Keloids: pathogenesis, clinical features, and management

Can Electrical Stimulation Prevent Recurrence of Keloid Scars? A Scoping Review

Objective: Keloids represent a symptomatic, aberrant healing process that is difficult to treat with high recurrence rates spanning from 55% to 100% if treated via excision without adjuvant therapy. Electrical stimulation (ES) has demonstrated findings that suggest it could reduce the recurrence rate of keloids after resection. Therefore, the aim of this study is to conduct a scoping review to investigate ES as an adjuvant therapy for decreasing keloid recurrence after excision. Approach: A scoping review was performed using PubMed and Web of Science databases. The search strategy encompassed terms linking keloids and various aspects of electrical stimulation. Results: Our search yielded 2,229 articles, of which 115 articles were analyzed as full text and 1 article met inclusion criteria. Despite this, ES has demonstrated other evidence that suggests its utility. ES has been shown to counter keloidic features by reducing mast cell counts, shifting wound composition from M2 to M1 macrophages, promoting angiogenesis, and controlling fibroblast orientation and location. An alternating current will orient fibroblasts perpendicular to the current without unintended migration. Innovation: Our study indicates that, based on a compilation of clinical and preclinical in vitro data, the optimal scenario for ES in the role of keloid treatment is after excision with a biphasic pulsed application and square waveform. Conclusions: ES could serve as a multifaceted, adjuvant treatment after keloid excision, steering the healing process away from keloid-associated characteristics. Its cost-effectiveness means it could be adopted globally, providing a strategy to mitigate the burden of keloids irrespective of other available treatments or economic conditions.

Targeting the Epigenome Reduces Keloid Fibroblast Cell Proliferation, Migration, and Invasion

Keloids are pathological fibroproliferative scars resulting from abnormal collagen deposition within and beyond the margins of the initial cutaneous insult. Keloids negatively impact QOL functionally and cosmetically, with current treatment modalities unsatisfactory. Recent studies indicate that epigenetic dysregulation is central to the development and progression of keloids. In this study, we evaluate the functional significance of epigenetic targeting strategies in vitro using patient-derived keloid fibroblasts treated with small-molecule inhibitors of histone deacetylases, LSD1, CoREST, and p300, as potential therapies for keloids. We find that both the dual-acting CoREST inhibitor corin and the histone deacetylase inhibitor entinostat reduce fibroblast proliferation more than the LSD1 inhibitor GSK-LSD1; in addition, corin was the most effective inhibitor of migration and invasion across keloid fibroblasts. RNA-sequencing analysis of keloid fibroblasts treated with corin demonstrates coordinate upregulation of many genes, including key mediators of cell adhesion such as claudins. Corin also downregulates gene sets involved in cell cycle progression, including reduced expression of cyclins A1 and B2 compared with that of DMSO. These results highlight a significant role for epigenetic regulation of pathologic mediators of keloidal scarring and suggest that inhibitors of the epigenetic CoREST repressor complex may prove beneficial in the prevention and/or treatment of keloidal scarring in patients.

Navigating vaccination choices: The intersecting dynamics of institutional trust, belonging and message perception among Congolese migrants in London, UK (a reflexive thematic analysis)

The COVID-19 pandemic disproportionately impacted intersectionally marginalised migrants, revealing systemic disparities in health outcomes and vaccine uptake. Understanding the underlying social and structural factors influencing health behaviours is necessary to develop tailored interventions for migrants, but these factors have been seldom explored. This qualitative study aimed to explore contextual factors shaping COVID-19 vaccination decision-making among Congolese migrants in the UK.A community-based participatory research study was designed and led by a community-academic partnership in London, UK (2021-2022). Peer-led, semi-structured interviews were conducted in Lingala with 32 adult Congolese migrants and explored beliefs, perceptions and lived experiences of migration, healthcare, vaccination and the COVID-19 pandemic. Reflexive thematic analysis generated two themes and a model conceptualising the vaccination decision-making process. Participants and community partners were financially compensated; ethics was granted by the University of London ethics committee (REC: 2021.0128).Participants highlighted the incompatibility of lockdown restrictions with their communal culture, which intensified feelings of exclusion and alienation. Concerns about COVID-19 vaccination were attributed to safety and effectiveness, partly informed by experiences and legacies of racial discrimination and exploitation. Inequality in the pandemic response and COVID-19 outcomes heightened participants' sense that their views and needs were being overlooked, and government sources and information were perceived as coercive. Our model depicts the interplay between institutional trust, belonging, and message perception, which shaped participants' vaccination decisions and led to (non-)engagement with COVID-19 vaccination. This research enhances understanding of how social and contextual factors may influence migrants' engagement with health interventions. It underscores the importance of partnering with migrant communities to understand their needs in context and co-design tailored interventions and inclusive messaging strategies that promote trust and belonging. Implementing systemic changes to address structural inequalities will be crucial to create an environment that supports engagement with health-protective behaviours and enhances health outcomes among migrant communities.

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.

Intralesional 5-Fluorouracil for Keloids: A Systematic Review

Keloids are benign, fibroproliferative dermal tumours, often arising after trauma, that are more common in darker skin types. Numerous therapeutic options have been employed for the treatment of keloids; however, there is no one gold standard approach. Five-fluorouracil, a potent chemotherapeutic agent, has emerged as a promising therapeutic option. Therefore, this systematic review, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focused on providing a broad overview of the use of 5-fluorouracil for the management of keloids. Forty studies (2325 patients) met inclusion criteria and investigated 5-fluorouracil for keloid management, with 19 studies (1043 patients) including a 5-fluorouracil monotherapy group. Five-fluorouracil monotherapy demonstrated consistent keloid improvement with >254 keloids injected across various anatomical regions. Five-fluorouracil monotherapy was most often compared to intralesional triamcinolone acetonide, utilizing the Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale. The most common keloid parameters assessed were height, size, volume, width, length, induration, pruritus, and erythema. Five-fluorouracil monotherapy exhibited substantial improvements, with weight averages of 73% of patients experiencing >25% improvement and 67% achieving >50% improvement. Relapse rate was 16% at 27 weeks after 5-fluorouracil monotherapy treatment. Limitations included potential selection bias, language restrictions, and heterogenous data analysis among studies. Overall, our findings underscore the potential effectiveness of 5-fluorouracil monotherapy in the management of keloids, with an encouraging safety profile. Larger prospective trials are needed to determine optimal therapy or combination therapy for the management of keloids. This detailed compilation of treatment protocols, outcomes, and relapse rates stand as a valuable resource for further research and clinical applications.

