Application of topical mitomycin C to the base of shave-removed keloid scars to prevent their recurrence

Pharmacotherapy for Keloids and Hypertrophic Scars

Keloids (KD) and hypertrophic scars (HTS), which are quite raised and pigmented and have increased vascularization and cellularity, are formed due to the impaired healing process of cutaneous injuries in some individuals having family history and genetic factors. These scars decrease the quality of life (QOL) of patients greatly, due to the pain, itching, contracture, cosmetic problems, and so on, depending on the location of the scars. Treatment/prevention that will satisfy patients' QOL is still under development. In this article, we review pharmacotherapy for treating KD and HTS, including the prevention of postsurgical recurrence (especially KD). Pharmacotherapy involves monotherapy using a single drug and combination pharmacotherapy using multiple drugs, where drugs are administered orally, topically and/or through intralesional injection. In addition, pharmacotherapy for KD/HTS is sometimes combined with surgical excision and/or with physical therapy such as cryotherapy, laser therapy, radiotherapy including brachytherapy, and silicone gel/sheeting. The results regarding the clinical effectiveness of each mono-pharmacotherapy for KD/HTS are not always consistent but rather scattered among researchers. Multimodal combination pharmacotherapy that targets multiple sites simultaneously is more effective than mono-pharmacotherapy. The literature was searched using PubMed, Google Scholar, and Online search engines.

Topical versus interlesional mitomycin C in auricular keloids

BACKGROUND

The Keloid is an elevated fibrous scar that may extend beyond the borders of the original wound.

OBJECT

To compare between topical and intralesional mitomycin C in the treatment of auricular keloids.

PATIENTS AND METHODS

Prospective randomized study in which 40 patients with auricular keloids were included. The patients were divided into 2 groups, Group I included 32 patients who underwent topical mitomycin C application after the surgical removal of the auricular keloids, while Group II included 8 cases who underwent intra-lesional injection of mitomycin C after surgical removal of the auricular keloids.

RESULTS

The two groups showed no significant difference regarding patient or lesion criteria (p>.05). VSS decreased significantly from 10.63 and 11.0 down to 1.38 and 3.0 after treatment in the topical and intra-lesional groups respectively (p<.001). However, greater improvement and satisfaction was detected in the topical group.

CONCLUSION

Both topical and intra-lesional mitomycin C injection are effective methods in managing auricular keloids. However, better VSS scores and patient satisfaction are reported with topical administration.

Management of keloid scars: noninvasive and invasive treatments

Scars vary from mature linear scars to abnormal excessive scars such as hypertrophic scars and keloid scars. Keloid scars are fibro-proliferative disease entities that reflect an abnormal process of wound healing. They can cause pain, itching, stiffness, and psychological distress, all of which can affect quality of life. Various treatment options have been advocated as ways to prevent and treat keloid scars. These include noninvasive treatments such as use of silicone gel sheeting and compression therapy, and invasive treatments such as intralesional corticosteroid injections, surgery, and radiotherapy. Novel treatments include chemotherapy, immunotherapy, and anti-inflammatory therapies. Unfortunately, keloids continue to pose a significant challenge due to the lack of efficacious treatments. Therefore, clinicians should be familiar with various therapeutic options and apply the most suitable treatment plan for patients. In this review, we introduce the current therapeutic options for the management of keloid scars.

Drug delivery to optimize angiogenesis imbalance in keloid: A review

The wound healing process involves three continuous stages. Where, any imbalance can lead to the formation of unwanted keloids, hypertrophic scar, or tumors. Keloids are any unpleasant, non-compliant comorbidity affecting a major section of people around the globe who acquire it either genetically or by pathological means as a result of a skin injury. Angiogenesis is unavoidable in the healing process after an injury or disruption of skin to promote tissue regeneration. Uncontrolled angiogenesis during the healing process can initiate the unwanted response in the wound that facilitate keloid. Angiogenic therapy is adapted to accelerate healing after an injury. Else ways, there exists a risk of keloid formation due to excessive angiogenesis during the wound healing process. There are numerous strategies to treat keloid. Anti-angiogenic factors are provided to patients post-surgery to prevent the keloid formation; however, they come into the picture after the formation of keloid. The available strategies to treat keloids are steroidal injections, surgical excision of the keloid, radiotherapy, pressure therapy, the use of cryosurgery, and many more. The available treatments are not promising in reducing the recurrent rate of keloids as there are chances of high re-occurrences with similar/larger lesions on the removed keloid site. In this review, we are discussing the importance of controlled angiogenesis with the help of controlled drug delivery strategies enabling the wound healing process without the induction of keloid.

