Reconstructed human keloid models show heterogeneity within keloid scars

CD74+ fibroblasts proliferate upon mechanical stretching to promote angiogenesis in keloids

The healing of human skin wounds is susceptible to perturbation caused by excessive mechanical stretching, resulting in enlarged scars, hypertrophic scars, or even keloids in predisposed individuals. Keloids are fibro-proliferative scar tissues that extend beyond the initial wound boundary, consisting of the actively progressing periphery and the quiescent center. The stretch-associated outgrowth and enhanced angiogenesis are two features of the periphery of keloids. However, which cell population is responsible for transducing the mechanical stimulation to the progression of keloids remains unclear. Herein, through integrative analysis of single-cell RNA sequencing of keloids, we identified CD74+ fibroblasts, a previously unappreciated subset of fibroblasts with pro-angiogenic and stretch-induced proliferative capacities, as a key player in stretch-induced progression of keloids. Immunostaining of keloid cryosections depicted a predominant distribution of CD74+ fibroblasts in the periphery, interacting with the vasculature. In vitro tube formation assays on purified CD74+ fibroblasts ascertained their pro-angiogenic function. BrdU assays revealed that these cells proliferate upon stretching, through PIEZO1-mediated calcium influx and the downstream ERK and AKT signaling. Collectively, our findings propose a model wherein CD74+ fibroblasts serve as pivotal drivers of stretch-induced keloid progression, fueled by their proliferative and pro-angiogenic activities. Targeting the attributes of CD74+ fibroblasts holds promise as a therapeutic strategy for the management of keloids.

Artificial keloid skin models: understanding the pathophysiological mechanisms and application in therapeutic studies

Keloid is a type of scar formed by the overexpression of extracellular matrix substances from fibroblasts following inflammation after trauma. The existing keloid treatment methods include drug injection, surgical intervention, light exposure, cryotherapy, etc. However, these methods have limitations such as recurrence, low treatment efficacy, and side effects. Consequently, studies are being conducted on the treatment of keloids from the perspective of inflammatory mechanisms. In this study, keloid models are created to understand inflammatory mechanisms and explore treatment methods to address them. While previous studies have used animal models with gene mutations, chemical treatments, and keloid tissue transplantation, there are limitations in fully reproducing the characteristics of keloids unique to humans, and ethical issues related to animal welfare pose additional challenges. Consequently, studies are underway to create in vitro artificial skin models to simulate keloid disease and apply them to the development of treatments for skin diseases. In particular, herein, scaffold technologies that implement three-dimensional (3D) full-thickness keloid models are introduced to enhance mechanical properties as well as biological properties of tissues, such as cell proliferation, differentiation, and cellular interactions. It is anticipated that applying these technologies to the production of artificial skin for keloid simulation could contribute to the development of inflammatory keloid treatment techniques in the future.

Modelling Keloids Dynamics: A Brief Review and New Mathematical Perspectives

Keloids are fibroproliferative disorders described by excessive growth of fibrotic tissue, which also invades adjacent areas (beyond the original wound borders). Since these disorders are specific to humans (no other animal species naturally develop keloid-like tissue), experimental in vivo/in vitro research has not led to significant advances in this field. One possible approach could be to combine in vitro human models with calibrated in silico mathematical approaches (i.e., models and simulations) to generate new testable biological hypotheses related to biological mechanisms and improved treatments. Because these combined approaches do not really exist for keloid disorders, in this brief review we start by summarising the biology of these disorders, then present various types of mathematical and computational approaches used for related disorders (i.e., wound healing and solid tumours), followed by a discussion of the very few mathematical and computational models published so far to study various inflammatory and mechanical aspects of keloids. We conclude this review by discussing some open problems and mathematical opportunities offered in the context of keloid disorders by such combined in vitro/in silico approaches, and the need for multi-disciplinary research to enable clinical progress.

