Abnormal wound healing: keloids

Presentation, Management, and Outcomes of Pathologic Scars Within a Pediatric Otolaryngology Practice

OBJECTIVES

This study aims to review the spectrum of scarring that may present to an urban, pediatric otolaryngology practice and determine if associations exist between race, scar location, treatment modality, and outcomes following interventions for scarring.

METHODS

Retrospective cohort study among 115 pediatric patients with 138 unique keloids or hypertrophic scars (HTS), and 141 children presenting for tonsillectomy at Tufts Medical Center. Age at presentation and sex assigned at birth were collected for both populations. For those presenting for pathologic scars, income quintile, self-identified race/ethnicity, anatomical location, treatment number and type, and clinical outcome were also analyzed. Multivariate analyses calculated adjusted odds ratios (aORs) and 95% confidence intervals to assess associations between scar subsite, intervention type, and persistence after treatment.

RESULTS

Compared to individuals presenting for tonsillectomy, a disproportionate percentage of patients presenting for scarring identified as Black (26.6% vs. 13.5%) or Asian (17.4% vs. 7.1%, p = 0.016) or were male (61.7% vs. 49.7%, p = 0.053). Individuals identifying as Black or Asian were more likely to present with ear lobe and neck scars, respectively (50.0% vs. 45.5%, p = <0.001). Ear scars were significantly more likely to receive excision at initial treatment (aOR = 5.86 [1.43-23.96]) compared to other subsites, and were more likely to require >1 treatment (aOR = 5.91 [1.53-22.75]).

CONCLUSION

Among pediatric patients presenting with keloids or HTS, children who identified as Black or Asian were more likely to present with ear and neck scars, respectively. Ear scars were frequently treated with excision and appear more likely to require adjuvant treatments and multiple interventions.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3127-3135, 2024.

A Single-Institution Review of the Use of Radiation in the Adjuvant and Definitive Management of Keloids

AIMS

Many individuals suffer from keloids that are refractory to standard treatment modalities, including surgical excision alone. Radiation therapy can be used to reduce the risk of recurrent keloids post-operatively, as well as be used as primary treatment for keloids not amenable to surgical resection. The purpose of this study was to review our institutional experience of radiation therapy for keloid management.

MATERIALS AND METHODS

A retrospective review of patients treated with radiation therapy for keloids between 2014 and 2020 at our institution was performed.

RESULTS

A total of 70 keloids in 41 patients were treated. For the 55 keloids treated with post-operative radiation therapy (16Gy delivered in 2 fractions), 82.5% (33/40) of evaluable lesions did not recur. Among the 15 keloids treated with definitive radiation therapy (24Gy delivered in 3 fractions), 78.6% (11/14) of evaluable keloids showed complete flattening, and 14.3% (2/14) had partial flattening. Both acute and late toxicities were mild, with only a single instance of grade 3 toxicity (dermatitis).

CONCLUSION

Our study confirms that radiation therapy has a role in reducing the risk of keloid recurrence post-operatively, and plays an important role in the definitive management of unresectable keloids.

Biomechanical Activation of Keloid Fibroblasts Promotes Lysosomal Remodeling and Exocytosis

Keloids are a severe form of scarring for which the underlying mechanisms are poorly understood, and treatment options are limited or inconsistent. Although biomechanical forces are potential drivers of keloid scarring, the direct cellular responses to mechanical cues have yet to be defined. The aim of this study was to examine the distinct responses of normal dermal fibroblasts and keloid-derived fibroblasts (KDFs) to changes in extracellular matrix stiffness. When cultured on hydrogels mimicking the elasticity of normal or scarred skin, KDFs displayed greater stiffness-dependent increases in cell spreading, F-actin stress fiber formation, and focal adhesion assembly. Elevated actomyosin contractility in KDFs disrupted the normal mechanical regulation of extracellular matrix deposition and conferred resistance on myosin inhibitors. Transcriptional profiling identified mechanically regulated pathways in normal dermal fibroblasts and KDFs, including the actin cytoskeleton, Hippo signaling, and autophagy. Further analysis of the autophagy pathway revealed that autophagic flux was intact in both fibroblast populations and depended on actomyosin contractility. However, KDFs displayed marked changes in lysosome organization and an increase in lysosomal exocytosis, which was mediated by actomyosin contractility. Together, these findings demonstrate that KDFs possess an intrinsic increase in cytoskeletal tension, which heightens the response to extracellular matrix mechanics and promotes lysosomal exocytosis.

Surgery and superficial x-ray radiotherapy for keloids of the preauricular and contralateral ear lobe: Case report

The combined approach of surgical resection along with superficial x-ray radiotherapy emerges as a superior treatment option for individuals with keloids, which hold huge potential for enhancing aesthetic outcomes and preventing keloid recurrence.

Parecoxib decreases cellular growth and Bcl-2 protein levels in primary cultures of keloid fibroblasts

Keloids seem to overexpress cyclo-oxygenase-2 (COX-2), suggesting a role in its deregulated pathway in inducing an altered epithelial-mesenchymal interaction, which may be responsible for the overgrowth of dermal components resulting in scars or keloid lesions. This study aimed to evaluate the effect of Parecoxib, a COX-2 inhibitor, on cell growth in fibroblast primary cultures obtained from human keloid tissues. Tissue explants were obtained from patients who underwent intralesional excision of untreated keloids; central fractions were isolated from keloid tissues and used for establishing distinct primary cultures. Appropriate aliquots of Parecoxib, a COX-2 inhibitor were diluted to obtain the concentration used in the experimental protocols in vitro (1, 10 or 100 μM). Treatment with Parecoxib (at all concentrations) caused a significant decrease in cellular growth from 24 hours onwards, and with a maximum at 72 hours (P < .02). Moreover, at 72 hours Parecoxib significantly reduced cellular vitality. Parecoxib treatment also induced an increase in fragmented nuclei with a maximum effect at 100 μM and a significant decrease in Bcl-2 and an increase in activated caspase-3 protein levels at 72 hours compared with control untreated cultures. Our findings suggest a potential use of the COX-2 inhibitor, Parecoxib, as the therapy for keloids.

Keloid Intralesional Excision Reduces Recurrence: A Meta-analytic Study of the Available Literature on 608 Keloids

Background

The objective of this meta-analysis was to examine the effectiveness of keloid intralesional excision (KILE) in preventing recurrence. Treatment of keloids using surgical excision alone leads to high rates of recurrence. To date, there are no widely accepted guidelines for keloid treatment, and a multitude of adjunctive therapies are used to reduce recurrence. Despite these efforts, recurrence remains high. In this study, we conducted a meta-analysis of the existing literature on KILE to determine its role in recurrence reduction.

Methods

A literature review using PubMed, Scopus, and Web of Science databases was performed. Two authors independently evaluated studies for eligibility. Incidence of keloid recurrence was recorded, and a comprehensive meta-analysis was performed to assess the pooled keloid recurrence rate, as well as the effect of additional therapies.

Results

Twenty-two studies evaluating intralesional excision of 608 keloids were included in the study. Average time to follow-up was 19.2 months (range 6-35 months). A meta-analysis of proportions was conducted, demonstrating a pooled recurrence rate of 13% (95% confidence interval, 9%-16%). There was no evidence that using therapies in addition to KILE had a significant effect on the overall pooled recurrence rate.

Conclusions

A meta-analysis of 608 keloids shows that KILE is an effective technique in preventing keloid recurrence, with a pooled recurrence rate of 13% compared with previously reported rates of 45%-100% after complete excision. Although there are no standard guidelines for keloid treatment, our meta-analysis shows that KILE is promising in recurrence reduction.

Comparative Efficacy of Drug Interventions for Keloids: A Network Meta-analysis

BACKGROUND

Keloids are common benign skin lesions originating from a disorganized fibroproliferative collagen response; these lesions often lead to both physical and psychological problems. The optimal treatment for keloids is yet to be standardized. Intralesional injection, which is simple and nontraumatic, is one of the most commonly used treatment modalities for these lesions. In this study, we compared 5 different drugs (intralesional injections) for the treatment of keloids in terms of efficacy.

METHODS

We systemically searched relevant studies on PubMed, EMBASE, and Cochrane Library. Randomized clinical trials on the safety and efficacy of triamcinolone acetonide (TAC), 5-fluorouracil (5-FU), botulinum toxin A (BTA), verapamil, and bleomycin were included in this study.