Histologic Evaluation of Healing Lip Defects Treated With Injected Onabotulinum Toxin A and Topical Mitomycin C

OBJECTIVE

Using an experimental rat model, the efficacy of injected Onabotulinum Toxin A (BoNT-A) versus topical Mitomycin C in surgical wound healing of rat lip defects was evaluated.

METHODS AND MATERIALS

Sixty-seven male Wister rats received a triangular cut (7 × 7 × 4 mm) on their upper lip. Then they were divided randomly into 4 equal groups: group A (topical Mitomycin C plus injected BoNT-A); group B (topical Mitomycin C); group C or control group (saline solution) and group D (injected (BoNT-A). After 3 months, the animals were euthanized and scars were evaluated using hematoxylin and eosin and Masson's trichrome.For qualitative analysis, inflammatory cell density, new capillary formation, fibroblast proliferation, and collagen deposition were reported using relative ranks from 0 to 3 (absence, mild, moderate, marked). Data were analyzed by post hoc and Kruskal-Wallis tests. The significance level was P < 0.05.

RESULT

Mean collagen deposition values and fibroblast proliferation in the 4 groups showed statistically significant differences with each other (P value < 0.001). A significant difference between group A and controls existed for fibroblast proliferation (median 1 versus 2, P value < 0.001); also, collagen deposition (median 1 versus 2, P value < 0.001). A significant difference existed between the control and group D (median 2 versus 1, P value = 0.004); also, group A and B (median 1 versus 2, P value = 0.002) for collagen deposition. However, no significant differences existed between the 4 groups regarding inflammatory cells and angiogenesis (P value > 0.05).

CONCLUSION

Local injection of BoNT-A plus Mitomycin C followed by BoNT-A alone provided less collagen formation and fibroblastic proliferation in the healing lip defect in a rat model.

Evaluation of the use of tacrolimus ointment for the prevention of hypertrophic scars in experimental model

BACKGROUND

Tacrolimus, for its activity on modulation of collagen production and fibroblast activity, may have a role in the prevention of hypertrophic scars.

OBJECTIVES

Evaluate macroscopic, microscopic, metabolic, laboratory effects and side effects of the use of topical tacrolimus ointment, in different concentrations, in the prevention of hypertrophic scars.

METHODS

Twenty-two rabbits were submitted to the excision of 2 fragments of 1 cm of each ear, 4 cm apart, down to cartilage. The left ear of the animals was standardized as control and Vaseline applied twice a day. The right ear received tacrolimus ointment, at concentrations of 0.1% on the upper wound and 0.03% on the lower wound, also applied twice a day. Macroscopic, microscopic, laboratory criteria and the animals' weight were evaluated after 30 days of the experiment.

RESULTS

Wounds treated with tacrolimus, at concentrations of 0.1% and 0.03%, when compared to control, showed a lower average degree of thickening (p = 0.048 and p <0.001, respectively). The average of scar thickness and lymphocyte, neutrophil and eosinophil concentrations are lower in the treated wounds compared to the control (p <0.001, p=0.022, p=0.007, p=0.044, respectively). The mean concentration of lymphocytes is lower in wounds treated with a higher concentration of the drug (p=0.01).

STUDY LIMITATIONS

experiment lasted only 30 days.

CONCLUSIONS

Tacrolimus at the 2 concentrations evaluated reduced the severity of inflammatory changes and positively altered the macroscopic aspect of the scar in the short term. Its use was shown to be safe, with no evidence of systemic or local adverse effects.

Novel Insights on Understanding of Keloid Scar: Article Review

Keloid scar, dermal benign fibro-proliferative growth that extends outside the original wound and invades adjacent dermal tissue due to extensive production of extracellular matrix, especially collagen, which caused by over expression of cytokines and growth factors. Although many attempts were made to understand the exact pathophysiology and the molecular abnormalities, the pathogenesis of keloid scar is yet to be determined. Even though there are several treatment options for keloid scars include combination of medical and surgical therapies like combination of surgical removal followed by cryotherapy or intralesional steroid therapy, the reoccurrence rate is still high despite the present treatment. In this review, PubMed, clinical key and Wright State Library web site have been used to investigate any update regarding Keloid disease. We used Keloid, scar formation, hypertrophic scar and collagen as key words. More than 40 articles have been reviewed. This paper reviews literature about keloid scar formation mechanism, the most recent therapeutic options including the ones under research.