Hyper- and Hypopigmentation in a Subject with Fitzpatrick Skin Phototype VI: A New Treatment Option

Background: Laser therapies can cause hyper- and hypopigmentation of the skin. There is little evidence in the literature of effective treatments for these types of problems in Fitzpatrick skin phototypes IV-VI. The main aim of this retrospective study is to evaluate the effects of a new therapy that combines the application of electromagnetic fields and vacuum on a subject with Fitzpatrick skin phototype VI, who presented extensive, laser-induced facial dyschromia. The secondary aim is to test the effectiveness of a free imaging software for assessing skin pigmentation. Methods: The level of improvement after therapy was evaluated, with a 5-point Likert scale, one month after the end of the treatment by the subject and by the doctor who performed the treatment, and by two blinded dermatologists. With the free software, a three-dimensional reconstruction of the treated area and the evaluation of the color distribution were performed. Results: Both the subject and the doctors involved in the study positively evaluated the effects of the treatment. The image analysis highlighted the homogenization of the skin color in the treated area. Conclusions: The combination of electromagnetic fields and vacuum for dyschromia treatments appears promising. The new method of assessing melanin levels resulted particularly efficient.

Natural History of Keloids: A Sociodemographic Analysis Using Structured and Unstructured Data

INTRODUCTION

Keloids are lesions characterized by the growth of dense fibrous tissue extending beyond original wound boundaries. Research into the natural history of keloids and potential differences by sociodemographic factors in the USA is limited. This real-world, retrospective cohort study aimed to characterize a population of patients with keloids compared with matched dermatology and general cohorts.

METHODS

Patients with ≥ 2 International Classification of Diseases codes for keloid ≥ 30 days apart and a confirmed keloid diagnosis from clinical notes enrolled in the OM1 Real-World Data Cloud between 1 January 2013 and 18 March 2022 were age- and sex-matched 1:1:1 to patients without keloids who visited dermatologists ("dermatology cohort") and those who did not ("general cohort"). Results are presented using descriptive statistics and analysis stratified by cohort, race, ethnicity, household income, and education.

RESULTS

Overall, 24,453 patients with keloids were matched to 23,936 dermatology and 24,088 general patients. A numerically higher proportion of patients with keloids were Asian or Black. Among available data for patients with keloids, 67.7% had 1 keloid lesion, and 68.3% had keloids sized 0.5 to < 3 cm. Black patients tended to have larger keloids. Asian and Black patients more frequently had > 1 keloid than did white patients (30.6% vs. 32.5% vs. 20.5%). Among all patients with keloids who had available data, 56.4% had major keloid severity, with major severity more frequent in Black patients. Progression was not significantly associated with race, ethnicity, income, or education level; 29%, 25%, and 20% of the dermatology, keloid, and general cohorts were in the highest income bracket (≥ US$75,000). The proportion of patients with income below the federal poverty line (< US$22,000) and patterns of education level were similar across cohorts.

CONCLUSION

A large population of patients in the USA with keloids was identified and characterized using structured/unstructured sources. A numerically higher proportion of patients with keloids were non-white; Black patients had larger, more severe keloids at diagnosis.

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.

Needle-free electronically-controlled jet injector treatment with bleomycin and lidocaine is effective and well-tolerated in patients with recalcitrant keloids

OBJECTIVES

The treatment of recalcitrant keloids is challenging. Although intralesional bleomycin using conventional needle injectors (CNI) is effective, it has important drawbacks, such as the need for repetitive and painful injections. Therefore, we aimed to evaluate the effectiveness, tolerability and patient satisfaction of intralesional bleomycin with lidocaine administered with a needle-free electronically-controlled pneumatic jet-injector (EPI) in recalcitrant keloids.

METHODS

This retrospective study included patients with recalcitrant keloids who had received three intralesional EPI-assisted treatments with bleomycin and lidocaine. Effectiveness was assessed using the Patient and Observer Scar Assessment Scale (POSAS) at baseline and four to six weeks after the third treatment. Additionally, treatment related pain scores numeric rating scale, adverse effects, patient satisfaction and Global Aesthetic Improvement Scale (GAIS) were assessed.

RESULTS

Fifteen patients with a total of >148 recalcitrant keloids were included. The median total POSAS physician- and patient-scores were respectively 40 and 41 at baseline, and reduced with respectively 7 and 6-points at follow-up ( p < 0.001; p < 0.001). The median pain scores during EPI-assisted injections were significantly lower compared to CNI-assistant injections, (2.5 vs. 7.0, respectively ( p < 0.001)). Adverse effects were mild. Overall, patients were "satisfied" or "very satisfied" with the treatments (14/15, 93.3%). The GAIS was "very improved" in one patient, "improved" in nine patients and "unaltered" in four patients.

CONCLUSIONS

EPI-assisted treatment with bleomycin and lidocaine is an effective, well tolerated, patient-friendly alternative for CNI in patients with recalcitrant keloid scars. Randomized controlled trials are warranted to confirm our findings and improve the clinical management of recalcitrant keloids.

Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review

» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.

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.

