Therapie von hypertrophen Narben und Keloiden: Ein Update

[Surgical management of burn injury patients : Comments on the guidelines on treatment of thermal injuries in adults]

The treatment of burn injury patients is a unique challenge for clinicians. The extent of thermal injuries ranges from very small burns to life-threatening burn injuries. Insufficient treatment can result in a substantial impairment in the quality of life. In order to avoid such sequelae a targeted treatment must be carried out. A precise diagnosis determines the necessary treatment. Superficial second-degree burns (2a) not involving the face, hand or joints with a total body surface area smaller than 10% can usually be treated with modern wound dressings in an outpatient setting. Deep second-degree burns (2b) are an indication for debridement. In addition to the classical surgical procedures with tangential excision, enzymatic debridement can also be employed. Similarly, indeterminate burns (2a/2b) are also considered to be an indication for enzymatic debridement. Third-degree burns are treated with early debridement and skin grafting. These patients can also benefit from special dermal replacement procedures for an improvement of the functional and esthetic results. Due to the long-term visible sequelae of burns, aftercare of these patients is indicated.

[Surgical management of burn injury patients : Comments on the guidelines on treatment of thermal injuries in adults]

The treatment of burn injury patients is a unique challenge for clinicians. The extent of thermal injuries ranges from very small burns to life-threatening burn injuries. Insufficient treatment can result in a substantial impairment in the quality of life. In order to avoid such sequelae a targeted treatment must be carried out. A precise diagnosis determines the necessary treatment. Superficial second-degree burns (2a) not involving the face, hand or joints with a total body surface area smaller than 10% can usually be treated with modern wound dressings in an outpatient setting. Deep second-degree burns (2b) are an indication for debridement. In addition to the classical surgical procedures with tangential excision, enzymatic debridement can also be employed. Similarly, indeterminate burns (2a/2b) are also considered to be an indication for enzymatic debridement. Third-degree burns are treated with early debridement and skin grafting. These patients can also benefit from special dermal replacement procedures for an improvement of the functional and esthetic results. Due to the long-term visible sequelae of burns, aftercare of these patients is indicated.

Liposome-encapsulated statins reduce hypertrophic scarring through topical application

Hypertrophic scar is an important clinical problem with limited therapeutic options. Aside from their roles as 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, statins have also been demonstrated to decrease scarring by reducing connective tissue growth factor (CTGF) expression. However, poor penetrative ability limits their utility as topical treatments for hypertrophic scar. Here, we aim to develop novel statin formulations using liposomes to enhance dermal penetrative ability and to evaluate their efficacy against formation of hypertrophic scar utilizing our validated rabbit ear hypertrophic scar model. Liposomal simvastatin or pravastatin were compounded using a novel, flexible liposomal formulation and applied topically to rabbit ear hypertrophic scars daily from postoperation day (POD) 14 until POD 25. Scar color, including erythema and melanin, was measured using reflectance spectrophotometry on POD 28, and scar tissue was harvested for evaluation of scar elevation index as well as gene and protein expression. Human foreskin fibroblasts were also treated with statin formulations and CCN2 expression was determined by quantitative PCR. Both simvastatin and pravastatin were efficiently encapsulated in liposomes, forming nanometer-scale particles possessing highly negative charges. Topical treatment with liposomal simvastatin and pravastatin at 6.5% concentration significantly reduced scar elevation index and decreased type I/III collagen content and myofibroblast persistence in the wound. The erythema/vascularity of scars was reduced by liposomal statin treatment, with concomitant decrease of CD31 expression as measured histologically. Expression levels of transcripts encoding CTGF, collagen I, and collagen III collagen in scar tissue were also decreased by liposomal pravastatin treatment, as were myofibroblast persistence and the type I/III collagen ratio as assessed by immunofluorescence and picrosirus red staining, respectively. Treatment of human foreskin fibroblasts with simvastatin or with liposome-encapsulated pravastatin resulted in decreased expression of transcript encoding CTGF. Overall, our novel statin formulations encapsulated in liposomes were successfully delivered through topical application, significantly reducing hypertrophic scarring in a rabbit ear model.