Mathematical investigation of normal and abnormal wound healing dynamics: local and non-local models

The movement of cells during (normal and abnormal) wound healing is the result of biomechanical interactions that combine cell responses with growth factors as well as cell-cell and cell-matrix interactions (adhesion and remodelling). It is known that cells can communicate and interact locally and non-locally with other cells inside the tissues through mechanical forces that act locally and at a distance, as well as through long non-conventional cell protrusions. In this study, we consider a non-local partial differential equation model for the interactions between fibroblasts, macrophages and the extracellular matrix (ECM) via a growth factor (TGF-$ \beta $) in the context of wound healing. For the non-local interactions, we consider two types of kernels (i.e., a Gaussian kernel and a cone-shaped kernel), two types of cell-ECM adhesion functions (i.e., adhesion only to higher-density ECM vs. adhesion to higher-/lower-density ECM) and two types of cell proliferation terms (i.e., with and without decay due to overcrowding). We investigate numerically the dynamics of this non-local model, as well as the dynamics of the localised versions of this model (i.e., those obtained when the cell perception radius decreases to 0). The results suggest the following: (ⅰ) local models explain normal wound healing and non-local models could also explain abnormal wound healing (although the results are parameter-dependent); (ⅱ) the models can explain two types of wound healing, i.e., by primary intention, when the wound margins come together from the side, and by secondary intention when the wound heals from the bottom up.

UCHL1 aggravates skin fibrosis through an IGF-1-induced Akt/mTOR/HIF-1α pathway in keloid

Keloid is a heterogeneous disease featured by the excessive production of extracellular matrix. It is a great challenge for both clinicians and patients regarding the exaggerated and uncontrolled outgrowth and the therapeutic resistance of the disease. In this study, we verified that UCHL1 was drastically upregulated in keloid fibroblasts. UCHL1 had no effects on cell proliferation and migration, but instead promoted collagen I and α-SMA expression that was inhibited by silencing UCHL1 gene and by adding in LDN-57444, a pharmacological inhibitor for UCHL1 activity as well. The pathological process was mediated by IGF-1 promoted Akt/mTOR/HIF-1α signaling pathway because inhibition of any of them could reduce the expression of collagen I and α-SMA driven by UCHL1 in fibroblasts. Also, we found that UCHL1 expression in keloid fibroblasts was promoted by M2 macrophages via TGF-β1. These findings extend our understanding of the pathogenesis of keloid and provide potential therapeutic targets for the disease.

A Reconstructed Human Melanoma-in-Skin Model to Study Immune Modulatory and Angiogenic Mechanisms Facilitating Initial Melanoma Growth and Invasion

Invasion, immune modulation, and angiogenesis are crucial in melanoma progression. Studies based on animals or two-dimensional cultures poorly recapitulate the tumor-microenvironmental cross-talk found in humans. This highlights a need for more physiological human models to better study melanoma features. Here, six melanoma cell lines (A375, COLO829, G361, MeWo, RPMI-7951, and SK-MEL-28) were used to generate an in vitro three-dimensional human melanoma-in-skin (Mel-RhS) model and were compared in terms of dermal invasion and immune modulatory and pro-angiogenic capabilities. A375 displayed the most invasive phenotype by clearly expanding into the dermal compartment, whereas COLO829, G361, MeWo, and SK-MEL-28 recapitulated to different extent the initial stages of melanoma invasion. No nest formation was observed for RPMI-7951. Notably, the integration of A375 and SK-MEL-28 cells into the model resulted in an increased secretion of immune modulatory factors (e.g., M-CSF, IL-10, and TGFβ) and pro-angiogenic factors (e.g., Flt-1 and VEGF). Mel-RhS-derived supernatants induced endothelial cell sprouting in vitro. In addition, observed A375-RhS tissue contraction was correlated to increased TGFβ release and α-SMA expression, all indicative of differentiation of fibroblasts into cancer-associated fibroblast-like cells and reminiscent of epithelial-to-mesenchymal transition, consistent with A375's most prominent invasive behavior. In conclusion, we successfully generated several Mel-RhS models mimicking different stages of melanoma progression, which can be further tailored for future studies to investigate individual aspects of the disease and serve as three-dimensional models to assess efficacy of therapeutic strategies.

Human In Vitro Skin Models for Wound Healing and Wound Healing Disorders

Skin wound healing is essential to health and survival. Consequently, high amounts of research effort have been put into investigating the cellular and molecular components involved in the wound healing process. The use of animal experiments has contributed greatly to the knowledge of wound healing, skin diseases, and the exploration of treatment options. However, in addition to ethical concerns, anatomical and physiological inter-species differences often influence the translatability of animal-based studies. Human in vitro skin models, which include essential cellular and structural components for wound healing analyses, would improve the translatability of results and reduce animal experiments during the preclinical evaluation of novel therapy approaches. In this review, we summarize in vitro approaches, which are used to study wound healing as well as wound healing-pathologies such as chronic wounds, keloids, and hypertrophic scars in a human setting.

