Evaluating keloid recurrence after surgical excision with prospective longitudinal scar assessment scales

Insights into the role of mesenchymal stem cells in cutaneous medical aesthetics: from basics to clinics

With the development of the economy and the increasing prevalence of skin problems, cutaneous medical aesthetics are gaining more and more attention. Skin disorders like poor wound healing, aging, and pigmentation have an impact not only on appearance but also on patients with physical and psychological issues, and even impose a significant financial burden on families and society. However, due to the complexities of its occurrence, present treatment options cannot produce optimal outcomes, indicating a dire need for new and effective treatments. Mesenchymal stem cells (MSCs) and their secretomics treatment is a new regenerative medicine therapy that promotes and regulates endogenous stem cell populations and/or replenishes cell pools to achieve tissue homeostasis and regeneration. It has demonstrated remarkable advantages in several skin-related in vivo and in vitro investigations, aiding in the improvement of skin conditions and the promotion of skin aesthetics. As a result, this review gives a complete description of recent scientific breakthroughs in MSCs for skin aesthetics and the limitations of their clinical applications, aiming to provide new ideas for future research and clinical transformation.

Recent Progress in Mesenchymal Stem Cell-Derived Exosomes for Skin Wound Repair

BACKGROUND

Exosomes are nanometer-sized, lipid bilayer membrane vesicles that are secreted by various cell types. Mesenchymal stem cells (MSCs) have been shown to exert therapeutic effects through the secretion of exosomes via a paracrine pathway. Functions: Recent studies have demonstrated that MSC-derived exosomes (MSC-Exos) can effectively transport various bioactive substances, including proteins, mRNAs, microRNAs, long non-coding RNAs, circular RNAs, and lipids, into target cells. This process regulates multiple aspects during wound repair, such as the inflammatory response, cell proliferation, migration, differentiation, angiogenesis, and matrix remodeling.

POTENTIAL APPLICATIONS

By promoting wound healing and inhibiting scar formation, MSC-Exos have shown great promise for clinical applications in wound repair. This review highlights the recent advances in our understanding of the role and mechanism of MSC-Exos during wound repair, providing insights into their potential use in future therapeutic strategies.

Treatment of Hypertrophic Burn Scars With Laser Therapy: A Review of Adverse Events

ABSTRACT

Hypertrophic scarring, characterized by excessive scar tissue formation, is a debilitating outcome that significantly impairs physical and psychosocial recovery after burn injury. Hypertrophic scarring affects a substantial proportion of burn survivors, with reported prevalence as high as 70%. Fractional CO 2 laser (FCL) therapy, a therapy commonly used in acne scar treatment or skin rejuvenation, has become popular in treating hypertrophic scars. Little is known regarding FCL's adverse events for burn scar treatment. We hypothesize that FCL is a safe treatment modality with minimal adverse events in the management of hypertrophic burn scars. This is a retrospective chart review of adverse events after FCL at 2 centers within a single institution. Burn patients undergoing FCL between May 1, 2019, and June 1, 2021 were included. Demographics, injury etiology, laser treatment details, and adverse events were collected. A total of 170 patients, 77 (45.3%) males and 93 (54.7%) females, underwent 544 FCL therapies for burn scars. The average number of treatments per patient was 3 ± 2.23, with a range of 1 to 17 sessions. From the total 544 laser therapy sessions, 13 adverse events (2.4%) were reported. There were 5 reports (0.9%) of increased postprocedural pain and 1 report (0.2%) of increased paresthesia/numbness to laser site. Three instances (0.6%) of increased erythema and 4 reports (0.7%) of epidermal sloughing or blistering were reported. All but 5 patients (2.9%) reported improvements to scar symptoms. This study demonstrates minimal adverse events associated with FCL for hypertrophic burn scar treatment.

Fibrosis in burns: an overview of mechanisms and therapies

Scar development remains a common occurrence and a major healthcare challenge affecting the lives of millions of patients annually. Severe injuries to the skin, such as burns can lead to pathological wound healing patterns, often characterized by dermal fibrosis or excessive scarring, and chronic inflammation. The two most common forms of fibrotic diseases following burn trauma are hypertrophic scars (HSCs) and keloids, which severely impact the patient's quality of life. Although the cellular and molecular mechanisms are similar, HSC and keloids have several distinct differences. In this review, we discuss the different forms of fibrosis that occur postburn injury, emphasizing how the extent of burn influences scar development. Moreover, we highlight how a systemic response induced by a burn injury drives wound fibrosis, including both the role of the inflammatory response, as well as the fate of fibroblast during skin healing. Finally, we list potential therapeutics aimed at alleviating pathological scar formation. An understanding of the mechanisms of postburn fibrosis will allow us to effectively move studies from bench to bedside.

