Hypertrophic scars and keloids--a review of their pathophysiology, risk factors, and therapeutic management

Keloids in Rubinstein-Taybi syndrome: a clinical study

BACKGROUND

Rubinstein-Taybi syndrome (RSTS) is a multiple congenital anomalies-intellectual disability syndrome. One of the complications is keloid formation. Keloids are proliferative fibrous growths resulting from excessive tissue response to skin trauma.

OBJECTIVES

To describe the clinical characteristics of keloids in individuals with RSTS reported in the literature and in a cohort of personally evaluated individuals with RSTS.

PATIENTS AND METHODS

We performed a literature search for descriptions of RSTS individuals with keloids. All known individuals with RSTS in the Netherlands filled out three dedicated questionnaires. All individuals with (possible) keloids were personally evaluated. A further series of individuals with RSTS from the U.K. was personally evaluated.

RESULTS

Reliable data were available for 62 of the 83 Dutch individuals with RSTS and showed 15 individuals with RSTS (24%) to have keloids. The 15 Dutch and 12 U.K. individuals with RSTS with keloids demonstrated that most patients have multiple keloids (n > 1: 82%; n > 5: 30%). Mean age of onset is 11·9 years. The majority of keloids are located on the shoulders and chest. The mean length × width of the largest keloid was 7·1 × 2·8 cm, and the mean thickness was 0·7 cm. All affected individuals complained of itching. Generally, treatment results were disappointing.

CONCLUSIONS

Keloids occur in 24% of individuals with RSTS, either spontaneously or after a minor trauma, usually starting in early puberty. Management schedules have disappointing results. RSTS is a Mendelian disorder with a known molecular basis, and offers excellent opportunities to study the pathogenesis of keloids in general and to search for possible treatments.

Vascular patterns in mature hypertrophic burn scars treated with fractional CO2 laser

BACKGROUND AND OBJECTIVE

Fractional CO2 laser has recently emerged as a promising therapeutic modality to improve the texture and appearance of burn scars. An issue in many burn scars is persistent erythema, which traditionally has been treated with vascular lasers. Interestingly, fractional CO2 lasers have been shown to improve the appearance of burn scars, including erythema, but no mechanism has been proposed for this change. Our objective is to evaluate the histopathologic changes in vasculature in burn scars treated with fractionated CO2 laser, and to attempt to describe the mechanism behind reduced erythema following treatment.

STUDY DESIGN/MATERIALS AND METHODS

Uncontrolled, prospective study of ten patients with mature burn scars, from a clinical and histological perspective. Biopsy specimens were obtained before and 2 months after 3 treatment sessions. Anti-CD31 immunostaining was performed to highlight vascular patterns in biopsy specimens.

RESULTS

In histological analysis, an increase in vascular density, particularly of small caliber vessels, was seen following treatment, with an 82.6% average increase in vasculature (P = 0.028). This increase in vascularity correlated with a decrease in clinical erythema and vascularity scores, measured using the Vancouver Scar Scale.

CONCLUSION

Mature hypertrophic burn scars treated with a fractional CO2 laser showed a statistically significant increase in vascular density in the superficial dermis. A non-statistical decrease in clinically perceived erythema and improvement of overall appearance was seen. To our knowledge, this is the first report of increased vascular density in burn scars treated with fractional CO2 laser and suggests our prior assumptions on causes of erythema in mature hypertrophic scars may need to be challenged.

Anti-fibrotic actions of interleukin-10 against hypertrophic scarring by activation of PI3K/AKT and STAT3 signaling pathways in scar-forming fibroblasts

Background

The hypertrophic scar (HS) is a serious fibrotic skin condition and a major clinical problem. Interleukin-10 (IL-10) has been identified as a prospective scar-improving compound based on preclinical trials. Our previous work showed that IL-10 has anti-fibrotic effects in transforming growth factor (TGF)-β1-stimulated fibroblasts, as well as potential therapeutic benefits for the prevention and reduction of scar formation. However, relatively little is known about the mechanisms underlying IL-10-mediated anti-fibrotic and scar-improvement actions.

Objective

To explore the expression of the IL-10 receptor in human HS tissue and primary HS fibroblasts (HSFs), and the molecular mechanisms contributing to the anti-fibrotic and scar-improvement capabilities of IL-10.

Methods

Expression of the IL-10 receptor was assessed in HS tissue and HSFs by immunohistochemistry, immunofluorescence microscopy, and polymerase chain reaction analysis. Primary HSFs were treated with IL-10, a specific phosphatidylinositol 3 kinase (PI3K) inhibitor (LY294002) or a function-blocking antibody against the IL-10 receptor (IL-10RB). Next, Western blot analysis was used to evaluate changes in the phosphorylation status of AKT and signal transducers and activators of transcription (STAT) 3, as well as the expression levels of fibrosis-related proteins.

Results

HS tissue and primary HSFs were characterized by expression of the IL-10 receptor and by high expression of fibrotic markers relative to normal controls. Primary HSFs expressed the IL-10 receptor, while IL-10 induced AKT and STAT3 phosphorylation in these cells. In addition, LY294002 blocked AKT and STAT phosphorylation, and also up-regulated expression levels of type I and type III collagen (Col 1 and Col 3) and alpha-smooth muscle actin (α-SMA) in IL-10-treated cells. Similarly, IL-10RB reduced STAT3/AKT phosphorylation and blocked the IL-10-mediated mitigation of fibrosis in HSFs.