TWEAK/Fn14 signaling may function as a reactive compensatory mechanism against extracellular matrix accumulation in keloid fibroblasts

Overabundance of the extracellular matrix resulting from hyperproliferation of keloid fibroblasts (KFs) and dysregulation of apoptosis represents the main pathophysiology underlying keloids. TWEAK is a weak apoptosis inducer, and it plays a critical role in pathological tissue remodeling via its receptor, Fn14. However, the role of TWEAK/Fn14 signaling in the pathogenesis of keloids has not been investigated. In this study, we confirmed the overexpression levels of TWEAK and Fn14 in clinical keloid tissue specimens and primary KFs. The extracellular matrix (ECM)-related genes were also evaluated between primary KFs and their normal counterparts to determine the factors leading to the formation or development of keloids. Unexpectedly, exogenous TWEAK significantly reduced the levels of collagen I and collagen III, as well as alpha-smooth muscle actin (α-SMA). Additionally, TWEAK promoted MMPs expression and apoptosis activity of KFs. Furthermore, we verified that the inhibitory effect of TWEAK on KFs is through down-regulation of Polo-like kinase 5, which modulates cell differentiation and apoptosis. The TWEAK-Fn14 axis seems to be a secondary, although less effective, compensatory mechanism to increase the catabolic functions of fibroblasts in an attempt to further decrease the accumulation of collagen. DATA AVAILABILITY: All data generated or analyzed during this study are included in this published article (and its Supporting Information files).

Histology and Vascular Architecture Study of Keloid Tissue to Outline the Possible Terminology of Keloid Skin Flaps

BACKGROUND

Using the keloid "epidermis" to cover a wound is widely used during treatment for keloids. Many flap terminologies have been used in literature. However, the definition of the flap is not well established. Here, we refined the definition of the flap and associated terminology and explored the survival mechanism of the 'flap' through histological analysis and blood supply studying.

METHODS

Histology and vascular study of keloid was carried out with keloid and its surrounding normal skin tissue which were collected from keloid patients following keloid resection operations. The histological structures and thicknesses of epidermal and subepidermal of the keloids were analyzed and measured using hematoxylin & eosin (H&E) staining. Vascular density and blood perfusion in the subepidermal layer of keloids (KDS) were analyzed using CD31 immunohistochemical staining and a laser speckle contrast imaging system (LSCI), respectively. The vascular network in KDS was visualized by CD31 immunofluorescence staining and three-dimensional reconstruction.

RESULTS

29 pieces of keloid and its surrounding normal skin tissue sample from ten patients were collected. Keloid samples were about 2 cm wide and 5 cm long. The normal skin samples were about 2 to 3 mm in width. The thickness of epidermal layer of keloids was (136.4 ± 35.3) μm, and the thickness of epidermal layer of surrounding normal skin was (78.8 ± 13.9) μm. There was statistical thickness difference between the two layers, t(20) = 7.469, P < 0.001. The total thickness of keloid epidermal and subepidermal layers was 391.4 ± 2.3 μm. The vascular density (13.9 ± 3.4/field) and blood flow perfusion (132.7 ± 31.3) PU in KDS were greater than that of surrounding normal skin (7.8 ± 2.3/field, 73.9 ± 17.9 PU), P < 0.001. Horizontally distributed vessels with several vertical branches were observed in 3D vascular network reconstruction.

CONCLUSION

The epidermal layer of keloid is thicker than that of surrounding normal skin. There is a vascular network structure under it. The vessels mainly locate at a depth of about 150 to 400 μm from the surface of keloid epidermis, randomly distribute and run parallel to the epidermis. Based on these characteristics which may ensure an adequate blood supply, we propose the concept of a "keloid subepidermal vascular network flap."

LEVEL OF EVIDENCE V

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Construction of a HOXA11-AS-Interact Ed Network in Keloid Fibroblasts Using Integrated Bioinformatic Analysis and in Vitro Validation

Background: Expression of the long noncoding RNA (lncRNA) HOXA11-AS significantly increased in keloids by unclarified molecular regulation mechanisms.

