS

This study revealed that a combined therapy (intralesional corticosteroid injection + IPL) increases the recovery level of hypertrophic and keloid scars. It was also demonstrated that this method had no significant side effect and patients were highly satisfied with this method.

In vivo inhibition of hypertrophic scars by implantable ginsenoside-Rg3-loaded electrospun fibrous membranes

Clinically, hypertrophic scarring (HS) is a major concern for patients and has been a challenge for surgeons, as there is a lack of treatments that can intervene early in the formation of HS. This study reports on a Chinese drug, 20(R)-ginsenoside Rg3 (GS-Rg3), which can inhibit in vivo the early formation of HS and later HS hyperplasia by inducing the apoptosis of fibroblasts, inhibiting inflammation and down-regulating VEGF expression. Implantable biodegradable GS-Rg3-loaded poly(l-lactide) (PLA) fibrous membranes were successfully fabricated using co-electrospinning technology to control drug release and improve drug utilization. The in vivo releasing time of GS-Rg3 lasts for 3 months, and the drug concentration released in rabbits can be controlled by varying the drug content of the electrospun fibers. Histological observations of HE staining indicate that GS-Rg3/PLA significantly inhibits the HS formation, with obvious improvements in terms of dermis layer thickness, epidermis layer thickness and fibroblast proliferation. The results of immunohistochemistry staining and Masson's trichrome staining demonstrate that GS-Rg3/PLA electrospun fibrous membranes significantly inhibit HS formation, with decreased expression of collagen fibers and microvessels. VEGF protein levels are much lower in the group treated with GS-Rg3/PLA eletrospun membranes compared with other groups. These results demonstrate that GS-Rg3 is a novel drug, capable of inhibiting the early formation of HS and later HS hyperplasia. GS-Rg3/PLA electrospun membrane is a very promising new treatment for early and long-term treatment of HS.

Minimal extracorporeal circulation (MECC) does not result in less hypertrophic scar formation as compared to conventional extracorporeal circulation (CECC) with dexamethasone

INTRODUCTION

Cardiopulmonary bypass surgery is associated with a systemic inflammatory response through the interaction of air, blood and synthetic components in the bypass system and the physical trauma of surgery. An alternative cardiopulmonary bypass system, minimal extracorporeal circulation (MECC), has shown promising results in terms of reducing the inflammatory response. We hypothesized that this system may reduce pathological excessive scarring. To study this assumption, the effects of MECC and the effects of conventional extracorporeal circulation (CECC) with dexamethasone on skin scarring were compared in a standardized wound-healing model.

METHODS AND RESULTS

Pre-sternal scars were evaluated prospectively at four and 12 months postoperatively. The height and width of the scars were measured, using a slide caliper and sonography. The scars were scored using the validated Patient and Observer Scar Assessment Scale. Additional risk factors for hypertrophic scar formation were identified by means of a questionnaire. During surgery, MECC was used in 45 patients and CECC/dexamethasone in 42 patients. Four months postoperatively, 22 patients of the MECC group (49%) and 18 patients in the CECC/dexamethasone group (43%) had developed hypertrophic scars. Twelve months postoperatively, the hypertrophic scars in four patients of the MECC group and in two patients of the CECC/dexamethasone group had become normotrophic. In 18 patients of the MECC group (38%) and 16 patients of the CECC group (41%) the scars remained hypertrophic at 12 months. These differences between the two groups were not statistically significant.

CONCLUSION

MECC does not reduce hypertrophic scar formation compared with CECC with dexamethasone, but its use is more beneficial than the use of CECC/dexamethasone because of the circulatory and immunological advantages and because treatment with dexamethasone can be omitted.

Altered TGF-β signaling in fetal fibroblasts: what is known about the underlying mechanisms?

Scarless wound healing is a unique and intrinsic capacity of the fetal skin that is not fully understood. Further insight into the underlying mechanisms of fetal wound healing may lead to new therapeutic approaches promoting adult scarless wound healing. Differences between fetal and adult wound healing are found in the extracellular matrix, the inflammatory reaction and the levels of growth factors present in the wound. This review focuses specifically on transforming growth factor β (TGF-β), as this growth factor is prominently involved in wound healing and fibroblast-to-myofibroblast differentiation. Although fetal fibroblasts do respond to TGF-β, they lack a proliferative and a contractile response and display short-lived myofibroblast differentiation, autocrine response, and collagen up-regulation in comparison with adult fibroblasts. Curiously, prolonged TGF-β activation is associated with fibrosis, and therefore, this short-lived response in fetal fibroblasts might contribute to scarless healing. This review gives an overview of the current knowledge on TGF-β signaling and the intracellular TGF-β signaling pathway in fetal fibroblasts. Furthermore, this review also describes the various components that regulate the cellular TGF-β response and hypothesizes about the possible roles these components might play in the altered response of fetal fibroblasts to TGF-β.