Conclusion

IL-10 apparently inhibits fibrosis by activating AKT and STAT3 phosphorylation downstream of the IL-10 receptor, and by facilitating crosstalk between the PI3K/AKT and STAT3 signal transduction pathways.

Pilot Study of the Efficacy of 578 nm Copper Bromide Laser Combined with Intralesional Corticosteroid Injection for Treatment of Keloids and Hypertrophic Scars

Background

Treatments including intralesional corticosteroid injection, pressure therapy, cryotherapy, and various laser therapies have had limited success for keloids and hypertrophic scars.

Objective

This trial evaluated the efficacy of a combination of 578 nm copper bromide laser and the more traditional intralesional corticosteroid injection for the treatment of keloids and hypertrophic scars with respect to scar color.

Methods

Keloids or hypertrophic scars of 12 Korean patients were treated five times by the combined treatment at 4-week intervals. Clinical improvement was assessed by the physicians' global assessment (PGA) comparing pre- and post-treatment photographs, as well as 4 weeks after the last treatment. Erythema intensity was quantified using a mexameter.

Results

Most scars showed significant clinical improvement in PGA and decreased erythema intensity after 5 treatments. All patients showed improvements in symptoms like pruritus.

Conclusion

The combined treatment is effective for keloids and hypertrophic scars, especially when the telangiectatic portion of the scars is prominent. The adjunctive use of 578 nm copper bromide laser decreased the telangiectatic side effects of an intralesional corticosteroid injection by reducing the vascular components of scars.

The application of the starfish hatching enzyme for the improvement of scar and keloid based on the fibroblast-populated collagen lattice

Various bioactivities of the starfish hatching enzyme (HE) including collagen gel contraction, MMPs activity, hydroxyproline release, and gene regulation based on the fibroblast-populated collagen lattice (FPCL) in three-dimensional medium were investigated for the improvement of scar and keloid. The starfish HE significantly inhibited the collagen gel contraction over 2 days of culture. MMP-2 and MMP-9 activities were also identified by gelatin zymography and RT-PCR products with both HE and collagenase treatments, which resulted in the high amount of hydroxyproline release. The HE treatment on the FPCL significantly inhibited the fibroblast proliferation at 3 days of culture. The LPS-induced NO level and iNOS mRNA expression at low concentrations of HE presented a certain ability to inflammatory response. The COX-2 mRNA from the FPCL indicated no significant inflammation-mediated activity at 5 μg/mL of HE, whereas the cytokines of TNF-α and IL-1β were significantly higher than those of the control. Hence, the starfish hatching enzyme can regulate the fibroblast-populated collagen gel conditions by the contraction, MMP production, inflammatory gene expression, etc. Therefore, the starfish HE could be a potential cosmeceutical to heal the scar and keloid tissue.

Comparative proteomic analysis of extracellular matrix proteins secreted by hypertrophic scar with normal skin fibroblasts

The formation of hypertrophic scars (HSs) is a fibroproliferative disorder of abnormal wound healing. HSs usually characterize excessive proliferation of fibroblasts, abnormal deposition of extracellular matrix (ECM) during wound healing, associated with cosmetic, functional, and psychological problems. Owing to the role of ECM proteins in scar formation, we comparatively analyzed matrix proteins secreted by normal skin fibroblasts (NSFs) and HS fibroblasts (HSFs). The acetone-extracted secreted proteins were separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and identified by mass spectrometry (MS). Based on Go annotation of MS data, the profiling of ECM proteins was established and scar-related proteins have been screened out. The functions of several ECM proteins identified by MS have been discussed, such as collagens I, VI, XII, fibronectin, decorin, lumican, and protein procollagen C endopeptidase enhancer 1 (PCPE-1). Among them, the MS result of PCPE-1 was supported by Western blotting that PCPE-1 from HSFs were significantly upregulated than that from NSFs. It is suggested that PCPE-1 could be a potential target for scar treatment. The exploration of scar related proteins may provide new perspectives on understanding the mechanism of scar formation and open a new way to scar treatment and prevention.

[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.

Stability of an extemporaneously prepared bleomycin-lidocaine-epinephrine intradermal admixture used in dermatology

INTRODUCTION

Bleomycin (0.75 g/L)-lidocaine (3.5 g/L)-epinephrine (3.5 mg/L) admixture (BLE) is indicated for keloids treatment. Effect of short-term storage, influence of BLE components and temperature on efficacy and chemical compatibility of bleomycin were studied.

METHODS

The stability study of BLE was conducted in polypropylene infusion bags at 4℃ and 22℃ over a period of 7 days versus bleomycin diluted alone in normal saline and stored in the same conditions. Active Bleomycin fractions, bleomycin A2 (BA2) and bleomycin B2 (BB2) and inactive demethylbleomycin A2 (DBA2) were analyzed by a validated stability-indicating HPLC method.

