Cicatrices chéloïdes sur peau noire : mythe ou réalité

Treatment of keloids and hypertrophic scars. Position statement of the Brazilian expert group GREMCIQ

Keloids (K) and hypertrophic scars (HS) are abnormal responses to wound healing that occur as the result of dermal inflammation. Despite the advances on their treatment, many patients still suffer from the negative effects of excessive scarring; its approach is impaired by the lack of objective data on different treatments and the large genetic variability among patients and the difficulties in producing multicentre studies. Their incidence among the Brazilian population is high, as the result of an admixture of Amerindians, Europeans and Africans ancestral roots. With the aim of producing multicentre studies on K and HS, a panel of senior Brazilian dermatologists focused on their treatment was invited to contribute with the K and HS Treatment Brazilian Guidelines. In the first part of this study, different treatment modalities for keloids and HS are fully reviewed by the panel. The second part of the study presents a consensus recommendation of treatment for different types of lesions. More than a literature review, this article aims to show the pitfalls and pearls of each therapeutic option, as well as a therapeutic approach by the Panel of Experts on keloids and Scars on a highly mixed population, providing simple guidelines.

A new therapeutic protocol for the treatment of keloid scars: a retrospective study

OBJECTIVE

There are few means to treat large keloid scars, as exeresis-even if partial-impedes direct closure without tension in the absence of a flap or a skin graft. This study evaluates the efficacy, indications for use and limitations of a new therapeutic protocol, combining an extralesional keloid excision left to heal by secondary intention with a paraffin dressing and glucocorticoid ointment, followed by monthly intrascar injections of corticosteroids upon full re-epithelialisation.

METHOD

A retrospective study of patients treated for keloid scars by using the new therapeutic protocol. Scars were categorised as either healed or recurring. Their recurrence was scored according to the changes in functional signs and the scar volume.

RESULTS

A total of 36 scars were studied. The mean follow-up was 14.1 months. Healing occurred in a mean of 6.8 weeks. The mean surface area was 21.6cm². Healing rate was 30.5%. Scar volume was improved in 60% of recurrent cases and functional signs in 56%. Based on adherence with the corticotherapy, two patient groups could be discerned. For patients in the 'adherent' group, the healing rate was 40%, and scar volume was improved in 75% of recurrent cases and the functional signs in 83% of cases.

CONCLUSIONS

The healing rate in this study was close to that reported in the literature. Excision-healing by secondary intention could therefore be offered to patients for whom adherence is uncertain. The protocol in this study offers a straightforward, fast, accessible solution that does not appear to entail any risk of additional keloids. It could potentially offer a treatment option in case of failure of other treatments, large keloid scars or scalp keloids.

MicroRNA-21 may be involved in the therapeutic effects of Galla chinensis ointment on keloid

Objective

Galla chinensis ointment can inhibit the proliferation of keloid fibroblasts and decrease keloid formation. We investigated whether Galla chinensis ointment inhibits keloid fibroblast proliferation through expression of microRNA-21, phosphorylated (p)-phosphatidylinositol 3-kinase (p-PI3K), chromosome 10 neutropenic protein phosphatase (PTEN), protein kinase B (p-Akt), and mammalian target of rapamycin (p-mTOR).

Methods

A keloid mouse model and human keloid-derived fibroblasts were developed and treated with Galla chinensis. Immunohistochemistry, western blot, and reverse transcription-PCR were used to detect miR-21, PI3K, PTEN, Akt, and mTOR in keloid tissues.

Results

p-Akt and p-mTOR were highly expressed in the control group, PTEN was highly expressed in the treatment group, and p-PI3K was highly expressed in keloid tissue in both groups. Galla chinensis reduced miR-21 expression and increased PTEN mRNA expression in keloid fibroblasts compared with the control group, resulting in increased PTEN protein and decreased p-Akt and p-mTOR protein. Galla chinensis had no effect on p-PI3K.

Conclusion

Galla chinensis might inhibit proliferation of keloid fibroblasts by upregulating PTEN, thus inhibiting expression of miR-21 and downregulating p-Akt and p-mTOR expression. These results confirm the effect of Galla chinensis ointment on fibroblasts and suggest that it could be used to manage keloids clinically.

Effects of hyperbaric oxygen therapy on the expression levels of the inflammatory factors interleukin-12p40, macrophage inflammatory protein-1β, platelet-derived growth factor-BB, and interleukin-1 receptor antagonist in keloids

BACKGROUND

Our study aimed to screen and explore the expression of inflammatory factors in keloid patients and to investigate how hyperbaric oxygen (HBO) therapy affects the expression levels of interleukin-12p40 (IL-12p40), macrophage inflammatory protein-1β (MIP-1β), platelet-derived growth factor-BB (PDGF-BB), and interleukin-1 receptor antagonist (IL-1Ra).

