Intralesional botulinum toxin type A equally effective and better tolerated than intralesional steroid in the treatment of keloids: a randomized controlled trial

Kreotoxin A administration inhibits hyperproliferation and inflammation of human ear keloid tissue and keloid-derived fibroblasts by downregulating HIF-1α expression

Keloids represent a prevalent dermal fibroproliferative disorder. They only affect humans and exhibit several tumor characteristics, such as excessive extracellular matrix (ECM) deposition, which usually occurs after skin injury. Kreotoxin type A (KTA) can inhibit the release of acetylcholine, and thereby inhibit the proliferation of keloid fibroblasts and reducing the formation of scars. Thus, KTA could be used as a therapeutic agent for keloids. However, the mechanisms of action of KTA in keloid treatment remain unclear. In this study, we aimed to explore the underlying mechanisms of action of KTA in human keloid treatment using human tissue and a cell-based model. Integrative microarray analysis revealed that hypoxia-inducible factor 1-alpha (HIF-1α) expression was frequently upregulated in hypertrophic scar and keloid tissues, whereas it was downregulated in the KTA-treated samples. Furthermore, KTA addition to keloid-derived fibroblasts (KDFs) reduced the growth rate and viability, induced apoptosis, and decreased inflammation and oxidative stress in KDFs. However, overexpression of HIF-1α restored cell number and survival, decreased apoptosis, and promoted inflammation and oxidative stress in KTA-treated KDFs. Furthermore, KTA treatment reduced the expression of ECM proteins, including vascular endothelial growth factor (VEGF), collagen I and III, whereas HIF-1α overexpression abolished the effects of KTA on KDFs. In conclusion, our findings provide novel insights into the mechanisms of action of KTA as a potential therapeutic agent for keloids via modulating HIF-1α expression.

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.

Acne-induced pathological scars: pathophysiology and current treatments

Acne is a common chronic inflammatory dermatosis that can lead to pathological scars (PSs, divided into hypertrophic scars and keloids). These kinds of abnormal scars seriously reduce the quality of life of patients. However, their mechanism is still unclear, resulting in difficult clinical prevention, unstable treatment effects and a high risk of recurrence. Available evidence supports inflammatory changes caused by infection as one of the keys to abnormal proliferation of skin fibroblasts. In acne-induced PSs, increasing knowledge of the immunopathology indicates that inflammatory cells directly secrete growth factors to activate fibroblasts and release pro-inflammatory factors to promote the formation of PSs. T helper cells contribute to PSs via the secretion of interleukin (IL)-4 and IL-13, the pro-inflammatory factors; while regulatory T cells have anti-inflammatory effects, secrete IL-10 and prostaglandin E2, and suppress fibrosis production. Several treatments are available, but there is a lack of combination regimens to target different aspects of acne-induced PSs. Overall, this review indicates that the joint involvement of inflammatory response and fibrosis plays a crucial role in acne-induced PSs, and also analyzes the interaction of current treatments for acne and PS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comprehensive Treatment of a Rare Case of Complete Primary Pachydermoperiostosis with Large Facial Keloid Scars: A Case Report and Literature Review

Introduction

Pachydermoperiostosis (PDP), or primary hypertrophic osteoarthropathy, is a rare autosomal dominant disease with primary clinical features of pachydermia (thickening of skin) and periostosis (new bone formation). Keloid scar formation is also rather obscure, and some scientists have claimed that keloid scars contain an excessive amount of fibroblasts compared with normal skin as well as a dense mass of irregularly deposited connective tissues.

Case Presentation

A 25-year-old man exhibited extensive skin folding on his face, a gyrus-like scalp, depressed nasolabial folds, and keloids. Symptoms began at 18 years of age, progressing insidiously. Additionally, he experienced clubbing of fingers and toes, joint pain, muscle soreness, and hyperhidrosis. Radiographic examinations revealed thickened bone and cystic regions. Diagnosed with complete primary PDP and facial keloid scars, he underwent skin dermabrasion, biopsies, and a comprehensive treatment involving, botulinum toxin injections, 5-fluorouracil, and a carbon dioxide lattice laser.