MiR-21 Regulates Keloid Formation by Downregulating Smad7 via the TGF-β/Smad Signaling Pathway

A keloid is a benign fibroproliferative skin tumor that results from abnormal wound healing after injury and tends to grow beyond the boundary of the original wound; the mechanism of keloid formation is still unclear. MicroRNA-21 (MiR-21) is a representative microRNA that plays a key role in a variety of fibrotic diseases via the transforming growth factor-β/Smad signaling pathway. The aim of our study was to explore the mechanism of keloid formation. First, we found that the expression of miR-21 in keloids and keloid fibroblasts was significantly upregulated by microRNA microarray and real-time polymerase chain reaction. Additionally, at the protein level, our study confirmed that the overexpression of miR-21 could promote the process of keloid fibrosis to some extent and also indicated that a low expression of miR-21 could inhibit the process of keloid fibrosis. Finally, the results proved that miR-21 could participate in the keloid fibrosis process through negative regulation of its downstream target gene Smad7 via the transforming growth factor-β/Smad signaling pathway, which provides a guiding framework for further studies and new theoretical support for keloid clinical treatment.

Tissue expanders; review of indications, results and outcome during 15 years' experience

BACKGROUND

Tissue expanders (TE) are frequently used worldwide. In this study we surveyed outcome of our patients retrospectively during 15 years.

MATERIALS AND METHODS

We had 1105 patients for whom 3059 TEs have been used. Demographic data, age, sex, indications, type of tissue expander devices, volume of devices, site of scar and site TE insertion, our technique for tissue expander insertion and flap design, complications and outcome were gathered. A complete and through technical points and tips will be discussed.

RESULTS

In 91% of patients overexpansion was done. (Expansion ratio=2.1-4.5). Re-expansion has been done in about 12% of patients. Complications were perforation of skin of pocket (11%) or exposure, infection (6%), dehiscence of the wound (1.5%), perforation of the port or disconnection of the tubes (2.1%), expansion of the scar itself (1%), saggy flap (3%), dog ear (5%), lack of adhesions of flap to its new site (4%).

OUTCOME

In 93% of the patients we could totally remove the scar. Around 9.1% of our patients had two sessions of expansion in the same area and 2.9% had three sessions of expansion. 51% of our patients were highly satisfied and 42% were satisfied of the results of expansion.

CONCLUSION

Our patients were satisfied with the results. In 12% cases we have done re-expansion. Re-expansion is possible as long as you have enough thickness of dermis in the skin. More than 50% of our patients were optimistic for 2nd or 3rd session of re-expansion.

Delivery systems of current biologicals for the treatment of chronic cutaneous wounds and severe burns

While wound therapy remains a clinical challenge in current medical practice, much effort has focused on developing biological therapeutic approaches. This paper presents a comprehensive review of delivery systems for current biologicals for the treatment of chronic wounds and severe burns. The biologicals discussed here include proteins such as growth factors and gene modifying molecules, which may be delivered to wounds free, encapsulated, or released from living systems (cells, skin grafts or skin equivalents) or biomaterials. Advances in biomaterial science and technologies have enabled the synthesis of delivery systems such as scaffolds, hydrogels and nanoparticles, designed to not only allow spatially and temporally controlled release of biologicals, but to also emulate the natural extracellular matrix microenvironment. These technologies represent an attractive field for regenerative wound therapy, by offering more personalised and effective treatments.

Free flaps in scar treatment

Introduction:

Scar management needs defined concepts and an algorithm to restore functional and aesthetic units. After an unsuccessful conservative treatment, surgical measures provide a vast spectrum of possibilities for remediation. The spectrum of possibilities consists of excision and Z-plasty, regional flaps, vascularized pedicled flaps, tissue expansion, and finally free tissue transfer. Severe scarring and highly destructed tissues with inferior functional and aesthetic units can be effectively treated with radical excision and free flap reconstruction. The complexity of flap architecture and tissue qualities allows for an individualized approach. Specific attention should be paid to the long-term consequences of severe scarring with progressive loss of functionality.

Materials and methods:

We worked out the most common surgical approaches and treatment algorithm for a stepwise and effective approach. Part of this algorithm is a seven-step surgical approach.

Results:

This article provides modern plastic and reconstructive surgery concepts with an algorithm for scar management.

Discussion:

The treatment of scars follows an algorithm with the level of complexity of techniques adjusted to the individual case and the conditions. Disabilities induced by scarring can lead to further functional loss. In these cases, surgical strategies have to be considered.