RESULTS

This network meta-analysis included a total of 1114 patients from 20 randomized controlled trials. Botulinum toxin A alone and TAC plus 5-FU exhibited significantly better efficacy than did 5-FU, TAC, and verapamil. No significant difference in efficacy between BTA alone and TAC combined with 5-FU was observed. No significant differences were noted in the adverse event rate between BTA, TAC plus 5-FU, 5-FU, and TAC. Furthermore, we performed surface under the cumulative ranking curve analyses to predict the rank of each intervention (by efficacy and adverse event rate). The predicted ranking by efficacy was as follows: TAC plus 5-FU, BTA, bleomycin, TAC, 5-FU, and verapamil; the predicted ranking by adverse events was as follows: TAC, 5-FU, TAC plus 5-FU, and BTA. Funnel plot analysis revealed no publication bias.

CONCLUSIONS

Botulinum toxin A and TAC plus 5-FU appear to have outstanding therapeutic efficacy for keloids. The rate of adverse events was similar among BTA, TAC, 5-FU, and TAC plus 5-FU. Nonetheless, additional reviews of rigorous, large-scale randomized controlled trials are warranted for further validation of our findings.

Weighted gene co-expression network analysis and machine learning identified the lipid metabolism-related gene LGMN as a novel biomarker for keloid

The aetiology of keloid formation remains unclear, and existing treatment modalities have not definitively established a successful approach. Therefore, it is necessary to identify reliable and novel keloid biomarkers as potential targets for therapeutic interventions. In this study, we performed differential expression analysis and functional enrichment analysis on the keloid related datasets, and found that multiple metabolism-related pathways were associated with keloid formation. Subsequently, the differentially expressed genes (DEGs) were intersected with the results of weighted gene co-expression network analysis (WGCNA) and the lipid metabolism-related genes (LMGs). Then, three learning machine algorithms (SVM-RFE, LASSO and Random Forest) together identified legumain (LGMN) as the most critical LMGs. LGMN was overexpressed in keloid and had a high diagnostic performance. The protein-protein interaction (PPI) network related to LGMN was constructed by GeneMANIA database. Functional analysis of indicated PPI network was involved in multiple immune response-related biological processes. Furthermore, immune infiltration analysis was conducted using the CIBERSORT method. M2-type macrophages were highly infiltrated in keloid tissues and were found to be significantly and positively correlated with LGMN expression. Gene set variation analysis (GSVA) indicated that LGMN may be related to promoting fibroblast proliferation and inhibiting their apoptosis. Moreover, eight potential drug candidates for keloid treatment were predicted by the DSigDB database. Western blot, qRT-PCR and immunohistochemistry staining results confirmed that LGMN was highly expressed in keloid. Collectively, our findings may identify a new biomarker and therapeutic target for keloid and contribute to the understanding of the potential pathogenesis of keloid.

Comprehensive Analysis of Current Treatment Approaches for Keloids in Pediatrics: A Systematic Review

Keloids, benign fibrous growths resulting from atypical skin responses to injuries, present a complex challenge in dermatology. These lesions, characterized by excessive collagen production, often lead to physical discomfort and psychological distress. While various treatment methods exist, the lack of a universally effective modality underscores the need for a systematic evaluation of current approaches. This systematic review aims to comprehensively analyze the current available treatment modalities used for the management of keloids in the pediatric population in terms of their effectiveness, safety, and quality of life outcomes. The review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted on PubMed and Google Scholar databases to identify relevant studies published in English. The review specifically focused on randomized controlled trials involving patients under 18 diagnosed with keloids, assessing different treatment modalities, and reporting validated measures of treatment efficacy, safety outcomes, and quality of life. The risk of bias was assessed using Cochrane's Risk of Bias Tool for randomized studies to ensure the methodological quality of the included trials. Four studies met the inclusion criteria, collectively involving 196 pediatric patients. Treatment interventions included glucocorticosteroid and fusidic acid cream with silicone gel patches, botulinum toxin type A injections, and Scarban silicone gel sheets. Patient-reported outcomes exhibited varying degrees of improvement in scar size, vascularity, and pliability. Complications, such as rash and wound infection, were reported in some cases. Based on our review of the selected studies and due to the incompletely understood pathogenesis of keloids, there is an ongoing lack of universally effective treatment modality for the management of keloids resulting in their persistently high recurrence rate.

Needle-free electronically controlled jet injection with corticosteroids in recalcitrant keloid scars: a retrospective study and patient survey

First-line treatment of keloids consists of intralesional needle injections with corticosteroids, but generally entails multiple painful sessions, resulting in variable clinical outcomes. Novel needle-free jet injectors may facilitate more effective and patient-friendly dermal drug delivery. Here, we evaluated the effectiveness, tolerability and patient satisfaction of intralesional triamcinolone-acetonide (TCA) treatment in recalcitrant keloids using an electronically controlled pneumatic injector (EPI). A retrospective study was conducted in recalcitrant keloid patients with a history of severe pain during needle injections who received three sessions of EPI + TCA. Outcome measures included Patient and Observer Scar Assessment Scale (POSAS), Global Aesthetic Improvement Scale (GAIS), treatment-related pain (NRS), adverse effects, and patient satisfaction (survey). Ten patients with in total 283 keloids were included. The POSAS score significantly improved at follow-up and GAIS was reported as '(very) improved' for all patients. EPI + TCA was well-tolerated with a significantly lower NRS pain score compared to needle + TCA (pilot treatment). Only minor adverse effects occurred, and 90% of patients preferred EPI over needle treatment. EPI + TCA is an effective and tolerable treatment for patients with recalcitrant keloids. The minimal treatment-related pain and high patient satisfaction makes it a promising treatment for patients with needle-phobia and/or severe pain during needle injections.

Identification of a potential bioinformatics-based biomarker in keloids and its correlation with immune infiltration

Keloid formation is a pathological consequence resulting from cutaneous irritation and injury, primarily attributed to excessive collagen matrix deposition and fibrous tissue proliferation. Chronic inflammation, left uncontrolled over an extended period, also stands as a substantial contributing factor. The precise mechanisms underlying keloid formation remain unclear. Therefore, this study aimed to identify key genes for diagnostic purposes. To achieve this, we used two Gene Expression Omnibus (GEO) data sets to identify differentially expressed genes. We identified one particular gene, homeobox C9 (HOXC9), using a thorough strategy involving two algorithms (least absolute shrinkage and selection operator and support vector machine-recursive feature elimination) and weighted gene co-expression network analysis. We then assessed its expression in normal and keloid tissues. In addition, we explored its temporal expression patterns via Mfuzz time clustering analysis. In our comprehensive analysis, we observed that immune infiltration, as well as cell proliferation, are crucial to keloid formation. Thus, we investigated immune cell infiltration in the keloid and normal groups, as well as the correlation between HOXC9 and these immune cells. It was found that HOXC9 was closely associated with the immune microenvironment of keloids. This shows that HOXC9 can serve as a potential biomarker and therapeutic target for keloids.

An Open-Label, Uncontrolled, Single-Arm Clinical Trial of Tofacitinib, an Oral JAK1 and JAK3 Kinase Inhibitor, in Chinese Patients with Keloid

BACKGROUND

The keloid treatment is still a thorny and complicated clinical problem, especially in multiple keloids induced by wound, severe burn, ethnic background or cultural behaviors, or unexplained skin healing. Mainstream treatments have limited efficacy in treating multiple keloids. As no oral treatment with painlessness and convenience is available, oral treatment strategies should be formulated.

OBJECTIVES

This study aimed to investigate the efficacy and therapeutic mechanism of oral tofacitinib in keloid patients.

METHODS

We recruited the 7 patients with keloid scars and prescribed 5 mg of tofacitinib twice a day orally with a maximum follow-up of 12 weeks. The Patient and Observer Scar Assessment Scale (POSAS), the Vancouver scar scale (VSS), ANTERA 3D camera, and the DUB Skin Scanner 75 were used to assess the characteristics of the lesion. Immunohistochemistry was performed to evaluate collagen synthesis, proliferation, and relative molecular pathways. Moreover, the effects of tofacitinib were assessed on keloid fibroblast in vitro.