Treatment of traumatic hypertrophic scars and keloids: a systematic review of randomized control trials

Exaggerated healing and remodeling after skin injury may cause hypertrophic and keloidal scars, which are associated with functional and quality of life impairment. There is limited guidance available regarding the relative effectiveness of therapies for hypertrophic scars and keloids. In this review, we aim to compare the effectiveness of treatments for hypertrophic scars and keloids. MEDLINE, Embase, Scopus, and the Cochrane Collaboration database were searched from inception to March 2019 for randomized control trials of treatments for hypertrophic and keloid scars that included 20 or more patients. Outcomes evaluated included the standardized mean reduction in scarring and adverse events. The type of scar and the demographic features were analyzed for their effect on clinical outcome. Based on 25 included clinical trials, intralesional injection (64.1% [95% CI 60.8-67.5%]) may be more effective than physical (29.9% [95% CI 28.9-30.9%]) or topical treatments (34% [95% CI 31.8-36.8%]). Combination of 5-fluorouracil and triamcinolone (9:1 dilution) appeared superior among intralesional treatments for keloids. Ablative laser and pulsed-dye laser were the most useful laser treatments. Regression modeling showed laser treatment response was linked to Fitzpatrick skin type (p = 0.002). Adverse events were uncommon for all treatments and mostly transient. Intralesional treatments for keloid and hypertrophic scars may be the most reliable treatment option to improve pathologic scars, while laser treatment may have specific benefits for Fitzpatrick skin types I-III over types IV-VI. Management of pathological scars is an area of critical need, where appropriate treatment can have a significant impact on quality of life.

The Importance of Psychometric and Physical Scales for the Evaluation of the Consequences of Scars-A Literature Review

BACKGROUND

Scars affect patients after trauma, burns, or surgical procedures and can generate both physical and psychosocial changes. The aesthetic damage represents the modification of a person's physical appearance, in its bodily integrity, causing numerous sufferings and determining social or economic consequences. The aim of this research is to evaluate the advantages and disadvantages offered by the available psychosocial and physical scar scales in assessing the physical, aesthetic, psychosocial, and juridical consequences of scars. This will aid to inform medical examiners about the most valued existing scales to allow them to select the most appropriate instrument to manage their patient.

METHODS

A broad search of relevant scientific studies on the psychosocial determinants of post-traumatic and surgical scars was conducted by using the following international database tools: PsycINFO, MedLine Social Science Index, Scopus, Web of Science, published from 1960 until 2022.

RESULTS

We analyzed 63 scientific studies to assess the advantages and limits of several psychometric and physical scar evaluation scales.

CONCLUSIONS

The researchers analyzed in this review highlight the advantages and limitation of existing instruments, evidencing the demand for future scar evaluation instruments and a scar-assessing algorithm that takes into account the physical, aesthetic, psychosocial, and legal consequences of scars.

From Chronic Wounds to Scarring: The Growing Health Care Burden of Under- and Over-Healing Wounds

Significance: Wound healing is the largest medical market without an existing small molecule/drug treatment. Both "under-healing" (chronic wounds) and "over-healing" (scarring) cause a substantial biomedical burden and lifelong consequences for patients. These problems cost tens of billions of dollars per year in the United States alone, a number expected to grow as the population ages and the prevalence of common comorbidities (e.g., diabetes) rises. However, no therapies currently exist to produce the "ideal" healing outcome: efficient wound repair through regeneration of normal tissue. Recent Advances: Ongoing research continues to illuminate possible therapeutic avenues for wound healing. By identifying underlying mechanisms of wound repair-for instance, tissue mechanics' role in fibrosis or cell populations that modulate wound healing and scarring-novel molecular targets may be defined. This Advances in Wound Care Forum issue includes reviews of scientific literature and original research from the Hagey Laboratory for Pediatric Regenerative Medicine at Stanford and its alumni, including developing approaches for encouraging wound healing, minimizing fibrosis, and coaxing regeneration. Critical Issues: Wound healing problems reflect an enormous and rapidly expanding clinical burden. The issues of both under- and over-healing wound outcomes will continue to expand as their underlying causes (e.g., diabetes) grow. Targeted treatments are needed to enable wound repair with functional tissue restoration and decreased scarring. Future Directions: Basic scientists will continue to refine understanding of factors driving undesirable wound outcomes. These discoveries are beginning to be translated and, in the coming years, will hopefully form the foundation for antiscarring drugs and other wound therapeutics.

