1
|
Tsubouchi H, Awaji T, Hirose R, Kishida K, Yamashita S, Furuya K, Chang Y, Shikado K, Kohta M, Ogita K. Preventive Effect of Hydrocolloid Dressings on Hypertrophic Scarring of Post-Cesarean Section Wounds: A Randomized Pilot Study. Adv Skin Wound Care 2024; 37:360-367. [PMID: 38899817 DOI: 10.1097/asw.0000000000000155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
OBJECTIVE To determine the prophylactic effect of hydrocolloid dressings on hypertrophic scarring in post-cesarean section wounds. METHODS Patients who underwent cesarean section (C/S) at the authors' hospital and provided informed consent to participate were randomly assigned to the intervention and control groups. The intervention group commenced applying hydrocolloid dressings to the wound on postoperative day 7 or 8 and continued with weekly dressing changes for 6 months. The control group refrained from any dressing application but was followed up. In each group, the condition of the wound was evaluated 6 and 12 months postoperatively using the Japan Scar Workshop Scar Scale 2015, the Patient and Observer Scar Assessment Scale version 2.0, the modified Vancouver Scar Scale, and patient-reported outcomes. RESULTS During this period, 135 patients underwent C/S at the authors' institution, and 47 (23 in the intervention group and 24 in the control group) were included in the analysis. In all assessment methods, the intervention group scored lower than the control group at 6 and 12 months after C/S. Twelve months after C/S, hypertrophic scarring (Japan Scar Workshop Scar Scale 2015 score of 6-15) was found in 14 of the 47 (29.8%) patients: 11 of 24 (45.8%) in the control group and 3 of 23 (13.0%) in the intervention group. The intervention's relative risk was 0.623 (95% CI, 0.417-0.930). The risk factor for hypertrophic scarring was midline vertical incision, with an odds ratio of 20.53 (95% CI, 4.18-100.92). CONCLUSIONS The study reveals that the application of hydrocolloid dressings to wounds reduces the risk of hypertrophic scarring after C/S.
Collapse
Affiliation(s)
- Hiroaki Tsubouchi
- In the Department of Obstetrics and Gynecology, Rinku General Medical Centre, Izumisano, Osaka, Japan, Hiroaki Tsubouchi, MD, PhD, is Deputy Chief; Takuya Awaji, MD, is Deputy Chief; Rikuto Hirose, MD, is Senior Resident; Kenji Kishida, MD, is Physician; Saya Yamashita, MD, PhD, is Deputy Head Physician; Kiichiro Furuya, MD, PhD, is Deputy Head Physician; Yangshil Chang, MD, is Deputy Head Physician; and Kayoko Shikado, MD, is Staff Doctor. Masushi Kohta, PhD, is Senior Assistant Professor, Research Center for Implementation Nursing Science Initiative, Fujita Health University, Toyoake, Aichi, Japan. Also in the Department of Obstetrics and Gynecology, Rinku General Medical Centre, Kazuhide Ogita, MD, PhD, is Chief Obstetrician
| | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Xia G, Dohi T, Abdelhakim M, Tosa M, Ogawa R. The effects of systemic diseases, genetic disorders and lifestyle on keloids. Int Wound J 2024; 21:e14865. [PMID: 38584345 PMCID: PMC10999570 DOI: 10.1111/iwj.14865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/09/2024] Open
Abstract
Keloid are a fibroproliferative disorder caused by abnormal healing of skin, specifically reticular dermis, when subjected to pathological or inflammatory scars demonstrating redness, elevation above the skin surface, extension beyond the original wound margins and resulting in an unappealing cosmetic appearance. The severity of keloids and risk of developing keloids scars are subjected to elevation by other contributing factors such as systemic diseases, general health conditions, genetic disorders, lifestyle and natural environment. In particular, recently, daily physical work interpreted into mechanical force as well as the interplay between mechanical factors such as stress, strain and stiffness have been reported to strongly modulate the cellular behaviour of keloid formation, affect their location and shape in keloids. Herein, we review the extensive literature on the effects of these factors on keloids and the contributing predisposing mechanisms. Early understanding of these participating factors and their effects in developing keloids may raise the patient awareness in preventing keloids incidence and controlling its severity. Moreover, further studies into their association with keloids as well as considering strategies to control such factors may help clinicians to prevent keloids and widen the therapeutic options.