Evaluating skin colour diversity in the validation of scar assessment tools

Across scar studies, there is a lack of dark-skinned individuals, who have a predisposition for keloid formation, altered pigmentation and poorer quality of life (QOL). There is a need for patients of colour to be included in scar scale development and validation. In this study, we evaluate the racial diversity of patients included in the validation of scar assessment scales. A systematic review was conducted for articles reporting on the validation of a scar assessment tool. Racial, ethnic and Fitzpatrick skin type (FST) data were extracted. Fifteen scar scale validation studies were included. Nine of the studies did not mention FST, race or ethnicity of the patients. Two of the studies that reported FST or race information only included White patients or included no FST V/VI patients: mapping assessment of scars (MAPS) and University of North Carolina '4P'. Only four studies included non-White patients or dark-skinned patients in the validation of their scar scale: the modified Vancouver Scar Scale (VSS), modified Patient and Observer Scar Assessment Scale (POSAS), acne QOL and SCAR-Q scales. The patients included in the modified VSS validation were 7% and 13% FST V/VI, 14% African in the modified POSAS and 4.5% FST V/VI in the SCAR-Q. We highlight the severe lack of diversity in scar scale validation, with only 4 out of 15 studies including dark-skinned patients. Given the susceptibility of darker-skinned individuals to have poorer scarring outcomes, it is critical to include patients of colour in the very assessment tools that determine their scar prognosis. Inclusion of patients of colour in scar scale development will improve scar assessment and clinical decision-making.

Efficacy of a multimodal approach of laser therapy for earlobe keloids management in dark population

BACKGROUND

Patients with keloids are often younger than 30 years old and have darker skin.

AIM

To evaluate the efficacy and safety of CO2 laser therapy in the management of earlobe and helix keloids in dark subjects.

METHODS

A total of 21 dark patients (five men and 16 women) presented with the earlobe and ear helix keloids, with a mean age of 30.5 (±6.7) years and with phototype between III-VI, were enrolled. In order to improve their earlobe and helix keloids, all patients underwent a single session of CO2 laser therapy immediately followed by a pulsed Dye laser procedure. A single well-experienced doctor performed all treatment sessions and the response to treatment. Patients were followed-up for 6 months after termination of therapy. Clinical images were examined and collected: all patients were examined clinically and with Dermoscopy.

RESULTS

The majority of the patients treated show complete remission of keloid lesions. Clinical photographs show a visible aesthetic improvement of several types of keloids in dark subjects.

CONCLUSIONS

Our data demonstrate that this combined laser therapeutic protocol appears to be effective and well tolerated for the management of earlobe and helix keloids in dark subjects, with no high recurrence rate and avoiding the adverse effects and lengthy recovery time.

A role for vitamin D and the vitamin D receptor in keloid disorder

Keloids are disfiguring fibroproliferative lesions that can occur in susceptible individuals following any skin injury. They are extremely challenging to treat, with relatively low response rates to current therapies and high rates of recurrence after treatment. Although several distinct genetic loci have been associated with keloid formation in different populations, there has been no single causative gene yet identified and the molecular mechanisms guiding keloid development are incompletely understood. Further, although it is well known that keloids are more commonly observed in populations with dark skin pigmentation, the basis for increased keloid risk in skin of colour is not yet known. Because individuals with dark skin pigmentation are at higher risk for vitamin D deficiency, the role of vitamin D in keloid pathology has gained interest in the keloid research community. A limited number of studies have found lower serum vitamin D levels in patients with keloids, and reduced expression of the vitamin D receptor (VDR) in keloid lesions compared with uninjured skin. Vitamin D has documented anti-inflammatory, anti-proliferative and pro-differentiation activities, suggesting it may have a therapeutic role in suppression of keloid fibrosis. Here we review the evidence supporting a role for vitamin D and VDR in keloid pathology.

Defining a Unique Gene Expression Profile in Mature and Developing Keloids

Keloids are benign, fibroproliferative dermal tumors that typically form owing to abnormal wound healing. The current standard of care is generally ineffective and does not prevent recurrence. To characterize keloid scars and better understand the mechanism of their formation, we performed transcriptomic profiling of keloid biopsies from a total of 25 subjects of diverse racial and ethnic origins, 15 of whom provided a paired nonlesional sample, a longitudinal sample, or both. The transcriptomic signature of nonlesional skin biopsies from subjects with keloids resembled that of control skin at baseline but shifted to closely match that of keloid skin after dermal trauma. Peripheral keloid skin and rebiopsied surrounding normal skin both showed upregulation of epithelial-mesenchymal transition markers, extracellular matrix organization, and collagen genes. These keloid signatures strongly overlapped those from healthy wound healing studies, usually with greater perturbations, reinforcing our understanding of keloids as dysregulated and exuberant wound healing. In addition, 219 genes uniquely regulated in keloids but not in normal injured or uninjured skin were also identified. This study provides insights into mature and developing keloid signatures that can act as a basis for further validation and target identification in the search for transformative keloid treatments.

A Roadmap for a Consensus Human Skin Cell Atlas and Single-Cell Data Standardization

Single-cell technologies have become essential to driving discovery in both basic and translational investigative dermatology. Despite the multitude of available datasets, a central reference atlas of normal human skin, which can serve as a reference resource for skin cell types, cell states, and their molecular signatures, is still lacking. For any such atlas to receive broad acceptance, participation by many investigators during atlas construction is an essential prerequisite. As part of the Human Cell Atlas project, we have assembled a Skin Biological Network to build a consensus Human Skin Cell Atlas and outline a roadmap toward that goal. We define the drivers of skin diversity to be considered when selecting sequencing datasets for the atlas and list practical hurdles during skin sampling that can result in data gaps and impede comprehensive representation and technical considerations for tissue processing and computational analysis, the accounting for which should minimize biases in cell type enrichments and exclusions and decrease batch effects. By outlining our goals for Atlas 1.0, we discuss how it will uncover new aspects of skin biology.

