Abnormal wound healing: keloids

High-mobility Group Box Protein-1, Matrix Metalloproteinases, and Vitamin D in Keloids and Hypertrophic Scars

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.

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.

Loureirin B inhibits fibroblast proliferation and extracellular matrix deposition in hypertrophic scar via TGF-β/Smad pathway

The ethanolic extract of Resina Draconis (RDEE) has been reported beneficial to normal wound healing yielding more regularly arranged collagen fibres. Loureirin B, a major component in RDEE, has been supposed to be effective on the prevention and treatment of pathological scars. To investigate the therapeutic effects of loureirin B on hypertrophic scar (HS), fibroblasts from human HS and normal skin (NS) were isolated. Results showed that loureirin B dose-dependently downregulated both mRNA and protein levels of type I collagen (ColI), type III collagen (ColIII) and α-smooth muscle actin (α-SMA) in HS fibroblasts. Loureirin B also suppressed fibroblast proliferative activity and redistributed cell cycle, but did not affect cell apoptosis. In vivo rabbit ear scar model, loureirin B significantly improved the arrangement and deposition of collagen fibres, decreased protein levels of ColI, ColIII and α-SMA and suppressed myofibroblast differentiation and scar proliferative activity. In NS fibroblasts, loureirin B effectively inhibited TGF-β1-induced upregulation of ColI, ColIII and α-SMA levels, myofibroblast differentiation and the activation of Smad2 and Smad3. Loureirin B also affected mRNA levels of major MMPs and TIMPs in TGF-β1-stimulated fibroblasts. Taken together, this study demonstrates that loureirin B could downregulate the expression of fibrosis-related molecules by regulating MMPs and TIMPs levels, inhibit scar fibroblast proliferation and suppress TGF-β1-induced fibrosis, during which TGF-β1/Smad2/3 pathway is likely involved. These findings suggest that loureirin B is a potential therapeutic compound for HS treatment.

Custom made pressure appliance for presurgical sustained compression of auricular keloid

Keloid is dermal lesion characterized by nodular fibroblastic proliferation, which is considered an aberration of wound healing process. It is believed to be the confused scar that does not know when to stop growing. Pressure therapy using clips or splints is widely used for the treatment of keloids; however, it is often very difficult to control the amount and direction of pressure applied. Among the most common complications of this therapy is ulceration due to excessive pressure. A case of presurgical size reduction for a large ear keloid with a custom made pressure appliance is presented. This novel design of the appliance allows for better control over the amount and direction of the pressure applied on the scar tissue.

Adjuvance in refractory keloids using electron beams with a spoiler: Recent results

AIM

To present clinical results of adjuvant irradiation of excised refractory keloid wounds using a novel bolus-free technique developed within our group to irradiate the skin surface with a linear accelerator.

BACKGROUND

The use of a bolus to increase surface dose over a newly excised keloid presents several problems. Previous solutions are unsatisfactory. Our technique is promising but needs to be evaluated in practice.

MATERIALS AND METHODS

Twenty refractory skin keloids in 19 patients were excised and irradiated in Hospital Plató (Barcelona, Spain) using a 6 MeV electron beam with a 4-mm aluminium spoiler. 15 Gy in fractions of 3 Gy were delivered to the excision site plus a safety margin. All patients were examined during the follow-up (median: 40 months, interval: 12-68 months) and toxicities were recovered.

RESULTS

At the end of the follow-up period, 76% of the cases had not recurred, while the complete response rate amounted to 53%. Residual hypertrophic scars were classified as partial responses. After therapy, itching and pain were observed in 30% of the patients, as well as one telangiectasia and two hyperchromatic scars.

CONCLUSION

Our technique avoids using a bolus while combining the benefits of electron beam therapy in keloids (fewer secondary effects, and fewer and shorter treatments) with a dose deposition adequate for skin surface treatments. Our results are in line with the most successful therapies evaluated in the literature, as secondary effects are acceptable and recurrence rates are low.