Conclusion

PDP presents challenges due to its unclear etiology but stabilizes over time in most cases. Comprehensive treatment strategies, including dermabrasion and a combination of intralesional therapies, are effective in managing keloids in PDP patients. This case contributes to the understanding of managing rare diseases and underscores the importance of personalized approaches to improve therapeutic outcomes in patients with complete primary PDP and concurrent keloids.

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

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

Bioinformatics analysis and verification of m6A related genes based on the construction of keloid diagnostic model

Keloids are formed due to abnormal hyperplasia of the skin connective tissue. We explored the relationship between N6-methyladenosine (m6A)-related genes and keloids. The transcriptomic datasets (GSE44270 and GSE185309) of keloid and normal skin tissues samples were obtained from the Gene Expression Omnibus database. We constructed the m6A landscape and verified the corresponding genes using immunohistochemistry. We extracted hub genes for unsupervised clustering analysis using protein-protein interaction (PPI) network; gene ontology enrichment analysis was performed to determine the biological processes or functions affected by the differentially expressed genes (DEGs). We performed immune infiltration analysis to determine the relationship between keloids and the immune microenvironment using single-sample gene set enrichment analysis and CIBERSORT. Differential expression of several m6A genes was observed between the two groups; insulin-like growth factor 2 mRNA-binding protein 3 (IGF2BP3) was significantly upregulated in keloid patients. PPI analysis elucidated six genes with significant differences between the two keloid sample groups. Enrichment analysis revealed that the DEGs were mainly enriched in cell division, proliferation, and metabolism. Moreover, significant differences in immunity-related pathways were observed. Therefore, the results of this study will provide a reference for the elucidation of the pathogenesis and therapeutic targets of keloids.

Treatment of traumatic hypertrophic scars and keloids: a systematic review of randomized control trials

Exaggerated healing and remodeling after skin injury may cause hypertrophic and keloidal scars, which are associated with functional and quality of life impairment. There is limited guidance available regarding the relative effectiveness of therapies for hypertrophic scars and keloids. In this review, we aim to compare the effectiveness of treatments for hypertrophic scars and keloids. MEDLINE, Embase, Scopus, and the Cochrane Collaboration database were searched from inception to March 2019 for randomized control trials of treatments for hypertrophic and keloid scars that included 20 or more patients. Outcomes evaluated included the standardized mean reduction in scarring and adverse events. The type of scar and the demographic features were analyzed for their effect on clinical outcome. Based on 25 included clinical trials, intralesional injection (64.1% [95% CI 60.8-67.5%]) may be more effective than physical (29.9% [95% CI 28.9-30.9%]) or topical treatments (34% [95% CI 31.8-36.8%]). Combination of 5-fluorouracil and triamcinolone (9:1 dilution) appeared superior among intralesional treatments for keloids. Ablative laser and pulsed-dye laser were the most useful laser treatments. Regression modeling showed laser treatment response was linked to Fitzpatrick skin type (p = 0.002). Adverse events were uncommon for all treatments and mostly transient. Intralesional treatments for keloid and hypertrophic scars may be the most reliable treatment option to improve pathologic scars, while laser treatment may have specific benefits for Fitzpatrick skin types I-III over types IV-VI. Management of pathological scars is an area of critical need, where appropriate treatment can have a significant impact on quality of life.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of botulinum toxin type A for treating post burn hypertrophic scars and keloid in children: An intra-patient randomized controlled study

BACKGROUND

Consequently, the management of post burn hypertrophic scars and keloid in children are a great challenge for the physicians, parents, and children themselves.

PURPOSE OF THE STUDY

To assess the efficacy and safety of treating hypertrophic and keloid scars with botulinum toxins injections.

