Laser and light-based treatment of Keloids--a review

Identification of potential therapeutic target SPP1 and related RNA regulatory pathway in keloid based on bioinformatics analysis

OBJECTIVE

To explore the complex mechanisms of keloid, new approaches have been developed by different strategies. However, conventional treatment did not significantly reduce the recurrence rate. This study aimed to identify new biomarkers and mechanisms for keloid progression through bioinformatics analyses.

METHODS

In our study, microarray datasets for keloid were downloaded from the GEO database. Differentially expressed genes (DEGs) were identified by R software. Multiple bioinformatics tools were used to identify hub genes, and reverse predict upstream miRNAs and lncRNA molecules of target hub genes. Finally, the total RNA-sequencing technique and miRNA microarray were combined to validate the identified genes.

RESULTS

Thirty-one DEGs were screened out and the upregulated hub gene SPP1 was finally identified, which was consistent with our RNA-sequencing analysis results and validation dataset. In addition, a ceRNA network of mRNA (SPP1)-miRNA (miR-181a-5p)-lncRNA (NEAT1, MALAT1, LINC00667, NORAD, XIST and MIR4458HG) was identified by the bioinformatics databases. The results of our miRNA microarray showed that miR-181a-5p was upregulated in keloid, also we found that the lncRNA NEAT1 could affect keloid progression by retrieving the relevant literature.

CONCLUSIONS

We speculate that SPP1 is a potential candidate biomarker and therapeutic target for patients with keloid, and NEAT1/miR-181a-5p/SPP1 might be the RNA regulatory pathway that regulates keloid formation.

Absorption Coefficient Estimation of Pigmented Skin Phantoms Using Colorimetric Parameters

The increasing use of light-based treatments requires a better understanding of the light tissue interaction for pigmented skin. To enhance comprehension in this area, this study proposes the use of pigmented-mimicking skin phantoms to assess the optical properties based on their tone, represented by the Individual Typology Angle (ITA) color scale. In this study, an epoxy resin matrix alongside compact facial powder and titanium dioxide was used to mimic the absorption, scattering, and shade properties of human skins. Eight phantoms covering the skin tones, light (ITA = 45.2°), tan (ITA = 23.3°), brown (ITA = 6.9°, -5.7°, and -16.9°), and dark (ITA = -34.6°, -41.6°, and -48.6°), were crafted. The absorption and reduced scattering coefficients were obtained using integrating spheres and calibrated spectrometers in the 500-900 nm range, and tones were measured using a commercial colorimeter. The experimental fitting proposed in this study could estimate the optical properties as a function of the skin tones through ITA values, by using an exponential function with a second-order polynomial exponent. This investigation aligns with prior studies involving human skin samples, and these findings hold promise for future clinical and diagnostic applications, particularly in the realm of light-based treatments to individual dermatological corrections in pigmented skin.

Identifying the Pattern Characteristics of Anoikis-Related Genes in Keloid

Objective: Anoikis is a kind of programmed cell death that is triggered when cells lose contact with each other or with the matrix. However, the potential value of anoikis-related genes (ARGs) in keloid (KD) has not been investigated. Approach: We downloaded three keloid fibroblast (KF) RNA sequencing (RNA-seq) datasets from the Gene Expression Omnibus (GEO) and obtained 338 ARGs from a search of the GeneCards database and PubMed articles. Weighted correlation network analysis was used to construct the coexpression network and obtain the KF-related ARGs. The LASSO-Cox method was used to screen the hub ARGs and construct the best prediction model. Then, GEO single-cell sequencing datasets were used to verify the expression of hub genes. We used whole RNA-seq for gene-level validation and the correlation between KD immune infiltration and anoikis. Results: Our study comprehensively analyzed the role of ARGs in KD for the first time. The least absolute shrinkage and selection operator (LASSO) regression analysis identified six hub ARGs (HIF1A, SEMA7A, SESN1, CASP3, LAMA3, and SIK2). A large number of miRNAs participate in the regulation of hub ARGs. In addition, correlation analysis revealed that ARGs were significantly correlated with the infiltration levels of multiple immune cells in patients with KD. Innovation: We explored the expression characteristics of ARGs in KD, which is extremely important for determining the molecular pathways and mechanisms underlying KD. Conclusions: This study provides a useful reference for revealing the characteristics of ARGs in the pathogenesis of KD. The identified hub genes may provide potential therapeutic targets for patients. This study provides new ideas for individualized therapy and immunotherapy.

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.

Efficacy and safety of fractional carbon dioxide laser followed by 5-aminolevulinic acid photodynamic therapy for keloids

BACKGROUND

Keloids are aggressive fibroproliferative disorders that cause aesthetic and functional damage. Photodynamic therapy (PDT) has shown promise as a novel treatment for keloids. However, the limited penetration of 5-aminolevulinic acid (ALA) and unsatisfactory outcomes in dense scars hinder its effectiveness as a monotherapy. The objective of this study is to assess the efficacy and safety of fractional CO2 laser followed by 5-ALA PDT for keloids.