Combination of Fractional Er:YAG Laser, Pulsed Dye Laser, and Intralesional Triamcinolone With 5-Fluorouracil for Keloid Treatment

Introduction: Benign fibroproliferative scars that are larger than the initial lesion are called keloids. Keloids treatment in clinical practice is still difficult. Although there are various therapy choices, none is embraced by everyone or is relapse-free. Various treatment modalities such as intralesional corticosteroid injection with 5-fluorouracil (5-FU), fractional Er:YAG laser, pulsed dye laser (PDL), and others can be used either as monotherapies or combined therapies. Therefore, efforts should be made to select the treatment that will provide the best results. Case Presentation: A 6-year-old boy with keloids on the lower lips extending to the chin was successfully treated with a 2940-nm fractional Er:YAG laser alternated with a 595-nm long-PDL followed by the combined intralesional injection of corticosteroid and 5-FU. The patient was followed up for 1 year with no lesion recurrence. Conclusion: Our case supports a combined therapy to successfully treat a patient with a keloid on the chin. Therapy using a combination of these four modalities seems safe and effective and may have a synergistic effect with minimal downtime.

Keloids After Herpes Zoster: Report of Wolf's Isotopic Phenomenon and Literature Review

Wolf's isotopic response (WIR) refers to the appearance of a new skin disorder at the exact site of an unrelated skin disorder that had previously been cured. The most common primary skin disease in which WIR occurs is herpes zoster. Despite numerous theories being put forward to explain this occurrence, including viral, vascular, immunological, and neurological hypotheses, the pathogenesis of WIR after herpes zoster remains unclear. We report the case of a 76-year-old patient who presented with keloids at the site of the original herpes zoster. Based on this observation and a review of the literature, The clinical characteristics and possible theoretical reasons for keloids after herpes zoster will be discussed.

The Role of Radiation Therapy in Adult and Pediatric Keloid Management: A National Survey of Radiation Oncologists

INTRODUCTION

Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management.

AIM

The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers.

METHODS

An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed.

RESULTS

A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%).

CONCLUSION

Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

Pediatric Keloids and Review of the Efficacy of Current Treatment Modalities

BACKGROUND

Keloids and hypertrophic scars are the result of excessive fibroblast proliferation and collagen deposition in the wound healing process, leaving patients with irritating and cosmetically displeasing lesions. Despite there being numerous modalities for treatment, keloids are notoriously recalcitrant to therapy and recurrence rates are high.

OBJECTIVE

Because many keloids begin to develop during childhood and adolescence, it is important to better understand which treatment options may be best suited toward the pediatric population specifically.

METHODS

We reviewed 13 studies that focus specifically on effectiveness of treatment options for keloids and hypertrophic scars in the pediatric population. These studies cover 545 keloids in 482 patients, all aged 18 and younger.

RESULTS

Many treatment modalities were used, with multimodal treatment being the most common (76%). There were 92 instances of recurrence, with a total recurrence rate of 16.9%.

CONCLUSION

Data from the combined studies suggest that keloid development is less common before adolescence and that higher rates of recurrence are observed among patients who have received monotherapy compared with those who received multimodal treatments. More well-designed studies with standardized ways of assessing outcomes are needed to expand our understanding on how to optimally treat keloids in the pediatric population.

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.

Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies

Hypertrophic scars and keloids can have significant detrimental effects on patients both psychosocially and functionally. A careful identification of patient risk factors and a comprehensive management plan are necessary to optimize outcomes. Patients with a history of dystrophic scarring should avoid unnecessary procedures and enhance the wound-healing process using various preventive strategies. As there is no single, fully efficacious treatment modality, prevention remains the best approach in reducing aberrant scar formation. When prevention therapies fail, keloids have been shown to be respond to a variety of therapies including topical and injectable corticosteroids, 5-fluorouracil, radiotherapy, lasers, and surgical excision, all with varying efficacies. As such, management should be tailored to the individual patient's risk factors with the use of combination therapies to reduce recurrence rates. Still, keloid and hypertrophic scar therapies are widely diverse with novel treatment modalities providing alternatives for recurring lesions. Laser-assisted drug delivery, skin priming, and novel topical therapies may provide alternative options for the management of hypertrophic scars and keloids.

Treatment of Keloids with Surgery and Immediate Postoperative Radiotherapy: Knowledge Gained Over 17 Years

Background The treatment of keloidal scars with radiotherapy has been practiced for more than a century. Radiotherapy post-surgery has been deemed necessary and effective in preventing recurrence but still, no clear guidelines exist as to the best modality of radiotherapy, the ideal dose, and the time it should be given for keloidal scars. The purpose of this study is to confirm the effectiveness of this treatment and address these issues.

Methods Since 2004, 120 patients presenting with keloidal scars were seen by the author. Out of them, 50 were managed with surgery followed by HDR brachytherapy/electron beam radiotherapy delivering 2000 rads to the scar within 24 hours of surgery. Patients were followed up for at least 18 months to assess the scar status and the recurrence of keloids. Recurrence was defined as the appearance of a nodule or an obvious return of the keloid within 1 year of treatment.

Results Three patients developed a nodule in the scar, which was deemed a recurrence, making an incidence of 6%. There was no major problem after immediate postoperative radiotherapy. Five patients had delayed healing at 2 weeks and a hypertrophic scar was noted in five patients at 4 weeks that settled with conservative measures.

Conclusion Treating the vexing problem of keloids with surgery and immediate postoperative radiotherapy is safe and effective. We recommend that this be adopted as the standard treatment in keloid management.

Addressing the Physical and Mental Impacts of Postsurgical Scarring Among Transgender and Gender Diverse People

Few studies have considered the diverse mental and physical health impacts of scarring among transgender and gender diverse (TGD) patients after medically necessary gender-affirming surgery (GAS). For some TGD patients, post-GAS scarring may exacerbate gender dysphoria. For others, it is a physical representation of authenticity. The dearth of research or validated instruments capturing the diversity of priorities and concerns pre- and post-GAS hinders providers' ability to deliver optimal clinical care throughout the gender-affirmation process and impedes progress for evidence-based policy change regarding post-GAS scar treatment. This article provides suggestions for future research directions to address post-GAS scar-related health needs.