Refractive surgery in systemic and autoimmune disease

Patients with underlying systemic disease represent challenging treatment dilemma to the refractive surgeon. The refractive error in this patient population is accompanied by a systemic disease that may have an ocular or even a corneal component. The literature is rather sparse about the use of laser refractive surgery (LRS) and such procedure is not approved by the United States Food and Drug Administration (FDA) in this patient population. Patients with collagen vascular disease, diabetes mellitus (DM), allergic and atopic disease, or human immunodeficiency virus (HIV) are never ideal for LRS. Patients with uncontrolled systemic disease or ocular involvement of the disease should not undergo LRS. However, a patient with well-controlled and mild disease, no ocular involvement, and not on multidrug regimen may be a suitable candidate if they meet stringent criteria. There is a need for a large, multicenter, controlled trial to address the safety and efficacy of LRS in patients with systemic disease before such technology can be widely adopted by the refractive surgery community.

Objective assessment of endogenous collagen in vivo during tissue repair by laser induced fluorescence

Collagen, a triple helical protein with the primary role of mechanical function, provides tensile strength to the skin, and plays a pivotal task in tissue repair. During tissue regeneration, collagen level increases gradually and therefore, monitoring of such changes in vivo by laser induced fluorescence was the main objective behind the present study. In order to accomplish this, 15 mm diameter excisional wounds were created on six to eight week old Swiss albino mice. The collagen deposition accelerated upon irradiation of single exposure of 2 J/cm² He-Ne laser dose immediately after wounding was recorded by laser induced autofluorescence in vivo along with un-illuminated and un-wounded controls. Autofluorescence spectra were recorded for each animal of the experimental groups on 0, 5, 10, 30, 45 and 60 days post-wounding, by exciting the granulation tissue/skin with 325 nm He-Cd laser. The variations in the average collagen intensities from the granulation tissue/skin of mice were inspected as a function of age and gender. Further, the spectral findings of the collagen synthesis in wound granulation tissue/un-wounded skin tissues were validated by Picro-Sirius red- polarized light microscopy in a blinded manner through image analysis of the respective collagen birefringence. The in vivo autofluorescence studies have shown a significant increase in collagen synthesis in laser treated animals as compared to the un-illuminated controls. Image analysis of the collagen birefringence further authenticated the ability of autofluorescence in the objective monitoring of collagen in vivo. Our results clearly demonstrate the potential of laser induced autofluorescence in the monitoring of collegen synthesis during tissue regeneration, which may have clinical implications.

[Differential diagnosis between keloid and hypertrophic scars: a new approach by full-field optical coherence tomography]

OBJECTIVE

To evaluate the efficacy of full-field optical coherence tomography to differentiate hypertrophic and keloid scars on ex-vivo tissues.

PATIENTS AND METHODS

All patients who underwent resection of pathological scar from November 2012 to September 2013 were analyzed. The scars were fixed in formalin and analyzed by conventional histology and full-field optical coherence tomography. The criteria for evaluation were: presence of dermal nodules, presence of cells and hyalinization of collagen.

RESULTS

Nineteen pathological scars were analyzed. Histology found 7 keloid scars, 7 mixed and 3 hypertrophic scars. The sensitivity of optical coherence tomography for the detection of dermal nodules was 100%. This technology was not helpful for detection of cells and hyalinized collagen.

CONCLUSION

In the present state of technology, optical coherence tomography did not identify the presence of cells, which makes the differential diagnosis difficult in the case of hypertrophic and keloid scars.

Robotic thyroidectomy for benign thyroid diseases: a stepwise strategy to the adoption of robotic thyroidectomy (gasless, transaxillary approach)

PURPOSE

Thyroid surgery for benign diseases mainly involves young women, and thus, cosmetic considerations have motivated the development of "no scar to the neck" procedures. Endoscopic techniques are often strenuous, and therefore, discouraging to adopt. However, the recent incorporation of robotic technology proposes a feasible, safe, extracervical approach that alleviates most of the technical difficulties associated with endoscopy. Here, the authors present a series of robotic thyroidectomies performed to treat benign thyroid diseases and detail the key issues of initial patient selection.

PATIENTS AND METHODS

From November 2007 to December 2010, 44 patients with benign thyroid disease were operated upon using a robotic procedure. Indications were follicular/Hürthle cell lesions smaller than 5 cm, nodules with an indefinite/suspicious cytology, or Graves disease. All patients underwent robotic gasless, transaxillary thyroidectomy using the da Vinci S system.