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

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

Hydrogel Functionalized Janus Membrane for Skin Regeneration

In this study, a hydrogel functionalized Janus membrane is developed and its capacity is examined as a wound dressing biomaterial. A hydrophobic fluoropolymer, poly(3,3,4,4,5,5,6,6,7,7,8,8,9,9,10,10,10-heptadecafluorodecyl methacrylate) (PHFDMA), is uniformly coated onto macroporous polyester membrane through initiated chemical vapor deposition process on both sides. PHFDMA-coated macroporous membrane exhibits antibacterial property, allows air permeation, and inhibits water penetration. Janus membrane property is obtained by exposing one side of PHFDMA coated membrane with 1 m KOH solution, which allows PHFDMA cleavage resulting in carboxylic acid residue. This carboxylic acid residue is then further functionalized with gelatin methacrylate-based photocrosslinkable hydrogel for moisture retention and growth factor release. When applied to full thickness dorsal skin defect model, functionalized hydrogel allows moisture retention and hydrophobic surface prevents exudate leaks via water repellence. Furthermore, hydrogel functionalized Janus membrane enhances the wound healing rate and induces thick epidermal layer formation. In conclusion, the multifunctional Janus membrane with hydrophobic outer surface and immobilized hydrogel on the other surface is fabricated for an innovative strategy for wound healing.

Comparing Two Methods of Cryotherapy and Intense Pulsed Light with Triamcinolone Injection in the Treatment of Keloid and Hypertrophic Scars: A Clinical Trial

Objectives

Keloid and hypertrophic scars are abnormal manifestations of wounds that occur following skin injuries in the form of local proliferation of fibroblasts and increased production of collagen. There are several ways to cure these scars; treatment must be selected based on the nature of the scars. In this clinical trial, two methods—cryotherapy and intense pulsed light (IPL)—are compared in the treatment of scars, and the results are presented in terms of improvement level, complications, and patient satisfaction.

Methods

This clinical trial was conducted in southeastern Iran. The intervention group included scars that underwent the IPL method and the control group, which consisted of scars that were subjected to cryotherapy. In both methods, intralesional corticosteroid injection was administered. To select samples, the easy sampling method was used. To determine the expected outcomes, the criteria determined in the Vancouver scar scale were used. Data were analyzed using the Mix Model, chi-square test, and t test.

Results

In this study, 166 samples of keloid and hypertrophic scars were cured using two methods (Cryotherapy, 83; IPL, 83). The recovery rate was higher in the Cryotherapy group than in the IPL group (p > 0.05), and the incidence of complications was also higher in the Cryotherapy group (14.5% vs. 12%). Moreover, patients were more satisfied, although not significantly so, with the cryotherapy method (p = 0.09).

Conclusion

Both methods were highly successful in curing scars; participants were totally satisfied with both methods.

[Topical treatment of infections, tumors and hyperkeratotic disorders]

In this review substances for the topical treatment of skin infections, skin tumors and hyperkeratotic disorders are presented. Substances with specific actions as topical antimycotic, antibiotic, antiseptic, antiviral and antiparasitic agents as well as diclofenac in hyaluronic acid, 5-fluoruracil, imiquimod, ingenol mebutate, bexarotene, mechlorethamine, BCNU, alitretinoin, silicone gel, salicylic acid and urea are discussed with respect to their mode of action, indication and side effects.

Effect of hematoporphyrin monomethyl ether-sonodynamic therapy (HMME-SDT) on hypertrophic scarring

Objective

The aim of the present study was to explore the potential for hematoporphyrin monomethyl ether-Sonodynamic Therapy (HMME-SDT) treatment of hypertrophic scars within rabbit ears.

Methods

60 white rabbits were randomly divided into five groups: 1) untreated controls, 2) lesioned, 3) lesioned + HMME, 4) lesioned + US (Ultrasound), and 5) lesioned +HMME-SDT. After induction of a lesion upon the ears of the rabbits, hypertrophic scars were assessed at 14, 28, 42 and 56 days post-lesion +/− treatment. Assessments consisted of visual inspection in the change of the skin, scar formation pathological morphology by hematoxylin and eosin (HE) staining technique with optical microscopy, calculation of a hypertrophic index, fibroblastic density measures, and observation of collagen changes in the scar tissue by Van Gieson's (VG)Stain along with calculation of collagen area density.

Results

With continued HMME-SDT treatment there was a gradual improvement in all parameters over the duration of the experiment. The lesion-induced scars of rabbits receiving HMME-SDT treatment were soft, the size was reduced, hyperplasia was flat and the color pale. The fibroblasts and collagens were reduced and the collagens were light red, sparse and orderly. The hypertrophic index was reduced, since the fibroblastic density was lowered and collagen area density was decreased.

Conclusion

HMME is an effective sonosensitizer and the combination of HMME-SDT treatment can exert significant benefits in reducing the formation of hypertrophic scars.