RESULTS

After 12 weeks of oral tofacitinib, significant improvement in POSAS, VSS, and Dermatology Life Quality Index (DLQI) scores was observed (p < 0.05). The volume, lesion height, and dermis thickness of the keloid decreased (p < 0.05). Moreover, significant decreases in the expression of collagen I, Ki67, p-STAT 3, and p-SMAD2 were observed after 12 weeks of administration. In vitro experiments suggested that tofacitinib treatment inhibits fibroblast proliferation and collagen I synthesis via suppression of STAT3 and SMAD2 pathway.

CONCLUSION

Tofacitinib, a new candidate oral drug for keloid, could reduce keloid lesion volume by inhibiting collagen synthesis and inhibiting fibroblast proliferation, and alleviate itch and pain to obtain a better life quality.

Evaluation of the Risk of Hypertrophic Scarring and Keloid Following Eyelid Procedures: A Systematic Review

BACKGROUND

Eyelid surgeries are common operations performed for both cosmetic and functional purposes. Because the periorbital region is highly visible, it is important to avoid poor scar formation in this cosmetically sensitive region. No study to date has investigated the possible existence of keloid formation following eyelid procedures.

OBJECTIVES

This study systematically reviewed the literature to identify cases of hypertrophic scar and keloid formation following cosmetic or functional (nonburn) eyelid procedures to aid surgeons when counseling patients.

METHODS

A PubMed/MEDLINE search was conducted on May 17, 2022, using appropriate search terms: "blepharoplasty," "tarsorrhaphy," "canthotomy," "ptosis repair," "epicanthoplasty," "keloid," "hypertrophic scar," and related lay terms. All eligible articles in English with no lower date limit were included for analysis. Descriptive statistics, exclusion criteria, and summarized results are reported.

RESULTS

The PubMed search yielded 107 abstracts/articles. Full-text review resulted in 34 articles included for analysis. Twenty manuscripts reported no occurrences of hypertrophic scars. Only 13 manuscripts reported patients with hypertrophic scarring, which equated to 36 patients out of 3650. One individual was identified in a series of 77 patients who developed a keloid after a tarsorrhaphy. No articles reported a keloid as an outcome of strictly cosmetic procedures.

CONCLUSIONS

This study concludes that there are no reported instances of keloid formation following cosmetic (nonburn) eyelid procedures in the existing literature. Hypertrophic scar formation is minimally reported. The absence of keloid scar formation on the eyelid is critical knowledge for surgeons when educating patients about maladaptive scarring risks following eyelid procedures.

LEVEL OF EVIDENCE: 4

Keloid Development After Fine Needle Aspiration of the Thyroid: A Rare Case and Review of Management Strategies

Keloids are pathological scars characterized by abnormal proliferation of tissue as a result of cutaneous injury. There is a high prevalence of keloid development in certain ethnicities. Individuals from African, Hispanic, and Asian backgrounds have a higher likelihood of developing keloids when compared to Caucasians. Keloids are known to lack spontaneous regression and have a high rate of recurrence after removal, thereby causing a cosmetic problem that affects people physically and emotionally. Keloids commonly occur after burns, tattoos, piercings, and deep wounds; however, in rare cases, they may develop after minimally invasive procedures. This case describes the experience of a 48-year-old African American male who underwent a thyroid fine needle aspiration biopsy and subsequently developed a keloid in the neck region. This report aims to explore this unique occurrence, highlight the interplay between epidemiology, race, and genetics in influencing the development of keloids, and review the management strategies for neck keloids.

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.

Keloid treatments: an evidence-based systematic review of recent advances

BACKGROUND

Keloids are pathologic scars that pose a significant functional and cosmetic burden. They are challenging to treat, despite the multitude of treatment modalities currently available.

OBJECTIVE

The aim of this study was to conduct an evidence-based review of all prospective data regarding keloid treatments published between 2010 and 2020.

METHODS

A systematic literature search of PubMed (National Library of Medicine), Embase (Elsevier), and Cochrane Library (Wiley) was performed in November of 2020. Search strategies with the keywords "keloid" and "treatment" were performed by a medical librarian. The search was limited to prospective studies that were peer-reviewed, reported on clinical outcomes of keloid therapies, and were published in the English language between January 1, 2010, and November 24, 2020.

RESULTS

A total of 3462 unique citations were identified, of which 108 studies met inclusion criteria. Current literature supports silicone gel or sheeting with corticosteroid injections as first-line therapy for keloids. Adjuvant intralesional 5-fluorouracil (5-FU), bleomycin, or verapamil can be considered, although mixed results have been reported with each. Laser therapy can be used in combination with intralesional corticosteroids or topical steroids with occlusion to improve drug penetration. Excision of keloids with immediate post-excision radiation therapy is an effective option for recalcitrant lesions. Finally, silicone sheeting and pressure therapy have evidence for reducing keloid recurrence.

CONCLUSIONS

This review was limited by heterogeneity of subject characteristics and study outcome measures, small sample sizes, and inconsistent study designs. Larger and more robust controlled studies are necessary to further understand the variety of existing and emerging keloid treatments, including corticosteroids, cryotherapy, intralesional injections, lasers, photodynamic therapy, excision and radiation, pressure dressings, and others.

Biomedical materials for wound dressing: recent advances and applications

Wound healing is vital to maintain the physiological functions of the skin. The most common treatment is the use of a dressing to cover the wound and reduce infection risk and the rate of secondary injuries. Modern wound dressings have been the top priority choice for healing various types of wounds owing to their outstanding biocompatibility and biodegradability. In addition, they also maintain temperature and a moist environment, aid in pain relief, and improve hypoxic environments to stimulate wound healing. Due to the different types of wounds, as well as the variety of advanced wound dressing products, this review will provide information on the clinical characteristics of the wound, the properties of common modern dressings, and the in vitro, in vivo as well as the clinical trials on their effectiveness. The most popular types commonly used in producing modern dressings are hydrogels, hydrocolloids, alginates, foams, and films. In addition, the review also presents the polymer materials for dressing applications as well as the trend of developing these current modern dressings to maximize their function and create ideal dressings. The last is the discussion about dressing selection in wound treatment and an estimate of the current development tendency of new materials for wound healing dressings.

The objective evaluation of triamcinolone acetonide efficacy in keloids management using Antera3D® imaging system

Background

Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. These lesions do not spontaneously regress and can cause cosmetic disfigurements and functional disabilities. IntraLesional Injection of Triamcinolone Acetonide (ILITA), alone or in combination with other therapy, is one of the first-line treatment modalities. In this study the authors evaluated the objective efficacy of ILITA treatment in keloids management using this new imaging system.

Materials and Methods

37 patients with 45 keloid scars were treated with intralesional injection of triamcinolone acetonide (TAC) 20 mg/ml at an interval of three weeks. Antera3D® camera took the images and dates of the treated area in each patient, before the treatment (T0) and at three weeks after the last injection (T1). The system processed the levels of color, elevations, melanin and hemoglobin expression. All the scars were also evaluated, at the same times, by validated Vancouver Scar Scale (VSS). Comparison of the variables was performed using a Wilcoxon signed-rank test with a p < 0.05.

Results

At T0, mean VSS score was 8.67 ± 1.35 which reduced to 3.62 ± 1.72 at final follow up. Antera3D® scores were statistically significant differences in color (8.14 ± 2.41 vs 9.54 ± 1.81), protrusion (381.3 ± 15.6 vs 198.6 ± 21.3), melanin (0.53 ± 0.02 vs 0.62 ± 0.2) and hemoglobin (1.26 ± 0.41 vs 2.21 ± 0.41) expression levels after the treatment.

Conclusions

In our clinical trial, the data results demonstrated that ILITA seems to be effective in reducing keloid dimensions and symptoms such as itching and pain, even if the treatment has local minimal adverse effects such as pain, telangiectasias and atrophy.

Lay Summary

Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. Large keloids can cause cosmetic disfigurements and functional disabilities that affect quality of life. In literature, several treatment approaches have been described but, to date, no single method is considered superior. The International Advisory Panel on Scar Management recommended the use of intralesional steroid injections for keloids treatment. The efficacy of treatment may be evaluated with subjective scale; as no one can guarantee an objective evaluation. To eliminate the observer and/or patient factors, and to obtain a reliable, consistent, feasible, valid and objective evaluation a skin analysis camera system called Antera3D® (Miravex, Dublin, Ireland) can be used.In this study the authors evaluated the objective efficacy of triamcinolone acetonide treatment in keloids management using this imaging system. In this series, for Antera3D® scores there were statistically significant differences in color, protrusion, melanin and hemoglobin expression levels before and after treatment. The device directly shows the treatment changes, measured objectively and accurately, without bias of traditional evaluation scoring scale.Antera3D® system guarantees an objective evaluation of effectiveness of scar treatment enabling clinicians to modulate the therapy according to the scores registered.