RESULTS

Thirty-nine of the 44 patients were women, and the overall mean age was 38.2 years (range, 16 to 60 y). The most common pathology was adenomatous hyperplasia (20 lesions) followed by follicular adenoma (10 lesions). Seven patients had Graves disease. The mean tumor size was 1.68 cm (range, 0.3 to 5 cm). Thirty-nine patients underwent less than total thyroidectomy and 5 underwent total or near total thyroidectomy. The mean total operative time was 129.8 minutes (range, 75 to 242 min) and the mean duration of postoperative hospital stay was 3.1 days (range, 2 to 5 d). Postoperative complications were 1 transient hoarseness, 1 transient hypocalcemia, and 1 permanent recurrent laryngeal nerve injury.

CONCLUSIONS

Robotic thyroidectomy, although novel and sophisticated, has already been used to treat over 4000 thyroid cancer patients in Korea. Female patients with a small to average build, with a follicular lesion and concerned about neck scarring, seem to be the best candidates. Patients with small suspicious nodules without severe thyroiditis are also a rational choice. In contrast, patients with Graves disease should be reserved, unless significant experience has been gained.

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.

Site-specific keloid fibroblasts alter the behaviour of normal skin and normal scar fibroblasts through paracrine signalling

Keloid disease (KD) is an abnormal cutaneous fibroproliferative disorder of unknown aetiopathogenesis. Keloid fibroblasts (KF) are implicated as mediators of elevated extracellular matrix deposition. Aberrant secretory behaviour by KF relative to normal skin fibroblasts (NF) may influence the disease state. To date, no previous reports exist on the ability of site-specific KF to induce fibrotic-like phenotypic changes in NF or normal scar fibroblasts (NS) by paracrine mechanisms. Therefore, the aim of this study was to investigate the influence of conditioned media from site-specific KF on the cellular and molecular behaviour of both NF and NS enabled by paracrine mechanisms. Conditioned media was collected from cultured primary fibroblasts during a proliferative log phase of growth including: NF, NS, peri-lesional keloid fibroblasts (PKF) and intra-lesional keloid fibroblasts (IKF). Conditioned media was used to grow NF, NS, PKF and IKF cells over 240 hrs. Cellular behavior was monitored through real time cell analysis (RTCA), proliferation rates and migration in a scratch wound assay. Fibrosis-associated marker expression was determined at both protein and gene level. PKF conditioned media treatment of both NF and NS elicited enhanced cell proliferation, spreading and viability as measured in real time over 240 hrs versus control conditioned media. Following PKF and IKF media treatments up to 240 hrs, both NF and NS showed significantly elevated proliferation rates (p<0.03) and migration in a scratch wound assay (p<0.04). Concomitant up-regulation of collagen I, fibronectin, α-SMA, PAI-1, TGF-β and CTGF (p<0.03) protein expression were also observed. Corresponding qRT-PCR analysis supported these findings (P<0.03). In all cases, conditioned media from growing marginal PKF elicited the strongest effects. In conclusion, primary NF and NS cells treated with PKF or IKF conditioned media exhibit enhanced expression of fibrosis-associated molecular markers and increased cellular activity as a result of keloid fibroblast-derived paracrine factors.

Therapy of pathological scars

The various clinical manifestations of scarring are an important topic for physicians in many disciplines. The prevention of excessive scarring is more successful than the treatment afterwards. Multiple options exist for prevention, wound repair modulation, and treatment of scars. This publication includes an overview of the pathogenesis, clinical classification, documentation, prevention, and invasive and non-invasive therapy options.

Isolated corymbose collagenoma responding to intralesional triamcinolone acetonide and hyaluronidase injections

Collagenomas are connective tissue nevi with circumscribed hamartomatous proliferation of collagen. Due to their benign nature and lack of any simple medical treatment, they are most often left untreated. We present a case of isolated corymbose collagenoma, a distinct morphological variant not described hitherto that was successfully treated with intralesional injections of combination of triamcinolone acetonide and hyaluronidase.

Evidence of a role for fibrocyte and keratinocyte-like cells in the formation of hypertrophic scars