Methods: Using successfully primary cultured keloid-derived fibroblasts from central region of chronic keloid tissues (sample 0), small interfering RNAs were designed and transfected into two keloid fibroblast samples (samples 1 and 2) to knockdown HOXA11-AS. One nonspecific transfection control (sample 3) and one blank control (sample 4) were used to remove nonspecific overlap from the studied group. The lncRNAs, messenger RNAs (mRNAs), and microRNAs (miRNAs) of five samples were sequenced to identify differentially expressed (DE) profiles in HOXA11-AS-knockdown keloid fibroblasts in samples 1 and 2 (by intersection), which facilitated removal of overlap with the nonspecific controls (samples 3 and 4, by union). Using stepwise bioinformatic analysis, a HOXA11-AS-interacted competing endogenous network (ceRNA) was screened based on three DE profiles.

Results: Keloid fibroblasts with or without HOXA11-AS as well as with or without nonspecific interferences were successfully constructed respectively. A total of 1,396 mRNAs and 39 lncRNAs were significantly changed in keloid fibroblast with HOXA11-AS knockdown. Simultaneously, 1,626 mRNAs and 99 lncRNAs were significantly changed in keloid fibroblast with nonspecific interference. With removal of nonspecific overlap, a lncRNA–mRNA interactive network characterized by close natural/intronic antisense relationship was initially constructed in keloid fibroblast with HOXA11-AS knockdown. Based on this network, a lncRNA–mRNA–protein interaction network was extended by integration of the human protein–protein interaction network. Significant functional genes were screened using PageRank algorithm in the extended network. Three genes, including SNED1, NIPAL3, and VTN, were validated by real-time PCR in HOXA11-AS-knockdown keloid fibroblasts. Only NIPAL3 was predicted to be a target gene for HOXA11-AS via three competing endogenous miRNAs (hsa-miRNA-19a-3p, hsa-miR-141-3p, and hsa-miR-140-5p).

Conclusion: An interactive network of HOXA11-AS–three miRNAs–NIPAL3 was predicted in keloid fibroblasts by integrative bioinformatic analysis and in vitro validation.

The Polygenic Map of Keloid Fibroblasts Reveals Fibrosis-Associated Gene Alterations in Inflammation and Immune Responses

Due to many inconsistencies in differentially expressed genes (DEGs) related to genomic expression changes during keloid formation and a lack of satisfactory prevention and treatment methods for this disease, the critical biomarkers related to inflammation and the immune response affecting keloid formation should be systematically clarified. Normal skin/keloid scar tissue-derived fibroblast genome expression data sets were obtained from the Gene Expression Omnibus (GEO) and ArrayExpress databases. Hub genes have a high degree of connectivity and gene function aggregation in the integration network. The hub DEGs were screened by gene-related protein–protein interactions (PPIs), and their biological processes and signaling pathways were annotated to identify critical biomarkers. Finally, eighty-one hub DEGs were selected for further analysis, and some noteworthy signaling pathways and genes were found to be closely related to keloid fibrosis. For example, IL17RA is involved in IL-17 signal transduction, TIMP2 and MMP14 activate extracellular matrix metalloproteinases, and TNC, ITGB2, and ITGA4 interact with cell surface integrins. Furthermore, changes in local immune cell activity in keloid tissue were detected by DEG expression, immune cell infiltration, and mass CyTOF analyses. The results showed that CD4+ T cells, CD8+ T cells and NK cells were abnormal in keloid tissue compared with normal skin tissue. These findings not only support the key roles of fibrosis-related pathways, immune cells and critical genes in the pathogenesis of keloids but also expand our understanding of targets that may be useful for the treatment of fibrotic diseases.