RESULTS AND DISCUSSION

BA2 and BB2 remained stable for up to 7 days, in both types of bleomycin preparations, whatever the temperature (<10% loss of the initial peak response). In BLE, DBA2 fraction (2.2% at T0) decreased with time. Less degradation was noted with refrigeration (remained % at day 7: 0.86 ± 0.06% at 4℃ versus 0.43 ± 0.02% at 22℃; p = 0.0004). A degradation product (DP) was observed. More significant percentage (of the total of bleomycin fractions) was reached at room temperature (at day 7, 0.97 ± 0.03% at 4℃ versus 1.41 ± 0.06% at 22℃, p = 0.0004). DP attained an identification threshold of 0.5% between the third and fourth days at 4℃ and between the first and the second days at 22℃.

CONCLUSION

A maximum of three days storage at 4℃ and only one day at 22℃ was approved for BLE.

New molecular medicine-based scar management strategies

Keloids and hypertrophic scars are prevalent disabling conditions with still suboptimal treatments. Basic science and molecular-based medicine research have contributed to unravel new bench-to-bedside scar therapies and to dissect the complex signalling pathways involved. Peptides such as the transforming growth factor beta (TGF-β) superfamily, with Smads, Ski, SnoN, Fussels, endoglin, DS-Sily, Cav-1p, AZX100, thymosin-β4 and other related molecules may emerge as targets to prevent and treat keloids and hypertrophic scars. The aim of this review is to describe the basic complexity of these new molecular scar management strategies and point out new fibrosis research lines.

Inhibitory role of Id1 on TGF-β-induced collagen expression in human dermal fibroblasts

Inhibitor of DNA binding 1 (Id1) is a basic helix-loop-helix (bHLH) protein that has a variety of functional roles in cellular events including differentiation, cell cycle and cancer development. In addition, it has been demonstrated that Id1 is related with TGF-β and Smad signaling in various biological conditions. In this study, we investigated the effect of Id1 on TGF-β-induced collagen expression in human dermal fibroblasts. When Id1-b isoform was overexpressed, TGF-β-induced collagen expression was markedly inhibited. Consistent with this result, Id1-b significantly inhibited TGF-β-induced collagen gel contraction. In addition, Id1-b inhibited TGF-β-induced phosphorylation of Smad2 and Smad3. Finally, immunohistochemistry showed that Id1 expression was decreased in fibrotic skin diseases while TGF-β signaling was increased. Together, these results suggest that Id1 is an inhibitory regulator on TGF-β-induced collagen expression in dermal fibroblasts.

Skin, fascias, and scars: symptoms and systemic connections

Every element or cell in the human body produces substances that communicate and respond in an autocrine or paracrine mode, consequently affecting organs and structures that are seemingly far from each other. The same also applies to the skin. In fact, when the integrity of the skin has been altered, or when its healing process is disturbed, it becomes a source of symptoms that are not merely cutaneous. The skin is an organ, and similar to any other structure, it has different functions in addition to connections with the central and peripheral nervous system. This article examines pathological responses produced by scars, analyzing definitions and differences. At the same time, it considers the subcutaneous fascias, as this connective structure is altered when there is a discontinuous cutaneous surface. The consequence is an ample symptomatology, which is not limited to the body area where the scar is located, such as a postural or trigeminal disorder.

Intralesional cryotherapy versus excision and corticosteroids or brachytherapy for keloid treatment: study protocol for a randomised controlled trial

BACKGROUND

Keloids are a burden for patients due to physical, aesthetic and social complaints and treatment remains a challenge because of therapy resistance and high recurrence rates. The main goal of treatment is to improve the quality of life (QoL); this implies that, apart from surgical outcomes, patient-reported outcome measures (PROMs) need to be taken into account. Decision making in keloid treatment is difficult due to heterogeneity of the condition and the lack of comparative studies.

METHODS/DESIGN

This is a multicentre, randomised controlled open trial that compares 1) intralesional cryotherapy versus excision and corticosteroids for primary keloids, and 2) intralesional cryotherapy versus excision and brachytherapy for therapy-resistant keloids. The primary outcome is the Patient and Observer Scar Assessment Scale (POSAS), a 12-item scale (with score 12 indicating the best and 120 indicating the worst scar imaginable). A difference of six points on the total score is considered to be of clinical importance. Secondary outcomes are recurrence rates, volume reduction, Skindex-29 scores, SF-36 scores and complication rates. Primary and secondary outcome measurements are taken at baseline, and at 2, 12, 26 and 52 weeks postoperatively. For analysis, a linear mixed model is used. A total of 176 patients will be included over a period of 2.5 years. The protocol is approved by the Medical Ethics Committee of the Erasmus University Medical Centre Rotterdam and follows good clinical practice guidelines.

DISCUSSION

The outcomes of this study will improve evidence-based decision making for the treatment of keloids, as well as patient education.

TRIAL REGISTRATION

Dutch Trial Register NTR4151.

Late revision or correction of facial trauma-related soft-tissue deformities

Surgical approaches used in accessing the facial skeleton for fracture repair are often the same as or similar to those used for cosmetic enhancement of the face. Rarely does facial trauma result in injuries that do not in some way affect the facial soft-tissue envelope either directly or as sequelae of the surgical repair. Knowledge of both skeletal and facial soft-tissue anatomy is paramount to successful clinical outcomes. Facial soft-tissue deformities can arise that require specific evaluation and management for correction. This article focuses on revision and correction of these soft-tissue-related injuries secondary to facial trauma.