Burn injuries affect millions of people every year, and dermal fibrosis is a common complication for the victims. This disfigurement has functional and cosmetic consequences and many research groups have made it the focus of their work to understand the mechanisms that underlie its development. Although significant progress has been made in wound-healing processes, the complexity of events involved makes it very difficult to come up with a single strategy to prevent this devastating fibrotic condition. Inflammation is considered one predisposing factor, although this phase is a necessary aspect of the wound-healing process. Inflammation, driven by infiltrated immune cells, begins minutes after the burn injury and is the prevalent phase of wound healing in the early stages. Accompanying the inflammatory infiltrate, there is evidence that subpopulations of bone marrow-derived cells are also present. These populations include fibrocytes and keratinocyte-like cells, derivatives of CD14 monocytes, a component of the peripheral blood mononuclear cell infiltrate. There is evidence that these cells contribute to regeneration and repair of the wound site, but it is interesting to note that there are also reports that these cells can have adverse effects and may contribute to the development of dermal fibrosis. In this article, the authors present a review of the origin and transdifferentiation of these cells from bone marrow stem cells, the environments that direct this transdifferentiation, and evidence to support their role in fibrosis, as well as potential avenues for therapeutics to control their fibrotic effects.

Keloid: A case report and review of pathophysiology and differences between keloid and hypertrophic scars

Keloids extend beyond the borders of the original wound invading normal skin. Usually appear as firm nodules, often pruritic and painful, and generally do not regress spontaneously. Most often occur on the chest, shoulders, upper back, back of the neck, and earlobes. The aim of the paper is to discuss a case of keloid, review the pathophysiology and also to highlight the differences between keloid and hypertrophic scars. A 26-year-old female complains of swelling on ear lobe since 3 years. Swelling was firm, non-tender, dumbell-shaped with central wooden stick still present, measuring 3 cm in diameter medial to the inferior part of the helix. A clinical diagnosis of keloid was given. Histopathological sections showed hyperorthokeratinized stratified squamous epithelium with deep dermal sclerosis showing large dense bundle of glassy collagen diagnostic of Keloid. Special stain like Van Gieson's was used to identify collagen bundles. The sections were also subjected to immunohistochemical markers such as α-SMA (alpha Smooth muscle actin), Desmin, and S-100. Despite decades of research, the pathophysiology of keloids remains incompletely understood. Recent studies indicate that TGF-β (Transforming growth factor beta) and PDGF (Platelet-derived growth factor) play an integral role in the formation of keloids. In future, development of selective inhibitors of TGF-β might produce new therapeutic tools with enhanced efficacy and specificity for the treatment of keloids. Patients with a previous history of keloid or other risk-factors should avoid body piercing and elective cosmetic procedures. Keloid scars should be sent for histopathology in order to avoid missing potentially malignant conditions particularly those showing unusual features.

Management of keloids and hypertrophic scars: current and emerging options

In the context of growing aesthetic awareness, a rising number of patients feel disappointed with their scars and are frequently seeking help for functional and aesthetic improvement. However, excessive scarring following surgery or trauma remains difficult to improve despite a plethora of advocated treatment strategies as frequently observed in daily clinical routine. It is thus still preferable to prevent scarring by minimizing risk factors as much as possible. Hence, it remains crucial for the physician to be aware of basic knowledge of healing mechanisms and skin anatomy, as well as an appreciation of suture material and wound closure techniques to minimize the risk of postoperative scarring. Next to existing, well known prophylactic and therapeutic strategies for the improvement of excessive scarring, this article discusses emerging techniques such as intralesional cryotherapy, intralesional 5-fluorouracil, interferon, and bleomycin. Some of them have been successfully tested in well-designed trials and already have extended or may extend the current spectrum of excessive scar treatment in the near future. Innovative options such as imiquimod 5% cream, photodynamic therapy, or botulinum toxin A may also be of certain importance; however, the data currently available is too contradictory for definite recommendations.

Prosthetic conformer as a pressure device in the prophylactic management of postsurgical auricular keloid formation: a clinical report

Keloids 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, keloids significantly affect the patient's quality of life, both physically and psychologically. Multiple studies have been conducted for decades and have led to a plethora of therapeutic strategies to prevent or attenuate keloid formation, of which no single treatment has proven to be widely effective. Also, there is a dearth of information in the prosthodontic literature regarding appropriate management of such cases, especially when located in cosmetic areas. This clinical report presents an interdisciplinary cooperative approach between maxillofacial prosthetics and dermatology in prophylactic management of postsurgical auricular keloid. A new and an innovatively designed custom prosthesis for the management of the same is presented.