Integration of Flow Cytometry and Computational Analysis to Dissect the Epidermal Cellular Subsets in Keloids that Correlate with Recurrence

Keloid disease is a benign skin disease that does not have an effective therapy. More and more research shows that epidermal abnormalities are involved in keloid pathogenesis. Little is known about the relationship between the abnormal epidermal immunophenotype and clinical outcome. Nine-color flow cytometry with computational analysis was performed to detect the altered cellular subpopulation distribution in keloid lesions. Receiver operating characteristic curves were drawn to compare predictive ability between the alteration of cell subgroup frequency and the Vancouver Scar Scale. The frequency of CD49f^hi/CD29⁺/TLR7⁺ cellular subsets increased in the keloid epidermis compared with that in the healthy control. CD49f^mid-hi/CD29⁺/TLR7⁺/CD24⁺ cellular subpopulation level was increased significantly in keloids, whereas CD49f^lo-mid/CD29^‒/TLR7^‒/CD24^‒ cellular subpopulation frequency was decreased. The CD49f^lo/CD29^‒/TLR7^‒/CD24⁺/CD117⁺ cellular subpopulation showed an increased frequency during recurrence with a sensitivity of 66.7% and specificity of 91.7%. The area under the curve was 0.806 for cellular subpopulation analysis, which was higher than the area under the curve for the Vancouver Scar Scale (0.583). The alteration of keloid epidermal subpopulation frequency is related to recurrence, which will provide an optional predictive marker for keloid recurrence and a potential target subset for investigating the generation of keloid.

Blood perfusion in hypertrophic scars and keloids studied by laser speckle contrast imaging

BACKGROUND

This study used laser speckle contrast imaging (LSCI) to evaluate the difference in blood perfusion between hypertrophic scars and keloids.

MATERIALS AND METHODS

A total of 30 keloids, 21 early hypertrophic scars, 20 proliferative hypertrophic scars, 20 regressive hypertrophic scars, and 20 mature hypertrophic scars were enrolled into this study. Vancouver Scar Scale (VSS) was assessed by a plastic surgeon. LSCI was used to evaluate perfusion of the whole (W), marginal (M), central (C) regions, and surrounding normal skin of the scars, and ratios (M/N, C/N) were calculated.

RESULTS

The perfusion of the marginal region in the keloid was significantly higher than that of the central region. Nevertheless, there was no significant difference in perfusion between the central and marginal regions in the early, proliferative, regressive, and mature hypertrophic scars. The degree of perfusion and perfusion ratio in the marginal region of keloid was similar to that of proliferative hypertrophic scars, and the degree of perfusion and perfusion ratio in central region of keloid group was similar to that of early and regressive hypertrophic scars.

CONCLUSIONS

The difference in perfusion distribution in keloids and hypertrophic scars may provide ideas for their identification. LSCI may be a useful method for differentiating between keloids and hypertrophic scars.

Heterogeneous Features of Keloids Assessed by Laser Speckle Contrast Imaging: A Cross-Sectional Study

BACKGROUND AND OBJECTIVES

Keloids are described as benign dermal fibroproliferative lesions, and vascularization may play a significant role in their pathogenesis. In this study, laser speckle contrast imaging (LSCI) was used to assess perfusion within keloids and surrounding skin, and perfusion of keloids at different stages was compared.

STUDY DESIGN/MATERIALS AND METHODS

A total of 59 patients with 110 untreated keloids on the anterior chest were enrolled in this study. Different keloid stages (progressive, stable, and regressive) were defined according to patients' descriptions of whether keloids became larger, stable, or smaller during the previous year. Vancouver Scar Scale (VSS) was assessed by a plastic surgeon, and patient reports on pain and itching were documented. LSCI was used to evaluate blood perfusion of keloids (K), skin adjacent to keloids (A), and nonadjacent skin (N). The mean perfusion of these regions was determined, and ratios (K/N, A/N) were calculated.

RESULTS

A heterogeneous perfusion map was observed among the keloid groups, as well as within each keloid. A positive correlation was found between keloid perfusion and VSS. There were 62 (56.4%) keloids in the progressive stage, 33 (30.0%) keloids in the stable stage, and 15 (13.6%) keloids in the regressive stage. The mean K/N ratios in the progressive, stable, and regressive stages were 2.3 ± 0.5, 1.8 ± 0.3, and 1.5 ± 0.5, respectively. The mean A/N ratios were 1.2 ± 0.4, 1.2 ± 0.2, and 1.0 ± 0.5, respectively. Within each keloid, significantly higher perfusion was noted in the keloid and adjacent skin compared with nonadjacent skin.