Collapse
Affiliation(s)
- Guangpeng Xia
- Department of Plastic, Reconstructive and Aesthetic SurgeryNippon Medical SchoolTokyoJapan
| | - Teruyuki Dohi
- Department of Plastic, Reconstructive and Aesthetic SurgeryNippon Medical SchoolTokyoJapan
| | - Mohamed Abdelhakim
- Department of Plastic, Reconstructive and Aesthetic SurgeryNippon Medical SchoolTokyoJapan
| | - Mamiko Tosa
- Department of Plastic, Reconstructive and Aesthetic SurgeryNippon Medical SchoolTokyoJapan
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic SurgeryNippon Medical SchoolTokyoJapan
| |
Collapse
|
3
|
Arellano-Huacuja A. Effective keloid management using a combinatorial continuous-wave and repeat fractionated ablative CO 2 laser regimen. J Cosmet Dermatol 2024; 23 Suppl 1:7-12. [PMID: 38587305 DOI: 10.1111/jocd.16282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/03/2024] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Keloids are benign proliferative scars that form as a result of dysregulated growth and collagen deposition in response to cutaneous injury. Laser therapies have emerged as promising options for the treatment of keloids, with performance varying by laser type and lesion characteristics. PURPOSE To assess the combined continuous wave and repetitive fractionated CO2 laser treatment of keloids. METHODS A retrospective chart review of 22 cases of keloid scars treated with combined CO2 laser modes. A single session of continuous wave followed by five sessions of fractional delivery. Efficacy was assessed using the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale. The Numeric Rating Scale was used to assess patient satisfaction and pain. RESULTS Most patients were female (77.3%) with skin type IV (72.7%), age was 24.3 ± 9.3 years, most keloids were located on the earlobe (56.5%) or arm or hand (17.4%), size ranged from 5 to 10 cm, and time since injury ranged from 3 months to 35 years. No serious adverse events were reported. At 6 months, significant improvements from baseline occurred in all characteristics, scar color (4.8 ± 2.8 to 1.9 ± 1.1), rigidity (5.0 ± 2.8 vs. 5.4 ± 2.8), thickness (5.4 ± 2.8 vs. 2.0 ± 1.1), and irregularity (5.9 ± 2.4 vs. 1.9 ± 0.9). The Vancouver scores followed a similar trend. Patient-rated overall improvement from 37 ± 17.6 at baseline to 16.1 ± 8.5 at 6 months, and improvement in associated pain and pruritus. CONCLUSION Combination of two ablative laser delivery modes within a single laser platform provided for effective and safe keloid management and left patients highly satisfied.
Collapse
Affiliation(s)
- Aristides Arellano-Huacuja
- Plastic Surgeon, Clínica Dermatológica y Cirugía Estética de Puebla, Bella Vista, Puebla, 72500, Puebla, Mexico
| |
Collapse
|
4
|
Gill HS, O-Wern L, Tiwari P, Gill GKS, Goh C, Hung J, Lee JT, Lim TC, Lim J, Yap YL, Nallathamby V. Postoperative Scar Management Protocol for Asian Patients. Aesthetic Plast Surg 2024; 48:461-471. [PMID: 37943348 DOI: 10.1007/s00266-023-03696-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/12/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Postoperative scar formation remains a morbidity for patients even with the advent of minimally invasive techniques. Furthermore, the significant difference between the Asian and Caucasian skin results in poorer postoperative scar outcomes in Asians, supporting the need for an evidence-based scar management protocol. METHODS Following a literature review of the PubMed and the Cochrane databases over the past 10 years, we constructed a novel postoperative scar management protocol for the Asian skin, utilized in a Singaporean tertiary healthcare institution. RESULTS We describe a timeline-based scar protocol from the point of skin closure to a minimum of 1 year of follow-up. We support the use of intraoperative botulinum toxin for selected high-risk individuals upon skin closure with a follow-up regimen in the postoperative setting. For recalcitrant keloids, we have described a multimodal therapy comprising elements of intralesional steroids, botulinum toxin, lasers, surgery, and radiotherapy. CONCLUSIONS A consolidated postoperative scar management protocol provides the necessary guidance for improved scar outcomes in the Asian skin. There is inherent potential in expanding the protocol to include post-traumatic and burn wounds or support other skin types including the Caucasian skin. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .
Collapse
Affiliation(s)
- Hargaven Singh Gill
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Low O-Wern
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Priya Tiwari
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore.
| | - Gurveer Kaven Singh Gill
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Chance Goh
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Janet Hung
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Jing Tzer Lee
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Thiam Chye Lim
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Jane Lim
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Yan Lin Yap
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Vigneswaran Nallathamby
- Department of Plastic, Reconstructive and Aesthetic Surgery, National University Hospital (NUH), 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| |
Collapse
|
5
|
Noishiki C, Hayasaka Y, Yoshida R, Ogawa R. Over 90% Percent of Childhood BCG Vaccine-Induced Keloids in Japan Occur in Women. Dermatol Ther (Heidelb) 2023; 13:1137-1147. [PMID: 36952124 PMCID: PMC10034230 DOI: 10.1007/s13555-023-00916-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023] Open
Abstract
INTRODUCTION Keloids are a fibroproliferative, multifactorial, cutaneous disorder whose pathophysiology is not completely understood. Various factors such as high blood pressure, pregnancy, female gender, mechanical tension of local sites, and prolonged wound healing are known to worsen keloids. Childhood-onset keloids are keloids that form before 10 years of age, before various factors in adulthood come into play, and thus studying childhood-onset keloids may provide additional insight into the underlying mechanisms that lead to keloid formation. METHODS Retrospective chart review was performed on all patients with childhood-onset keloids who were evaluated at our plastic surgery clinic (one of the largest keloid referral centers in Japan) over a 1-year period. RESULTS Of the 1443 patients with diagnosis of keloids, 131 patients had childhood-onset keloids. Of these, 106 patients (80.9%) were female, 38.9% of patients had family history of keloids, and 48.9% of patients had allergies or allergy-related conditions (asthma, atopic dermatitis, or allergic rhinitis). Vaccination (47.5%) and chickenpox (19.9%) were the most common triggers. Of vaccinations, BCG was the most common trigger. The majority of keloids from BCG were in female patients (92.9%). The most common location was the chest in male patients (30.0%) and the arm in female patients (41.1%). CONCLUSION To our knowledge, this is the largest report in the literature on childhood-onset keloids. There was overall female predominance in childhood-onset keloids, and even more significant female predominance in BCG-induced keloids.
Collapse
Affiliation(s)
- Chikage Noishiki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-Ku, Tokyo, 113-8603, Japan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Ryu Yoshida
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-Ku, Tokyo, 113-8603, Japan.
| |
Collapse
|
6
|
Friction-Aggravated Skin Disorders-A Review of Mechanism and Related Diseases. Dermatitis 2022:01206501-990000000-00081. [PMID: 36255396 DOI: 10.1097/der.0000000000000961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Skin is subject to frequent friction injury. Friction affects different structures of the skin, including keratinocytes, melanocytes, fibroblasts, and follicular units. Friction can also stimulate cytokine production. Friction is sensed by the mechanoreceptors, resulting in signal transduction to the nucleus, activating transcription factors and mechanoresponsive genes. Numerous friction-aggravated diseases have been identified, including inflammatory, depositional, follicular, genetic, infectious, and vesiculobullous disorders. Friction, as a potential modifiable aggravator, should be considered when skin diseases are located at friction-prone areas.
Collapse
|
7
|
Kakinuma T, Kagimoto M, Kaneko A, Ichii N, Kakinuma K, Kawarai Y, Yanagida K, Tanaka H, Ohwada M, Takeshima N. Prevention and management of hypertrophic scars after laparoscopic surgery using silicone gel sheets: a pilot study. J Int Med Res 2022; 50:3000605221107597. [PMID: 35929020 PMCID: PMC9358567 DOI: 10.1177/03000605221107597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To assess the effectiveness and safety of modified silicone gel sheets applied to hypertrophic scars and keloids following laparoscopic surgery. Methods Patients who had undergone laparoscopic surgery and who had either conventional or modified silicone gel sheets affixed to their surgical lesions for 6 months postoperatively (treatment groups), and control patients who had not received postsurgical treatment involving silicone gel sheets, were enrolled. The surgical wounds were assessed visually and using the Japan Scar Workshop (JSW) Scar Scale. Patients were interviewed before, 3 months after, and 6 months after sheet affixation. Results A total of 45 patients were included, comprising 15 patients per group. Both silicone gel-sheet groups had significantly lower JSW Scar Scale scores at 3 and 6 months after affixation compared with controls. The scores were not significantly different between the conventional and modified treatment groups and no adverse events were observed in the latter. Conclusions Modified silicone gel sheets were more effective than controls and comparable to conventional gel sheets, and there were no adverse events related to laparoscopic surgical wounds in the improved silicone gel sheet group, demonstrating the safety and effectiveness of the modified silicone gel sheets.