Efficacy of 2 Representative Topical Agents to Prevent Keloid Recurrence After Surgical Excision

PURPOSE

Keloids are difficult to remove successfully and there is no universally accepted treatment. After surgical excision of the keloid, there are various management methods for prevention of keloid recurrence, such as intralesional injection, radiation, and topical agents. A few studies have compared topical agents with other treatments. The aim of this study was to investigate effective topical agents for the prevention of recurrent keloid after surgical excision.

MATERIALS AND METHODS

Eligible articles were sought using core databases, including Medline, Embase, and Cochrane databases, up to April 2016. The predictor variables were mitomycin C (MC) and imiquimod cream treatment after keloid excision. The outcome variable was keloid recurrence rate.

RESULTS

The search strategy identified 120 publications. After screening, 9 articles were selected for review. Articles were divided into 2 groups: MC and imiquimod cream. The recurrence rate after surgical excision in the MC group was estimated to be 16.5%, and that in the imiquimod cream group was estimated to be 24.7%.

CONCLUSION

If intralesional injection or radiation is not available, then MC or imiquimod 5% cream could be an effective alternative in preventing keloid recurrence.

Keloids and Hypertrophic Scars: A Spectrum of Clinical Challenges

Since their earliest description, keloids and hypertrophic scars have beleaguered patients and clinicians alike. These scars can be aesthetically disfiguring, functionally debilitating, emotionally distressing, and psychologically damaging, culminating in a significant burden for patients. Our current understanding of keloid pathophysiology has grown and continues to advance while molecular biology, genetics, and technology provide ever-deepening insight into the nature of wound healing and the pathologic perturbations thereof. Greater understanding will lead to the development and application of refined therapeutic modalities. This article provides an overview of our current understanding of keloids, highlighting clinical characteristics and diagnostic criteria while providing a comprehensive summary of the many therapeutic modalities available. The proposed mechanism, application, adverse events, and reported efficacy of each modality is evaluated, and current recommendations are summarized.

A comprehensive evidence-based review on the role of topicals and dressings in the management of skin scarring

Wound healing after dermal injury is an imperfect process, inevitably leading to scar formation as the skin re-establishes its integrity. The resulting scars have different characteristics to normal skin, ranging from fine-line asymptomatic scars to problematic scarring including hypertrophic and keloid scars. Scars appear as a different colour to the surrounding skin and can be flat, stretched, depressed or raised, manifesting a range of symptoms including inflammation, erythema, dryness and pruritus, which can result in significant psychosocial impact on patients and their quality of life. In this paper, a comprehensive literature review coupled with an analysis of levels of evidence (LOE) for each published treatment type was conducted. Topical treatments identified include imiquimod, mitomycin C and plant extracts such as onion extract, green tea, Aloe vera, vitamin E and D, applied to healing wounds, mature scar tissue or fibrotic scars following revision surgery, or in combination with other more established treatments such as steroid injections and silicone. In total, 39 articles were included, involving 1703 patients. There was limited clinical evidence to support their efficacy; the majority of articles (n = 23) were ranked as category 4 LOE, being of limited quality with individual flaws, including low patient numbers, poor randomisation, blinding, and short follow-up periods. As trials were performed in different settings, they were difficult to compare. In conclusion, there is an unmet clinical need for effective solutions to skin scarring, more robust long-term randomised trials and a consensus on a standardised treatment regime to address all aspects of scarring.

Intralesional therapy for psoriasis

Localized resistant plaques of psoriasis often remain despite highly effective anti-psoriasis treatment. Intralesional therapy is often used to treat various malignant, infectious or inflammatory cutaneous diseases, including psoriasis. Despite the presence of many review articles on the treatment of psoriasis, no articles exist which review the use of intralesional therapy for psoriasis. In this article, we review the published literatures of intralesional therapy for psoriasis. Corticosteroids, methotrexate, cyclosporin, biologics, botulinum toxin type-A, 15-hydroxyeicosatetraenoic acid, and chemotherapy agents such as 5-fluorouracil are discussed. Also, agents which may be used intralesionally and have the potential to treat psoriasis will also be reviewed such as bleomycin, vincristine or vinblastine, mitomycin-C, aminophylline, 5-aminolevulinic acid, rituximab, bevacizumab and pentoxifylline are included.