The outcome of postoperative radiation therapy following plastic surgical resection of recurrent ear keloid: a single institution experience

Background

Ear keloids are abnormal continuously growing healing process following cutaneous injury. Surgical excision is the standard treatment strategy; however, 50–80% of cases develop recurrence. Adjuvant radiotherapy (RT) is commonly offered with a marked decrease in the recurrence rate. The variation in RT protocols used in different studies leads to a bias of results analysis. The aim is to present our experience of using surgical excision with postoperative radiotherapy for recurrent ear keloids. Also, studying different variables especially dose and keloid size that affects recurrence rate. Radiotherapy complications were reported and assessed.

Patients and methods

Keloids between 2006 and 2021 were retrospectively reviewed. Fifty-five ear keloids out of 83 cases who received RT after surgical excision were included in the study. Different dose regimens including 13 Gy/1fx, 8 Gy/1fx, 10 Gy/2fx, 15 Gy/3fx, and other fractionated regimens were used. The Median follow-up period was 35 months. Recurrence-free rate (RFR), side effects, and prognostic factors were assessed.

Results

The overall 2-year RFR was 88 ± 5%. The 2-year RFR was 83 ± 8% for dose regimens with biological effective dose (BED) ≤ 40 and 92 ± 5% for regimens with BED > 40 Gy with an insignificant p value. The 2-year RFR was 74 ± 10% compared to 97 ± 3% for keloids > 2 cm and keloids ≤ 2 cm respectively (p value 0.02). The higher dose used for keloids with > 2 cm size significantly improved RFR. The orthovoltage therapy showed marginally better 2-year RFR compared to electron beam therapy; however, statistically insignificant (p value 0.09). The side effects were minimal with no reported second malignancy or serious G3-4 complications.

Conclusion

Excision followed by RT is a safe and effective treatment for recurrent ear keloids. Low and modest radiation doses are effective; however, a higher dose is recommended for keloids > 2 cm. We recommend a prospective larger-scale study to test the effect of dose and keloid size on the treatment results.

Efficacy of Surgical Excision and Adjuvant High-dose Rate Brachytherapy in Treatment of Keloid: Our Experience

Background

Keloids are dermal tumors that are due to increased production of collagen caused by abnormal and prolonged wound healing. The incidence of recurrence is extremely high if only conservative measures are used. This study was conducted to evaluate the feasibility and efficacy surgery and high dose rate brachytherapy as an adjuvant therapy for treatment of keloids.

Materials and Methods

50 patients with clinically diagnosed 71 keloids were treated with excision of keloid and post-operative high-dose rate brachytherapy were studied. Complete excision of the keloid till the healthy skin margin was excised. The wound were closed in 2 layers. Subcutaneous tissue closed using absorbable suture, over which a 6F flexible polyethylene tube was placed. High dose rate cobalt-60 brachytherapy was administered. Total of 15 Gy in divided dose, 5 Gy in 3 fractions were administered.

Results

50 patients with 71 keloids were studied. Out of the 50 patients, 12 were male (24%) and 38 were females (76%). Age of the patients ranged between 14 and 71 years. Recurrence rate was 2% with 2 keloids recurring at 5 months interval. 4 patients scored the results as unacceptable, remaining 45 patients rated their results as excellent during their follow up at 10 days, 3 months and 6 months.

Conclusion

Treatment of keloids in the plastic surgeon's practice even today is still challenging. Many therapies have been described, but recurrence rate is high with mono-therapy. Combination therapy especially surgical excision with postoperative radiotherapy is best in preventing recurrence.

Keloid scars. Modern aspects of diagnosis and treatment

Cicatricial skin hypertrophy includes keloids and hypertrophic scars. Keloid scarring is thought to result from an imbalance between increased synthesis of collagen and extracellular matrix and decreased degradation of these products. Current knowledge of keloid pathophysiology prompts clinicians to investigate new methods for the diagnosis and treatment of keloids, as well as their prevention.

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.

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.