PATIENTS AND METHODS

This is a randomized intra-patient comparative study was conducted on 15 children with post burn hypertrophic and keloid scars. Children were randomized to receive Intralesional injection of botulinum toxins on one part of the hypertrophic scar/keloid where the other part was left as a control. The assessment of clinical improvement was measured by the Vancouver scar scale (VSS) and by skin analysis camera system. Sessions were performed every month for 6 months.

RESULTS

Clinical and statistical dramatic improvement in the vascularity, pliability, and height of the lesions which have been injected with neuronox. Evaluation of the lesions by the Antera camera has proven marked changes in the vascularity and height. There was no correlations between Vancouver score improvement and variables such as the age, sex, skin type, and duration and lesion type.

CONCLUSIONS

The botulinum toxins proved its efficacy and safety in treatment of hypertrophic scars and keloid in children. It improved the associated itching and pain. Moreover it improves the pliability, erythema, and thickness of the scars.

Comparing the Efficacy of Multiple Drugs Injection for the Treatment of Hypertrophic Scars and Keloid: A Network Meta-Analysis

BACKGROUND

There is no consensus regarding the choice of injected drugs for pathological scars. Although the clinical efficacy of different drug treatments was shown in many randomized controlled trials, the efficacies of many drugs are inconsistent. Therefore, this study aimed to determine how different effective drugs are for treating pathological scars. It is anticipated that the study findings may serve as guidelines for plastic surgeons.

METHODS

Relevant literature was extracted from the following databases Cochrane Library, Embase, PubMed, Web of Science, CNKI, Weipu, and Wanfang until June 2022, such as randomized clinical trials (RCTs) evaluating different injected drugs for the treatment of pathological scars, including BTA, TAC, 5-Fu, VER, and BLE.

RESULTS

This network meta-analysis of 1539 patients from 23 articles revealed that the most effective treatment for a pathological scar was TAC + BTA. The effective rate of TAC + BTA combination therapy was significantly different from that of the BTA, TAC, 5-Fu, VER, and BLM monotherapies. TAC+5-FU was more effective than TAC, 5-FU, VER, or BLM alone, and BTA was more effective than both TAC and 5-Fu. The effectiveness of VER and BLM was the same, but both were better than TAC and 5-Fu. No big differences were found between any of the other local injection therapies.

CONCLUSIONS

According to this network meta-analysis, a combination of keloid and hypertrophic scar injection treatment is recommended, especially BTA+TAC. However, this network meta-analysis has some limitations and must be further verified by larger samples and higher quality RCTs.

LEVEL OF EVIDENCE III

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

Microneedle delivery of botulinum toxin type A combined with hyaluronic acid for the synergetic management of multiple sternal keloids with oily skin: A retrospective clinical investigation

BACKGROUND

For the treatment of sternal keloids, corticosteroid therapy has side effects including abnormal sebum secretion and acne. Relapse of keloids is common after corticosteroid injection in patients with oily skin. To reduce side effects and keloid recurrence, we used a combination of botulinum toxin type A (BTX-A) and hyaluronic acid (HA) as synergetic management for multiple sternal keloids in patients with oily skin.

METHODS

In total, 58 patients with multiple sternal keloids who received monthly steroid injections were retrospectively included. Thirty-two patients in the intervention group received an additional injection of BTX-A/HA on the same day as the first injection of the steroid, while the remaining 26 patients were treated as the control group. At baseline and follow-up visits, sebum production and transepidermal water loss (TEWL) were assessed as primary outcomes, and the Vancouver Scar Scale (VSS) score, keloid recurrence, visual analog scale (VAS) score, and patient satisfaction were assessed as secondary outcomes.

RESULTS

In the control group, average sebum production and TEWL were increased to 132% and 104% of baseline, respectively, at the 24-week follow-up. In the intervention group, average sebum production and TEWL reached nadir at the 8-week follow-up and then increased to 96% and 91% of baseline, respectively, at the 24-week follow-up. Sternal keloid relapse was observed in 88.5% of the patients in the control group and none of the patients in the intervention group. The total VSS score at 24 weeks was 11.04 ± 0.14 and 8.93 ± 0.26 (p < 0.001) in the control group and intervention group, respectively, and the VAS score was 75 ± 5.10 and 19.14 ± 3.80 (p < 0.001) in the control group and intervention group, respectively. Higher patient satisfaction was reported in the intervention group.