CONCLUSION

These results indicate that LSCI is a promising technique for evaluating keloid blood perfusion and distinguishing heterogeneous keloids. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

MiR-4328 inhibits proliferation, metastasis and induces apoptosis in keloid fibroblasts by targeting BCL2 expression

Keloids are considered to be a type of benign tumor. MicroRNAs have been reported to be involved in the formation and growth of keloids. MicroRNA-4328 (miR-4328) was found to be abnormally expressed in keloids, while the role and the detailed molecular mechanism of miR-4328 in keloids remain unclear. The expression of miR-4328 and B-cell lymphoma 2 (BCL2) mRNA was detected by qRT-PCR. The proliferation, migration, invasion and apoptosis of keloid fibroblasts (KFs) was examined using Cell Counting Kit-8 assay, transwell assay or flow cytometry, respectively. Western blot was used to detect the level of proliferating cell nuclear antigen, cleaved-caspase 3, collagen I, collagen III and BCL2 protein. The interaction between miR-4328 and BCL2 was confirmed by luciferase reporter analyses. It was observed that miR-4328 was down-regulated in keloid tissues and fibroblasts, and miR-4328 restoration mediated the inhibition of proliferation, metastasis, collagen synthesis and the promotion of apoptosis in KFs. BCL2 was up-regulated in keloid tissues and fibroblasts, and BCL2 knockdown promoted the deterioration of KFs. In addition, BCL2 was confirmed to be a target of miR-4328, and the rescue experiment indicated that the inhibitory action of miR-4328 on keloid fibroblast progression was reversed by BCL2 overexpression. Thus, our results demonstrated that miR-4328 restrained the deterioration of KFs by targeting BCL2, which sheds new light on miR-4328 as a promising target for keloid development and therapeutic.

The Keloid Disorder: Heterogeneity, Histopathology, Mechanisms and Models

Keloids constitute an abnormal fibroproliferative wound healing response in which raised scar tissue grows excessively and invasively beyond the original wound borders. This review provides a comprehensive overview of several important themes in keloid research: namely keloid histopathology, heterogeneity, pathogenesis, and model systems. Although keloidal collagen versus nodules and α-SMA-immunoreactivity have been considered pathognomonic for keloids versus hypertrophic scars, conflicting results have been reported which will be discussed together with other histopathological keloid characteristics. Importantly, histopathological keloid abnormalities are also present in the keloid epidermis. Heterogeneity between and within keloids exists which is often not considered when interpreting results and may explain discrepancies between studies. At least two distinct keloid phenotypes exist, the superficial-spreading/flat keloids and the bulging/raised keloids. Within keloids, the periphery is often seen as the actively growing margin compared to the more quiescent center, although the opposite has also been reported. Interestingly, the normal skin directly surrounding keloids also shows partial keloid characteristics. Keloids are most likely to occur after an inciting stimulus such as (minor and disproportionate) dermal injury or an inflammatory process (environmental factors) at a keloid-prone anatomical site (topological factors) in a genetically predisposed individual (patient-related factors). The specific cellular abnormalities these various patient, topological and environmental factors generate to ultimately result in keloid scar formation are discussed. Existing keloid models can largely be divided into in vivo and in vitro systems including a number of subdivisions: human/animal, explant/culture, homotypic/heterotypic culture, direct/indirect co-culture, and 3D/monolayer culture. As skin physiology, immunology and wound healing is markedly different in animals and since keloids are exclusive to humans, there is a need for relevant human in vitro models. Of these, the direct co-culture systems that generate full thickness keloid equivalents appear the most promising and will be key to further advance keloid research on its pathogenesis and thereby ultimately advance keloid treatment. Finally, the recent change in keloid nomenclature will be discussed, which has moved away from identifying keloids solely as abnormal scars with a purely cosmetic association toward understanding keloids for the fibroproliferative disorder that they are.

Hypertrophic and keloid scars fail to progress from the CD34- /α-smooth muscle actin (α-SMA)+ immature scar phenotype and show gradient differences in α-SMA and p16 expression

BACKGROUND

Our understanding of the pathogenesis underlying keloid scar formation is still very limited, and the morphological distinction between hypertrophic and keloid scars remains difficult.

OBJECTIVES

To test whether hypertrophic and keloid scars may reflect an inability to progress from immaturity to the desired mature normotrophic scar phenotype.

METHODS

Using whole-biopsy imaging and an objectively quantifiable way to analyse immunoreactivity, we have compared the immunohistopathological profiles of young immature scars with mature normotrophic scars, hypertrophic scars, and keloids with their surrounding-normal-skin.