METHODS

A total of 12 patients with keloid were included in our study. Each lesion was pretreated by fractional CO2 laser with 26-28 W to create microthermal zones. After topical application of 5-ALA solution, an irradiation of 635 nm red light with 120 J/cm2 was performed. The treatment was repeated at least every 2 weeks. Efficacy and safety were evaluated using the Vancouver Scar Scale (VSS), the Visual Analogue Scale (VAS) for keloid-related symptoms and documentation of postoperative complications. Statistical analysis was performed to compare VSS and keloid-related symptom VAS scores of the baseline and final treatment sessions.

RESULTS

The final treatment resulted in a statistically significant decrease in all parameters of VSS and VAS for pruritus and pain compared to the baseline. Except for postoperative hyperpigmentation, no infections, scar aggravation, or recurrence were observed during at least 6 months of follow-up. Overall, patients expressed a high level of satisfaction with the treatment outcome.

CONCLUSIONS

Fractional CO2 laser followed by 5-ALA PDT is a promising method for treating keloids. However, its synergetic effects need to be validated through clinical trials involving larger patient cohorts.

Ear keloids: An innovative 3-steps combined treatment

INTRODUCTION

An excessive proliferation of fibroblasts and collagen synthesis after an injury may lead to a benign fibrous tumor, known as keloid, which does not regress spontaneously. Earlobes are a very frequent site of onset, since after a trauma (i.e., piercing) keloids may develop either on the helix and on the anterior or posterior lobe, from a few months up to several years after the injury.

OBJECTIVES

To report the effectiveness of a combined protocol of CO2 laser + Dye laser + a portable Blue LED Light medical device for Photobiomodulation Therapy (EmoLED®).

METHODS

Fifty-two patients with a total of 56 ear keloids have been treated in the same session with a single CO2 laser procedure + a pulsed Dye laser procedure with an adjunctive EmoLED® procedure for 3 up to 6 min. A monthly follow-up has been performed with an adjunctive EmoLED® session in case of signs of inflammation.

RESULTS

Among 56 treated keloids, 89.3% of them (50/56) did not recur during a follow-up period (from 6 up to 24 months, mean 16.3 months) while six keloids recurred (6/56, 10.7%) with mild thickening of the scar, thus requiring further treatments.

CONCLUSIONS

Even if an excellent outcome obtained by the synergistic effect of combined laser treatments has already been described (i.e., CO2 laser + Dye Laser), the present study showed the adjuvant procedure with EmoLED® can reduce significantly the risk of keloids recurrences.

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.

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.

Photobiomodulation therapy with an 830-nm light-emitting diode for the prevention of thyroidectomy scars: a randomized, double-blind, sham device-controlled clinical trial

This randomized, double-blind, and sham device-controlled trial aimed to evaluate the efficacy and safety of home-based photobiomodulation therapy using an 830-nm light-emitting diode (LED)-based device for the prevention of and pain relief from thyroidectomy scars. Participants were randomized to receive photobiomodulation therapy using an LED device or a sham device without an LED from 1 week postoperatively for 4 weeks. Scars were assessed using satisfaction scores, the numeric rating scale (NRS) score for pain, Global Assessment Scale (GAS), and Vancouver Scar Scale (VSS) scores. The scars were also assessed using a three-dimensional (3D) skin imaging device to detect color, height, pigmentation, and vascularity. Assessments were performed at the 1-, 3-, and 6-month follow-ups. Forty-three patients completed this trial with 21 patients in the treatment group and 22 patients in the control group. The treatment group showed significantly higher patient satisfaction and GAS scores and lower NRS and VSS scores than the control group at 6 months. Improvements in color variation, height, pigmentation, and vascularity at 6 months were greater in the treatment group than in the control group, although the differences were not significant. In conclusion, early application of 830-nm LED-based photobiomodulation treatment significantly prevents hypertrophic scar formation and reduces postoperative pain without noticeable adverse effects.

Evaluating the efficacy of photodynamic therapy with indocyanine green in the treatment of keloid

BACKGROUND

This study aimed to evaluate the efficacy of photodynamic therapy (PDT) with topical indocyanine green (ICG) in the treatment of keloid lesions.

METHODS

In this pilot study, fifteen keloids (6 lesions on the sternal area, 3 on the shoulders, 2 on the abdomen, 2 on the legs, and 2 on the forearms) were selected. To enhance drug penetration, pretreatment with CO2 laser was performed. Then Lesions were covered with 0.2% transfersomal ICG gel with 1mm thickness and occluded with light-proof plastic nylon for 2 hours. Afterward, it was wiped off and underwent photodynamic therapy with source LumaCare with 730 nm probe and fluence of 23 J/cm2 every week for 6 sessions. Patients were also assessed 6 and 12 weeks after the treatment for any recurrences. The Patient and Observer Scar Assessment Scale (POSAS) was used to evaluate the scars.

RESULTS

The mean POSAS score significantly reduced by 23.69% from 46.86 at baseline to 35.76 at the 6^th treatment session (P< 0.001). The mean scores of patient and observer overall opinion significantly decreased by 16.35% (P< 0.001) and 12.31 % (P= 0.001) respectively. No side effects were observed during treatment and after 3 months of follow-ups. After discontinuation of therapy, the mean score of POSAS significantly increased by 13.77% to 40.80. (P= 0.001) CONCLUSION: : According to our study, ICG-PDT is an effective and safe treatment for keloid. However, due to the recurrence following discontinuation of treatment, further studies are needed.