Topical gel containing Polysiloxanes and hyaluronic acid for skin scar: Formulation design, characterization, and In vivo activity

BACKGROUND

Scar formation is undesirable both cosmetically and functionally. It shows that silicone gel is effective in preventing and improving scars formed due to a wound formation after injury.

OBJECTIVES

This study investigates whether a silicone gel composition based on a novel concept of infusing a biologically active material such as hyaluronic acid and/or salts with various polysiloxane derivatives in a specific proportion to achieve desired viscosity range and their action has a synergistic beneficial effect on skin scar after injury.

METHODS

We have developed a topical gel utilizing a combination of emulsifiers, sodium hyaluronate, polysiloxane, and its derivatives. The method of preparation comprises mixing of aqueous phase dispersion and polysiloxanes blend under stirring at room temperature.

RESULTS

It results in the formation of a homogenous smooth gel formulation. The developed topical gel formulation was characterized for physicochemical properties, rheology, stability, and anti-scar activity in Wistar rats. It was found that the developed formulation system consists of desirable attributes for skin applications. In vivo investigation of developed polysiloxane gel formulation for anti-scar activity shown promising outcomes compared to marketed product (Kelo-cote scar gel). Furthermore, a histopathology study of healed skin tissues observed the formation of microscopic skin structures compared to the Kelo-cote scar gel.

CONCLUSIONS

It indicates that the combination of polysiloxanes and sodium hyaluronate resulting an improvement in anti-scar activity compared to the marketed product containing polysiloxanes alone.

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.

Keloid: Genetic susceptibility and contributions of genetics and epigenetics to its pathogenesis

Keloid, characterized by fibroproliferative disorders of the skin, can be developed in people of different genders, ages, and ethnicities. Keloid can appear in any part of the body but are especially common on the earlobe, upper torso, and triangular muscle. The genetic heterogeneity and susceptibility of KD (keloid) vary among different races and ethnicities. Studies have found that multiple loci on multiple chromosomes are associated with the pathogenesis of KD, and specific gene variants may also be involved. Despite multiple investigations attempting to uncover the etiology of keloid formation, the genetic mechanism of keloid formation remains unknown. To establish a foundation for a better understanding of the genetics and epigenetics of keloids, we have evaluated and summarized current studies which are mostly related to heredity, genetic polymorphisms, predisposing gene, DNA methylation, and non-coding RNA. We also discussed the problems and potential of genetic and epigenetic investigations of keloids, with the goal of developing new therapeutic approaches to enhance the prognosis of keloid patients.

Effect of Mortalin on Scar Formation in Human Dermal Fibroblasts and a Rat Incisional Scar Model

Wound healing is a complicated cascading process; disequilibrium among reparative processes leads to the formation of pathologic scars. Herein, we explored the role of mortalin in scar formation and its association with the interleukin-1α receptor using in vitro and in vivo models. To investigate the effects of mortalin, we performed an MTT cell viability assay, qRT-PCR, and Western blot analyses, in addition to immunofluorescence and immunoprecipitation studies using cultured fibroblasts. A rat incisional wound model was used to evaluate the effect of a mortalin-specific shRNA (dE1-RGD/GFP/shMot) Ad vector in scar tissue. In vitro, the mortalin-treated human dermal fibroblast displayed a significant increase in proliferation of type I collagen, α-smooth muscle actin, transforming growth factor-β, phospho-Smad2/3-complex, and NF-κB levels. Immunofluorescence staining revealed markedly increased mortalin and interleukin-1α receptor protein in keloid tissue compared to those in normal tissue, suggesting that the association between mortalin and IL-1α receptor was responsible for the fibrogenic effect. In vivo, mortalin-specific shRNA-expressing Ad vectors significantly decreased the scar size and type-I-collagen, α-SMA, and phospho-Smad2/3-complex expression in rat incisional scar tissue. Thus, dE1-RGD/GEP/shMot can inhibit the TGF-β/α-SMA axis and NF-κB signal pathways in scar formation, and blocking endogenous mortalin could be a potential therapeutic target for keloids.

Identification and validation of HOXD3 and UNC5C as molecular signatures in keloid based on weighted gene co-expression network analysis

BACKGROUND

Keloid is a benign proliferative disease characterized by excessive deposition of extracellular matrix collagen during skin wound healing. The mechanisms of keloid formation have not been fully elucidated, and the current treatment methods are not effective for all keloid patients. Therefore, there is an urgent need to find more effective therapies, and our research focused on identifying characteristic molecular signatures of keloid to explore potential therapeutic targets.

METHODS

Gene expression profiles of keloid and control group samples were retrieved from the GEO database. Taking the GSE113619 dataset as the training set, the dataset collected skin tissues from non-lesion sites of healthy and keloid-prone individuals, denoted as Day0. The second sampling was performed 42 days later at the original sampling site of control and keloid groups, denoted as Day42.The 'limma' package and Venn diagram identified differentially expressed genes (DEGs) specific to keloid day42 versus day0 samples. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), Reactome pathway functional enrichment, and annotation of the characteristic genes were conducted on the Metascape website. Ingenuity canonical pathways, disease & function enrichment analysis and gene interaction network were performed and predicted in Ingenuity Pathway Analysis (IPA) software. Key module genes related to keloid were filtered out by Weighted Gene Co-expression Network Analysis (WGCNA). We utilized the Least Absolute Shrinkage and Selection Operator (LASSO) algorithm to screen the characteristic genes in keloid by the 'glmnet' package. The area under the curve (AUC) of receiver operating characteristic (ROC) was utilized to determine the effectiveness of potential signatures in discriminating keloid samples from normal samples and performed by using the 'pROC' package. The enrich scores of 24 immune cells in each sample were calculated by the single-sample gene set enrichment analysis (ssGSEA) algorithm， and then the Gene Set Variation Analysis (GSVA) was performed. Finally, RNA from 4 normal and 6 keloid samples was extracted, and RT-qPCR and Western Blot validated the expression of characteristic genes.