Collapse
Affiliation(s)
- Toshiyuki Kakinuma
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Masataka Kagimoto
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Ayaka Kaneko
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Naoki Ichii
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Kaoru Kakinuma
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Yoshimasa Kawarai
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Kaoru Yanagida
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Hirokazu Tanaka
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Michitaka Ohwada
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| | - Nobuhiro Takeshima
- Department of Obstetrics and Gynaecology, International University of Health and Welfare Hospital, Iguchi, Nasushiobara-City, Tochigi, Japan
| |
Collapse
|
8
|
Ogawa R. The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago. Plast Reconstr Surg 2022; 149:79e-94e. [PMID: 34813576 PMCID: PMC8687618 DOI: 10.1097/prs.0000000000008667] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review. METHODS All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available. RESULTS Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis. CONCLUSIONS Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.
Collapse
Affiliation(s)
- Rei Ogawa
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
| |
Collapse
|
9
|
Zhang D, Li B, Zhao M. Therapeutic Strategies by Regulating Interleukin Family to Suppress Inflammation in Hypertrophic Scar and Keloid. Front Pharmacol 2021; 12:667763. [PMID: 33959031 PMCID: PMC8093926 DOI: 10.3389/fphar.2021.667763] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/05/2021] [Indexed: 12/28/2022] Open
Abstract
Hypertrophic scar (HS) and keloid are fibroproliferative disorders (FPDs) of the skin due to aberrant wound healing, which cause disfigured appearance, discomfort, dysfunction, psychological stress, and patient frustration. The unclear pathogenesis behind HS and keloid is partially responsible for the clinical treatment stagnancy. However, there are now increasing evidences suggesting that inflammation is the initiator of HS and keloid formation. Interleukins are known to participate in inflammatory and immune responses, and play a critical role in wound healing and scar formation. In this review, we summarize the function of related interleukins, and focus on their potentials as the therapeutic target for the treatment of HS and keloid.
Collapse
Affiliation(s)
- Dan Zhang
- Department of Plastic and Cosmetic Surgery, The Second Hospital of Dalian Medical University, Dalian, China
| | - Bo Li
- Department of Plastic and Cosmetic Surgery, The Second Hospital of Dalian Medical University, Dalian, China
| | - Muxin Zhao
- Department of Plastic and Cosmetic Surgery, The Second Hospital of Dalian Medical University, Dalian, China
| |
Collapse
|
10
|
Huang C, Ogawa R. Systemic factors that shape cutaneous pathological scarring. FASEB J 2020; 34:13171-13184. [DOI: 10.1096/fj.202001157r] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/29/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Chenyu Huang
- Department of Dermatology Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University Beijing China
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery Nippon Medical School Tokyo Japan
| |
Collapse
|
11
|
Ogawa R, Dohi T, Tosa M, Aoki M, Akaishi S. The Latest Strategy for Keloid and Hypertrophic Scar Prevention and Treatment: The Nippon Medical School (NMS) Protocol. J NIPPON MED SCH 2020; 88:2-9. [PMID: 32741903 DOI: 10.1272/jnms.jnms.2021_88-106] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In 2006, we established a scar/keloid-specialized unit in the Department of Plastic, Reconstructive, and Aesthetic Surgery at Nippon Medical School (NMS) in Tokyo, Japan. In the ensuing 15 years, we treated approximately 2,000 new scar/keloid patients annually. This extensive experience has greatly improved the efficacy of the treatments we offer. Therefore, we discuss here the latest NMS protocol for preventing and treating keloids and hypertrophic scars. While this protocol was optimized for Japanese patients, our experience with a growing body of non-Japanese patients suggests that it is also effective in other ethnicities. The extensive evidence-based experience underlying the NMS protocol suggests that it may be suitable as the foundation of a standard international prevention/treatment algorithm for pathological scars.