Combination of fractional carbon dioxide laser and topical triamcinolone vs intralesional triamcinolone for keloid treatment: A randomised clinical trial

To compare the therapeutic effect of fractional carbon dioxide (CO₂) laser + topical triamcinolone (TA) with intralesional TA on keloids. Twenty‐two participants were randomised into two groups: group A, treated with fractional CO₂ laser + topical TA, and group B, treated with intralesional TA. The interventions were performed at every 4‐week interval until the keloids were resolved or at the completion of 1 year. At each session, the scar volume, Vancouver Scar Scale (VSS) were assessed. Recurrence was observed for 1 year. The mean scar volumes and VSS scores were not significantly different between the two groups. After 1 year, the scar volume change in group B was greater than group A (86.5% vs 59.1%, P‐value = .016). The mean VSS scores were significantly decreased in group A (8.0 ± 1.5 to 4.8 ± 1.6, P‐value <.001) and group B (8.4 ± 0.8 to 4.8 ± 1.6, P‐value <.001). The keloids were completely resolved in 63.6% and 72.7% of the patients, and recurrence was observed in 9.1% and 18.2% of the patients in groups A and B, respectively. The combination of fractional CO₂ laser with topical TA was an alternative option for the treatment of keloids.

Combined laser treatment for ear keloids: Case series: Comparison between two mini-invasive protocols

BACKGROUND

Keloids are benign fibrous tumors derived by excessive proliferation of fibroblasts and collagen synthesis after an injury, and they do not regress spontaneously. Earlobes keloids may develop either on the helix or on the anterior or posterior lobe, up to several years after piercing.

AIMS

To evaluate the effectiveness of a combined protocol of CO2 laser + dye laser versus CO2 laser + dye laser + Enerjet.

METHODS

Eighty patients with a total of 83 ear keloids were divided in two groups: One group has been treated in the same session with a single CO2 laser procedure + a pulsed Dye laser procedure; the second group has been treated as the group one with an adjunctive Enerjet procedure.

RESULTS

Of the 40 patients for a total of 41 treated keloids in the first group, 85.4% of keloids did not recur during a follow-up period (3 months-7 years), 14.6% of the lesions recurred (6/41) with mild thickening of the scar and underwent to further treatments. The second group (40 patients, 42 keloids) results showed a 90.5% of keloids which did not recur during a follow-up period (3 months-2 years), while 9.5% of the lesions recurred (4/42) with mild thickening of the scar and underwent to further treatments.

CONCLUSIONS

Lasers demonstrated a synergistic effect when combined together and an excellent outcome has been obtained in the 88% of treated lesions, with a slighter higher prevalence of excellent outcome of the group treated with a further procedure with Enerjet.

Tauroursodeoxycholic Acid Decreases Keloid Formation by Reducing Endoplasmic Reticulum Stress as Implicated in the Pathogenesis of Keloid

Keloids are a common form of pathologic wound healing and are characterized by an excessive production of extracellular matrix. This study examined the major contributing mechanism of human keloid pathogenesis using transcriptomic analysis. We identified the upregulation of mitochondrial oxidative stress response, protein processing in the endoplasmic reticulum, and TGF-β signaling in human keloid tissue samples compared to controls, based on ingenuity pathway and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. Electron microscopic examinations revealed an increased number of dysmorphic mitochondria and expanded endoplasmic reticulum (ER) in human keloid tissue samples than that in controls. Western blot analysis performed using human tissues suggested noticeably higher ER stress signaling in keloids than in normal tissues. Treatment with tauroursodeoxycholic acid (TUDCA), an ER stress inhibitor, significantly decreased scar formation in rabbit models, compared to normal saline and steroid injections. In summary, our findings demonstrate the contributions of mitochondrial dysfunction and dysregulated ER stress signaling in human keloid formation and the potential of TUDCA in the treatment of keloids.

The Horse as a Model for the Study of Cutaneous Wound Healing

Significance: Cutaneous wounds are a major problem in both human and equine medicine. The economic cost of treating skin wounds and related complications in humans and horses is high, and in both species, particular types of chronic wounds do not respond well to current therapies, leading to suffering and morbidity. Recent Advances: Conventional methods for the treatment of cutaneous wounds are generic and have not changed significantly in decades. However, as more is learned about the mechanisms involved in normal skin wound healing, and how failure of these processes leads to chronic nonhealing wounds, novel therapies targeting the specific pathologies of hard-to-heal wounds are being developed and evaluated. Critical Issues: Physiologically relevant animal models are needed to (1) study the mechanisms involved in normal and impaired skin wound healing and (2) test newly developed therapies. Future Directions: Similarities in normal wound healing in humans and horses, and the natural development of distinct types of hard-to-heal chronic wounds in both species, make the horse a physiologically relevant model for the study of mechanisms involved in wound repair. Horses are also well-suited models to test novel therapies. In addition, studies in horses have the potential to benefit veterinary, as well as human medicine.