Pediatric burn rehabilitation: Philosophy and strategies

Burn injuries are a huge public health issue for children throughout the world, with the majority occurring in developing countries. Burn injuries can leave a pediatric patient with severely debilitating and deforming contractures, which can lead to significant disability when left untreated. Rehabilitation is an essential and integral part of pediatric burn treatment. The aim of this article was to review the literature on pediatric burn rehabilitation from the Medline, CINAHL, and Web of Science databases. An attempt has been made to present the basic aspects of burn rehabilitation, provide practical information, and discuss the goals and conceptualization of rehabilitation as well as the development of rehabilitation philosophy and strategies.

The anti-scar effects of basic fibroblast growth factor on the wound repair in vitro and in vivo

Hypertrophic scars (HTS) and keloids are challenging problems. Their pathogenesis results from an overproduction of fibroblasts and excessive deposition of collagen. Studies suggest a possible anti-scarring effect of basic fibroblast growth factor (bFGF) during wound healing, but the precise mechanisms of bFGF are still unclear. In view of this, we investigated the therapeutic effects of bFGF on HTS animal model as well as human scar fibroblasts (HSF) model. We show that bFGF promoted wound healing and reduced the area of flattened non-pathological scars in rat skin wounds and HTS in the rabbit ear. We provide evidence of a new therapeutic strategy: bFGF administration for the treatment of HTS. The scar elevation index (SEI) and epidermal thickness index (ETI) was also significantly reduced. Histological reveal that bFGF exhibited significant amelioration of the collagen tissue. bFGF regulated extracellular matrix (ECM) synthesis and degradation via interference in the collagen distribution, the α-smooth muscle actin (α-SMA) and transforming growth factor-1 (TGF-β1) expression. In addition, bFGF reduced scarring and promoted wound healing by inhibiting TGFβ1/SMAD-dependent pathway. The levels of fibronectin (FN), tissue inhibitor of metalloproteinase-1 (TIMP-1) collagen I, and collagen III were evidently decreased, and matrix metalloproteinase-1 (MMP-1) and apoptosis cells were markedly increased. These results suggest that bFGF possesses favorable therapeutic effects on hypertrophic scars in vitro and in vivo, which may be an effective cure for human hypertrophic scars.

Outcome after burns: an observational study on burn scar maturation and predictors for severe scarring

Long-term outcome of burn scars as well as the relation with clinically relevant parameters has not been studied quantitatively. Therefore, we conducted a detailed analysis on the clinical changes of burn scars in a longitudinal setup. In addition, we focused on the differences in scar quality in relation to the depth, etiology of the burn wound and age of the patient. Burn scars of 474 patients were subjected to a scar assessment protocol 3, 6, and 12 months postburn. Three different age groups were defined (≤5, 5-18, and ≥18 years). The observer part of the patient and observer scar assessment scale revealed a significant (p < 0.001) improvement in scar quality at 12 months compared with the 3- and 6-month data. Predictors for severe scarring are depth of the wound (p < 0.001) and total body surface area burned (p < 0.001). Etiology (p = 0.753) and age (p > 0.230) have no significant influence on scar quality when corrected for sex, total body surface area burned, time, and age or etiology, respectively.

Topical treatment for facial burns

BACKGROUND

Burn injuries are an important health problem. They occur frequently in the head and neck region - the area central to a person's identity, that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of partial-thickness burns to the face.

OBJECTIVES

To assess the effects of topical interventions on wound healing in people with facial burns of any depth.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 12 November 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to November Week 1 2012); Ovid MEDLINE - In-process & Other Non-Indexed Citations (searched November 12, 2012); Ovid EMBASE (1980 to 2012 Week 45); and EBSCO CINAHL (1982 to 9 November 2012) for relevant trials. We did not apply date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and included the references identified by the search strategy. Included trials were assessed using a risk of bias form, and data were extracted using a standardised data extraction sheet. For dichotomous and continuous outcomes, we calculated risk ratios and mean differences, respectively, both with 95% confidence intervals (CI).

MAIN RESULTS

We included five RCTs, comprising a total of 119 participants. Two studies compared two different antimicrobial agents and three compared a biological or bioengineered skin substitute with an antimicrobial agent. All studies had small sample sizes and were at high risk of bias. Heterogeneity of interventions and outcomes prevented pooling of data. In three studies time to complete wound healing was significantly shorter for those using a skin substitute than for those using an antibacterial agent, but the quality of the evidence was low. Pain was significantly reduced with the use of skin substitutes in both studies that reported this outcome in all groups, range mean differences -2.00 (95% CI -3.82 to -0.18) to -4.00 (95% CI -5.05 to -2.95) on a 10-point scale.