Mesenchymal stem cell therapy in hypertrophic and keloid scars

Scars are the normal outcome of wound repair and involve a co-ordinated inflammatory and fibrotic process. When a scar does not resolve, uncontrolled chronic inflammation can persist and elicits excessive scarring that leads to a range of abnormal phenotypes such as hypertrophic and keloid scars. These pathologies result in significant impairment of quality of life over a long period of time. Existing treatment options are generally unsatisfactory, and there is mounting interest in innovative cell-based therapies. Despite the interest in mesenchymal stem cells (MSCs), there is yet to be a human clinical trial that investigates the potential of MSCs in treating abnormal scarring. A synthesis of existing evidence of animal studies may therefore provide insight into the barriers to human application. The aim of this PRISMA systematic review was to evaluate the effectiveness of MSC transplantation in the treatment of hypertrophic and keloid scars in in vivo models. A total of 11 case-control studies were identified that treated a total of 156 subjects with MSCs or MSC-conditioned media. Ten studies assessed hypertrophic scars, and one looked at keloid scars. All studies evaluated scars in terms of macroscopic and histological appearances and most incorporated immunohistochemistry. The included studies all found improvements in the above outcomes with MSC or MSC-conditioned media without complications. The studies reviewed support a role for MSC therapy in treating scars that needs further exploration. The transferability of these findings to humans is limited by factors such as the reliability and validity of the disease model, the need to identify the optimal MSC cell source, and the outcome measures employed.

A retrospective study of hypofractionated radiotherapy for keloids in 100 cases

At present, the consensus on the best treatment for keloids is the combination of clinical and surgical therapies, if necessary, associated with adjuvant radiotherapy like brachytherapy. Whereas, the uniform scheme of radiotherapy in keloids is unclear. Here, we conducting a retrospective analysis to assess the efficacy and safety of a specific treatment regimen (20 Gy in 5 fractions) in keloid patients. We retrospectively analysed the medical records of keloid patients receiving auxiliary postoperative radiotherapy (PORT) treatment from 2009 to 2019. The patients were treated with the hypofractionation method of 20 Gy in 5 fractions. We compared the local control rate and complications, using the chi-square test and logistic regression analyses. After screening, we identified 100 keloid patients in this study, with a median follow-up of 59 months. In this study, the overall local control rate of keloid lesions was 84.8%. After multivariate analyses (primary keloid or not, family history, interval from surgery to irradiation and site), our research showed that primary keloid, site and interval from surgery to irradiation were significantly related to recurrence. Acute radiation injury and late radiation injury accounted for 3% (erythema) and 1% (skin sclerosis) of the total cases, respectively. Our results indicate that a postoperative hypofractionation with radiation dose of 20 Gy in 5 fractions may be effective, easy to accept and safe for keloid patients.

Pirfenidone inhibits epithelial-mesenchymal transition in keloid keratinocytes

Background

Keloids are benign fibroproliferative skin lesions that are difficult to treat and become a lifetime predicament for patients. Several treatment modalities have been put forth, but as yet no satisfactory approach to the prevention or treatment of keloids has been identified. The process of epithelial-to-mesenchymal transition (EMT) has been implicated in keloid scarring, as keloid keratinocytes display an EMT-like phenotype. This study investigated the potential of pirfenidone, an antifibrotic agent, to counteract EMT-like alterations in keloid keratinocytes, including gene expression, cell migratory and proliferative functions.

Methods

Normal and keloid keratinocytes were isolated from discarded normal skin tissues and from resected keloid tissues, respectively. Cells were quiesced for 24 h without epidermal growth factor DS-Qi1MCDigital and were exposed to transforming growth factor-beta1 (TGF-β1; 10 ng/mL), with or without pirfenidone (400 μg/mL), for an additional 24 h. The effects of pirfenidone on cytotoxicity, cell migration, cell proliferation, and on expression of genes and proteins involved in EMT were assayed. Statistical significance was determined by two-way ANOVA using Sigma Plot.

Results

We found that pirfenidone did not elicit any cytotoxic effect at concentrations up to 1000 μg/mL. A statistically significant dose-dependent decrease in basal cell proliferation rate was noted in both normal and keloid keratinocytes when exposed to pirfenidone at concentrations ranging from 200 to 1000 μg/mL. Pirfenidone significantly decreased basal cell migration in both normal and keloid keratinocytes, but a significant decrease in TGF-β1-induced cell migration was seen only in keloid keratinocytes. Significant inhibition of the expression of TGF-β1-induced core EMT genes, namely hyaluronan synthase 2, vimentin, cadherin-11, and wingless-type MMTV integration site family, member 5A along with fibronectin-1, was observed in both normal and keloid keratinocytes treated with pirfenidone. In addition, the protein levels of vimentin and fibronectin were significantly reduced by pirfenidone (400 μg/mL) in both normal and keloid keratinocytes.