Circ_0057452 sponges miR-7-5p to promote keloid progression through upregulating GAB1

Increasing evidence has shown that circular RNAs (circRNAs) play critical roles in various diseases, including keloid. The purpose of this study was to investigate the role of circ_0057452 and related action mechanisms during the development of keloid. The expression levels of circ_0057452, microRNA-7-5p (miR-7-5p) and GRB2 associated binding protein 1 (GAB1) mRNA were determined by quantitative real-time PCR (qRT-PCR). Cell proliferation was evaluated using methylthiazolyldiphenyl-tetrazolium bromide (MTT) and 5-Ethynyl-2'-deoxyuridine (Edu) assays. Flow cytometry analysis was utilized to determine cell cycle distribution and cell apoptosis. Western blot assay was used to measure apoptosis-related, collagen synthesis-related, and GAB1 protein levels. Cell migration and invasion were detected by wound healing assay and transwell assay. The interaction between miR-7-5p and circ_0057452 or GAB1 was confirmed by dual-luciferase reporter, RNA pull-down, and RNA Immunoprecipitation (RIP) assays. Circ_0057452 and GAB1 were upregulated in keloid tissues and keloid fibroblasts (KFs), while miR-7-5p was downregulated. Circ_0057452 knockdown or miR-7-5p overexpression inhibited the proliferation, migration, invasion, and collagen synthesis and induced cell cycle arrest and apoptosis of KFs. MiR-7-5p was targeted by circ_0057452, and its inhibition overturned the effects of circ_0057452 knockdown. In addition, GAB1 was a target of miR-7-5p, and GAB1 upregulation abolished the role of miR-7-5p overexpression and circ_0057452 knockdown in KFs. Circ_0057452 regulated the expression of GAB1 by adsorbing miR-7-5p in KFs. Circ_0057452 knockdown suppressed keloid development by regulating miR-7-5p/GAB1 axis, which might provide a promising therapeutic target for keloid.

Case series of keloid wedge resection in the ear: a focus on aesthetic aspects

Keloid scars may cause a range of symptoms and aesthetic problems. The ear is one of the most frequent sites of keloids, and the earlobe and ear helix account for more than 80% of ear keloids. There are various surgical methods for removing keloids in the ear. Standard keloidectomy and core excision can be effective surgical methods compared to wedge resection since they preserve normal tissue surrounding the keloid. However, ears often show various types of asymmetry by default, which can be relatively difficult to detect, so wedge resection continues to be a useful surgical method for ear keloids. Here, we report four cases of keloids in the earlobe and ear helix that were successfully treated by wedge resection without a postoperative deformity or recurrence.

Glucocorticosteroid and Silicone Gel During Patch Application Without Clinical Scar Improvement After Central Venous Catheter Removal: A Randomized Trial

INTRODUCTION

We studied whether glucocorticosteroid during patch occlusion has a beneficial effect on scar outcome in children and adolescents treated for cancer.

METHODS

A double-blinded placebo-controlled randomized clinical trial was performed. The main outcome was the Vancouver Scar Scale. Secondary outcomes were scar width and scar quality measured using the Patient and Observer Scar Assessment Scale. The patients were divided into an intervention groups and a control group. The intervention group was randomized into active and placebo group. The active treatment consisted of cream with glucocorticosteroid and fusidic acid. The placebo treatment consisted of cream with fusidic acid. Both groups received silicone gel patch after central venous catheter removal. The control group received no specific skin care.

RESULTS

Assessment at 12 months showed that the intervention group had a significantly lower Vancouver Scar Scale and a smaller scar (0,1 cm) compared with the control group ( P =0.00, P =0.02) but no benefit of glucocorticosteroid. The Patient and Observer Scar Assessment Scale showed no significant difference between the intervention and control groups ( P =0.84, P =0.36).

CONCLUSIONS

Silicone gel sheet alone or in combination with application of glucocorticosteroid during sheet occlusion does not clinically improve scar outcome after removal of central venous catheter in children treated for neoplastic diseases.

Efficacy of Topical Losartan in Management of Mammoplasty and Abdominoplasty Scars: A Randomized, Double-Blind Clinical Trial

BACKGROUND

Annually, millions of people suffer from skin scars' psychological and physical disadvantages. Pathologic scars prevention is challenging and requires developing feasible and effective therapeutic strategies. Regarding promising results of losartan (an angiotensin 1 receptor inhibitor) on skin scar in preclinical studies, we aimed to assess the losartan ointment's impact on surgical scars in a clinical setting.

MATERIAL AND METHOD

Twenty-four patients with surgical wounds were enrolled from Razi hospital's plastic and reconstructive surgery department. The patients were trained to apply ointments 14-18 days post-surgery on the determined scar side, twice a day for 6 months. Two dermatologists independently evaluated scar formation at 3 and 6-month follow-ups using the Vancouver Scar Scale (VSS) score.

RESULT

Twenty-four female patients with cosmetic surgeries were included. The mean VSS score of losartan-treated sides was 7.1 ± 2.06 (at month 3) and 5.21 ± 1.71 (at month 6) that significantly were different from placebo-treated sides (9.77 ± 1.55 and 8.31 ± 1.88 at 3 and 6 months, respectively) (P value < 0.001 and < 0.001, respectively, for months 3 and 6). The subset analysis demonstrated a significant improvement in height (P value < 0.001 at 3 and 6 months), pliability (P value  < 0.001 at 3 and 6 months), and vascularity (P value < 0.001 at 3 and 6 months) subsets at losartan compared to placebo-treated side. Losartan ointment was well tolerated with no complication.

CONCLUSION

Losartan ointment successfully improved scar formation in mammoplasty and abdominoplasty patients. The losartan preventive effect should be confirmed in future large-scale studies with long-term follow-ups.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Keloid Therapy: A Neoteric Comparative Study

BACKGROUND

Keloids are considered disorders of fibroproliferation characterized by accumulation of collagen fibers in hypodermis and dermis, caused by inflammation, surgery, and trauma.

OBJECTIVES

The main goal of the study was to approach a better modality for the treatment of keloids by comparing the effects and the side effects of intralesional cryotherapy and intralesional injection of bleomycin.

METHODS

This interventional, comparative clinical trial was conducted on 60 cases and were divided equally into the group (A) combined group where who were subjected to intralesional bleomycin followed by cryotherapy in the same session, group (B) who were subjected to intralesional injection of bleomycin, and group (C) intralesional cryotherapy. All cases were subjected to clinical examination, complete history taking, dermatological examination, examination, and evaluation of scar lesion using the Vancouver scar scale.

RESULTS

There was a statistically significant decrease in pliability among the combined group. Also, pliability decreased in the bleomycin group and cryotherapy, but this decrease wasn't statistically significant. Our results revealed that there was a statistically significant decrease in lesion height among all the studied groups, but the decrease was more among the combined group.

CONCLUSION

Intralesional cryotherapy was effective as Intralesional bleomycin. Combined therapy was a valid and more effective technique with few adverse effects than either alone for keloids as it achieved a decrease in volumes of scars or accompanied symptoms.