Use of Integra and interval brachytherapy in a 2-stage auricular reconstruction after excision of a recurrent keloid

Keloids present a formidable clinical challenge. Surgical excision in conjunction with radiation therapy may decrease the chance of keloid recurrence. Split-thickness skin grafts, however, are more prone to failure in the setting of radiation. In this report, we present a patient with a recurrent auricular keloid who underwent excision and immediate Integra (Integra LifeSciences, Plainsboro, NJ) application, followed by high-dose rate brachytherapy and interval split-thickness skin graft placement. A 23-year-old woman with a history of a recurrent auricular keloid after previous surgical excision, corticosteroid injection, and radiation underwent reexcision of her keloid. Integra was used to cover the resultant exposed auricular perichondrium. The patient then received high-dose rate brachytherapy (1500 cGy) on postoperative days 1 and 2, followed by definitive split-thickness skin graft placement 3 weeks after her initial surgery. The patient recovered from all interventions without complication. There was no evidence of keloid formation 27 months after the interval split-thickness skin graft placement at either the auricular recipient or thigh donor sites. We report the first case of a 2-stage reconstruction of a recurrent auricular keloid (composed of keloid excision and placement of Integra in conjunction with high-dose rate brachytherapy, followed by interval split-thickness skin grafting), resulting in an acceptable cosmetic result without evidence of recurrence at long-term follow-up.

Organ fibrosis inhibited by blocking transforming growth factor-β signaling via peroxisome proliferator-activated receptor γ agonists

BACKGROUND

Organ fibrosis has been viewed as one of the major medical problems, which can lead to progressive dysfunction of the liver, lung, kidney, skin, heart, and eventually death of patients. Fibrosis is initiated by a variety of pathological, physiological, biochemical, and physical factors. Regardless of their different etiologies, they all share a common pathogenetic process: excessive activation of the key profibrotic cytokine, transforming growth factor-beta (TGF-beta). Peroxisome proliferator-activated receptor gamma (PPARgamma), a ligand-activated transcription factor of the nuclear receptor superfamily, has received particular attention in recent years, because the activation of PPARgamma by both natural and synthetic agonists could effectively inhibit TGF-beta-induced profibrotic effects in many organs.

DATA SOURCES

The English-language medical databases, PubMed, Elsevier and SpringerLink were searched for articles on PPARgamma, TGF-beta, and fibrosis, and related topics.

RESULTS

TGF-beta is recognized as a key profibrotic cytokine. Excessive activation of TGF-beta increases synthesis of extracellular matrix proteins and decreases their degradation, associated with a gradual destruction of normal tissue architecture and function, whereas PPARgamma agonists inhibit TGF-beta signal transduction and are effective antifibrogenic agents in many organs including the liver, lung, kidney, skin and heart.

CONCLUSIONS

The main antifibrotic activity of PPARgamma agonists is to suppress the TGF-beta signaling pathway by so-called PPARgamma-dependent effect. In addition, PPARgamma agonists, especially 15d-PGJ2, also exert potentially antifibrotic activity independent of PPARgamma activation. TGF-beta1/Smads signaling not only plays many essential roles in multiple developmental processes, but also forms cross-talk networks with other signal pathways, and their inhibition by PPARgamma agonists certainly affects the cytokine networks and causes non-suspected side-effects. Anti-TGF-beta therapies with PPARgamma agonists may have to be carefully tailored to be tissue- and target gene-specific to minimize side-effects, indicating a great challenge to the medical research at present.

Cell-free derivatives from mesenchymal stem cells are effective in wound therapy

AIM

To compare the efficacy of cell-free derivatives from Bone marrow derived human mesenchymal stem cells (hMSCs) in wound therapy.

METHODS

hMSCs have been shown to play an important role in wound therapy. The present study sought to compare efficacy of hMSCs and cell-free derivatives of hMSCs, which may be clinically more relevant as they are easier to prepare, formulate and transport. hMSCs were isolated from human bone marrow and cultured. Multi lineage differentiation of hMSCs was performed to confirm their identity. The ability of hMSCs to migrate was evaluated using in vitro and in vivo migration assays. Cell lysates and conditioned medium concentrate was prepared from hMSCs (see Methods for details). Wounds were induced in mice and wound areas were measure before and after cell and cell-free derivative treatment. RNA and proteins were extracted from the skin and cytokine levels were measured.