Asiatic acid isolated from Centella asiatica inhibits TGF-β1-induced collagen expression in human keloid fibroblasts via PPAR-γ activation

Keloids are fibroproliferative disorders characterized by exuberant extracellular matrix deposition and transforming growth factor (TGF)-β/Smad pathway plays a pivotal role in keloid pathogenesis. Centella asiatica extract has been applied in scar management for ages. As one of its major components, asiatic acid (AA) has been recently reported to inhibit liver fibrosis by blocking TGF-β/Smad pathway. However, its effect on keloid remains unknown. In order to investigate the effects of AA on cell proliferation, invasion and collagen synthesis, normal and keloid fibroblasts were exposed to TGF-β1 with or without AA. Relevant experiments including 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay, 5-ethynyl-2-deoxyuridine (EdU) incorporation assay, Transwell invasion assay, enzyme-linked immunosorbent assay, Western blot, quantitative polymerase chain reaction and RNA interference assay were conducted. As a result, keloid fibroblasts showed higher responsiveness to TGF-β1 stimulation than normal fibroblasts in terms of invasion and collagen synthesis. AA could suppress TGF-β1-induced expression of collagen type I, inhibit Smad 2/3 phosphorylation and plasminogen activator inhibitor-1 (PAI-1) expression, while elevate Smad 7 protein level. Noteworthy, the effects of AA on keloid fibroblasts could be abrogated by PPAR-γ antagonist GW9662 and by silencing of PPAR-γ. The present study demonstrated that AA inhibited TGF-β1-induced collagen and PAI-1 expression in keloid fibroblasts through PPAR-γ activation, which suggested that AA was one of the active constituents of C. asiatica responsible for keloid management, and could be included in the arsenal for combating against keloid.

Treatment of refractory keloids with pulsed dye laser alone and with rotational pulsed dye laser and intralesional corticosteroids: A retrospective case series

BACKGROUND AND AIMS

The limited available effective treatments make the management of keloids challenging. Intralesional triamcinolone and pulsed dye laser have been used for the treatment of keloids. We sought to assess the efficacy of a treatment regime using rotational intralesional triamcinolone and pulsed dye laser in the management of keloids. Materials (Subjects) and Methods: Case notes and photographic records of 99 patients with keloids treated with pulsed dye laser (PDL) alone or rotational PDL and intralesional triamcinolone (ILT) at our centre between 2005 and 2010 were reviewed. Patients with raised, erythematous and/or symptomatic keloids unresponsive to ILT alone (usually 6 treatments) are referred for consideration of PDL. Patients are offered repeated rotational treatments of three PDL (4-15 J/cm(2), 7 mm spot, 1.5 msec pulse duration, 595 nm wavelength, DCD, 30 msec spray: 20 msec delay; spaced at 6-8 weeks intervals) followed by one ILT (10 mg or 40 mg/dl). ILT-treated flat but erythematous and/or symptomatic keloids are treated with PDL alone at 6-8 week intervals. Response after each laser treatment is documented as a percentage improvement from baseline. Based on the improvement in redness, thickness and pruritus the operator classified the response to treatment as mild (0-49%), moderate (50-75%) or excellent (>75%). Patients are reviewed at 6 months following last treatment. A patient satisfaction questionnaire was also sent out to all patients who received treatments between 2005 and 2010 and this was compared with the information gathered from the notes.

RESULTS

Of the 99 patients, 58 were women and 41 were men and most were Caucasian (n=84). A total of 755 keloids were treated. The average number of PDL treatments to achieve a moderate-excellent result was 14 in male and 12 in females. Moderate-excellent improvement was seen in 76% patients. The average number of ILT required to achieve a moderate-excellent result was 5 in males and 4 in females. All patients were sent a satisfaction questionnaire and 33 responses were received wherein patients reported an average of 70% improvement in the redness and thickness of the keloids. Localised cutaneous atrophy, self-limiting erythema and injection site discomfort were noted in 3 female patients whilst no side-effects noted in the male cohort.

CONCLUSIONS

Pulsed dye laser with or without intralesional triamcinolone is a moderately effective treatment of keloid scars with a very good side-effect profile and high patient satisfaction.

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.

Apoptosis and angiogenesis: an evolving mechanism for fibrosis

Fibrosis, seen in the liver, lung, heart, kidney, and skin, is a significant global disease burden. Currently, therapeutic treatment is limited, and the number of cases continues to grow. Apoptosis has been identified as a potential initiator and propagator of fibrosis. This review specifically examines the correlation between the presence of apoptotic cells and their effect on fibroblast phenotype and collagen metabolism in several different experimental models of fibrosis. Fibrosis in these models is generally preceded by robust angiogenesis and vascular regression, suggesting that the vascular apoptotic burden may be important to fibrotic outcomes. This review considers the emerging evidence that angiogenesis or vascular regression contributes to fibrosis and identifies initial vascular outgrowth or vascular apoptotic cell presence as possible regulators of fibrosis. A further understanding of the cellular mechanisms of fibrosis may suggest novel methods for the reduction of the fibrotic response and promotion of regeneration.

Topical delivery of triamcinolone via skin pretreated with ablative radiofrequency: a new method in hypertrophic scar treatment

BACKGROUND

Epidermal permeability alterations induced by ablative fractional resurfacing and low-frequency ultrasound technology may offer drug delivery for the treatment of hypertrophic scars through transepidermal drug delivery (TED). This technology can improve treatment efficacy and minimize side effects.