Identifying miRNAs Associated with the Progression of Keloid through mRNA-miRNA Network Analysis and Validating the Targets of miR-29a-3p in Keloid Fibroblasts

Background. Keloid has brought great trouble to people and currently has no uniformly successful treatment. It is urgent to find new targets to effectively prevent the progress of keloid. The current research mainly identifies the differentially expressed genes (DEGs) in keloid through high-throughput sequencing technology and bioinformatics analysis technology, to screen new therapeutic targets and potential biomarkers. However, due to the different samples, different control groups, and small sample sizes, the sequencing results obtained from different studies are quite different and lack reliability. It is necessary to analyze the existing datasets in a reasonable way. Methods. Datasets about keloid were filtered in Gene Expression Omnibus (GEO) and ArrayExpress databases according to the inclusion and exclusion criteria. The discovery datasets were used for summarizing significant DEGs, and the validation datasets were to validate the mRNA and miRNA expression levels. The Encyclopedia of RNA Interactomes (ENCORI) online platform was used to predict the interactions between miRNAs and their target mRNAs. Protein-protein interaction network (PPI network) analysis and functional enrichment analysis were conducted. miRNA-mRNA network was established by Cytoscape software and verified in keloid tissue ( $n=8$ ) by RT-qPCR. miR-29a-3p mimic and inhibitor were transfected into keloid fibroblasts (KFs) to preliminary verify its targets, the prognostic value of which was estimated by the receiver operating characteristic (ROC) curve. Results. A total of 6 datasets involving 20 patients were included. 15 miRNAs and 12 target mRNAs were identified as potential biomarkers for keloid patients. The RT-qPCR results showed that miR-29a-3p, miR-92a-3p, and miR-143-3p were downregulated, and all their target mRNAs were upregulated in keloid tissue ( $P<0.05$ ). The expression of COL1A1, COL1A2, COL3A1, COL5A1, and COL5A2 decreased when miR-29a-3p was overexpressed but increased when miR-29a-3p was knocked down ( $P<0.05$ ). And these genes had a good performance in the diagnosis of keloid, especially when using keloid nonlesional skin or normal scar tissues as controls. Conclusion. The miRNA-mRNA network, especially miR-29a-3p and its targets, may provide insights into the underlying pathogenesis of keloid and serve as potential biomarkers for keloid treatment.

The role of altered fatty acid in pathological scars and their dermal fibroblasts

PURPOSE

The proposed pathological mechanism for scar formation is controversial, and increased attention has been paid to the fatty acids (FAs) in the formation of pathological scars. Notably, FAs are known to be important in inflammation and mechanotransduction, which is closely related to scar formation. Therefore, it is necessary to clarify the roles of FA in scar formation.

METHODS

Hypertrophic scar and keloid formed for more than a year and without other treatment, as well as normal skin samples were obtained from patients who underwent plastic surgery. Finally, keloids (n = 10), hypertrophic scars (n = 10), and normal skin samples (n = 10) were collected under informed consent. Primary dermal fibroblasts were isolated and cultured. The amount and variety of FAs were detected by lipid chromatography-mass spectrometry. Immunohistochemistry, real-time PCR, and western blotting were used to verify the expression of sterol regulatory element-binding protein-1 (SREBP1) and fatty acid synthase (FASN) in the samples and their fibroblasts. Student's t-test, ANOVA, and orthogonal partial least square discriminant analysis were performed for statistical analysis (∗p < 0.05, ∗∗p < 0.01, ∗∗∗p < 0.001, ∗∗∗∗p < 0.0001).

RESULTS

Compared with full-thickness normal skin, there were 27 differential FAs in keloids and 15 differential FAs in hypertrophic scars (∗p < 0.05 and variable influence on projection >1.0). The expression of SREBP1 and FASN was lower in pathological scars both at mRNA and protein levels (all ∗p < 0.05). However, the mRNA levels of SREBP1 (∗∗∗p = 0.0002) and FASN (∗∗∗p = 0.0021) in keloid-derived fibroblasts were higher than that in normal skin fibroblasts (NFBs), while the expression in hypertrophic scar-derived fibroblasts was lower than that in NFBs (both ∗p < 0.05). Whereas there was no significant difference in FASN protein expression between keloid-derived fibroblasts and NFBs (p > 0.05).

CONCLUSION

FAs involved in pathological scars are abnormally changed in scar formation. Thus, fatty acid-derived inflammation and de novo synthesis pathway of FA may play a key role in the formation of pathological scars.

Quality-of-life of people with keloids and its correlation with clinical severity and demographic profiles

Though the impairment of quality of life in individuals with keloids is profound, it has neither been well quantified nor correlated with severity in people with skin of colour. This cross-sectional, questionnaire-based study comprised 110 patients with keloid(s). A physician measured the severity of keloids using the Vancouver Scar scale and impairment of quality of life using the patient-filled Hindi version of Dermatology Life Quality Index questionnaire. The relationship among QoL and severity score as well as with components of demographic data was analysed using SPSS. Our study found the severity of keloid(s) to be moderately but significantly correlated with the quality of life of its sufferers. Individuals with multiple keloids were found to be significantly younger than those with solitary ones. Itching, pain, along with restricted mobility significantly impacted the quality of life as well as severity of keloids. Individuals who had undergone prior treatment were found to have a worse quality of life than the treatment naive. Recurrence was found to be associated with lower scar severity, multiple keloids, and younger age. Increasing age, though associated with greater scar severity, lacked any relationship with the quality of life. Our study also found that individuals with bigger keloids sought treatment earlier and more often. Hyperpigmented keloid(s), more common in individuals with skin of colour, were associated with a significantly worse quality of life as well as a higher scar severity.

Downregulated cytotoxic CD8+ T-cell identifies with the NKG2A-soluble HLA-E axis as a predictive biomarker and potential therapeutic target in keloids

Keloids are an abnormal fibroproliferative wound-healing disease with a poorly understood pathogenesis, making it difficult to predict and prevent this disease in clinical settings. Identifying disease-specific signatures at the molecular and cellular levels in both the blood circulation and primary lesions is urgently needed to develop novel biomarkers for risk assessment and therapeutic targets for recurrence-free treatment. There is mounting evidence of immune cell dysregulation in keloid scarring. In this study, we aimed to profile keloid scar tissues and blood cells and found that downregulation of cytotoxic CD8+ T cells is a keloid signature in the peripheral blood and keloid lesions. Single-cell RNA sequencing revealed that the NKG2A/CD94 complex was specifically upregulated, which might contribute to the significant reduction in CTLs within the scar tissue boundary. In addition, the NKG2A/CD94 complex was associated with high serum levels of soluble human leukocyte antigen-E (sHLA-E). We subsequently measured sHLA-E in our hospital-based study cohort, consisting of 104 keloid patients, 512 healthy donors, and 100 patients with an interfering disease. The sensitivity and specificity of sHLA-E were 83.69% (87/104) and 92.16% (564/612), respectively, and hypertrophic scars and other unrelated diseases exhibited minimal interference with the test results. Furthermore, intralesional therapy with triamcinolone combined with 5-fluorouracil drastically decreased the sHLA-E levels in keloid patients with better prognostic outcomes, while an incomplete reduction in the sHLA-E levels in patient serum was associated with higher recurrence. sHLA-E may effectively serve as a diagnostic marker for assessing the risk of keloid formation and a prognostic marker for the clinical outcomes of intralesional treatment.

Risk factors associated with the progression from mild keloids to severe mild keloids

Background:

Keloids are benign fibrous growths that are caused by excessive tissue build-up. Severe keloids exert more significant effects on patients’ quality of life than do mild keloids. We aimed to identify factors associated with the progression from mild keloids to severe keloids, as distinct from those associated with the formation of keloids.

Methods:

In this retrospective case-control study, 251 patients diagnosed with keloids at West China Hospital between November 2018 and April 2021 were grouped according to the severity of lesions (mild [n = 162] or severe [n = 89]). We collected their basic characteristics, living habits, incomes, comorbidities, and keloid characteristics from Electronic Medical Records in the hospital and the patients’ interviews. Conditional multivariable regression was performed to identify the independent risk factors for the progression of keloids.

Results:

Eighty-nine patients (35.5%) were classified as having severe keloids. We found the distribution of severe keloids varied with sex, age, excessive scrubbing of keloids, family income, the comorbidity of rheumatism, disease duration, characteristics of the location, location in sites of high-stretch tension, the severity and frequency of pain, the severity of pruritus, and infection. Multivariable analysis revealed significant associations between severe keloids and infection (odds ratio [OR], 3.55; P = 0.005), excessive scrubbing of keloids (OR, 8.65; P = 0.001), low or middle family income (OR, 13.44; P = 0.021), comorbidity of rheumatism (OR, 18.97; P = 0.021), multiple keloids located at multiple sites (OR, 3.18; P = 0.033), and disease duration > 15 years (OR, 2.98; P = 0.046).

Conclusion:

Doctors should implement more active and thorough measures to minimize the progression of mild keloids in patients who have any of the following risk factors: infection, excessive scrubbing of keloids, low or middle family income, comorbidity of rheumatism, multiple keloids located at multiple sites, and disease duration > 15 years.