RESULTS

A total of 640 DEGs specific to keloid day42 versus day0 samples were detected. 69 key module genes were uncovered and implicated in 'NCAM signaling for neurite out-growth', 'oncogenic MAPK signaling', 'transmission across chemical synapses' pathways, and the mitotic cell cycle-related processes. Five characteristic genes (MTUS1, UNC5C, CEP57, NAA35, and HOXD3) of keloid were identified by LASSO, and among which UNC5C and HOXD3 were validated by ROC plot in external dataset, RT-qPCR and Western Blot in validation samples. The result of ssGSEA indicated that the infiltration of neutrophils showed a relatively higher abundance and natural killer cells with relatively low enrichment in the keloid group compared to the control group. UNC5C was correlated with more immune cells compared with other characteristic genes.

CONCLUSION

In this study, characteristic genes associated with keloid were identified by bioinformatic approaches and verified in clinical validation samples, providing potential targets for the diagnosis and treatment of keloid.

Recognizing Drug Hypersensitivity in Pigmented Skin

The imagery of pigmented skin is underrepresented in teaching materials such as textbooks, journals, and online references, and this has resulted in poorer diagnostic and management outcomes of skin pathology, including delayed cutaneous drug hypersensitivity reactions. In this review, we use clinical images to highlight factors that impact clinical presentations and sequelae of drug hypersensitivity reactions in pigmented skin compared with nonpigmented skin. We describe clinical features in some anatomic sites that aid diagnosis or are associated with more severe sequelae. Finally, we discuss strategies that may aid the diagnosis and management of these reactions in pigmented skin.

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.

Management of Spontaneous and Pruritic Keloids: A Case Report

Spontaneous chest wall keloid scars can occur without any history of trauma and are rare. Some keloids present with intense pruritus or paresthesia, prompting patients to seek treatment. Currently, many treatment options are available in medicine. However, for this case report a less invasive treatment modality is evaluated. This clinical case report will present Kenalog-40 injections as a treatment option to treat a spontaneous keloid scar. Observation of this treatment option has illustrated a reduction in size and improvement in pruritus, paraesthesia and discoloration.

Scar Perception After Two Surgical Approaches for Total Hip Arthroplasty

Background

There is a paucity of literature examining patients’ and health-care providers’ perception of surgical scars after total hip arthroplasty (THA). This study examined perception of surgical scars after direct anterior (DAA) or posterior approach (PA) for THA using validated scar-assessment scales.

Material and methods

Seventy-five DAA and 75 PA THA patients underwent scar assessment using the Patient Observer Scar Assessment Scale (POSAS) and Stony Brook Scar Evaluation Scales. Mean age was different between the cohorts (DAA 67 vs PA 62 years, P = .01). All patients had subcuticular running closure, secured with skin adhesive glue. Mean time from THA to scar assessment was 3.1 and 3.6 years for the DAA and PA groups, respectively (P = .18).

Results

Scar opinion on the POSAS patient-reported scale was graded closer to normal skin more often for DAA than for PA patients (P = .03). More irregularities were graded for the DAA scars on the POSAS observer scale (P = .02) and the Stony Brook Scar Evaluation Scales (P = .04). Age did not predict scar opinion on any of the scales (P > .05). Female gender and a history of keloids predicted poorer scar appearance (P = .001 and P = .02). Overall scar appearance was rated as “good” in 93% of the DAA and 91% of the PA patients (P = .63).

Conclusion

Differences exist in DAA and PA scar perception based on validated scales. Future randomized trials in scar assessment may control for confounding variables such as age and gender, as well as potential biases when using scar assessment scales.

Concomitant therapy of surgical shave excision and intralesional injections for ear keloids: Early results from a retrospective cohort study

Introduction

Keloids are hypertrophic scars that commonly arise in the ear region. The authors’ objectives were to (1) evaluate effectiveness of surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections; and (2) evaluate safety and patient satisfaction.

Methods and Materials

This study was a retrospective chart review of patients who received treatment of extralesional surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections to treat ear keloids at a single outpatient dermatology clinic. A prospective patient questionnaire was administered to the same patient population to collect recurrence and patient satisfaction.

Results

A total of 45 patients were included, consisting of 84.4% females (n = 38) and 15.6% males (n = 7) with a mean age of 25.5 years. Through retrospective chart review, early recurrence was seen in 6.7% of patients (n = 3), and via the prospective patient questionnaire, 11.1% of patients noted early keloid recurrence (n = 5). Of the patients who expressed their level of satisfaction in-clinic, 96.0% (n = 24) reported being satisfied or very satisfied and 4.0% (n = 1) were dissatisfied. Satisfaction was also assessed through the prospective patient questionnaire; of those who consented to the questionnaire, 100.0% (n = 24) were satisfied or very satisfied. Only 20.0% (n = 9) of all patients reported experiencing side effects, consisting of pruritus (11.1%; n = 5), tenderness (4.4%; n = 2), pain (2.2%; n = 1), and mild atrophy (2.2%; n = 1).

Conclusion

Extralesional surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections may represent a promising treatment option for ear keloids.

Evidence Level: 3 retrospective cohort study.

Lay Summary

Keloids are a type of raised scar, which can be painful and itchy for patients. Keloids can occur on various part of the body, including on the ear. They are challenging to treat and tend to come back. There are many treatment options, however, there is not one universal best treatment for keloids on the ear. We hoped to discover if shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections is effective at treating keloids on the ear. In order to answer this we completed a chart review of clinic patients, who have already completed the following combination treatment for keloids on the ear. The keloids were treated first by physically removing the bulk of the keloid with a scalpel, which is called shave excision. After the removal, triamcinolone acetonide and onabotulinumtoxinA were injected directly into the keloid. The rate of patient satisfaction and the rate of the keloid returning were collected during in-clinic visits and an optional post-clinic patient questionnaire. The treatment effectiveness and side effects experienced were reported during in-clinic visits. This indicated that with the low rate of side effects, high patient satisfaction, and low rate of keloid return, this treatment combination should be considered as an option for keloids on the ear. However, since this review was completed at one clinic with a small population of patients, it is not fully known if this treatment combination will work for all patients.