OBJECTIVE

To evaluate clinical response and side effects of TED technology in hypertrophic scars in the body and on the face using ablative fractional radiofrequency (RF) associated with low-frequency acoustic pressure ultrasound (US).

METHODS

Four patients with hypertrophic scars were treated with triamcinolone using fractional ablative RF and US. The treatment procedure comprised three steps: (i) ablative fractional RF for skin perforation; (ii) topical application of triamcinolone acetonide 20 mg/ml on the perforated skin; and (iii) acoustic pressure wave US applied to enhance triamcinolone penetration into the skin.

RESULTS

Complete resolution was seen after one session in patients with scars on the nose and mandibular area. The scar on the neck showed complete resolution after four sessions. The scar on the knee showed a marked improvement after four sessions. Mild and homogeneous atrophy was observed in hypertrophic scars on the neck.

CONCLUSION

Ablative fractional RF associated with acoustic pressure US is a new technology aiming to increase drug delivery into skin. This new method can improve the efficacy of steroids in hypertrophic scar treatment, minimizing the risks of localized atrophy and irregular appearance of the treated lesion.

Role of Hyaluronic Acid Treatment in the Prevention of Keloid Scarring

BACKGROUND

Keloids are benign dermal scars characterized by enhanced growth factor signaling, hyperproliferation activity and reduced extracellular matrix (ECM) deposition of hyaluronic acid. Our hypothesis is that high molecular weight HA can be used to replenish HA deposition in keloids thereby normalizing the keloid fibroblast phenotype.

METHODS

One normal (NF1) fibroblast culture and five keloid (KF1, KF2, KF3, KF4, KF5) fibroblast cultures were analyzed for changes in hyperproliferation, growth factor production and extracellular matrix deposition following 72 hour treatment with or without 10 μg/ml HA.

RESULTS

Proliferation activity decreased significantly in KF3 following HA treatment. Pro-collagen I expression in KF2 was decreased following HA treatment in association with changes in fiber arrangement to more parallel collagen bundles. In addition, HA demonstrated a downregulation on TGF-b1 growth factor expression in KF3 and KF4 and a decrease in active TGF-b1 release in KF2 and KF5 using ELISA.

CONCLUSION

Our data demonstrates that HA has the potential to normalize keloid fibroblast characteristic features such as hyperproliferation, growth factor production and ECM deposition depending on the specific genotype of the keloid fibroblast cell line. This study suggests that high molecular weight HA can be used to replenish HA deposition in keloid fibroblasts thereby decreasing fibrosis and ultimately decreasing keloid manifestation.

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.

The immunology of fibrosis

Fibrosis is the production of excessive amounts of connective tissue, i.e., scar formation, in the course of reactive and reparative processes. Fibrosis develops as a consequence of various underlying diseases and presents a major diagnostically and therapeutically unsolved problem. In this review, we postulate that fibrosis is always a sequela of inflammatory processes and that the many different causes of fibrosis all channel into the same final stereotypical pathways. During the inflammatory phase, both innate and adaptive immune mechanisms are operative. This concept is exemplified by fibrotic diseases that develop as a consequence of tissue damage, primary inflammatory diseases, fibrotic alterations induced by foreign body implants, "spontaneous" fibrosis, and tumor-associated fibrotic changes.

Cell-cell interaction between vocal fold fibroblasts and bone marrow mesenchymal stromal cells in three-dimensional hyaluronan hydrogel

Mesenchymal stromal cells (MSCs) are multipotential adult cells present in all tissues. Paracrine effects and differentiating ability make MSCs an ideal cell source for tissue regeneration. However, little is known about how interactions between implanted MSCs and native cells influence cellular growth, proliferation, and behaviour. By using an in vitro three-dimensional (3D) co-culture assay of normal or scarred human vocal fold fibroblasts (VFFs) and bone marrow-derived MSCs (BM-MSCs) in a uniquely suited hyaluronan hydrogel (HyStem-VF), we investigated cell morphology, survival rate, proliferation and protein and gene expression of VFFs and BM-MSCs. BM-MSCs inhibited cell proliferation of both normal and scarred VFFs without changes in VFF morphology or viability. BM-MSCs demonstrated decreased proliferation and survival rate after 7 days of co-culture with VFFs. Interactions between BM-MSCs and VFFs led to a significant increase in protein secretion of collagen I and hepatocyte growth factor (HGF) and a decrease of vascular endothelial growth factor (VEGF), monocyte chemotactic protein-1 (MCP-1) and interleukin-6 (IL-6). In particular, BM-MSCs significantly upregulated matrix metalloproteinase 1 (MMP1) and HGF gene expression for scarred VFFs compared to normal VFFs, indicating the potential for increases in extracellular matrix remodelling and tissue regeneration. Application of BM-MSCs-hydrogels may play a significant role in tissue regeneration, providing a therapeutic approach for vocal fold scarring. Copyright © 2013 John Wiley & Sons, Ltd.