CONCLUSIONS

Microneedle delivery of BTX-A/HA decreases sebum production while improving skin barrier function. Thus, this combined therapy can relieve the side effects of corticosteroid therapy and reduce keloid recurrence.

Druggable Targets and Compounds with Both Antinociceptive and Antipruritic Effects

Pain and itch are both important manifestations of various disorders, such as herpes zoster, atopic dermatitis, and psoriasis. Growing evidence suggests that both sensations have shared mediators, overlapping neural circuitry, and similarities in sensitization processes. In fact, pain and itch coexist in some disorders. Determining pharmaceutical agents and targets for treating pain and itch concurrently is of scientific and clinical relevance. Here we review the neurobiology of pain and itch and discuss the pharmaceutical targets as well as novel compounds effective for the concurrent treatment of these sensations.

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

Introduction

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

Methods and Materials

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

Results

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

Conclusion

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

Evidence Level: 3 retrospective cohort study.

Lay Summary

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

Emerging off-label esthetic uses of botulinum toxin in dermatology

Botulinum toxin is a neurotoxic protein produced by Clostridium botulinum, the bacterium responsible for botulism. Botulinum toxin was first used for therapeutic indications in the 1970s for the treatment of strabismus. With greater understanding of its underlying physiology and safety profile, the use of botulinum toxin has now expanded to a range of cosmetic and medical indications. We performed a systematic review of current literature on the applications of botulinum toxin on off-label esthetic uses. Electronic databases were searched for original published studies including randomized trials, observational or cohort studies, as well as relevant case reports. To add to the body of evidence, our review summarizes and synthesizes key study characteristics, results, and level of evidence for each use case. Although the body of evidence remains weak, there is increasing support for the use of botulinum toxin in emerging off-label esthetic uses of botulinum toxin in dermatology.

The Efficacy and Safety of Botulinum Toxin Injections in Preventing Postoperative Scars and Improving Scar Quality: A Systematic Review and Meta-Analysis

BACKGROUND

Scars exposed on the body surface lead to a large psychological burden on patients. However, no satisfactory scar treatments exist. Botulinum toxin type A is a neurotoxin that has been widely applied in the plastic and cosmetic surgery field. The purpose of this meta-analysis was to assess the efficacy and safety of botulinum toxin in scar management.

METHODS

PubMed, the Cochrane Library, EMBASE, MEDLINE, and Web of Science were searched for randomized controlled trials that evaluated the efficacy of botulinum toxin injections in preventing postoperative scars and improving scars quality and were published prior to Dec. 29, 2020. The outcome indicators were the visual analog scale score, Vancouver scar scale score, Stony Brook scar evaluation scales score, scar width, patient self-assessment results, and complications.

RESULTS

Seventeen randomized controlled trials with a total of 633 cases were identified in this meta-analysis. The quantitative synthesis results showed that compared with the control group, the botulinum toxin group had a significantly lower VSS score (MD = -0.97, 95%CI = -1.56 to -0.39, p = 0.001), higher VAS score (MD = 1.26, 95%CI = 1.04 to 1.47, p < 0.00001), thinner scar width (MD = -0.25, 95%CI = -0.37 to -0.12, p < 0.0001) and higher patient satisfaction (RR = 3.38 95%CI = 1.45 to 7.89, p = 0.005). There were no significant differences between the two groups in the number of adverse events.

CONCLUSIONS

This meta-analysis demonstrated that botulinum toxin injections can significantly improve cosmetic appearance and postoperative scar quality. At the therapeutic dose, no significant complications were observed, indicating that botulinum toxin injections are safe.