Conclusions

For the first time, this study shows the efficacy of pirfenidone in inhibiting the EMT-like phenotype in keratinocytes derived from keloids, suggesting that pirfenidone may counteract a critical contributor of keloid progression and recurrence.

Keloid treatment: what about adjuvant radiotherapy?

Background: Keloids are debilitating fibrous skin proliferations with a high recurrence rate after surgical treatment. Postoperative radiotherapy (PORT) is a well-tolerated adjuvant treatment to reduce the risk of recurrence, but the optimal regimen for this combined treatment remains unknown. The aim of this study is to evaluate the efficacy of combining surgical excision and immediate PORT.

Methods: We retrospectively reviewed the records of patients with keloid lesions treated with adjuvant PORT in the period 2005–2014 at Geneva University Hospitals. Main outcomes were the rates of complications and recurrence in patients with a minimal follow-up of 1 year, including the Patient and Observer Scar Assessment Scale satisfaction scores.

Results: 10 patients with 16 keloids were eligible (mean follow-up, 37 months). Only one recurrence was reported (6%). In 12.5% of cases, mild erythema appeared in the early postoperative period. No major complications were observed. The overall patient and observer satisfaction rate was excellent.

Conclusion: Surgical excision combined with immediate PORT is an effective and easy treatment with good esthetic results and an acceptable recurrence rate. It should be considered for patients with persistent keloid formation after failure of other treatments and those at high risk of relapse.

High in situ mRNA levels of IL-22, TFG-β, and ARG-1 in keloid scars

Keloid scars are currently considered a chronic inflammatory process and no longer a benign skin tumor. Keloids are defined as highly inflamed, hyperproliferative pathological scars. Growth factors and cytokines have important functions in the keloid inflammatory etiopathogenesis. The aim of this study was to analyze the in situ expression of cytokines and growth factors in keloid scars in comparison with that in normal scars. Among them, we specifically assessed TGF-β, FGF, IL-33, IL-22, ARG-1, ARG-2, iNOS, VIP, VIP-R1, TAC, and TAC-R1. A total of 98 biopsies were evaluated, including of 53 keloid and 45 normal scars. The age of patients with keloids ranged from 11 to 73 years, with a mean age of 28 years and predominance of the female gender (58.5% of the total patients). Around 64.15% of the patients belonged to the black ethnic group. Evaluated keloids were most commonly located in the earlobe because of ear piercing, representing 73.6% of the cases. We found significantly greater expression of TGF-β, IL-22, and ARG-1 in keloids when compared with that in normal scars. As for IL-33, ARG-2, and VIP-R1, despite the higher number of mRNA copies found in keloids, this difference was not significant. Furthermore, FGF, iNOS, VIP, TAC, and TAC-R1 mRNA levels were not detectable, and therefore these results were inconclusive in this study. Considering these results, understanding the cellular and molecular mechanisms that control the inflammatory response during cutaneous healing may promote the development of strategies to improve the treatment of patients with keloids.

The efficacy of excision followed by intralesional 5-fluorouracil and triamcinolone acetonide versus excision followed by radiotherapy in the treatment of ear keloids: A randomized control trial

BACKGROUND

The ear is the common site for keloid formation especially in women after ear piercing. Surgery is the main stay of treatment in these lesions but there are large numbers of treatment failures in surgery alone.

OBJECTIVE

The objective of this study was to compare the efficacy of post-excision intralesional 5-fluorouracil/triamcinolone acetonide (5-FU/TAC) and post-excision radiotherapy in the treatment of ear keloids.

STUDY DESIGN

A randomized controlled trial.

SETTING

The study was conducted from May 2014 to January 2015 at Jinnah Burn and Reconstructive Surgery Centre, Allama Iqbal Medical College, Lahore.

SUBJECT & METHODOLOGY

After approval from the hospital ethical committee, 60 patients presented in the outpatient department fulfilling the inclusion criteria were selected and randomly assigned in two groups with the help of the random number table. Patients in group A had excision followed by intralesional 5-FU/TAC injections while patients of group B had excision followed by radiotherapy. Patients were assessed at 6 months after completion of treatment for efficacy (no recurrence within 6 months of treatment).