Comparative Study between Nd-YAG laser, fractional CO2 Laser, and combined Nd-YAG with fractional CO2 Laser in the Management of keloid: clinical and molecular Study

BACKGROUND

Fractional CO2 laser and Nd-YAG laser have been reported to have promising results in the management of keloids. So far, there have been no comparative studies between these laser modalities.

AIMS

The study aimed to compare the efficacy of fractional CO2, Nd-YAG, and a combination of both in the management of keloids.

PATIENTS AND METHODS

Forty-five keloid patients were divided into 3 equal groups: the first received fractional CO2 only, the second received Nd-YAG only, and the third received a combination of both lasers. Each group received its designated treatment every 4 weeks for 4 sessions. The improvement was evaluated by the "Patient and Observer Scar Assessment Scale" (POSAS). Detection of procollagen I mRNA by RT-PCR analysis was done.

RESULTS

The assessment by POSAS showed the most significant clinical improvement in the combination group and a less significant improvement in the fractional CO2 group, while the least improvement was seen in the Nd-YAG group. Molecular assessment via procollagen I yielded matching results.

CONCLUSION

The study showed that the combination of fractional CO2 and Nd-YAG lasers has a synergistic effect being the most effective in the management of keloids, fractional CO2 being more effective than ND-YAG and Nd-YAG being the least effective.

Assessing keloid recurrence following surgical excision and radiation

Keloids are a fibroproliferative disorder that can result from a cutaneous injury to the reticular dermis. Recurrence rates as high as 100% have been reported following surgical excision alone. Consequently, a variety of post-surgical techniques have been employed to prevent keloid recurrence, including the use of radiation. Although numerous studies have shown post-excisional X-rays, electron beam, lasers and brachytherapy can reduce the rate of keloid recurrence, numerous inconsistencies, including a wide range of definitions for keloid recurrence, make it difficult to compare study outcomes. The review aims to examine the various means for defining keloid recurrence in clinical trials involving the use of radiation therapy. Searches of the Cochrane Library and PubMed were performed to identify the available information for post-surgical keloid recurrence following radiation therapy. Each identified study was reviewed for patient follow-up and criteria used to define keloid recurrence. The search results included clinical studies with external beam radiation, brachytherapy and superficial radiation therapy. Many studies did not include a definition of keloid recurrence, or defined recurrence only as the return of scar tissue. Other studies defined keloid recurrence based on patient self-assessment questionnaires, symptoms and scar elevation and changes in Kyoto Scar Scale, Japan Scar Workshop Scale and Vancouver Scar Scale scores. The results of this review indicate keloidectomy followed by radiation therapy provide satisfactory recurrence rates; however, clinical studies evaluating these treatments do not describe treatment outcomes or use different definitions of keloid recurrence. Consequently, recurrence rates vary widely, making comparisons across studies difficult. Keloid recurrence should be clearly defined using both objective and subjective measures.

Monoclonal Antibodies Addressed to Factors of Signalization in Keloid Scars: Opportunities and Areas of Action

The advance of technology has made possible the use of new techniques within medicine for the treatment of diseases; monoclonal antibodies are a clear example of this. Keloid scars are one of the most difficult pathologies to treat due to the high percentage of recidivism, formed by the growth of a scar with benign fibrous tissue in genetically predisposed individuals, resulting from a process of inflammation and abnormal scarring. Monoclonal antibodies, being a line of treatment that has increased over the years, can show a new frontier in the treatment of them by focusing on the signaling that causes it. We review the literature on the signaling mechanisms of keloid scars and the possible monoclonal approach.

Photodynamic therapy for keloids and hypertrophic scars: a review

PURPOSE

Keloid is a poorly understood disease that is unique to humans. Hypertrophic scars are similar to keloids and may transform into keloids over time. The standard treatments for these scars are limited by inconsistent efficacy and long treatment/follow-up times. Therefore, a new treatment that is effective for all abnormal scar cases is needed. One option may be photodynamic therapy (PDT). This review assesses the current evidence regarding the safety and efficacy of PDT for keloids and hypertrophic scars.

METHODS

PubMed, Medline and Web of Science were searched from 1900 onwards for the following terms: 'keloid and photodynamic therapy (PDT)'; 'hypertrophic scar and photodynamic therapy (PDT)'; and 'scar and photodynamic therapy (PDT)'. Articles were included if they reported using topical PDT to treat keloids or hypertrophic scars, the patient(s) had one or more keloids and/or hypertrophic scars, and the effect of PDT on these abnormal scars was described.

RESULTS

In total, 538 articles were identified. Thirteen fulfilled all inclusion criteria. Eight were laboratory studies on keloid/hypertrophic scar explants, fibroblasts or tissue-engineered skin models and five were clinical studies/case reports. The clinical results of PDT on keloids and hypertrophic scars are encouraging.

CONCLUSION

PDT appears to play a promising role in keloid and hypertrophic scar therapy but additional clinical studies, particularly randomised clinical trials, are needed.