Does Keloid Histology Influence Recurrence?

ABSTRACT

Keloids are fibroproliferative disorders characterized by high recurrence rates, with few factors known to influence the same. We conducted a study to determine whether keloid histology influences recurrence. This was a prospective longitudinal study to determine whether histopathological parameters of keloid influence recurrence. Patients with keloids managed by surgical excision were followed up at Kenyatta National Hospital between August 2018 and July 2020. The excised keloids were processed for histology using hematoxylin,/eosin, Masson, and trichrome stains. The slides were analyzed for inflammatory cells, fibroblasts, and capillary density using the hot spot technique and correlated to keloid recurrence. Postoperative follow-up was for a minimum of 1 year. A total of 90 patients with 104 keloids were recruited in the study. Overall keloid recurrence rate was 28.6%. There was a correlation between the absolute count of more than 50 per High power field of lymphocytes, fibroblasts, and macrophages with recurrence of the disease. The sensitivity and specificity for the above parameters were lymphocytes 48% and 81%, macrophages 57% and 83%, mast cells 32% and 33%, and fibroblasts 41% and 91%, respectively. There was no correlation between mast cells and vascularity status with recurrence. Routine histology should, therefore, be performed to determine these parameters. Close monitoring and second-line therapy should be considered for patients with elevated macrophages and/or lymphocytes so as to reduce the risk of 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.

Radiation Oncology Applications in Plastic and Reconstructive Surgery: A Nonsystematic Review of Concepts and Principles

SUMMARY

Careful consideration of radiotherapy can determine the success of reconstructive therapy. There is a broad spectrum of radiotherapy modalities, both benign and malignant. Delivery mechanisms differ in the physical design, setup, radiation source, administrable dosage, and mode of delivery. This range of options allows radiation oncologists to tailor individualized treatment; however, radiotherapy concepts can be challenging for nonspecialists. The purpose of this article is to review general radiation oncology concepts, including essential equipment and radiobiology, and provide plastic surgeons with a basic conceptual understanding to facilitate effective multidisciplinary collaboration with radiation oncologists.

Optimizing Surgical Procedures of Auricular Keloids According to Their Anatomic Morphological Features

BACKGROUND

Aesthetic surgical reconstruction of auricular keloids is still a conundrum. This study introduces our experiences in analyzing the anatomic morphological features of auricular keloids, and devising optimized surgical procedures accordingly.

METHODS

A total of 129 ears with auricular keloids were classified and operated. All patients were followed up for at least 12 months.

RESULTS

According to their anatomic positions, auricular keloids were divided into 3 Groups (A, B, and C). The morphological features of keloids were further interpreted according to Chang-Park classification of earlobe keloids. The authors optimized surgical procedures according to the anatomic morphological features from a range of surgical techniques. The recurrence rate of Group C was statistically higher than Group A and B. There was no significant difference in recurrence rate between keloids treated with "primary suture" and "filleted flaps."

CONCLUSIONS

According to the anatomic positions and morphological features of auricular keloids, we could conveniently devise optimized surgical strategies to obtain aesthetic reconstruction of auricular keloids.

Multiple Cytokines Elevated in Patients with Keloids: Is It an Indication of Auto-Inflammatory Disease?

BACKGROUND

Inflammation seems to play a major role in the pathophysiology of keloids. However, the role of cytokines in keloid pathophysiology has not been fully evaluated with only a few cytokines studied. We undertook this study to compare various cytokines in patients with keloids and a control group of patients without keloids nor family history of keloids so as to determine which cytokines are elevated and could thus be critical in keloid formation.

METHODS

This was a cross-sectional study of patients with keloids and a control group of those without. Patients in both groups were matched for age, sex and body mass index. Their plasma was analyzed for both inflammatory and anti-inflammatory cytokines using the Bio-flex ElisaTM method. Comparisons of cytokines means in both groups were done using Student's t-test.

RESULTS

A total of 84 participants with 42 participants in each group were followed during the study. Male to female ratio was 1:2. Age ranges were similar with a mean of 29.6 years. A total of 28 cytokines were assayed. Statistically significant differences were noted in 15 of the 28 cytokines assayed with 11 being elevated more in keloid patients with only four in the non-keloid forming group. Among elevated cytokines in keloid patients were granulocyte colony-stimulating factors, granulocyte-monocyte-colony-stimulating factors, interleukins 4, 6 and 13.

CONCLUSION

Patients with keloids have significantly higher cytokines compared with non-keloid forming patients. This finding suggests that keloid formation could be influenced by multiple inflammatory cytokines, an indication that the patient's immune system could play a role in keloid formation akin to auto-inflammatory disease.

Metformin Inhibits Transforming Growth Factor β-Induced Fibrogenic Response of Human Dermal Fibroblasts and Suppresses Fibrosis in Keloid Spheroids

ABSTRACT

Accumulation of excessive extracellular matrix (ECM) and aberrant transforming growth factor β (TGF-β) signaling pathway function can be potential therapeutic targets for keloid treatment. In this study, we examined the antifibrotic effect of metformin as a suppressor of TGF-β signaling pathways in human dermal fibroblasts (HDFs) and keloid spheroids. Human dermal fibroblasts were stimulated with TGF-β (10 ng/mL) and treated with metformin (10 mM). The mRNA and protein expression of ECM components were evaluated by quantitative polymerase chain reaction, western blot, and immunofluorescence assay. In addition, we immunohistochemically examined the expression levels of ECM proteins in keloid spheroids. After addition of metformin (10 mM), collagen types I and III and elastin mRNA levels were significantly decreased in HDFs, and collagen type I protein level was significantly decreased. In addition, the expression levels of collagen types I and III, fibronectin, and elastin were significantly reduced in keloid spheroids after treatment with metformin (100 mM). Collagen types I and III and p-Smad2/3 complex proteins were decreased in metformin-treated keloid spheroids. These findings indicated that metformin inhibits the expression of ECM components in TGF-β-stimulated HDFs and keloid spheroids. Therefore, we suggest the potential of metformin as an effective agent for the treatment of keloids.