AUTHORS' CONCLUSIONS

There is insufficient high quality research and evidence to enable conclusions to be drawn about the effects of topical interventions on wound healing in people with facial burns.

Curative effects of oleanolic Acid on formed hypertrophic scars in the rabbit ear model

Hypertrophic scarring is a common proliferative disorder of dermal fibroblasts characterized by collagen overproduction and excessive deposition of extracellular matrix (ECM). There is no consensus about the best therapeutics to produce complete and permanent improvement of scars with few side effects. To investigate the therapeutic effects of oleanolic acid (OA) on hypertrophic scars and explore the possible mechanism of action involved, a rabbit ear model with hypertrophic scars was established. OA (2.5%, 5%, and 10%) was given once daily to the scars for 28 consecutive days. As a result, OA significantly alleviated formed hypertrophic scars on rabbit ears. The levels of TGF-β₁, MMP-1, TIMP-1, and collagens I and III were notably decreased, and the number of apoptosis cells and mRNA expression of MMP-2, caspase-3, and caspase-9 were markedly increased in the scar tissue. The scar elevation index (SEI) was also evidently reduced. Histological findings exhibited significant amelioration of the collagen tissue. These results suggest that OA has the favorable curative effects on formed hypertrophic scars in the rabbit ear model, and the possible mechanism of action is that OA decreases HSFs proliferation and increases HSFs apoptosis by reduction of P311 gene expression and TGF-β₁ production, inhibition of TIMP-1 secretion, enhancement of MMP-2 activity, and subsequently facilitation of degradation of collagen types I and III.

Endostar Injection Inhibits Rabbit Ear Hypertrophic Scar Formation

This study aims to investigate the effect of Endostar injection on the rabbit ear hypertrophic scar formation and expand the use of Endostar. The rabbit ear hypertrophic scar models were established 4 weeks postoperation and were treated with Endostar injection; the control group was injected with saline, once a week, 3 times totally. At the seventh week, the scar tissue was harvested and processed with hematoxylin and eosin (HE) staining and CD34 immunohistochemistry and cell apoptosis assay. In addition, the endothelial cell was cultured and seeded on Martrigel with different concentrations of Endostar to observe the vessel tube formation. The results showed that the volume of the hypertrophic scar with Endostar injection was greatly reduced compared with what was seen in the control group; meanwhile, HE staining showed that the cell number decreased and collagen density became looser. In addition, the CD34 staining indicated that microvessel formation in the study group also decreased and cell apoptosis increased. In vitro, the addition of Endostar could reduce vessel tube formation in a dose-dependent manner. In conclusion, the Endostar is effective for hypertrophic scar inhibition and could be a potential tool to treat scars.

A review of the effects of moisturizers on the appearance of scars and striae

Scars are well known to have a stratum corneum (SC) that is malfunctional. Increases in transepidermal water loss and decreases in SC capacitance and conductance have been reported. Occlusion therapy is a well-known route to improving the signs and symptoms of scarring. Until recently that has been assumed to be totally pressure related. However, studies have demonstrated that the direct effects of hydration on keratinocytes and fibroblasts contribute to the reduction in hypertrophic scarring. Now it is well known that occlusion can regulate epidermal cytokine and growth factor production; changes in profibrotic and anti-fibrotic factors have been established. As a result, it is to be expected that moisturizers may improve the signs and symptoms of scars. As striae have been suggested to be anatomically similar to scars and as it is well established that paracrine signalling occurs in skin, it is expected that striae have similar SC issues. While one cannot exclude the effects of some of the ingredients used in the products, several studies are reported in this review that demonstrates that moisturization is a key component to reducing the clinical signs and symptoms of scars and striae. This is a good example of how knowledge of corneobiology leads to corneotherapies for these skin condition problems. The review is being written in memory of Professor Johann Wiechers who, before he died tragically in November 2011, performed two of the reported studies together with colleagues.

Conservative management of ulnar tunnel syndrome: secondary to excessive healing tissue; a rare complication after flexor tendon injury--a case report

The ulnar tunnel syndrome occurs usually from ganglions, lipoma, cysts, chronic repetitive trauma, bicycling, and the activities that require either prolonged wrist hyper extension or continued pressure on the hypothenar eminence. The ulnar tunnel syndrome after flexor tendon repair is a rare complication. We report on a 24-year-old man with ulnar tunnel syndrome after a flexor tendon repair secondary to girder cut injury. The patient was managed conservatively for his hypertrophic scar for 9 weeks. After 9 weeks, the patient presented with no clawing and complete closure of the hand.