Keloids: Current and emerging therapies

Keloids are pathological scars that grow over time and extend beyond the initial site of injury after impaired wound healing. These scars frequently recur and rarely regress. They are aesthetically disfiguring, can cause pain, itching, discomfort as well as psychological stress, often affecting quality of life. Many treatment modalities, including surgical and non-surgical, have been explored and have been reported to be beneficial; however, none have been absolutely satisfactory or optimal for the treatment of all keloid subtypes to date. This poses a major challenge to clinicians. Often, a combinational therapeutic approach appears to offer the best results with higher patient satisfaction compared to monotherapy. The aetiopathogenesis of keloids is not fully elucidated; however, with recent advances in molecular biology and genetics, insight is being gained on the complex process of scar formation and hence new therapeutic and management options for keloids. In this paper, we explore the literature and summarise the general concepts surrounding keloid development and review both current (corticosteroids, surgical excision, silicone-based products, pressure therapy, radiotherapy, cryotherapy, laser therapy, imiquimod and 5-fluorouracil) and emerging (stem cell therapy, mitomycin C, verapamil, interferons, bleomycin, botulinum toxin type A and angiotensin-converting enzyme inhibitors) treatments. Increased knowledge and understanding in this area may potentially lead to the discovery and development of novel therapeutic options that are more efficacious for all keloid types.

LAY SUMMARY

Keloids are problematic scars that are difficult to treat and manage. The aetiopathogenesis of keloids is not clear; however, recent advances in molecular biology and genetics are beginning to shed light on the underlying mechanisms implicated in keloid scar formation which will hopefully lead to the development of treatment options for all keloid types. This review summarises current and emerging therapies.

MicroRNA expression analysis of human skin fibroblasts treated with high-fluence light-emitting diode-red light

Skin fibrosis is a chronic debilitating feature of several skin diseases that lead to characteristic increases in dermal fibroblast proliferation and collagen deposition through upregulation in components of the transforming growth factor beta (TGF-B)/SMAD pathway. In contrast to ultraviolet phototherapy, high-fluence light-emitting diode-generated red light (HF-LED-RL, 633 ± 15 nm) is a safe, economic and non-invasive therapy with in vitro evidence that supports modulation of the key cellular characteristics involved in the pathogenesis of skin fibrosis. Limited data exists pertaining to the effects of HF-LED-RL on human skin fibroblast microRNA (miRNA). Herein, we explored the effects of HF-LED-RL on fibroblast miRNA levels using RNA-seq and miRNA expression analysis. Using RNA-seq analysis we found that HF-LED-RL at 320 and 640 J/cm² increased transcription of key miRNA that are involved in skin fibrosis including miRNA-29, miRNA-196a and Let-7a, and decreased transcription of miRNA-21, miRNA-23b and miRNA-31. These microRNA findings provide insight into the molecular underpinnings of HF-LED-RL and highlight potential therapeutic targets of interest for the treatment of skin fibrosis. Additional research on the specific molecular mechanisms underlying HF-LED-RL effects on fibroblasts may provide further mechanistic insight into this therapy and may reveal additional future therapeutic targets for skin fibrosis.

Effect of orange polarized light on post burn pediatric scar: a single blind randomized clinical trial

[Purpose] This study was carried out to investigate the effect of orange filtered polarized polychromatic light on post burn pediatric scar. [Participants and Methods] Thirty children with post burn scar in wrist and hands participated in this study. They were between 3 to 7 years old, having hypertrophic burn scar ≥2 months post healing, free from concomitant skin disease and keloids. They were randomly assigned into two groups. The control group (A) (n=15) received Scar Standard Management (SSM) protocol and the study group (B) (n=15) received SSM protocol along with 15 min/area polarized light with medical range filter followed by 15 min/area orange filtered polarized light. All children received the study protocol once a day, 3 times/week for one month. Scar assessment was done before and after the study protocol by using Vancouver Scar Scale (VSS). [Results] All participated children were analyzed. Comparison of post treatment results between groups revealed significant improvement of post burn scar for both groups with significant difference in favor to the study group. [Conclusion] Ultimately it was revealed that Orange filtered polarized light has a special and beneficial effect on decreasing post burn pediatric scar.

Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives

Keloids are pathological scars presenting as nodular lesions that extend beyond the area of injury. They do not spontaneously regress, often continuing to grow over time. The abnormal wound-healing process underlying keloid formation results from the lack of control mechanisms self-regulating cell proliferation and tissue repair. Keloids may lead to cosmetic disfigurement and functional impairment and affect the quality of life. Although several treatments were reported in the literature, no universally effective therapy was found to date. The most common approach is intralesional corticosteroid injection alone or in combination with other treatment modalities. Triamcinolone acetonide (TAC) is the most commonly used intralesional corticosteroid. The aim of this article was to review the use of TAC, alone or in combination, in the treatment of keloid scars. The response to corticosteroid injection alone is variable with 50-100% regression and a recurrence rate of 33% and 50% after 1 and 5 years, respectively. Compared to verapamil, TAC showed a faster and more effective response even though with a higher complication rate. TAC combined with verapamil was proved to be effective with statistically significant overall improvements of scars over time and long-term stable results. TAC and 5-fluorouracil (5-FU) intralesional injections were found to achieve comparable outcomes when administered alone, although 5-FU was more frequently associated with side effects. Conversely, the combination of 5-FU and TAC was more effective and showed fewer undesirable effects compared to TAC or 5-FU alone. Several kinds of laser treatments were reported to address keloids; however, laser therapy alone was burdened with a high recurrence rate. Better results were described by combining CO2, pulsed-dye or Nd: YAG lasers with TAC intralesional injections. Further options such as needle-less intraepidermal drug delivery are being explored, but more studies are needed to establish safety, feasibility and effectiveness of this approach.