LEVEL OF EVIDENCE III

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

Network Meta-Analysis of Different Clinical Commonly Used Drugs for the Treatment of Hypertrophic Scar and Keloid

Background: There is no uniform treatment for pathological scars, including keloids and hypertrophic scars, in clinic currently. Previously, multiple randomized controlled trials have examined the clinical efficacy of different treatments. Nonetheless, the results are inconsistent, and many treatments have not been directly compared. This makes it difficult to conclude which approach is more favorable, in terms of efficacy and safety, for the treatment of pathological scarring. This study aimed at evaluating the efficacy of different injection and topical treatment strategies for hypertrophic scar and keloid.

Methods: Relevant literature from PubMed, Medline, Embase, Scopus, the Cochrane Central Register of Controlled Trials (CCRCT), and WHO International Clinical Trials Registry Platform (WHO-ICTRP) were searched, from database inception through November 2020. Randomized clinical trials evaluating different treatment strategies of pathological scars, including triamcinolone acetonide (TAC), verapamil (VER), 5-fluorouracil (5-FU), botulinum toxin A (BTA), bleomycin (BLM), and silicone gels were included in the study.

Results: The network meta-analysis included a total of 2,009 patients from 29 studies. A network meta-analysis of injection and topical treatment strategies showed that the efficacy of TAC combined with BTA was best in the treatment of pathological scars. Combination therapies of TAC with 5-FU and TAC with BTA significantly improved the clinical efficiency. However, there was no statistically significant difference between other treatment strategies. The order of efficacy predicted by the surface under the cumulative ranking (SUCRA) curve was as follows: TAC+BTA (82.2%) > TAC+5-FU (69.8%) > BTA (67.3%) > 5-FU+silicone (59.4%) > TAC+silicone (58.3%) > 5-FU (49.8%) > BLM (42.0%) > TAC (26.7%) > VER (26.2%) > silicone (18.3%). There was no publication bias revealed based on the funnel diagram.

Conclusion: This study recommends intralesional injection of TAC-BTA and TAC-5-FU combined therapies. But for patients who cannot tolerate the side effects, the use of silicone gels in combination with TAC is recommended. However, these conclusions need to be further confirmed by more randomized controlled trials.

Botulinum toxin A promotes the transdifferentiation of primary keloid myofibroblasts into adipocyte-like cells

Keloid is a type of unusually raised scar. Botulinum toxin A (BTX-A) has a great application potential in keloids treatment. Here, we investigated the functional role of BTX-A in keloids. We separated keloid tissues and normal skin tissues from keloid patients and found that the expression of myofibroblast markers, α-SMA, Collagen I, and Collagen III was increased in the keloid tissues as compared with normal skin tissues. Keloid fibroblasts derived from keloid tissues were treated with TGF-β1 to induce the differentiation of fibroblasts into myofibroblasts. The keloid myofibroblasts displayed a significant up-regulation of α-SMA. BTX-A enhanced the expression of adipocyte markers, PPARγ and C/EBPα, and increased the accumulation of lipid droplets, and reduced the expression of α-SMA, Collagen I, and Collagen III in the keloid myofibroblasts. Moreover, BTX-A enhanced the expression of BMP4 and p-smad1/5/8. Noggin (BMP4 antagonist) treatment reversed BTX-A-mediated increase of PPARγ and C/EBPα expression and lipid droplets, and down-regulation of α-SMA, Collagen I, and Collagen III in primary keloid myofibroblasts. In conclusion, BTX-A promoted the transdifferentiation of primary keloid myofibroblasts into adipocyte-like cells, which may attribute to activate BMP4/Smad signalling pathway. Thus, this study provides new insights into the mechanism of BTX-A in keloid.

Update on management of keloid and hypertrophic scars: A systemic review

Numerous therapeutic strategies have been described for prevention and reduction of hypertrophic scars and keloids, but none of the treatments is effective in all patients. No universal consensus in treatment regimen has been established, and there is limited evidence-based literature to guide the correct management. The process of scar development is complex and requires deeper understanding of the molecular mechanisms that cause their development and recurrences. Despite many available modes of targeting keloid and hypertrophic scars, yet they remain an ongoing challenge to patients and clinicians. To date, no one therapy has been universally accepted as the gold standard for the treatment of all excessive scars nor has the capability of complete scar resolution The search of literature included peer-reviewed articles including clinical trials and scientific reviews. Literature was identified from electronic databases (MEDLINE/PubMed) through May 2021 and references of respective articles and only the articles published in English language were included.