Therapeutic effects of liposome-enveloped Ligusticum chuanxiong essential oil on hypertrophic scars in the rabbit ear model

Hypertrophic scarring, a common proliferative disorder of dermal fibroblasts, results from an overproduction of fibroblasts and excessive deposition of collagen. Although treatment with surgical excision or steroid hormones can modify the symptoms, numerous treatment-related complications have been described. In view of this, we investigated the therapeutic effects of essential oil (EO) from rhizomes of Ligusticum chuanxiong Hort. (Umbelliferae) on formed hypertrophic scars in a rabbit ear model. EO was prepared as a liposomal formulation (liposome-enveloped essential oil, LEO) and a rabbit ear model with hypertrophic scars was established. LEO (2.5, 5, and 10%) was applied once daily to the scars for 28 days. On postoperative day 56, the scar tissue was excised for masson's trichrome staining, detection of fibroblast apoptosis, assays of the levels of collagens I and III, and analysis of the mRNA expression of matrix metalloproteinase-1 (MMP-1), caspase-3 and -9, and transforming growth factor beta 1 (TGF-β₁). In addition, the scar elevation index (SEI) was also determined. As a result, LEO treatment significantly alleviated formed hypertrophic scars on rabbit ears. The levels of TGF-β₁, MMP-1, collagen I, and collagen III were evidently decreased, and caspase -3 and -9 levels and apoptosis cells were markedly increased in the scar tissue. SEI was also significantly reduced. Histological findings exhibited significant amelioration of the collagen tissue. These results suggest that LEO possesses the favorable therapeutic effects on formed hypertrophic scars in the rabbit ear model and may be an effective cure for human hypertrophic scars.

Clinical strategies for the alleviation of contractures from a predictive mathematical model of dermal repair

Hypertrophic scars arise when there is an overproduction of collagen during wound healing. These are often associated with poor regulation of the rate of programmed cell death (apoptosis) of the cells synthesizing the collagen or by an exuberant inflammatory response that prolongs collagen production and increases wound contraction. Severe contractures that occur, e.g., after a deep burn, can cause loss of function especially if the wound is over a joint such as the elbow or knee. Recently, we have developed a morphoelastic mathematical model for dermal repair that incorporates the chemical, cellular, and mechanical aspects of dermal wound healing. Using this model, we examine pathological scarring in dermal repair by first assuming a smaller than usual apoptotic rate for myofibroblasts, and then considering a prolonged inflammatory response, in an attempt to determine a possible optimal intervention strategy to promote normal repair, or terminate the fibrotic scarring response. Our model predicts that in both cases it is best to apply the intervention strategy early in the wound healing response. Further, the earlier an intervention is made, the less aggressive the intervention required. Finally, if intervention is conducted at a late time during healing, a significant intervention is required; however, there is a threshold concentration of the drug or therapy applied, above which minimal further improvement to wound repair is obtained.

Alternate splint for flexion contracture in children with burns

Splinting children and ensuring that children wear the splint can be challenging tasks for both the therapist and the caregiver. Sometimes creativity is needed to create a pediatric splint that is easy to don and stays in place. These authors describe their challenge with pediatric burn patients either not wearing or losing their splint and how they now combine the splint directly into the pressure garment to ensure better patient compliance

The effect of nano-scale topography on keratinocyte phenotype and wound healing following burn injury

Topographic modulation of tissue response is an important consideration in the design and manufacture of a biomaterial. In developing new tissue therapies for skin, all levels of architecture, including the nanoscale need to be considered. Here we show that keratinocyte phenotype is affected by nanoscale changes in topography with cell morphology, proliferation, and migration influenced by the pore size in anodic aluminum oxide membranes. A membrane with a pore size of 300 nm, which enhanced cell phenotype in vitro, was used as a dressing to cover a partial thickness burn injury in the pig. Wounds dressed with the membrane showed evidence of advanced healing with significantly less organizing granulation tissue and more mature epidermal layers than control wounds dressed with a standard burns dressing. The results demonstrate the importance of nanoscale topography in modulating keratinocyte phenotype and skin wound healing.

Hypertrophic scar

Hypertrophic scars are common complications of burn injury and other soft tissue injuries. Excessive extracellular matrix combined with inadequate remodeling of scar tissue results in an aesthetically and functionally unsatisfactory, painful, pruritic scar that can impair function. Treatment options are available to rehabilitation practitioners, but none are entirely satisfactory. An interdisciplinary clinical program is necessary for best outcomes. Challenges to be met by the rehabilitation community include research into the quantification of burn scar measurement, the effects of mechanical forces on wound healing and scar management, and the best combination of surgical, pharmacologic, and therapy interventions to maximize outcome from reconstructive procedures.