Treatment of Keloids With Excision and Adjuvant Radiation: A Single Center Experience and Review of the Literature

BACKGROUND

Management of keloids has remained a conundrum, because an optimum treatment regimen has yet to be elucidated. Currently, treatment varies widely between more conservative measures, such as steroid injections, topical medications, and silicone sheeting, to more aggressive options, such as surgery and postoperative radiation. The latter combination has been touted to have superior results, with the lowest rates of pathologic scar recurrence.

METHODS

We performed a retrospective review to critically evaluate the effectiveness of surgical excision and radiation treatment in patients with keloids. Surgical resection of surgeon-selected keloids, combined with state-of-the-art postoperative cutaneous radiation therapy, was used at a major tertiary referral center. For patients with poor follow-up, phone calls were made to determine recurrence. In addition, we present a review of the current literature to provide a comprehensive synopsis of current keloid treatment.

RESULTS

A total of 69 patients' records were reviewed. There were a total of 84 keloids upon pathology review. The overall recurrence rate for all keloids was 27%, and in those followed greater than 1 year, recurrence for keloids was 74%. About half the patients with more than 1 year of follow-up experienced recurrence more than 1 year after treatment.

CONCLUSIONS

At this time, the evidence supporting surgery and radiation for the treatment of keloids remains equivocal, and randomized controlled studies are needed to determine the efficacy of this treatment protocol. Most importantly, our data reinforce the need for long-term follow-up in this patient population.

Evidence-Based Scar Management: How to Improve Results with Technique and Technology

BACKGROUND

Scars represent the visible sequelae of trauma, injury, burn, or surgery. They may induce distress in the patient because of their aesthetically unpleasant appearance, especially if they are excessively raised, depressed, wide, or erythematous. They may also cause the patient symptoms of pain, tightness, and pruritus. Numerous products are marketed for scar prevention or improvement, but their efficacy is unclear.

METHODS

A literature review of high-level studies analyzing methods to prevent or improve hypertrophic scars, keloids, and striae distensae was performed. The evidence from these articles was analyzed to generate recommendations. Each intervention's effectiveness at preventing or reducing scars was rated as none, low, or high, depending on the strength of the evidence for that intervention.

RESULTS

For the prevention of hypertrophic scars, silicone, tension reduction, and wound edge eversion seem to have high efficacy, whereas onion extract, pulsed-dye laser, pressure garments, and scar massage have low efficacy. For the treatment of existing hypertrophic scars, silicone, pulsed-dye laser, CO2 laser, corticosteroids, 5-fluorouracil, bleomycin, and scar massage have high efficacy, whereas onion extract and fat grafting seem to have low efficacy. For keloid scars, effective adjuncts to excision include corticosteroids, mitomycin C, bleomycin, and radiation therapy. No intervention seems to have significant efficacy in the prevention or treatment of striae distensae.

CONCLUSION

Although scars can never be completely eliminated in an adult, this article presents the most commonly used, evidence-based methods to improve the quality and symptoms of hypertrophic scars, as well as keloid scars and striae distensae.

Resveratrol Prevents Reactive Oxygen Species-Induced Effects of Light-Emitting Diode-Generated Blue Light in Human Skin Fibroblasts

BACKGROUND

Light-emitting diode-generated blue light (LED-BL) is part of the visible light spectrum that does not cause DNA damage and may represent a safer alternative to ultraviolet phototherapy. Previous research demonstrated that LED-BL can inhibit adult human skin fibroblast proliferation and migration speed and is associated with increased reactive oxygen species (ROS) generation in a dose-dependent manner. In addition, resveratrol possesses potent intracellular antioxidative effects on ROS-free radicals in human skin fibroblasts.

OBJECTIVE

The authors studied the effects on migration speed as a surrogate to measure LED-BL effects on fibroblast function. The authors hypothesized that resveratrol, a potent scavenger of ROS, could prevent the effects of LED-BL on fibroblast migration speed. This would implicate ROS as the mechanistic driver of LED-BL effects on human skin fibroblasts.

METHODS

To demonstrate that resveratrol could prevent the effects of LED-BL (415-nm), fibroblasts were incubated with resveratrol (Sigma-Aldrich, St. Louis, MO) at concentrations of 0.001% and 0.0001% for 24 hours and then irradiated with LED-BL at fluences of 30, 45, and 80 J/cm. Postirradiation fibroblast migratory speed was assayed in an environment-controlled computer-assisted video microscopy system. Reactive oxygen species levels were measured by flow cytometric analysis of dihydrorhodamine. Statistical analyses with analysis of variance and Student t-test were performed to compare individual treatment arms and matched controls.