RESULTS

Co-culture of hMSCs with keratinocytes resulted in increased expression of CXCL-12 (SDF1) and ENA78 (CXCL-5) in the conditioned media indicating that the hMSCs can respond to signals from keratinocytes. Accelerated wound closure was observed when hMSCs were injected near the site of excisional wounds in athymic as well as NOD/SCID mice. Interestingly, cell-free lysates prepared from hMSCs were also effective in inducing accelerated wound closure and increased expression of SDF1 and CXCL-5 at the wound bed. Additionally, concentrated media from hMSCs as well as an emulsion containing lysates prepared from hMSCs was also found to be more effective in rapid re-epithelialization than fibroblasts or vehicle-alone control. Use of cell-free derivatives may help replace expensive wound care approaches including use of growth factors, epidermal/dermal substitutes, synthetic membranes, cytokines, and matrix components, and most importantly avoid transmission of pathogens from human and animal products.

CONCLUSION

These results encourage development of derivatives of hMSCs for wound care and re-epithelialization applications.

miRNA expression profiles in keloid tissue and corresponding normal skin tissue

BACKGROUND

Because the molecular mechanism behind keloid pathogenesis is still largely unknown, the clinical management of keloids remains problematic. miRNA (microRNA) is a novel class of small regulatory RNA that has emerged as post-transcriptional gene repressors and participants in diverse pathophysiological processes of skin disease. In the present study we aimed to investigate expression profiles of miRNA in keloid tissue and to develop a further understanding of the molecular mechanism involved in the pathogenesis of keloids.

METHODS

miRNA expression profiles in 12 pairs of keloid tissue and corresponding normal skin tissue were analyzed through a mammalian miRNA microarray containing established whole human mature and precursor miRNA sequences. Real-Time quantitative PCR was performed to confirm the array results. The putative targets of differentially expressed miRNA were functionally annotated by bioinformatics approaches.

RESULTS

miRNA microarray analysis identified 32 differentially expressed miRNAs, and a total of 23 miRNAs exhibited higher expression, while 9 miRNAs demonstrated lower expression in keloid tissue than in normal skin tissue. Functional annotations of differentially expressed miRNA targets revealed that they were enriched in several signaling pathways important for scar wound healing.

CONCLUSION

This study showed that the expressions of many miRNAs were altered in keloid tissue, and their expression profiling may provide a useful clue for exploring the pathogenesis of keloids. miRNAs might partly contribute to the etiology of keloids by affecting several signaling pathways relevant to scar wound healing.

Involvement of upper torso stress amplification, tissue compression and distortion in the pathogenesis of keloids

Keloids are benign tumours composed of fibrous tissue produced during excessive tissue repair triggered by minor injury, trauma or surgical incision. Although it is recognized that keloids have a propensity to form in the upper torso of the body, the predisposing factors responsible for this have not been investigated. It is crucial that the aetiopathoical factors implicated in keloid formation be established to provide guidelines for well-informed more successful treatment. We compared keloid-prone and keloid-protected skin, identified pertinent morphological differences and explored how inherent structural characteristics and intrinsic factors may promote keloid formation. It was determined that keloid prone areas were covered with high tension skin that had low stretch and a low elastic modulus when compared with skin in keloid protected areas where the skin was lax with a high elastic modulus and low pre-stress level. Factors contributing to elevated internal stress in keloid susceptible skin were the protrusion of hard connective tissue such as bony prominences or cartilage into the dermis of skin as well as inherent skin characteristics such as the bundled arrangement of collagen in the reticular dermis, the existent high tension, the low elastic modulus, low stretch ability, contractile forces exerted by wound healing fibroblastic cells and external forces. Stress promotes keloid formation by causing dermal distortion and compression which subsequently stimulate proliferation and enhanced protein synthesis in wound healing fibroblastic cells. The strain caused by stress also compresses and occludes microvessels causing ischaemic effects and reperfusion injury which stimulate growth when blood rich in growth factors returns to the tissue. The growth promoting effects of increased internal stress, primarily, and growth factors released by reperfusing blood, manifest in keloid formation. Other inherent skin characteristics promoting keloid growth during the late stages of wound healing in the upper torso are the thinner epidermis, the presence of vellus hairs, the absence of protective immunoglobulin A (IgA), and the thick fragile quality of upper torso skin. As it is not known why there is a predilection for keloids to form in the upper torso of the body, this hypothesis implicating and associating inherent morphological characteristics and elevated stress in the aetiopathogenesis of keloids is of potential value in terms of prevention, management and treatment of these enigmatic tumours.