Safety and efficacy of botulinum toxin type A in preventing and treating scars in animal models: A systematic review and meta-analysis

Previous studies have used botulinum toxin type A (BTXA) to improve postoperative and hypertrophic scars; however, there is lack of detailed verification on the safety and effectiveness of this approach. This study aimed to evaluate the therapeutic effect of BTXA on postoperative hypertrophic scars and its influence on cytokine expression in animal models. A computerised search of different databases was performed, including PubMed, Web of Science, Scopus, Cochrane, Embase, CNKI, and Wanfang, up to 10 March 2021. A meta-analysis was performed using R 4.0.0 based on hypertrophic index, epithelialisation time, wound area, and vascular endothelial growth factor (VEGF) expression. Eleven studies were included. The meta-analysis showed a significant difference in hypertrophic index (standardised mean difference [SMD] = -2.63, 95% confidence interval [CI]: -3.50 to -1.76, P < .01), wound area (SMD = -0.54, 95% CI: -1.24 to 0.16, P < .01), and VEGF expression (SMD = -2.56, 95% CI: -3.50 to -1.62, P < .01). This study shows that BTXA is safe and effective in preventing and treating scar hypertrophy in animal models, but excessive doses of BTXA and BTXA to treat large areas should be avoided.

Current Advances in Hypertrophic Scar and Keloid Management

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

The Efficacy of Drug Injection in the Treatment of Pathological Scar: A Network Meta-analysis

BACKGROUND

Pathological scars mainly include hyperplastic scars and keloids, and there is no uniform treatment standard for the treatment of pathological scar in clinic now. Drug injection in the treatment of pathological scar is widely used because of its advantages of less trauma and simple operation. Therefore, we used a network meta-analysis to compare the curative effect of four kinds of drugs which are commonly used in the treatment of pathological scar such as botulinum toxin type A, corticosteroids (including diprospan and triamcinolone acetonide (TAC)), verapamil and 5-fluorouracil (5-FU), systematically. It is hoped that our study will provide evidence for the choice of drugs in the treatment of pathological scar by injection.

METHODS

Relevant articles from Wanfang, VIP, CNKI, PubMed, Cochrane Library and Embase databases were extracted by us. They were included into a network meta-analysis to compare the four kinds of drugs which are commonly used in the treatment of pathological scar.

RESULTS

The network meta-analysis included a total of 1513 patients from 23 studies. Through meta-analysis, we found that the efficacy of botulinum toxin type A combined with corticosteroid drugs was best in the treatment of pathological scar by injection. There was no significant difference between botulinum toxin type A, corticosteroids combined with 5 Fu, verapamil and 5-FU. The efficacy of corticosteroids combined with 5-FU was better than that of corticosteroids alone and verapamil alone, but there was no significant difference between them and 5-FU. Further, the order of efficacy predicted by the SUCRA curve was as follows: botulinum toxin type A combined with corticosteroids > corticosteroids combined with 5-FU > botulinum toxin type A > corticosteroids > 5-FU > verapamil. Moreover, no publication bias was found in the funnel diagram.

CONCLUSION

In the injection treatment of pathological scar, we recommend the combined injection of two drugs, especially botulinum toxin type A combined with corticosteroids. The effective treatment of botulinum toxin type A combined with corticosteroids in the treatment of pathological scar is as follows: Patients were treated once monthly with intralesional injection of TAC (0.1 ml/cm³) mixed with botulinum toxin type A (2.5 IU/cm³) for a total of 3 treatments. However, there are still limitations in this network meta-analysis, and its conclusion still needs to be further confirmed by more randomized controlled trials.