RESULTS

The experimental results demonstrate that pretreatment of skin fibroblasts with resveratrol at concentrations of 0.001% and 0.0001% prevents the effects of 30, 45, and 80 J/cm of LED-BL on fibroblast migration speed. The authors found that LED-BL at a fluences of 30, 45, and 80 J/cm significantly increased ROS, whereas pretreatment with 0.001% resveratrol significantly reduced ROS generation.

CONCLUSION

The findings demonstrate that LED-BL-induced decreases in fibroblast migration speed can be prevented by pretreating cells with resveratrol. This finding supports the hypothesis that ROS generation is the most likely driver of LED-BL-induced alterations in migration speed and suggests that ROS generation may be responsible for a number of other alterations seen after LED-BL phototherapy, such as decreases in cellular migration, cytokine levels, and myofibroblast differentiation. The authors hypothesize that their findings may result in greater understanding of the fundamental mechanisms underlying visible light interaction with skin and they hope dermatologists and other researchers may use these pathways for patient benefit.

Low-Level Light Therapy with 410 nm Light Emitting Diode Suppresses Collagen Synthesis in Human Keloid Fibroblasts: An In Vitro Study

Background

Keloids are characterized by excessive collagen deposition in the dermis, in which transforming growth factor β (TGF-β)/Smad signaling plays an important role. Low-level light therapy (LLLT) is reported as effective in preventing keloids in clinical reports, recently. To date, studies investigating the effect of LLLT on keloid fibroblasts are extremely rare.

Objective

We investigated the effect of LLLT with blue (410 nm), red (630 nm), and infrared (830 nm) light on the collagen synthesis in keloid fibroblasts.

Methods

Keloid fibroblasts were isolated from keloid-revision surgery samples and irradiated using 410-, 630-, 830-nm light emitting diode twice, with a 24-hour interval at 10 J/cm². After irradiation, cells were incubated for 24 and 48 hours and real-time quantitative reverse transcription polymerase chain reaction was performed. Western blot analysis was also performed in 48 hours after last irradiation. The genes and proteins of collagen type I, TGF-β1, Smad3, and Smad7 were analyzed.

Results

We observed no statistically significant change in the viability of keloid fibroblasts after irradiation. Collagen type I was the only gene whose expression significantly decreased after irradiation at 410 nm when compared to the non-irradiated control. Western blot analysis showed that LLLT at 410 nm lowered the protein levels of collagen type I compared to the control.

Conclusion

LLLT at 410 nm decreased the expression of collagen type I in keloid fibroblasts and might be effective in preventing keloid formation in their initial stage.

Case Histories of Intense Pulsed Light Phototherapy in Dermatology - the HPPL™ and IFL™ Technologies

The intense pulsed light (IPL) and laser technologies are widely used for skin rejuvenation and for treating several dermatological disorders such as skin dyschromia and acne, and for non-ablative dermal remodeling of rhytides and hypertrophic scars. Technological evolution is rapid. The High Power Pulsed Light™ [HPPL™] and Incoherent Fast Light™ technologies [IFL™, Novavision Group S.p.A., 20826 Misinto (MB), Italy] are recent innovations in the field of IPL technologies; IFL™ is a further evolution of the already advanced HPPL™ system. The paper presents a selection of case histories of dermatological lesions treated with the HPPL™ and IFL™ technologies. All study materials were appropriately peer-reviewed for ethical problems.

Surgical Excision and Adjuvant Brachytherapy vs External Beam Radiation for the Effective Treatment of Keloids: 10-Year Institutional Retrospective Analysis

BACKGROUND

Surgically excised keloids reportedly recur at a rate of >45%. Post-excision radiation (RT) has been delivered via external beam radiotherapy (EBRT) or interstitial high dose rate (HDR) brachytherapy. Despite historical data showing 10% to 20% keloid recurrences with post-excision RT, there is a paucity of high-quality evidence comparing keloid recurrences between the two RT modalities.

OBJECTIVES

We performed the largest single-institution case-control retrospective study (2004-2014) of keloid recurrence rates and complications between post-excision EBRT and HDR brachytherapy.

METHODS

One-hundred and twenty-eight patients, with 264 keloid lesions, were treated by excision alone (n = 28), post-excision EBRT (n = 197), or post-excision HDR brachytherapy (n = 39). Patient and keloid recurrence data were analyzed using mixed effect Cox regression modeling with a statistical threshold of P < .05.

RESULTS

Fifty-four percent of keloids recurred after surgical excision alone (9-month median follow up); 19% of keloids recurred with post-excision EBRT (42-month median follow up); 23% of keloids recurred with post-excision brachytherapy (12-month median follow up). Adjuvant EBRT and brachytherapy each showed significant control of keloid recurrence compared to excision alone (P < .01). EBRT significantly delayed the time of keloid recurrence over brachytherapy by a mean difference of 2.5 years (P < .01).