OBJECTIVE

30 patients were randomly selected and divided into the following 3 groups: keloid samples from keloid patients treated with HBO therapy (A), keloid samples from keloid patients treated without HBO therapy (B), and normal control skin samples derived from individuals who had no clear scarring (C). Each group included 10 samples.

METHODS

Inflammatory factors in the keloid tissues were measured with the MILLIPLEX multiplexed Luminex system. Hematoxylin and eosin staining, immunohistochemical staining, and Western blotting were used to observe the morphological differences in different tissues and the expression levels.

RESULTS

The expression levels of inflammatory mediators, including IL-12p40, MIP-1β, PDGF-BB, and IL-1Ra, in keloid tissues were significantly different from those in samples of normal skin. Hematoxylin and eosin staining showed significantly greater inflammatory infiltration in keloid tissue. Significantly different expression levels were observed in group A, B, and C.

CONCLUSION

Significantly altered levels of inflammatory factors in the samples from keloid patients were observed, suggesting that formation of a keloid is potentially related to inflammatory responses. HBO therapy could significantly affect the expression levels of IL-12p40, MIP-1β, PDGF-BB, and IL-1Ra, indicating that the effects of HBO therapy are associated with the attenuation of inflammatory responses.

[Secondary surgical and medical treatment of scars]

The authors, through their experience, take stock of current secondary management of scars whether they are pathological (hypertrophic, cheloid) or dystrophic (enlarged, hypo- or hyper-pigmented, adherent) by presenting surgical or medical solutions.

An intra-individual surgical wound comparison shows that octenidine-based hydrogel wound dressing ameliorates scar appearance following abdominoplasty

Hypertrophic scar formation because of surgical procedures is associated with higher levels of pain, a lower quality of life, and poor cosmetic outcome and requires more resources in follow-up management. An octenidine-based hydrogel has been shown to modulate immunological function in an in vitro wound model, suggesting an improved scar formation. In this prospective, randomised, observer-blinded, and intra-patient-controlled study, 45 patients who underwent abdominoplasty or mastectomy with transverse rectus abdominis muscle (TRAM) flap reconstruction were given both a standard postoperative wound dressing on one wound side and an octenidine-based hydrogel with transparent film dressing, covered with standard postoperative dressing on the other side. Four instances of hypertrophia were reported in the gel side versus 12 in the standard dressing side. Visual Analogue Scale (VAS) pain scores taken during postoperative dressing changes showed reduced scores on the gel side at all time points. Vancouver Scar Scale (VSS) scores showed improvement in the gel side at 3, 6, and 12 months postoperatively. Skin distensibility measured using a cutometer showed significantly improved measures in gel-treated wounds, similar to measures of healthy skin. Trans-epidermal water loss (TEWL), measured using a tewameter, showed improved values on the gel side soon after surgery, with both the control and the gel side normalising after approximately 6 months. The octenidine-based wound dressing demonstrates improved wound healing associated with a lower incidence of hypertrophic scar formation.

Clitoral keloids after female genital mutilation/cutting

We aimed to describe the presentation of long-term complications of female genital mutilation/cutting and the surgical management of clitoral keloids secondary to female genital mutilation/cutting. Twenty-seven women who underwent surgery because of clitoral keloid between May 2014 and September 2015 in Sudan Nyala Turkish Hospital were evaluated in this retrospective descriptive case series study. The prevalence of type 1, type 2, and type 3 female genital mutilation/cutting were 3.7%, 22.2%, and 74.1%, respectively (type 1: 1/27, type 2: 6/27, and type 3: 20/27). All patients had long-term health problems (dysuria, chronic pelvic pain, vaginal discharge, and chronic pruritus) and sexual dysfunction. Keloids were removed by surgical excision. There were no postoperative complications in any patient. Although clitoral keloid lesions can be seen after any type of female genital mutilation/cutting, they usually develop after type 3 female genital mutilation/cutting. Most of these keloids were noticed after menarche. Keloids can be removed by surgical excision and this procedure can alleviate some long-term morbidities of female genital mutilation/cutting.