Collapse
Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital
| | - Teruyuki Dohi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital
| | - Mamiko Tosa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital
| | - Masayo Aoki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital
| | - Satoshi Akaishi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital
| |
Collapse
|
12
|
Ogawa R, Akita S, Akaishi S, Aramaki-Hattori N, Dohi T, Hayashi T, Kishi K, Kono T, Matsumura H, Muneuchi G, Murao N, Nagao M, Okabe K, Shimizu F, Tosa M, Tosa Y, Yamawaki S, Ansai S, Inazu N, Kamo T, Kazki R, Kuribayashi S. Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018. BURNS & TRAUMA 2019; 7:39. [PMID: 31890718 PMCID: PMC6933735 DOI: 10.1186/s41038-019-0175-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/14/2019] [Indexed: 01/05/2023]
Abstract
There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.
Collapse
Affiliation(s)
- Rei Ogawa
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Sadanori Akita
- 2Department of Plastic Surgery, Wound Repair and Regeneration, Fukuoka University, Fukuoka, 814-0180 Japan
| | - Satoshi Akaishi
- 3Department of Plastic Surgery, Nippon Medical School Musashikosugi Hospital, 1-396 Kosugicho, Nakahara-ku, Kawasaki-shi, Kanagawa 211-8533 Japan
| | - Noriko Aramaki-Hattori
- 4Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Teruyuki Dohi
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Toshihiko Hayashi
- 5Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638 Japan
| | - Kazuo Kishi
- 4Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Taro Kono
- 6Department of Plastic Surgery, Tokai University School of Medicine, 4-1-1 Kitakaname, Hiratsuka, Kanagawa 259-1292 Japan
| | - Hajime Matsumura
- 7Department of Plastic and Reconstructive Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Gan Muneuchi
- 8Department of Plastic and Reconstructive Surgery, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012 Japan
| | - Naoki Murao
- 5Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638 Japan
| | - Munetomo Nagao
- 9Department of Plastic, Reconstructive and Aesthetic Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate 020-8505 Japan
| | - Keisuke Okabe
- 4Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Fumiaki Shimizu
- 10Department of Plastic Surgery, Oita University Hospital, 1-1 Idaigaoka, Hasamamachi, Yufu-shi, Oita 879-5503 Japan
| | - Mamiko Tosa
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Yasuyoshi Tosa
- 11Department of Plastic Surgery, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa Japan
| | - Satoko Yamawaki
- Department of Plastic and Reconstructive Surgery, Japanese Red Cross Fukui Hospital, 2-4-1 Tsukimi, Fukui, 918-8501 Japan
| | - Shinichi Ansai
- 13Division of Dermatology and Dermatopathology, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugicho, Nakahara-ku, Kawasaki-shi, Kanagawa 211-8533 Japan
| | - Norihisa Inazu
- 14Faculty of Pharmaceutical Sciences, Teikyo Heisei University, 4-21-2 Nakano, Nakano-ku, Tokyo, 164-8530 Japan
| | - Toshiko Kamo
- Wakamatsu-cho Mental and Skin Clinic, 9-4 Wakamatsu-cho, Shinjyuku-ku, Tokyo, 162-0056 Japan
| | - Reiko Kazki
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Shigehiko Kuribayashi
- 16Department of Radiation Oncology, Nippon Medical School Hospital, Tokyo, 113-8603 Japan
| |
Collapse
|
13
|
Noishiki C, Hayasaka Y, Ogawa R. Sex Differences in Keloidogenesis: An Analysis of 1659 Keloid Patients in Japan. Dermatol Ther (Heidelb) 2019; 9:747-754. [PMID: 31586308 PMCID: PMC6828900 DOI: 10.1007/s13555-019-00327-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Keloids are a cutaneous fibroproliferative disorder. Despite the fact that keloids are relatively common lesions, the statistics of patient with keloids especially sex difference remain unknown. To better understand it, we conducted an extensive cross-sectional analysis of a large cohort of patients with keloids (n = 1659). The study showed for the first time that female sex may be an inherent keloid risk factor. METHODS This cross-sectional study of 1659 consecutive patients with keloids who attended a plastic surgery outpatient clinic in Japan in 2014 analyzed age at keloid onset, age at the first medical examination for keloid, and the influence of sex on these variables. RESULTS In both male and female patients, the keloids were most likely to start in puberty and there was no significant difference in the mode value for age of onset (16 vs. 20 years). Though female patients were twice as prevalent as male patients at nearly all onset ages, female patients predominated over male patients with a gender ratio of 2.7:1 in cases of onset before the age of 15 years. Moreover male and female patients did not differ in terms of the mean ± SD duration between keloid onset and the first medical examination. This finding shows that female patients do not get their keloids examined earlier than male patients. These observations together suggest that female sex may promote early keloid development due to physiological, not social, reasons. CONCLUSION This is the first report to suggest that female sex may drive keloidogenesis because of physiological reasons. Individuals were most likely to seek a medical examination almost 10 years after onset, regardless of sex. These findings provide new insight into the importance of sex in the development and progression of keloids. Future studies should address the influence of sex hormones on the keloid.