CONCLUSIONS

Post-excision RT shows significant reduction in keloid recurrence compared to excision alone. While the recurrence control rates are not statistically different between EBRT and brachytherapy, keloids treated with EBRT recurred significantly later than those treated by HDR brachytherapy by a mean of 2.5 years. Further workup with a randomized control study will help to refine optimal adjuvant RT treatment. LEVEL OF EVIDENCE 3.

An ex vivo study of photobiostimulation in the treatment of skin pathologies

Photodynamic therapy (PDT) and low level laser therapy (LLLT) may mutually improve the outcomes on the healing process of chronic wounds and other skin pathologies, through processes known to stimulate the proliferation of dermal cellular structures, as well as antimicrobial application. This study proposes the use of nanoemulsion containing aluminium phthalocyanine chloride (ClAlPc) as photosensitizer (PS), to establish the most appropriate protocol for photostimulation in human skin biopsies, associated to type I collagen and elastin production. The combined effect of PS and light (diode laser at 670 nm) at three different doses is compared to the effect of light itself at doses of 70, 140 and 700 mJ ċ cm^-2 , 7 and 14 days after irradiation. Histological analysis reveals the increase in collagen and elastin, higher than 20%, 14 days after treatment with PS and light at 140 mJ ċ cm^-2 . Higher doses of light promote an inhibitory effect, leading to tissue degradation. In addition, the expression levels of the enzymes MMP-2 and MMP-9 (Gelatinases A and B - participant in various processes including tumoral progression and wound healing) are detected by gelatin zymography, reinforcing the efficacy of the combined treatment with PS and light at the intermediate dose.

High fluence light emitting diode-generated red light modulates characteristics associated with skin fibrosis

Skin fibrosis, often referred to as skin scarring, is a significant international health problem with limited treatment options. The hallmarks of skin fibrosis are increased fibroblast proliferation, collagen production, and migration speed. Recently published clinical observations indicate that visible red light may improve skin fibrosis. In this study we hypothesize that high-fluence light-emitting diode-generated red light (HF-LED-RL) modulates the key cellular features of skin fibrosis by decreasing cellular proliferation, collagen production, and migration speed of human skin fibroblasts. Herein, we demonstrate that HF-LED-RL increases reactive oxygen species (ROS) generation for up to 4 hours, inhibits fibroblast proliferation without increasing apoptosis, inhibits collagen production, and inhibits migration speed through modulation of the phosphoinositide 3-kinase (PI3K)/Akt pathway. We demonstrate that HF-LED-RL is capable of inhibiting the unifying cellular processes involved in skin fibrosis including fibroblast proliferation, collagen production, and migration speed. These findings suggest that HF-LED-RL may represent a new approach to treat skin fibrosis. LED advantages include low cost, portability, and ease of use. Further characterizing the photobiomodulatory effects of HF-LED-RL on fibroblasts and investigating the anti-fibrotic effects of HF-LED-RL in human subjects may provide new insight into the utility of this therapeutic approach for skin fibrosis.

Three Hundred Patients Treated with Ultrapulsed 980 nm Diode Laser for Skin Disorders

The use of lasers in skin diseases is quite common. In contrast to other laser types, medical literature about 980 nm ultrapulsed diode laser is sparse in dermatology. Herein, we report the use of ultrapulsed diode 980 nm laser in 300 patients with vascular lesions, cysts and pseudocysts, infectious disease, and malignant tumors. This laser is a versatile tool with excellent safety and efficacy in the hands of the experienced user.

Visible Red Light Emitting Diode Photobiomodulation for Skin Fibrosis: Key Molecular Pathways

Skin fibrosis, also known as skin scarring, is an important global health problem that affects an estimated 100 million persons per year worldwide. Current therapies are associated with significant side effects and even with combination therapy, progression, and recurrence is common. Our goal is to review the available published data available on light-emitting diode-generated (LED) red light phototherapy for treatment of skin fibrosis. A search of the published literature from 1 January 2000 to present on the effects of visible red light on skin fibrosis, and related pathways was performed in January 2016. A search of PubMed and EMBASE was completed using specific keywords and MeSH terms. "Fibrosis" OR "skin fibrosis" OR "collagen" was combined with ("light emitting diode," "LED," "laser," or "red light"). The articles that were original research studies investigating the use of visible red light to treat skin fibrosis or related pathways were selected for inclusion. Our systematic search returned a total of 1376 articles. Duplicate articles were removed resulting in 1189 unique articles, and 133 non-English articles were excluded. From these articles, we identified six articles related to LED effects on skin fibrosis and dermal fibroblasts. We augmented our discussion with additional in vitro data on related pathways. LED phototherapy is an emerging therapeutic modality for treatment of skin fibrosis. There is a growing body of evidence demonstrating that visible LED light, especially in the red spectrum, is capable of modulating key cellular characteristic associated with skin fibrosis. We anticipate that as the understanding of LED-RL's biochemical mechanisms and clinical effects continue to advance, additional therapeutic targets in related pathways may emerge. We believe that the use of LED-RL, in combination with existing and new therapies, has the potential to alter the current treatment paradigm of skin fibrosis. There is a current lack of clinical trials investigating the efficacy of LED-RL to treat skin fibrosis. Randomized clinical trials are needed to demonstrate visible red light's clinical efficacy on different types of skin fibrosis.