Functional analysis of keratinocyte and fibroblast gene expression in skin and keloid scar tissue based on deviation analysis of dynamic capabilities

The aim of the present study was to select key genes that are associated with fibroblasts and keratinocytes during keloid scar progression and development. The gene expression profile of GSE44270, which includes 32 samples, was downloaded from the Gene Expression Omnibus database. Differentially expressed genes (DEGs) in case samples compared with control samples were screened using the Limma R package followed by hierarchical clustering analysis. Protein-protein interaction (PPI) networks of the total selected DEGs were constructed using Cytoscape. Moreover, the Gene Ontology biological processes and significant Kyoto Encyclopedia of Genes and Genomes pathways of the total selected DEGs were enriched using the Database for Annotation, Visualization and Integrated Discovery. Significant pathways that may be associated with keloid scar were analyzed using deviation analysis of dynamic capabilities. There were 658 DEGs in fibroblast keloid vs. normal, 112 DEGs in fibroblast non-lesion vs. normal, 439 DEGs in fibroblast keloid vs. non-lesion, 523 DEGs in keratocyte keloid vs. normal, 186 DEGs in keratocyte non-lesion vs. normal, and 963 DEGs in keratocyte keloid vs. non-lesion groups. HOXA9, BMP4, CDKN1A and SMAD2 in fibroblasts, and HOXA7, MCM8, PSMA4 and PSMB2 in keratinocytes were key genes in the PPI networks. Moreover, the amino sugar and nucleotide sugar metabolism pathway, cell cycle, and extracellular matrix (ECM)-receptor interaction pathway were significant pathways. This study suggests that several key genes (BMP4, HOXA9, SMAD2, CDKN1A, HOXA7, PSMA4 and PSMB2) that participate in some significant pathways (cell cycle and ECM-receptor interaction pathways) may be potential therapeutic targets for keloid scars.

Predisposing factors for adverse skin reactions with percutaneous bone anchored hearing devices implanted with skin reduction techniques

We present an analysis of adverse events after implantation of bone anchored hearing device in our patient population with focus on individual risk factors for peri-implant skin reactions. The investigation involved a chart review of adult Baha patients (n = 179) with 203 Bahas implanted with skin reduction techniques between 1993 and 2009, a questionnaire (n = 97) and a free clinical examination (n = 47). Skin reactions were graded by severity from 0 (no skin reaction) to 4 (implant loss resulting from infection) according to Holgers. We analyzed the skin reaction rate (SRR) defined as the number of skin reactions per year and the worst Holgers grade (WHG), which indicates the grade of the worst skin reaction per implant. We defined 20 parameters including the demographic characteristics, surgery details, subjective benefits, handling and individual factors. The most frequent adverse events (85 %) were skin reactions. The average SRR was 0.426 per Baha year. Six parameters showed an association with the SRR or the WHG. The clinically most relevant factors are an elevated Body Mass Index (BMI, p = 0.02) and darker skin type (p = 0.03). The SRR increased with the distance between the tragus and the implant (p = 0.02). Regarding the identified risk factors, the SRR might be reduced by selecting a location for the implant near the pinna and by specific counseling regarding post-operative care for patients with darker skin type or an elevated Body Mass Index (BMI). Few of the factors analyzed were found to influence the SRR and WHG. Since most adverse skin reactions could be treated easily with local therapy, our results suggest that in adult patients, individual risk factors for skin reactions are not a contraindication for Baha implantation. Thus, patients can be selected purely on audiological criteria.

Long-term prospective evaluation comparing robotic parathyroidectomy with minimally invasive open parathyroidectomy for primary hyperparathyroidism

BACKGROUND

Targeted parathyroidectomy is a popular technique for localized pathology. No single technique is established as superior. The purpose of this study was to compare robotic-assisted parathyroidectomy (RAP) with the most common approach.

METHODS

This was a prospective, nonrandomized study. Fifteen consecutive patients who underwent RAP were compared to 15 matched controls undergoing focused lateral parathyroidectomy (FLP).

RESULTS

Biochemical cure occurred in 29 of 30 patients (97%). No major complications occurred, although there was 1 robotic conversion. RAP demonstrated a significant time reduction (R(2)  = 0.436; p = .01) but took much longer to perform than FLP (119 minutes vs 34 minutes; p = .001). RAP was associated with less initial postoperative pain (p = .036) and higher satisfaction with scar cosmesis (p = .002) until 6 months. Quality of life (QOL) improved in both groups (p = .007).

CONCLUSION

RAP provides superior early cosmesis with equivalent global health improvement compared to FLP. The high cost and learning curve may preclude widespread adoption. Further evaluation is necessary to establish its clinical efficacy regarding scar cosmesis. © 2015 Wiley Periodicals, Inc. Head Neck 38: E300-E7, 2016.

[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.