Vaccine-associated fibrosarcoma with keloidal differentiation in a cat

A 6-year-old Domestic Shorthair cat was presented with a history of subcutaneous mass of the lateral left hind limb. The subcutaneous mass developed over a period of approximately 16 months subsequent to administration of Feline leukemia virus vaccines. Based on the histopathological and immunohistochemical examination, the subcutaneous mass was diagnosed as vaccine-associated fibrosarcoma with keloidal differentiation.

Management of ear lobule keloids using 980-nm diode laser

The objective of the study was to evaluate the 980-nm diode laser in conjunction with corticosteroids in the treatment of ear lobule keloids. Several methods have been described for the treatment of keloid scars, but none of them have been 100% successful. Advances in laser techniques have enabled surgeons to define the most appropriate lasers for use in the treatment of different scar types. The diode laser pulses are delivered interstitially in a single repeated mode in non-overlapping sites using a bare optical fiber, followed by intralesional triamcinolone acetonide injection. The number of sessions varies between two to five for the management of more than 75% of keloid size, with a total success rate of 75% and no recurrence in the follow-up of 12 months. The technique used proved to be effective in the treatment of ear lobule keloids.

Conventional Epi-LASIK and lamellar epithelial debridement in myopic patients with dermatologic keloids

We report the outcome of conventional epipolis laser in situ keratomileusis (Epi-LASIK, flap-on) and lamellar epithelial debridement (LED; Epi-LASIK, flap-off) in myopic patients with dermatologic keloids. Three patients, who were all noted to be susceptible to keloid scarring, received conventional Epi-LASIK in their right eyes and LED in their left eyes. The patients were followed-up for 6 to 21 months after their surgeries, and the outcomes were then evaluated. In case 1, the preoperative spherical equivalent (SE) was -6.5 diopters (D) in the right eye (OD) and -6.25 D in the left eye (OS). At 21 months postoperatively, the uncorrected visual acuity (UCVA) was 20 / 12.5 in both eyes. In case 2, the preoperative SE was -5.25 (OD) / -6.00 (OS). After six months, the postoperative UCVA was 20 / 12.5 in both eyes. In case 3, the preoperative SE was -4.5 (OD) / -2.0 (OS). The UCVA at the six-month follow-up was 20 / 12.5 in both eyes. No adverse events, including corneal haze, occurred in any of the patients. All three of our patients reported excellent visual outcomes following both conventional Epi-LASIK and LED, despite their histories of keloid formation. The present cases suggest that both Epi-LASIK and LED may be safe and effective techniques for myopic patients with dermatologic keloids.

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.

Radiotherapy in early-stage Dupuytren's contracture. Long-term results after 13 years

BACKGROUND AND PURPOSE

In early-stage Dupuytren's contracture, radiotherapy is applied to prevent disease progression. Long-term outcome and late toxicity of the treatment were evaluated in a retrospective analysis.

PATIENTS AND METHODS

Between 12/1982 and 02/2006, 135 patients (208 hands) were irradiated with orthovoltage (120 kV; 20 mA; 4-mm Al filter), in two courses with five daily fractions of 3.0 Gy to a total dose of 30 Gy; separated by a 6- to 8-week interval. The extent of disease was described according to a modified classification of Tubiana et al. Long-term outcome was analyzed at last follow-up between 02/2008 and 05/2008 with a median follow-up of 13 years (range, 2-25 years). Late treatment toxicity and objective reduction of symptoms as change in stage and numbers of nodules and cords were evaluated and used as evidence to assess treatment response.

RESULTS

According to the individual stages, 123 cases (59%) remained stable, 20 (10%) improved, and 65 (31%) progressed. In stage N 87% and in stage N/I 70% remained stable or even regressed. In more advanced stages, the rate of disease progression increased to 62% (stage I) or 86% (stage II). 66% of the patients showed a long-term relief of symptoms (i.e., burning sensations, itching and scratching, pressure and tension). Radiotherapy did not increase the complication rate after surgery in case of disease progression and only minor late toxicity (skin atrophy, dry desquamation) could be observed in 32% of the patients. There was no evidence for a second malignancy induced by radiotherapy.

CONCLUSION

After a mean follow-up of 13 years radiotherapy is effective in prevention of disease progression and improves patients' symptoms in early-stage Dupuytren's contracture (stage N, N/I). In case of disease progression after radiotherapy, a "salvage" operation is still feasible.