A combination of nonoperative treatment modalities used for treatment of keloids

Keloid is one abnormal wound healing that occurs commonly in predisposed individuals. Many treatment modalities have been tried, either alone or in variety, including surgical removal, laser therapy, radiation therapy, silicone cream or gel application, cryosurgery, and intralesional injection of various agents. These treatment options have been practiced with largely transient and limited success. In the present study, the present authors prospectively assessed the efficacy of combination methods of the treatment of recalcitrant keloid. One hundred fifty-one sites of keloids in 122 patients were chosen, age of patients varied between 15 and 60 years, size of scar more than 2 cm(2) with pain, itch, or other discomfort, and duration of more than 2 years. Keloids were treated with combination methods of lasers and (32) P radiation on originating scars. One hundred eleven of 151 evaluated sites scored "excellence" and 40 belonged to "effectiveness". These patients demonstrated local control and have remained free of local recurrence for more than 2 years. In addition, there were only 21 and 32 sites with pigmentation and depigmentation, respectively. Over the past 5 years, we established a treatment protocol combining laser with (32) P-patch contact brachyradiotherapy, which represents a safe and effective option in the treatment of keloids.

Totally implantable venous access device in children with cancer lead to disfiguring scar

BACKGROUND

In pediatric cancer patients scars of totally implantable venous access devices (TIVAD) are often widened and hypertrophic. This study report on the prevalence and deviation of abnormal scarring in children with a TIVAD and to describe the influencing factors for this abnormal scarring.

METHODS

In a cross-sectional study scars of 122 childhood cancer patients (age 1-21 years) were evaluated; 72 patients had a TIVAD in-situ and in 50 the TIVAD had been removed. Outcome parameters were hypertrophy (modified Vancouver Scar Scale (mVSS), scar surface area, pain, and itching. Scar abnormality was defined as mVSS of >2, or scar width >3 mm.

RESULTS

Abnormal TIVAD scars were found in 107 participants. The mVSS score was higher in patients ≤45 months after removal and the widest >45 months after TIVAD removal. Multivariable analyses showed that the mVSS score was positively related with scar width (mm) and children being ≤45 months after TIVAD removal. Furthermore, TIVAD scar width was positively related with age at last TIVAD surgery, and associated with suture material. In conclusion, there was a high incidence of abnormal TIVAD scars with some pain and itching complaints. However, no typical cancer related influencing factors were associated with increasing abnormalities.

Negative pressure surgical management after pathological scar surgical excision: a first report

Wound dehiscence is a surgical complication caused by the application of opposing and distracting forces tending to pull apart the suture line. In recent years, a novel negative pressure surgical management system has been developed to prevent surgical wound complications. This system creates a closed environment that removes exudates and other potentially infectious material, protects the surgical site from external contamination, provides support in holding the edges of the incision together and promotes wound healing. In this study, we describe our first experience with Prevena™, a closed incision negative pressure management system used on suture line following wide pathological scars excision for the prevention of postoperative wound dehiscence. Eight patients with wide and mature pathological skin scars were treated with Prevena™. The device was positioned directly after surgical correction for 8 days with a continuous application of -125 mmHg negative pressure. All treated patients had no postoperative surgical wound dehiscence. In one case, a limit of the device was represented by its poor adherence on hairy surface, hampering the maintenance of an appropriate local negative pressure. In another case, suture line was longer than Prevena™ foam and it was covered partially. Prevena™ system appears to be safe, easy to use and may represent a support technique to wide pathological skin scars surgical correction.

Effects of TRAP-1-like protein (TLP) gene on collagen synthesis induced by TGF-β/Smad signaling in human dermal fibroblasts

BACKGROUND

Hypertrophic scars are pathologic proliferations of the dermal skin layer resulting from excessive collagen deposition during the healing process of cutaneous wounds. Current research suggests that the TGF-β/Smad signaling pathway is closely associated with normal scar and hypertrophic scar formation. TRAP-1-like protein (TLP), a cytoplasmic protein, has been reported to efficiently regulate Smad2- and Smad3-dependent signal expression in the TGF-β pathway. The relationship between TLP and Type I/III collagen (Col I/III) synthesis explored in the present study provides an effective target for wound healing and gene therapy of hypertrophic scarring.

OBJECTIVE

To investigate the effects of TLP on collagen synthesis in human dermal fibroblasts.

METHODS

Lentiviral vectors encoding TLP was constructed to transfect fibroblasts derived from normal human skin. The expression of Col I/III and phosphorylation of Smad2 and Smad3 in fibroblasts were examined after TLP treatment. In addition, the comparison of TLP expression in normal skin tissues and in hypertrophic scar tissues was performed, and the effect of TLP on cell viability was analyzed by MTT assay.

RESULTS

TLP expression in hypertrophic scar tissue was markedly higher than in normal skin tissue. The Real Time PCR and Western blot test results both revealed that the synthesis of Col I/III was positively correlated with the expression of TLP. TLP also facilitate Smad2 phosphorylation while, conversely, inhibiting Smad3 phosphorylation. TLP may play a cooperative role, along with the cytokine TGF-β1, in improving the overall cell viability of skin fibroblasts.

CONCLUSIONS

TLP likely acts as a molecular modulator capable of altering the balance of Smad3- and Smad2-dependent signaling through regulation of phosphorylation, thus facilitating collagen synthesis in fibroblasts. Based on genetic variation in TLP levels in different tissues, these results suggest that TLP plays a key role in the process of TGF-β1/Smad3 signaling that contributes to wound healing and genesis of pathologic scars.