A systematic review of randomised controlled trials investigating laser assisted drug delivery for the treatment of keloid and hypertrophic scars

The objective of this article is to study the clinical efficacy and adverse events of laser-assisted drug delivery in the treatment of hypertrophic and keloid scars. We searched the following databases up to 22 October 2020: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (Clinical Trials) in The Cochrane Library, MEDLINE, EMBASE, and reference lists of articles for randomised clinical trials (RCTs) of laser-assisted drug delivery for the treatment of hypertrophic and keloid scars. We also searched online trials registries for ongoing trials and contacted trial authors where appropriate. Our outcomes of interest were objective clinical evaluation of scars, participant satisfaction, and adverse effects of the treatments. Two authors independently extracted data and assessed trial quality using Cochrane Risk of Bias 2. Two authors independently abstracted data. We included 10 RCTs involving a total of 329 participants: six trials utilised parallel-arm RCTs whilst four employed split-scar design. Three trials had high risk of bias with the remaining seven rated as having some concerns. The interventions and outcomes were too varied to be combined statistically. High-quality randomised controlled trials assessing laser-assisted delivery for drugs in the context of hypertrophic and/or keloid scarring are needed. Studies with a larger number of participants, with longer follow-up times, and standardised evaluation of outcome and adverse effects are warranted.

Umbilical trocar port site keloid management using a transposition flap after laparoscopic surgery

Background Keloids can occur anywhere in the human body. They are difficult to remove and can cause distress in patients. Although many options are available to treat keloids, no single method is considered the optimal treatment of choice. The authors encountered cases where an umbilical keloid developed at the trocar site after laparoscopic surgery and managed the keloid using a transposition flap.Methods A total of 10 umbilical keloid patients treated from 2013 to 2020 were included in this study. All patients developed a keloid due to the placement of a laparoscopic trocar incision port, and their major complaints varied from an asymptomatic nodule to pruritus or pain. All excisions were performed under local anesthesia, and transposition flaps were planned afterward. The surrounding tissue was rearranged so that the shape of the umbilicus was deformed to the minimum extent possible. The keloid scars were examined both preoperatively and 6 months postoperatively using the Patient and Observer Scar Assessment Scale (POSAS).Results All surgical wounds healed well without complications. The average time interval from laparoscopic surgery to keloid scar revision was 4.3 years. The mean postoperative follow-up period was 10.9 months, and no patient underwent reoperation. Four patients were treated with triamcinolone after surgery due to mild hypertrophy or pruritus. The POSAS observer scale showed significantly decreasing scores over time in all patients (P=0.002).Conclusions Cosmetically unfavorable keloids that form in the umbilicus following laparoscopic surgery can be improved with a simple procedure using excision and transposition flaps.

Novel targets and therapies for keloid

Keloids are the result of aberrant tissue scarring typically occurring in injured skin, and are caused by the overgrowth of granulation tissue or collagen type III during the healing process. There is a genetic component, thus a predisposition can be genetically transmitted. Keloids are difficult to treat because of their postexcisional recurrence, and they have an impact on patient quality of life due to psychological distress caused by cosmetic concerns and functional disability. Treatment ranges from classic corticosteroid therapy to multimodal approaches such as injections, cryotherapy, laser, radiation, radiofrequency ablation and extracorporeal shockwave therapy. Recent discoveries into the pathogenesis of keloid have enabled clinicians to expand the therapeutic options for treatment. The aim of this paper was to review the literature, clarify the general concept of keloid development, and assess emerging treatment options such as stem cell therapy, mitomycin C, bleomycin, interferon, botulinum toxin type A, calcium channel blockers, angiotensin-converting enzyme inhibitors and fat grafting, and the evolutionary advancement towards epigenetic modifications and gene therapy.

Multi-Antigen Imaging Reveals Inflammatory DC, ADAM17 and Neprilysin as Effectors in Keloid Formation

Keloid is an aberrant scarring process of the skin, characterized by excessive extracellular matrix synthesis and deposition. The pathogenesis of this prevalent cutaneous disorder is not fully understood; however, a persistent inflammatory process is observed. To obtain more insight into this process, we analyzed lesional, perilesional and healthy tissue using multi-antigen-analysis (MAA) in conjunction with a data mining approach. Here, we demonstrate that monocyte-derived inflammatory dendritic cells (CD1a+, CD11c+, CD14+) and activated CD4+ T lymphocytes (CD45 RO+) dominated the immune infiltration in keloids while associating with fibroblasts. In perilesional tissue, precursor immune cells were dominant in the perivascular area, suggesting that they were attracted by an immune process, potentially in the lesional area. Supporting this hypothesis, only in keloid lesions, high levels of ADAM10/17 and Neprilysin (CD10) were observed in both fibroblasts and leukocytes. The spatial proximity of these two cell types, which could be confirmed by image analysis only in lesional tissue, could be a potential factor leading to the activation of fibroblasts. Our findings provide new insight into the pathogenesis of keloid formation and reveal metalloproteinases as a target for therapeutical intervention.

Current Advances in Hypertrophic Scar and Keloid Management

Hypertrophic scars and keloids are caused by excessive tissue response to dermal injury due to local fibroblast proliferation and collagen overproduction. This response occurs because of pathologic wound healing due to dysregulation in the inflammatory, proliferative, and/or remodeling phase. Patients with hypertrophic scars or keloids report reduced quality of life, physical status, and psychological health. Hypertrophic scars or keloids will develop in 30 to 90% of individuals, and despite their prevalence, treatment remains a challenge. Of the treatments currently available for hypertrophic scars and keloids few have been adequately supported by studies with appropriate experimental design. Here, we aim to review the available literature to provide up-to-date information on the etiology, epidemiology, histology, pathophysiology, prevention, and management options available for the treatment of hypertrophic scars and keloids and highlight areas where further research is required.

A Case of Auricular Keloid Resulting from Conchal Cartilage Graft in Asian Rhinoplasty

When planning rhinoplasty, there are several options of grafts for augmentation, especially in relatively short and small Asian noses. Among such grafts, conchal cartilage is one of the most commonly used materials due to its histological similarity to nasal alar cartilage. Keloids and hypertrophic scars are fibroproliferative disorders that can occur after deep cutaneous injury. Since patients who wish to undergo rhinoplasty tend to have a lot of interest in cosmetic appearance, keloid formation can be serious complication to them. This case report presents an 18-year-old man who experienced keloid formation following conchal cartilage graft at 6 months after rhinoplasty. The authors introduce the case and review the considerations in prevention and treatment strategies for keloid scars after conchal cartilage harvest in Asian rhinoplasty.

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.

Chronic itch in African Americans: an unmet need

Chronic pruritus carries a significant burden of disease and is associated with a negative impact on quality of life. African Americans are disproportionately burdened by chronic pruritic disorders, including but not limited to atopic dermatitis, prurigo nodularis, inflammatory scalp dermatoses, pathologic scarring, and HIV-related dermatoses. Racial differences in skin structure and function may contribute to the pathogenesis of itch in African Americans. Itch perception and response to treatment in African Americans remain understudied and not well understood. As such, there is a large unmet need with regard to the knowledge and management of pruritus in African Americans. This review highlights notable differences in the epidemiology, pathophysiology, genetic predisposition, clinical presentation, and response to treatment for select pruritic skin conditions. By addressing itch as an unmet need in African Americans, we hope to improve patient outcomes and lessen disparities in dermatologic care.

Suppurative keloids: a complication of severe keloid disease

BACKGROUND

Some keloids show cystic cavities that give rise to acute inflammatory flares and oozing. These suppurative keloids (SK) have rarely been systematically studied. We conducted a retrospective cohort study to evaluate SK frequency and its risk factors. We also reviewed microbiological analyses as well as the histological features of removed SKs.

METHODS

Between July 1, 2015, and September 30, 2016, all adult patients attending a specialized keloid clinic were asked to participate. Clinical information and microbiological results were extracted from each patient's file. Histological features were observed and interpreted.

RESULTS

In this study, we observed an SK rate of 26% for a mean keloid history of 17.2 years. Male gender, African ancestry, and a family history of keloids were significantly associated with suppuration. Microbiological examination revealed commensal skin flora 7/9 (77.8%), Staphylococcus aureus 1/9 (11.1%), and Enterococcus faecalis 1/9 (11.1%).

CONCLUSION

Suppuration is a common complication of keloids occurring in patients with severe keloid disease and may arise from pilosebaceous occlusion and aseptic inflammation.

5-Fluorouracil Management of Oculofacial Scars: A Systematic Literature Review

PURPOSE

To review the literature for the safety and efficacy of intralesional 5-fluorouracil (5-FU) in the management of oculofacial scars.