Keloids: prevention and management

Keloids result from an abnormal wound-healing process in which the normal regulatory pathways during tissue regeneration and scar remodeling are disrupted. While the pathogenesis of keloids continues to be investigated, numerous treatment options exist. Although prevention of keloid formation is the best management, early recognition of keloid formation is integral in treatment and prevention of recurrence. Surgical resection with adjuvant silicone gel sheeting or triamcinolone injection is common, but can still result in recurrence. New treatments include chemotherapeutics such as 5-fluorouracil, bleomycin, and mitomycin C. Although further clinical investigation is required for newer treatments, initial results are promising.

The effects of repetitious topical use of mitomycin C on antrostomy patency in maxillary antrostomy created rabbit model

The aim of our study was to investigate the effect of the topical use of mitomycin C (MMC) intraoperatively in single dose and intra-postoperatively in two doses on the narrowing of antrostomy in maxillary rabbit sinus antrostomies created experimentally. And also to determine the local and systemic side effects of topical MMC. With this objective, 0.6 mg/ml MMC was used to the first group at single dose and to the second group intraoperatively and on third day postoperatively in two doses topically for 5 min. After 8 weeks, although the mean area of antrostomy was larger than that in the control side in the first group, which received single dose MMC, the difference was not statistically significant (p = 0.287). The second group received two doses, and the antrostomy areas were found to be significantly larger than the controls (p = 0.05). Overall, the sides that received MMC were significantly larger (p = 0.029). From the point of histopathological examination of the tissue, it was seen that two-dose MMC increased the edema indicating inflammation and antrostomy resolved with normal respiratory tract epithelium. It was shown by measuring the blood values that nephrotoxic and myelosupressant effect of MMC occurring in systemic use did not occur with single or double dose topical use. Our results demonstrate that even if the number of cases was low, two doses of topical MMC usage prevent the narrowing of antrostomy while single dose MMC does not. And two-dose topical MMC usage does not have local and systemic side effects.

Role of mitomycin C in reducing keloid recurrence: patient series and literature review

OBJECTIVE

To study the role of mitomycin C in reducing keloid recurrence.

STUDY DESIGN

Prospective, randomised, controlled trial.

SETTING

Tertiary care referral centre.

PATIENTS

Case series of 20 patients presenting with 26 pinna swellings, mostly following ear piercing.

INTERVENTIONS

We used the technique of surgical shave excision combined with topical application of mitomycin C and secondary wound healing, in all 26 pinnae.

RESULTS

Patients were followed up six to 24 months post-operatively. No recurrences were noted during this period.

CONCLUSION

Keloids are fibrotic lesions resulting from abnormal wound healing. The uncontrolled proliferation of normal tissue healing processes results in scarring that enlarges well beyond the original wound margins. Successful treatment of keloids remains a challenge because this disease process has a high propensity for recurrence. Various therapies have previously been reported, and success rates are highly variable. We believe that shave excision followed by topical mitomycin C application is a promising treatment option for the management of pinna keloids.

The emerging role of antineoplastic agents in the treatment of keloids and hypertrophic scars: a review

The management of keloids and hypertrophic scars continues to challenge health-care providers. Though both forms of pathologic scarring are distinct entities at the macro and microscopic level, their etiologies and treatment are often similar. Potential treatment approaches are progressing, and combinations of treatment options have been proposed in the literature with promising outcomes. The treatment evolution has reached a level where molecular therapeutic modalities are being investigated. Currently, no gold standard treatment exists. Overall success rates and patient satisfaction seem to be slowly climbing, but additional investigational studies must continue to be performed. Several studies have investigated antineoplastic agents, and there seems to be a marked improvement in rates of recurrence, patient satisfaction, and overall quality of scar when these agents are used. Intralesional injection and/or wound irrigation with interferon-a2b, interferon-g, mitomycin-C, bleomycin, or 5-fluorouracil seems to have a positive effect on the reduction of pathologic scars. There is mounting evidence that these drugs used alone or in combination therapy, have the potential to be an integral part of the treatment paradigm for hypertrophic scars and keloids.

A review of the effectiveness of antimitotic drug injections for hypertrophic scars and keloids

Hypertrophic scars and keloids are common problems after injury and cause functional and cosmetic deformities. A wide variety of treatments have been advocated for hypertrophic scars and keloids regression. Unfortunately, the reported efficacy has been variable. This article explores antimitotic drugs described in the literature such as steroid injection, 5-FU, mitomycin C, and bleomycin, which mainly target the fibroblasts in scar tissue, have been proposed as the effective modalities for scar treatment and scar prevention after surgery, but restricted due to possible side effects. The current accepted treatment for hypertrophic scar and keloid are combination therapy and the early treatment which could achieve better efficacy and less adverse effect.