Collapse
Affiliation(s)
- Chikage Noishiki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | | | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan.
| |
Collapse
|
14
|
Park TH, Kim CW, Choi JS, Park YJ, Chong Y, Park MJ, Cho Y. PARP1 Inhibition as a Novel Therapeutic Target for Keloid Disease. Adv Wound Care (New Rochelle) 2019; 8:186-194. [PMID: 31119062 PMCID: PMC6529855 DOI: 10.1089/wound.2018.0910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/07/2019] [Indexed: 12/24/2022] Open
Abstract
Objective: Inactivation of poly(ADP-ribose) polymerase 1 (PARP1) has been found to have protective effect in several fibrotic diseases. But the effect is not studied yet in keloids. Herein, we evaluated the therapeutic effect of PARP1 inhibitor, rucaparib, for keloids. Approach: The protein expressions of PARP1 and smad3 were evaluated with western blotting in keloids and controls. The effect of rucaparib was evaluated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and migration assay. We further analyzed the effect of rucaparib on patient-derived keloid xenograft murine model. Results: The protein expressions of PARP1 and smad3 were significantly higher in keloid tissue. Rucaparib (20 μM) significantly suppressed the proliferation of keloid fibroblasts. Moreover, the combination of rucaparib (20 μM) and triamcinolone (50 μM) showed additive suppressive effect on keloid fibroblasts. Migration assay showed that rucaparib (10 μM) significantly suppressed the migration of keloid fibroblasts. Fibrosis markers in keloid fibroblasts significantly decreased after rucaparib treatment (20 μM). In patient-derived keloid xenograft model, rucaparib significantly reduced the size of keloid tissue. Innovation and Conclusion: The study data suggest PARP1 might be a novel therapeutic target for keloid disease. PARP1 inhibitor, rucaparib, might be a promising therapeutic drug for the treatment of keloid disease.
Collapse
Affiliation(s)
- Tae Hwan Park
- Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Chan Woo Kim
- Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Jin Sik Choi
- Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Yun Joo Park
- Department of Radiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Yosep Chong
- Department of Hospital Pathology, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Min Ji Park
- Department of Internal Medicine, Gangnam CHA Medical Center, CHA University School of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Department of Internal Medicine, Gangnam CHA Medical Center, CHA University School of Medicine, Seoul, Republic of Korea
| |
Collapse
|
15
|
Euler T, Valesky EM, Meissner M, Hrgovic I, Kaufmann R, Kippenberger S, Zöller NN. Normal and keloid fibroblasts are differentially influenced by IFN-γ and triamcinolone as well as by their combination. Wound Repair Regen 2019; 27:450-461. [PMID: 30994217 DOI: 10.1111/wrr.12722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 12/14/2022]
Abstract
Impaired wound healing as well as imbalanced cell proliferation and extracellular matrix synthesis and degeneration can cause aberrant scarring. The most severe impacts of such scarring on patients' lives are stigmatization and physical restriction. Although, a broad variety of combinatorial approaches with, e.g., glucocorticoids, chemotherapeutics, and immunomodulators are used, there is still a high recurrence rate of keloids. The aim of this study was to investigate which influence interferon γ (IFN-γ, 1.000-10.000 IU/mL) and/or triamcinolone acetonide (TA, 1 μg/mL) have on proliferation, cell viability, collagen type I synthesis, and cytokine secretion in healthy and keloid fibroblasts. It was shown that mono-treatment with IFN-γ or TA for 2 days induced a severe reduction of the proliferative potential in both cell species. The combinatory treatment (IFN-γ plus TA) of keloid fibroblasts enhanced the anti-proliferative effect of the mono-treatments, whereas no additional anti-proliferative effect was observed in normal fibroblasts. Furthermore, we observed that the combinatory treatment regimen reduced the expression of α-smooth muscle actin (α-SMA), an actin isotype contributing to cell-generated mechanical tension, in keloid fibroblasts. In normal fibroblasts, α-SMA was reduced by the mono-treatment with IFN-γ as well as by the combinatory treatment. The analysis of collagen-type I synthesis revealed that TA did not reduce collagen type I synthesis in normal fibroblasts but in keloid fibroblasts. IFN-γ reduced in both cell species the collagen type I synthesis. The combination of TA and IFN-γ intensified the previously observed collagen type I synthesis reduction in keloid fibroblasts. The herein presented data suggest the combinatory application of IFN-γ and TA as a promising therapy concept for keloids.