RESULTS

In our study total of 60 patients completed the study, with 30 patients in each group. 7 patients (23.34%) in Group-A and 9 patients (30%) in Group-B were males while 23 patients (76.67%) in Group-A and 21 patients (70%) in Group-B were females i.e. male to female ratio is 1:2.75. Mean age was 31.8+6.48years. The comparison of frequency of efficacy in both groups showed that 73.33% (n=22) in Group-A and 43.33% (n=13) in Group-B had efficacy, p value was calculated as 0.01, showing a significant statistical difference.

CONCLUSION

Excision and intralesional 5-FU/TAC is an effective treatment for keloids on the ears.

In Situ Cytokine Expression and Morphometric Evaluation of Total Collagen and Collagens Type I and Type III in Keloid Scars

Keloids are characterized by excessive collagen deposition and growth beyond the edges of the initial injury, and cytokines may be related to their formation. The objective of this study was to evaluate the collagen fibers, analyze in situ expression of cytokines in keloid lesions, and compare to the control group. Results showed that there was a predominance of women and nonwhite and direct black ancestry. Keloid showed a significant increase in total and type III collagen. Significantly, the expression of mRNA for TGF-β in keloid was increased, the expressions of IFN-γ, IFN-γR1, and IL-10 were lower, and IFN-γR1 and TNF-α had no statistical difference. Correlations between collagen type III and TGF-β mRNA expression were positive and significant, IFN-γ, IFN-γR1, and IL-10 were negative and significant, and TNF-α showed no statistical difference. We conclude that there was a significant increase of total collagen in keloid and predominance of collagen type III compared to the controls, showing keloid as an immature lesion. There is a significant increase in TGF-β mRNA in keloid lesions, and a significant decrease in IFN-γ and IL-10, suggesting that these cytokines are related to keloid lesions.

Clinimetric properties and clinical utility in rehabilitation of postsurgical scar rating scales: a systematic review

The aim of this study was to review and critically assess the most used and clinimetrically sound outcome measures currently available for postsurgical scar assessment in rehabilitation. We performed a systematic review of the Medline and Embase databases to June 2015. All published peer-reviewed studies referring to the development, validation, or clinical use of scales or questionnaires in patients with linear scars were screened. Of 922 articles initially identified in the literature search, 48 full-text articles were retrieved for assessment. Of these, 16 fulfilled the inclusion criteria for data collection. Data were collected pertaining to instrument item domains, validity, reliability, and Rasch analysis. The eight outcome measures identified were as follows: Vancouver Scar Scale, Dermatology Life Quality Index, Manchester Scar Scale, Patient and Observer Scar Assessment Scale, Bock Quality of Life (Bock QoL) questionnaire, Stony Brook Scar Evaluation Scale, Patient-Reported Impact of Scars Measure, and Patient Scar Assessment Questionnaire. Scales were examined for their clinimetric properties, and recommendations for their clinical or research use and selection were made. There is currently no absolute gold standard to be used in rehabilitation for the assessment of postsurgical scars, although the Patient and Observer Scar Assessment Scale and the Patient-Reported Impact of Scars Measure emerged as the most robust scales.

Expression of embryonic stem cell markers in keloid-associated lymphoid tissue

AIMS

To identify, characterise and localise the population of primitive cells in keloid scars (KS).

METHODS

5-µm-thick formalin-fixed paraffin-embedded sections of KS samples from 10 patients underwent immunohistochemical (IHC) staining for the embryonic stem cell (ESC) markers OCT4, SOX2, pSTAT3 and NANOG, and keloid-associated lymphoid tissue (KALT) markers CD4 and CD20. NanoString gene expression analysis and in situ hybridisation (ISH) were used to determine the abundance and localisation of the mRNA for these ESC markers.

RESULTS

IHC staining revealed the expression of the ESC markers OCT4, SOX2, pSTAT3 and NANOG by a population of cells within KS tissue. These are localised to the endothelium of the microvessels within the KALTs. NanoString gene expression analysis confirmed the abundance of the transcriptional expression of the same ESC markers. ISH localised the expression of the ESC transcripts to the primitive endothelium in KS tissue.

CONCLUSIONS

This report demonstrates the expression of ESC markers OCT4, SOX2, pSTAT3 and NANOG by the endothelium of the microvessels within the KALTs. These findings show a unique niche of primitive cells within KS, expressing ESC markers, revealing a potential therapeutic target in the treatment of KS.

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.