Inhibitory Effect of the LY2109761 on the Development of Human Keloid Fibroblasts

Keloids are scars characterized by abnormal proliferation of fibroblasts and overproduction of extracellular matrix components including collagen. We previously showed that LY2109761, a transforming growth factor- (TGF-) β receptor inhibitor, suppressed the secretion of matrix components and slowed the proliferation of fibroblasts derived from human hypertrophic scar tissue. However, the exact mechanism underlying this effect remains unclear. Here, we replicated the above results in keloid-derived fibroblasts and show that LY2109761 promoted apoptosis, decreased the phosphorylation of Smad2 and Smad3, and suppressed TGF-β1. These results suggest that the development and pathogenesis of keloids are positively regulated by the Smad2/3 signaling pathway and the upregulation of TGF-β1 receptors. LY2109761 and other inhibitors of these processes may therefore serve as therapeutic targets to limit excessive scarring after injury.

Arthrofibrosis after total knee arthroplasty: patients with keloids at risk

BACKGROUND

Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without.

METHODS

Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant.

RESULTS

Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9).

CONCLUSION

Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study.

LEVEL OF EVIDENCE

Level III retrospective comparative study.

RNA Sequencing Keloid Transcriptome Associates Keloids With Th2, Th1, Th17/Th22, and JAK3-Skewing

Keloids are disfiguring, fibroproliferative growths and their pathogenesis remains unclear, inhibiting therapeutic development. Available treatment options have limited efficacy and harbor safety concerns. Thus, there is a great need to clarify keloid pathomechanisms that may lead to novel treatments. In this study, we aimed to elucidate the profile of lesional and non-lesional keloid skin compared to normal skin. We performed gene (RNAseq, qRT-PCR) and protein (immunohistochemistry) expression analyses on biopsy specimens obtained from lesional and non-lesional skin of African American (AA) keloid patients compared to healthy skin from AA controls. Fold-change≥2 and false-discovery rate (FDR)<0.05 was used to define significance. We found that lesional versus normal skin showed significant up-regulation of markers of T-cell activation/migration (ICOS, CCR7), Th2- (IL-4R, CCL11, TNFSF4/OX40L), Th1- (CXCL9/CXCL10/CXCL11), Th17/Th22- (CCL20, S100As) pathways, and JAK/STAT-signaling (JAK3) (false-discovery rate [FDR]<0.05). Non-lesional skin also exhibited similar trends. We observed increased cellular infiltrates in keloid tissues, including T-cells, dendritic cells, mast cells, as well as greater IL-4rα+, CCR9+, and periostin+ immunostaining. In sum, comprehensive molecular profiling demonstrated that both lesional and non-lesional skin show significant immune alternations, and particularly Th2 and JAK3 expression. This advocates for the investigation of novel treatments targeting the Th2 axis and/or JAK/STAT-signaling in keloid patients.

Tomotherapy as an Alternative Irradiative Treatment for Complicated Keloids

The aim of this study was to investigate the treatment of complicated keloids with helical tomotherapy (HT) and electron beam radiotherapy. From July 2018 to September 2018, 11 patients with 23 keloid lesions treated with HT were enrolled. Additionally, 11 patients with 20 lesions treated with electron beam radiotherapy in the same period were enrolled. Patients in both groups were treated within 24 h after surgical excision of the keloid lesion with 13.5 Gy in three consecutive daily fractions. The median follow-up period was 15 months. The local control rate was 91.3% and 80% in the HT group and the electron beam group, respectively. No acute adverse effects were observed in either group, but most patients exhibited pigmentation. No radiation-induced cancer occurred in these patients up to the time of this report. Pain and pruritus improved for all patients and more obviously for three patients with complicated keloids treated with HT. The measured surface dose was 103.7–112.5% and 92.8–97.6% of the prescribed dose in the HT group and the electron beam group, respectively. HT can be considered an alternative in cases where it is not feasible to use multiple electron fields, due to encouraging clinical outcomes.

Primary Ciliary Signaling in the Skin-Contribution to Wound Healing and Scarring

Primary cilia (PC) are solitary, post-mitotic, microtubule-based, and membrane-covered protrusions that are found on almost every mammalian cell. PC are specialized cellular sensory organelles that transmit environmental information to the cell. Signaling through PC is involved in the regulation of a variety of cellular processes, including proliferation, differentiation, and migration. Conversely, defective, or abnormal PC signaling can contribute to the development of various pathological conditions. Our knowledge of the role of PC in organ development and function is largely based on ciliopathies, a family of genetic disorders with mutations affecting the structure and function of PC. In this review, we focus on the role of PC in their major signaling pathways active in skin cells, and their contribution to wound healing and scarring. To provide comprehensive insights into the current understanding of PC functions, we have collected data available in the literature, including evidence across cell types, tissues, and animal species. We conclude that PC are underappreciated subcellular organelles that significantly contribute to both physiological and pathological processes of the skin development and wound healing. Thus, PC assembly and disassembly and PC signaling may serve as attractive targets for antifibrotic and antiscarring therapies.

Patterns of Skin Disease in the Context of a High Prevalence HIV Population in Botswana

The authors reviewed outpatients in a tertiary dermatology clinic in Botswana to expand knowledge on patterns of skin disease in this population with a high prevalence of human immunodeficiency virus (HIV). Approximately one-third of new and follow-up patients were HIV positive. Common dermatologic conditions included eczematous eruptions, viral and fungal infections, malignant neoplasms, vascular disorders, disorders of pigmentation, and mechanical/physical injury-related disorders. HIV has impacted patterns of dermatologic disease in Botswana, with Kaposi sarcoma being the most frequently biopsied condition. Given the shortage of dermatology specialists, resources should be allocated toward education and management of these most prevalent skin conditions.