METHODS

A literature search was performed in July 2019 in the PubMed database to identify reports of the use of 5-FU injections for modulating oculofacial cutaneous scars. The search yielded 152 articles, of which 15 met criteria outlined for assessment. Data were abstracted from these 15 relevant articles.

RESULTS

While there were no high-level prospective randomized controlled trials, 8 were lower-quality randomized controlled trial, 3 were retrospective cohort studies, and 4 were case series. Most studies pooled results of facial and nonfacial cutaneous applications. Three studies focused solely on oculofacial applications, and these were all lower-level evidence studies. The study outcomes included scar dimension reduction, erythema, patient satisfaction score, observer assessment of scar improvement, and recurrence rates. 5-Fluorouracil was administered as monotherapy or as part of multimodality treatment with other agents (usually corticosteroids) or with CO2 laser, radiotherapy, or pulsed dye laser. 5-Fluorouracil was usually given as an intralesional injection, but in some studies, it was applied topically after micropuncture of the skin. The number and timing of treatments varied between studies. Overall, the level of safety of 5-FU was high. Pain with injection was the most common reported side effect. Other common adverse side effects included pruritus, telangiectasias, changes in pigmentation, and purpura, and 2 studies noted more serious events, such as ulceration, superficial necrosis, and local infection. There were no severe side effects such as anaphylaxis, immune suppression, secondary malignancy, systemic infection, blindness, or death. In all studies, 5-FU was associated with prophylaxis of oculofacial scars or improvement of keloids or hypertrophic scars in terms of reducing size, erythema, and pruritus. 5-Fluorouracil application was associated with favorable patient satisfaction and observer assessment scores especially compared with corticosteroid injections alone.

CONCLUSIONS

High-quality randomized controlled trials are currently lacking, and the existing literature is predominately not specific to use of 5-FU on the face. These studies, however, suggest that intralesional 5-FU is safe and probably more effective than other options in the management of cutaneous scars in the oculofacial region. The delivery methods, timing, dosing, and concomitant therapies were highly variable. Further high-quality controlled studies specific to oculofacial scars may be indicated to assess the efficacy of 5-FU and to establish the best protocols for administering this medication.

Surgical scar revision using silicone gel sheet as an adjunct

Introduction:

Scar is often referred to as an unattractive mark after healing of a wound. An undesirable scar may have negative social, emotional, and functional impact on the patient. It is our job as surgeons to adequately understand the expectations of the patient and counsel them for a successful procedure.

Materials and Methods:

Twelve patients were randomly chosen for the study, of which five were males and seven were females. The scar tissue was removed surgically, and silicone gel sheets (SGSs) were applied on the 14^th postoperative day, and the dimensions of the new scar was measured periodically up to 12 months.

Results:

The study comprised of 12 patients- 5 males and 7 females. The descriptive statistics were calculated as median and interquartile range and comparison between time intervals was done using Wilcoxon signed rank test. Out of the 12 patients, 10 showing complete resolution of the scar and 2 patients had partial relapse of scar. However, they were satisfied with the final outcome.

Conclusion:

Our study found that SGSs applied to surgically revised scars significantly improves their appearance. The ease of use of the SGSs also makes it patient friendly. We observed almost complete resolution of the scar in ten patients and two patients exhibited partial relapse of the scar. However, there was a significant improvement in the overall appearance of the scar, and the patients were satisfied with the results of the procedure.

Differential responses to folic acid in an established keloid fibroblast cell line are mediated by JAK1/2 and STAT3

Keloids are a type of disordered scar formation which not only show heterogeneity between individuals and within the scar itself, but also share common features of hyperproliferation, abnormal extra-cellular matrix deposition and degradation, as well as altered expression of the molecular markers of wound healing. Numerous reports have established that cells from keloid scars display Warburg metabolism—a form of JAK2/STAT3-induced metabolic adaptation typical of rapidly dividing cells in which glycolysis becomes the predominant source of ATP over oxidative phosphorylation (OxPhos). Using the JAK1/2 inhibitor ruxolitinib, along with cells from patients with STAT3 loss of function (STA3 LOF; autosomal dominant hyper IgE syndrome) we examined the role of JAK/STAT signaling in the hyperproliferation and metabolic dysregulation seen in keloid fibroblasts. Although ruxolitinib inhibited hyperactivity in the scratch assay in keloid fibroblasts, it paradoxically exacerbated the hyper-glycolytic state, possibly by further limiting OxPhos via alterations in mitochondrial phosphorylated STAT3 (pSTAT3^Ser727). In healthy volunteer fibroblasts, folic acid exposure recapitulated the exaggerated closure and hyper-glycolytic state of keloid fibroblasts through JAK1/2- and STAT3-dependent pathways. Although additional studies are needed before extrapolating from a representative cell line to keloids writ large, our results provide novel insights into the metabolic consequences of STAT3 dysfunction, suggest a possible role for folate metabolism in the pathogenesis of keloid scars, and offer in vitro pre-clinical data supporting considerations of clinical trials for ruxolitinib in keloid disorder.

Hypertrophic scars and keloids: Overview of the evidence and practical guide for differentiating between these abnormal scars

Although hypertrophic scars and keloids both generate excessive scar tissue, keloids are characterized by their extensive growth beyond the borders of the original wound, which is not observed in hypertrophic scars. Whether or not hypertrophic scars and keloids are two sides of the same coin or in fact distinct entities remains a topic of much debate. However, proper comparison between the two ideally occurs within the same study, but this is the exception rather than the rule. For this reason, the goal of this review was to summarize and evaluate all publications in which both hypertrophic scars and keloids were studied and compared to one another within the same study. The presence of horizontal growth is the mainstay of the keloid diagnosis and remains the strongest argument in support of keloids and hypertrophic scars being distinct entities, and the histopathological distinction is less straightforward. Keloidal collagen remains the strongest keloid parameter, but dermal nodules and α-SMA immunoreactivity are not limited to hypertrophic scars alone. Ultimately, the current hypertrophic scars-keloid differences are mostly quantitative in nature rather than qualitative, and many similar abnormalities exist in both lesions. Nonetheless, the presence of similarities does not equate the absence of fundamental differences, some of which may not yet have been uncovered given how much we still have to learn about the processes involved in normal wound healing. It therefore seems pertinent to continue treating hypertrophic scars and keloids as separate entities, until such a time as new findings more decisively convinces us otherwise.

Treatment of hypertrophic scars and keloids using an intralesional 1470 nm bare-fibre diode laser: a novel efficient minimally-invasive technique

Hypertrophic and keloid scars result from abnormal wound healing and can have a variable response to a number of available treatment modalities. The evolution of laser treatments in recent years has shown a wide range of clinical applications including their use in the treatment of scars. We investigated the effectiveness of a 1470 nm diode laser using an intralesional optical fibre delivery device in the treatment of hypertrophic and keloid scars. We evaluated its safety and efficacy as a novel and minimally invasive treatment alternative for scar modulation and volume reduction. A prospective cohort study was performed involving 21 patients with hypertrophic scars (HS) (n = 9) and keloids (n = 12) resulting from various aetiology. Patients were treated with one to three treatment sessions. Comprehensive evaluations were performed using the Vancouver Scar Scale, Doppler ultrasound, Cutometer, Mexameter and PeriCam PSI. Scar thickness was reduced by an average of 0.308 ± 0.138 cm (p < 0.001). In particular the two subgroups showed a significant 27.7% and 28.2% reduction in scar thickness of HS and Keloids, respectively. Scar firmness showed a significant improvement of 1.2% (p < 0.05) for HS, though for keloids this was 0.4% (p = 0.26). Keloids had a significant reduction in pigmentation at 21.3%. Blood perfusion had a significant reduction of 29.6% in HS and 22.7% in Keloids. Overall VSS total score improvement of 42% in the HS and at 37.9% in the Keloid subgroup. No adverse events such as hypo/hyperpigmentation, skin infection, or recurrence were reported. This study shows that the intralesional 1470 nm bare-fibre diode laser significantly improved hypertrophic and keloid scars based on both subjective and objective analyses and supports this type of laser therapy as a safe and effective minimally-invasive treatment option.