Molecular dissection of abnormal wound healing processes resulting in keloid disease

Keloids are locally aggressive scars that typically invade into healthy surrounding skin and cause both physical and psychosocial distress to the patient. These pathological scars occur following minimal skin trauma after a variety of causes including burns and trauma. Although the pathogenesis of keloid disease is not well understood, it is considered to be the end product of an abnormal healing process. The aim of this review was to investigate the molecular and cellular pathobiology of keloid disease in relation to the normal wound healing process. The molecular aberrances in keloids that correlate with the molecular mechanisms in normal wound healing can be categorized into three groups: (1) extracellular matrix proteins and their degradation, (2) cytokines and growth factors, and (3) apoptotic pathways. With respect to cellular involvements, fibroblasts are the most well-studied cell population. However, it is unclear whether the fibroblast is the causative cell; they are modulated by other cell populations in wound repair, such as keratinocytes and macrophages. This review presents a detailed account of individual phases of the healing process and how they may potentially be implicated in aberrant raised scar formation, which may help in clarifying the mechanisms involved in keloid disease pathogenesis.

About strawberry, crab claws, and the Sir James Black's invention. Hypothesis: can we battle keloids with propranolol?

The cutaneous hemangiomas of infancy or infantile hemangiomas are the most common benign tumor of childhood. They were formerly known as strawberry hemangiomas in reason of its typical appearance although uncommon morphologic variations can be found. Usually hemangiomas are harmless growths that are the result of proliferation of endothelial cells during early childhood. Involution of the lesion occurs at 12-18 months and can last up to 7 years. Occasionally, infantile hemangiomas suffer dramatic overgrowth causing esthetical damages, as well compromises to vital structures that requires prompt intervention. Propranolol, a beta-adrenergic receptor antagonist that was invented by Sir James Black in 1960s, appears to be an effective treatment for infantile hemangiomas and should now be used as a first-line treatment in hemangiomas when intervention is required. Keloids (that resembles crab claws) and hypertrophic scars are fibrous tissue outgrowths that result from a derailment in the normal wound-healing process. Systemic or intralesional propranolol may play a role in the amelioration of keloids and hypertrophic scars due to their potential to induce vasoconstriction of over proliferating tissues, triggering apoptosis of endothelial cells and also to their effect as modulator of inflammatory process during wound healing. In adding the propranolol to the melting pot of abnormal (or supra-normal) wound healing, we hypothesized that we can battle keloids with propranolol.

Linear nodular collagenoma--successful treatment with intralesional triamcinolone acetonide

A 17-year-old boy presented with papules and nodules arranged linearly on the neck and on the forehead. A diagnosis of collagenoma was made. Intralesional injection of triamcinolone acetonide resulted in marked effacement of the lesions.

Exploring the role of stem cells in cutaneous wound healing

The skin offers a perfect model system for studying the wound healing cascade, which involves a finely tuned interplay between several cell types, pathways and processes. The dysregulation of these factors may lead to wound healing disorders resulting in chronic wounds, as well as abnormal scars such as hypertrophic and keloid scars. As the contribution of stem cells towards tissue regeneration and wound healing is increasingly appreciated, a rising number of stem cell therapies for cutaneous wounds are currently under development, encouraged by emerging preliminary findings in both animal models and human studies. However, we still lack an in-depth understanding of the underlying mechanisms through which stem cells contribute to cutaneous wound healing. The aim of this review is, therefore, to present a critical synthesis of our current understanding of the role of stem cells in normal cutaneous wound healing. In addition to summarizing wound healing principles and related key molecular and cellular players, we discuss the potential participation of different cutaneous stem cell populations in wound healing, and list corresponding stem cells markers. In summary, this review delineates current strategies, future applications, and limitations of stem cell-based or stem cell-targeted therapy in the management of acute and chronic skin wounds.

Surgical treatment of earlobe keloid with CO2 laser radiation: case report and clinical standpoints

Keloids are considered to be benign hyperproliferative growths of dense fibrous tissue and overabundant deposition of disorganized, thick, hyalinized collagen that result from an abnormal tissue response to cutaneous injury. Keloids do not have a specific cause, although genetic predisposition is heavily implicated. We present a case report of a patient with an earlobe keloid that was treated with carbon dioxide laser radiation (CO(2)) with an 0.8-mm focus, 7 W, a power density of 2.5 W/cm(2), in a continuous mode. The patient was seen for follow-up 6 months later. An intact hole for placement of an earring was observed with a very good esthetic and functional result.