RESULTS

Abnormal scars (hypertrophic scars and keloids) maintain the immature scar phenotype, characterized by a CD34^- (tumour biomarker) and α-smooth muscle actin (α-SMA)⁺ (myofibroblast) dermal region. This is in contrast to normal skin, surrounding-normal-skin and mature normotrophic scars that were CD34⁺ / α-SMA^- . Immature, hypertrophic and keloid scars showed abnormal epidermal differentiation (involucrin), but only hypertrophic scars and keloids showed increased epidermal thickness. Immature scars did show increased epidermal and dermal proliferation (Ki67), which was absent from abnormal scars, where mesenchymal hypercellularity (vimentin) and senescence (p16) were predominant. Keloidal collagen and α-SMA were previously considered to distinguish between hypertrophic scars and keloids. However, α-SMA staining was present in both abnormal scar types, while keloidal collagen was present mostly in keloids. There were no obvious signs of heterogeneity within keloid scars, and the surrounding-normal-skin resembled normal skin.

CONCLUSIONS

Both abnormal scar types showed a unique CD34^- /α-SMA⁺ /p16⁺ scar phenotype, but the differences between hypertrophic scars and keloids observed in this study were of a gradient rather than absolute nature. This suggests that scar progression to the mature normal scar phenotype is, for as yet unknown reasons, hindered in hypertrophic and keloid scars. What's already known about this topic? Hypertrophic and keloid scars both have sustained epidermal barrier dysfunction, suggesting the persistence of an immature scar phenotype. Morphological distinction between hypertrophic and keloid scars remains a topic of debate, although α-smooth muscle actin (α-SMA) and keloidal collagen have been considered distinguishing features of hypertrophic and keloid scars, respectively. It has been suggested that keloids are not simply homogeneous growths, as heterogeneity within keloid scars and possible involvement of the surrounding-normal-skin have been reported. What does this study add? An extensive whole-biopsy imaging and quantifiable immunohistochemical assessment of immature, mature normal, hypertrophic and keloid scars, including normal skin surrounding keloids. Hypertrophic and keloid scars maintain dermal characteristics of immature scars, rather than transitioning into the normal mature phenotype. Differences between hypertrophic and keloid scars were of a gradient rather than absolute nature, with keloids showing the more extreme phenotype. There was no obvious heterogeneity within keloids, and the normal skin surrounding keloids resembled normal skin. What is the translational message? Keloids remain primarily a clinical diagnosis. A raised scar with the CD34^- /α-SMA⁺ /p16⁺ phenotype with strong immunoreactivity for p16 and significant amounts of keloidal collagen, together with a thickened and strongly abnormal involucrin-stained epidermis, would sway the diagnosis towards keloid scars. A hypertrophic scar seems more likely when the CD34^- /α-SMA⁺ /p16⁺ phenotype shows very strong presence of α-SMA⁺ in large dermal nodules, with lesser p16 staining and absent or negligible keloidal collagen.

Monocytes co-cultured with reconstructed keloid and normal skin models skew towards M2 macrophage phenotype

Several abnormalities have been reported in the peripheral blood mononuclear cells of keloid-forming patients and particularly in the monocyte cell fraction. The goal of this in vitro study was to determine whether monocytes from keloid-prone patients contribute to the keloid phenotype in early developing keloids, and whether monocyte differentiation is affected by the keloid microenvironment. Therefore, keloid-derived keratinocytes and fibroblasts were used to reconstruct a full thickness, human, in vitro keloid scar model. The reconstructed keloid was co-cultured with monocytes from keloid-forming patients and compared to reconstructed normal skin co-cultured with monocytes from non-keloid-formers. The reconstructed keloid showed increased contraction, dermal thickness (trend) and α-SMA+ staining, but co-culture with monocytes did not further enhance the keloid phenotype. After 2-week culture, all monocytes switched from a CD11c^high/CD14^high/CD68^low to a CD11c^high/CD14^low/CD68^high phenotype. However, only monocytes co-cultured with either reconstructed keloid scar or normal skin models skewed towards the more fibrotic M2-macrophage phenotype. There was negligible fibroblast and fibrocyte differentiation in mono- and co-cultured monocytes. These results indicate that monocytes differentiate into M2 macrophages when in the vicinity of early regenerating and repairing tissue, independent of whether the individual is prone to normal or keloid scar formation.