Statin treatment and hypertrophic scarring after cardiac surgery

Wound healing process after surgical procedure plays a crucial role to prevent blood loss and infections. Hypertrophic scars might occur after surgery and are generally associated with an inflammatory burden. Cardiac surgery is intrinsically related to a strong systemic inflammatory state that might favor hypertrophic scarring. Besides lipid-lowering effects, statins are known for their pleiotropic and anti-inflammatory activity. The aim of this study was to investigate the impact of statins in the healing process after median sternotomy in patients undergoing cardiac surgery. All patients undergoing major cardiac surgery with median sternotomy and cardiopulmonary bypass, and subsequently evaluated in the outpatient clinic after discharge, were included in this study. A total of 930 Caucasian patients were retrospectively reviewed. At outpatient visit, 276 patients (29.7%) showed the formation of hypertrophic scars. Patients with hypertrophic scars tended to be younger (P = .001) and nonstatin users (P = .001). Logistic regression analysis confirmed the protective role of statins (odds ratio 0.39, 95% confidence interval 0.29-0.53, P = .001), after adjustment for age. A dose-dependent effect was confirmed, showing a more intensive protective effect for higher doses of statins. Statin use might be correlated with reduced hypertrophic scars after cardiac surgery through median sternotomy. A dose-dependent effect has been shown, and statin effect seems to be independent of age in a selected population undergoing surgery with an elevated inflammatory burden. Although further studies are warranted to elucidate the biologic mechanisms, the concept of using statins as anti-scarring agents is novel and should be investigated with tailored studies.

Cross-talk between Janus kinase-signal transducer and activator of transcription pathway and transforming growth factor beta pathways and increased collagen1A1 production in uterine leiomyoma cells

OBJECTIVE

To characterize the potential interaction between interleukin-6 (IL6), Janus kinase (JAK)-signal transducer and activator of transcription (STAT)-3 (JAK/STAT3) pathway, and Transforming growth factor beta (TGFβ)-3 , and to determine whether such cross-talk was a contributing factor in the dysregulation of type I collagen production in leiomyomas.

DESIGN

Laboratory study.

SETTING

University research laboratory.

PATIENTS

None.

INTERVENTIONS

Exposure of leiomyoma and myometrial cell lines to IL6 and STAT3 activators/inhibitors. Western immunoblot analysis and immunohistochemistry.

MAIN OUTCOME MEASURES

Expression of STAT3, pSTAT3, SOCS3, COL1A1, and TGFb3.

RESULTS

We observed that IL6 increased pSTAT3 as well as collagen1A1 in uterine leiomyoma cells. Direct activation of the JAK/STAT3 pathway increased collagen1A1 production in leiomyoma cells, whereas inhibition of the pathway significantly decreased collagen1A1 production. We further observed that modulation of the JAK/STAT3 pathway also increased the expression of TGFβ3 protein. Leiomyoma cells exposed to TGFβ3 demonstrated a significant decrease in pSTAT3 protein. Myometrial cells demonstrated a less sensitive response to STAT3 modulation and collagen production.

CONCLUSION

Cross-talk between the TGFβ pathway and JAK/STAT3 pathway contributes to the fibrotic nature of uterine leiomyomas.

Quality of life in black African patients with keloid scars

A keloid scar is a benign skin tumor and we aimed to assess the Quality of Life (QoL) of black Africans with keloid scars based on the Dermatology Life Quality Index (DLQI). We conducted a cross-sectional descriptive study in the department of dermatology of the teaching hospital of Treichville in Ivory Coast. We recruited 132 patients with keloid and 3612 dermatoses without keloid: The prevalence was 3.50% (132/3753). We included 120 patients aged from 16 to 63 years old, the sex ratio was 0.46 (38/82) and the mean age was 34.20 years. Keloid scars were mostly secondary to skin trauma in 30.00 % and infection in 21.67%. The commonest site was the ear in 29.17 %. We reported Keloid with pain in 53.33% and pruritus in 95.00%. We observed psychological impact in 65.83%. The DLQI scores were moderate and high in 61.66 %. QoL was impacted significantly when keloid was associated with pain (p=0.046), pruritus (p=0.81) and functional disorders (p=0.29). The DLQI score could be a valuable tool to assess QoL in black African patients with keloid, for better treatment option.

An open source pipeline for design of experiments for hyperelastic models of the skin with applications to keloids

The aim of this work is to characterize the mechanical parameters governing the in-plane behavior of human skin and, in particular, of a keloid-scar. We consider 2D hyperelastic bi-material model of a keloid and the surrounding healthy skin. The problem of finding the optimal model parameters that minimize the misfit between the model observations and the in vivo experimental measurements is solved using our in-house developed inverse solver that is based on the FEniCS finite element computational platform. The paper focuses on the model parameter sensitivity quantification with respect to the experimental measurements, such as the displacement field and reaction force measurements. The developed tools quantify the significance of different measurements on different model parameters and, in turn, give insight into a given model's ability to capture experimental measurements. Finally, an a priori estimate for the model parameter sensitivity is proposed that is independent of the actual measurements and that is defined in the whole computational domain. This estimate is primarily useful for the design of experiments, specifically, in localizing the optimal displacement field measurement sites for the maximum impact on model parameter inference.

Nonmuscle Myosin II Activation Regulates Cell Proliferation, Cell Contraction, and Myofibroblast Differentiation in Keloid-Derived Fibroblasts

Objective: Keloid is an abnormal scar that often develops in high-tension skin. It is caused by excessive fibroblast proliferation and collagen deposition. Nonmuscle myosin IIA (NM-IIA) is an important motor protein that regulates the mechanical transduction of cells. However, the role of NM-IIA in keloid pathogenesis remains unclear. Approach: NM-IIA expression was examined and compared in keloid skin and normal skin by immunofluorescence. The organization of smooth muscle actin (SMA)-mediated stress fibers in normal and keloid fibroblasts (NFs and KFs, respectively) were determined. Cell proliferation and cell contractility were measured in fibroblasts derived from normal and keloids. The NM-II pharmacological inhibitor (blebbistatin) and RNA interference were applied to block NM-IIA and investigate its regulatory role in SMA-mediated stress fibers, cell contractility, and cell proliferation after NM-IIA inhibition. Results: NM-IIA expression is increased in keloid tissue. Inhibition of NM-II by blebbistatin or targeting NM-IIA by RNA interference reduced transforming growth factor beta (TGF-β)-mediated SMA-mediated stress fiber formation, cell proliferation, and cell contractility of NFs and KFs. Although TGF-β failed to mediate phosphorylation of myosin light chain (pMLC, the activator of NM-II), pMLC can interact with SMA-mediated stress fiber. Finally, inhibition of NM-II by blebbistatin also reduced NF and KF proliferation after TGF-β stimulation. Innovation: NM-IIA synergizes with TGF-β to regulate fibroblast proliferation, contraction activity, and myofibroblasts differentiation. Conclusion: NM-IIA might be one of the therapeutic targets in keloids.

Long non-coding RNA LINC01116 accelerates the progression of keloid formation by regulating miR-203/SMAD5 axis

BACKGROUND

Emerging evidence reveals the importance of long non-coding RNAs (lncRNAs) in the development and progression of keloid formation. However, the roles and molecular mechanism of lncRNA LINC01116 in the progression of keloid formation remain largely unknown.

METHODS

The expression levels of LINC01116, microRNA-203 (miR-203) and SMAD family member 5 (SMAD5) were measured by quantitative real-time polymerase chain reaction (qRT-PCR) and western blot. Cell proliferation, migration and invasion were detected by Cell counting Kit-8 (CCK-8) assay and transwell assay. Flow cytometry and western blot assay were used to examine cell apoptosis and extracellular matrix (ECM) production. The interaction between miR-203 and LINC01116 or SMAD5 was predicted by bioinformatics analysis and verified by dual-luciferase reporter and RNA Immunoprecipitation (RIP) and RNA pull-down assays.

RESULTS

LINC01116 and SMAD5 were upregulated while miR-203 was downregulated in keloid tissues and keloid fibroblasts. LINC01116 knockdown suppressed the proliferation, migration, invasion, and ECM production but induced apoptosis in keloid fibroblasts through enhancing miR-203 and inhibiting SMAD5. Moreover, SMAD5 was identified as a direct target of miR-203 and miR-203 could directly bind to LINC01116. Besides, LINC01116 regulated SMAD5 expression by targeting miR-203.

CONCLUSION

Downregulation of LINC01116 inhibited the progression of keloid formation by regulating miR-203/SMAD5 axis, which might provide a novel target for keloid therapy.