Collapse
Affiliation(s)
- Teresa Euler
- Frankfurt/Main, Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Germany
| | - Eva M Valesky
- Frankfurt/Main, Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Germany
| | - Markus Meissner
- Frankfurt/Main, Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Germany
| | - Igor Hrgovic
- Frankfurt/Main, Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Germany
| | - Roland Kaufmann
- Frankfurt/Main, Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Germany
| | - Stefan Kippenberger
- Frankfurt/Main, Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Germany
| | - Nadja N Zöller
- Frankfurt/Main, Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt, Goethe University, Germany
| |
Collapse
|
16
|
Z-plasty and Postoperative Radiotherapy for Anterior Chest Wall Keloids: An Analysis of 141 Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2177. [PMID: 31044131 PMCID: PMC6467632 DOI: 10.1097/gox.0000000000002177] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/14/2019] [Indexed: 01/28/2023]
Abstract
Background The therapies for anterior chest wall keloids include surgical excision, postoperative radiotherapy, silicone taping stabilization, and steroid plaster. However, to date, there is no universally accepted combination treatment strategy for anterior chest wall keloids. Methods All consecutive patients with single or multiple anterior chest wall keloids who underwent keloid excision, tension-reducing suturing, z-plasty, and postoperative radiotherapy in 2013-2016 in Nippon Medical School were included in this case series study. Only keloids that arose from small injuries such as folliculitis or acne were selected. The surgery was followed by tension-reducing self-management of the wounds with silicone tape and steroid plaster. The postsurgical radiotherapy modality was 18 Gy administered in 3 fractions over 3 days. The primary study outcome was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the development of stiff and red lesions in even a small part of the scar that did not respond to 6 months of steroid plaster therapy. Results In total, 141 patients with 141 lesions were enrolled. Of the 141 lesions, 15 (10.6%) recurred. All recurrences were successfully treated by steroid plaster and steroid injection. The recurrence patients did not differ from the nonrecurrence patients in terms of the size of the original keloid or gender distribution. Conclusions Anterior chest wall keloids can be successfully treated by customized plans that involve appropriate surgical modalities (including z-plasty) followed by postoperative radiotherapy (18 Gy in 3 fractions over 3 days) and scar self-management with silicone tape and steroid plaster.
Collapse
|
17
|
Ogawa R, Tosa M, Dohi T, Akaishi S, Kuribayashi S. Surgical excision and postoperative radiotherapy for keloids. Scars Burn Heal 2019; 5:2059513119891113. [PMID: 31840001 PMCID: PMC6904783 DOI: 10.1177/2059513119891113] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Keloids can be treated in a number of ways, including by surgery. Multiple studies now show that while surgical monotherapy associates with extremely high rates of recurrence (50%-80%), postoperative radiotherapy can significantly reduce these recurrence rates. Ongoing improvements in radiation technology have further increased the safety and efficacy of this combination protocol. Of the various radiotherapies that have been used in this setting, electron beam (β-ray) irradiation is currently the best due to its excellent dose distribution and safety. The maximal biologically effective dose (BED) for keloids is 30 Gy (using an estimated α / β ratio of 10); increasing the dose has no further benefits and elevates side effects. Over the last two decades, we have modified and then fine-tuned our radiotherapy protocol for keloid excision wounds. Thus, our early protocol was used for all body sites and consisted of 15 Gy/3 fr/3 days. We then customised the radiotherapy protocol so that body sites that are highly prone to recurrence (e.g. the anterior chest) receive higher doses while low recurrence sites like the earlobe receive a much smaller dose. More recently, we tweaked this body site-customised protocol so that fewer fractions are employed. Therefore, we currently apply 18 Gy/3 fr/3 days to high-recurrence sites, 8 Gy/1 fr/1 day to earlobes and 15 Gy/2 fr/2 days to other body sites. These radiotherapy protocol changes were accompanied by the evolution of body site-customised surgical approaches. As a result of these developments, our overall keloid recurrence rate is now below 10%.
Collapse
Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Mamiko Tosa
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Teruyuki Dohi
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Satoshi Akaishi
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | | |
Collapse
|