The impact of ethnicity and obesity on the course of colonic diverticulitis

BACKGROUND

Little research has been performed on the impact of race/ethnicity and obesity on the course of diverticulitis.

PURPOSE

To determine whether patients of different racial/ethnic backgrounds and patients who are obese have disparate courses of disease with regard to complications, recurrence rates, and need for surgery.

METHODS

We conducted a retrospective review of the charts of 347 patients with confirmed diverticulitis in 2 university teaching hospitals at Bronx, NY.

RESULTS

African Americans were more likely [odds ratio (OR), 2.28, 95% confidence interval (CI), 1.04-5.00, P = 0.04] and Hispanics were less likely than other racial/ethnic groups (OR, 0.47; 95% CI, 0.22-0.97; P = 0.04) to require surgery for recurrent diverticulitis after at least 1 medically managed hospital admission for diverticulitis. Caucasians were less likely than other racial/ethnic groups to suffer a recurrence of diverticulitis (OR, 0.48; 95% CI, 0.27-0.86; P = 0.01). Obese patients [ body mass index (BMI) >30] were more likely than nonobese patients to experience a recurrent episode of diverticulitis (OR, 1.69; 95% CI, 1.08-2.64; P = 0.02). The odds of requiring surgery on the initial presentation of diverticulitis were not significantly different among the various races/ethnicities nor was the likelihood of surgery influenced by BMI. Complication rates did not differ significantly when patients were stratified by age, sex, race, BMI, or number of prior episodes of diverticulitis.

CONCLUSIONS

Surgery for diverticulitis after at least 1 medically managed hospital admission for diverticulitis is more frequently needed in African Americans and less frequently needed in Hispanics. Caucasians are less likely than other races/ethnicities to suffer a recurrence of diverticulitis. Finally, obesity is a risk factor for recurrent diverticulitis, but not for surgical therapy of diverticulitis.

Protection against TGF-β1-induced fibrosis effects of IL-10 on dermal fibroblasts and its potential therapeutics for the reduction of skin scarring

Scarring, tightly associated with fibrosis, is a significant symptomatic clinical problem. Interleukin 10 (IL-10) has been identified as a candidate scar-improving therapy based on preclinical studies. However, the molecular mechanism of IL-10 in scar improvement is still uncertain. In this study, human dermal fibroblasts stimulated with TGF-β1 were treated with IL-10 to analyze the mRNA and some of proteins' expression levels of type I collagen (Col1), type III collagen (Col3), alpha-smooth muscle actin (α-SMA), matrix metalloproteinase-1 (MMP1), MMP2, MMP8 and tissue inhibitor of metalloproteinase 1 (TIMP1), TIMP2 by real-time PCR and Western blot, to observe α-SMA-positive fibroblasts by immunocytochemistry. The contracture and improvement of fibroblast-populated collagen lattice (FPCL) and a murine model of wound healing were used to evaluate the scar-improving effects by histological staining. The results showed that IL-10 can significantly down-regulate the mRNA and protein expression levels of Col1, Col3, α-SMA, and up-regulate the mRNA expression levels of MMP1 and MMP8, and decrease α-SMA-positive fibroblasts. FPCL analysis showed that the IL-10 (20 ng/ml) can significantly inhibit the contracture, improve the architecture of FPCL. Wounds injected with IL-10 demonstrated that the appearance of scar was improved, the wound margin of scarring was narrow, and the deposition of collagens (Col1 and Col3) in regenerated tissue was relieved. These results provide direct evidences that IL-10 has the inhibitory effects on the excessive deposition of extracellular matrix components and fibroblast-to-myofibroblast transition, and show that IL-10 has the potential therapy in prevention and reduction of skin scarring.

Adjuvant chemotherapy reduces the incidence of abdominal hypertrophic scarring following immediate TRAM breast reconstruction

Among the many factors that affect the degree of completion and satisfaction of breast reconstruction, the scarring is one issue that a surgeon cannot completely control. We hypothesized that the administration of cytotoxic drugs following the immediate breast reconstruction using transverse rectus abdominis musculocutaneous (TRAM) flap might affect the process of scarring, thus resulting in reduced incidence of hypertrophic scarring at the donor site. Data have been collected from 1,000 consecutive patients between July 2001 and December 2009. The relationship between the adjuvant chemotherapy and the incidence of hypertrophic scarring was studied, and the influence of other presumed risk factors was analyzed. The incidence of hypertrophic scarring was 18.6 % (75 of 404) in the non-CTX group and 3.8 % (20 of 530) in the CTX group. Univariate analysis using logistic regression modeling confirmed the statistical significance of the reducing effect of chemotherapy on the incidence of hypertrophic scarring (p < 0.001; OR: 0.172). The incidence of donor-site hypertrophic scarring following immediate TRAM breast reconstruction was found in nearly 20 % of the patients without chemotherapy, showing a significant difference from the patients with chemotherapy. We believe that Asian patients who undergo immediate TRAM breast reconstruction without chemotherapy are a high-risk group that is prone to hypertrophic scarring, requiring active preventive measures.

Clinical characteristics of auricular keloids treated with surgical excision

Background and Objectives

Differences in morphology of auricular keloids possibly contribute to distinct results of treatment. The aim of this study was to evaluate clinical characteristics of the auricular keloids according to the modified Chang-Park classification and to compare the results of treatment including recurrence rate between the subgroups.

Subjects and Methods

Clinical data of 15 patients of auricular keloids were retrospectively reviewed. The keloids were classified according to modified Chang-Park classification. Clinical characteristics, the presence of recurrence, and the duration required for the recurrence were compared.

Results

Eight out of 15 patients (53.3%) were single sessile type (type II), followed by 4 patients of pedunculated type, 1 patient of multiple sessile type, 1 patient of buried type, and 1 patient of mixed type, respectively. Recurrent keloids after previous surgeries were noted in 7 out of 15 patients and most of them (6 of 7, 85.7%) were sessile type. Three patients who underwent surgery at our department showed recurrence.

Conclusions

The classification of auricular keloids according to morphologic patterns can assist surgeons in choosing the appropriate management.

SFRP2 and slug contribute to cellular resistance to apoptosis in hypertrophic scars

Hypertrophic scars (HS) are skin disorders which occur after wounding and thermal injury. Our previous studies have suggested that secreted frizzled-related protein 2 (SFRP2) is involved in HS formation and that the suppression of SFRP2 promotes apoptosis of hypertrophic scar fibroblasts (HSFBs). However, the mechanisms have not been clarified. Previous studies revealed that Slug expression inhibits cell apoptosis, in vitro and in vivo, and SFRP2 regulates the expression of Slug in cervical cancer cells. In the present study, we quantified differential expression levels of expression of SFRP2 and Slug in HS and normal skin tissues by immunohistochemistry, both of which have important anti-apoptosis roles. Furthermore, a short hairpin RNA approach was adopted to investigate the potential function of SFRP2 and Slug in HSFB apoptosis. Cell apoptosis was detected using fluorescence-activated cell sorting and Caspase-3 activity was assayed by spectrophotometry. This study demonstrates that SFRP2 expression, as well as Slug, is dramatically up-regulated in HS relative to normal skin tissues, and the Slug expression is positively correlated with SFRP2. Slug expression was down-regulated in SFRP2-deficient cells, and the down-regulation of Slug expression increased sensitivity to apoptosis which was induced through a caspase-3-dependent pathway. The infected cells with reduced levels of Slug were tested for the expression of apoptosis-related genes (Bcl-2, Bax and PUMA) which were previously identified as Slug targets. Bcl-2 expression was down-regulated in Slug-deficient cells. In conclusion, SFRP2 appears to interact with Slug to affect the apoptosis of hypertrophic scar fibroblasts.

Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches

Acne scarring is a commonly encountered yet extremely challenging problem to treat for the dermatologist. As acne scarring can lead to significant psychological distress and low self-esteem, it is of utmost importance to have effective and satisfying treatments in the physician's armamentarium. However, many treatments are unsatisfying, leading to patient disappointment and frustration. Although early treatment of acne lesions and inflammation with isotretinoin is beneficial in preventing acne scarring, many patients still present with troubling noticeable scars. Despite the advances in pharmacology and technology, scar treatment still remains suboptimal and is tainted with several adverse effects. However, some treatments can provide benefits. This review article exhaustively discusses and analyzes the various minimally invasive approaches to the treatment of acne scarring with an emphasis on pharmacologic agents, such as isotretinoin for atrophic acne scars and corticosteroids and chemotherapeutic drugs for hypertrophic scars. Intralesional injections of corticosteroids are efficacious in reducing keloid scar formation in addition to preventing recurrence following surgical excision. In-office and minimally invasive procedural management, including chemical peels, dermabrasion, tissue augmentation, and punch excision is also discussed. Superficial chemical peels are efficacious in treating atrophic scars with relatively few adverse effects and complications. Although dermabrasion is used less often with the advent of laser resurfacing, this technique remains as a viable option for those with atrophic scars. Post-inflammatory hyperpigmentation can be managed successfully with topical agents such as azelaic acid and hydroquinone. The efficacy of various treatment modalities is highlighted with a focus on choosing the correct modalities for specific scar types.

An ex vivo model employing keloid-derived cell-seeded collagen sponges for therapy development

The most distinctive feature of keloid is the extreme deposition of extracellular matrix, including collagens and proteoglycans (PGs). The focus of this study was the PG versican, which presumably defines keloid volume because of its ability to retain large amounts of water through its component glycosaminoglycans (GAGs). The excessive deposition of versican in keloids was examined by immunohistochemical analysis and by upregulation of the versican gene in these lesions by real-time PCR. The latter showed that mesenchymal cells derived from keloid lesion (KL) cells continue to exhibit above-normal versican production in culture. To establish a model of GAG deposition in keloids, collagen sponges seeded with KL cells (KL-SPos) were implanted in the subcutaneous space of nude mice. After 1 month, the KL-SPos were significantly heavier than the fibroblast (Fb)-seeded sponges (Fb-SPos). This ex vivo model was subsequently used to examine an inhibitory ability of IL-1β that was identified to reduce versican in vitro. IL-1β or chondroitinase ABC, when injected directly, successfully reduced the weight of the KL-SPos. Thus, on the basis of the change in weight of the seeded sponges, this ex vivo model can be used to test therapies aimed at reducing or inhibiting keloid formation and to study the pathogenesis of this aberrant response.