LEVEL OF EVIDENCE III

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

Combination Treatment of Intra/Perilesional Botulinum Toxin-A Injection and Ablative Fractional Laser for Better Clinical Outcomes of Hypertrophic Fibrotic Thyroidectomy Scars Following Fractional Ablative Laser Resurfacing

BACKGROUND

Recent reports have shown that intralesional botulinum toxin type-A (BTX-A) works on scar cosmesis.

OBJECTIVE

To evaluate the clinical efficacy of combination treatment of laser and BTX-A injection and compare the effects of conventional intralesional injection and intra- and perilesional BTX-A injection on fibrotic thyroidectomy scars.

METHODS

Patients with fibrotic thyroidectomy scars showing insufficient responses to previous ablative fractional laser (AFL) treatment were enrolled. Combination treatment with AFL and BTX-A injection was performed. Patients who received intra/perilesional BTX-A injections were classified into group A. Group B was patients in whom the injection was performed only intralesionally. The improvement was assessed based on the Vancouver Scar Scale (VSS).

RESULTS

A total of 24 patients was included. Statistically significant improvement in pliability and total VSS score after the combination treatment were observed in overall patient group. Subgroup analysis demonstrated that pliability, height, and total VSS improved significantly in group A. In group B, only pliability significantly improved.

CONCLUSION

BTX-A injection combined with AFL can provide better relief for the previously treated fibrotic thyroidectomy scars. Injection of BTX-A not only into the scar itself, but also into perilesional muscles that can exert tension on the scar site may provide additional benefit in flattening scar height.

Emerging and Novel Therapies for Keloids: A compendious review

Keloids are abnormal fibroproliferative scars with aggressive dermal growth expanding beyond the borders of the original injury. Different therapeutic modalities, such as corticosteroids, surgical excision, topical silicone gel sheeting, laser therapy, cryotherapy, photodynamic therapy and radiotherapy, have been used to treat keloids; however, none of these modalities has proven completely effective. Recently, researchers have devised several promising anti-keloid therapies including anti-hypertensive pharmaceuticals, calcineurin inhibitors, electrical stimulation, mesenchymal stem cell therapy, microneedle physical contact and ribonucleic acid-based therapies. The present review summarises emerging and novel treatments for keloids. PubMed^® (National Library of Medicine, Bethesda, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands) and Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA) were searched for relevant literature published between January 1987 to June 2020. A total of 118 articles were included in this review. A deeper understanding of the molecular mechanisms underlying keloid scarring pathogenesis would open further avenues for developing innovative treatments.

Botulinum toxin and platelet rich plasma as innovative therapeutic modalities for keloids

Keloids characterize a definitely challenging type of cutaneous scars for which a diversity of therapeutic modalities has been suggested. The aim of this work was to compare the therapeutic efficacy of intralesional injection of botulinum toxin type-A (BTX-A), platelet rich plasma (PRP), and triamcinolone acetonide (TAC) in keloids. A total of 60 keloids patients were enrolled and divided randomly into three equal groups. Group I treated by intralesional BTX-A injection, group II treated by intralesional PRP injection, and group III treated by intralesional TAC injection. Clinical assessment was done by Vancouver Scar Scale (VSS), Verbal Rating Scale (VRS), and dermoscopic examination. Additionally, histopathology and immunohistochemistry of connective tissue growth factor (CTGF) expression were evaluated. The results of this study revealed significant improvement of both VSS and VRS in response to all treatment modalities. There was significant improvement of VSS in BTX-A and PRP groups more than TAC group. However, no significant difference observed between BTX-A and PRP groups. Immunohistochemical examination showed significant decrease of CTGF expression after treatment in BTX-A and PRP groups more than TAC group. In conclusion, both BTX-A and PRP could yield a chance for cosmetically better outcomes in keloids treatment than conventional TAC injection.

The safety and efficacy of intralesional triamcinolone acetonide for keloids and hypertrophic scars: A systematic review and meta-analysis

BACKGROUND

Triamcinolone acetonide (TAC) is widely used for hypertrophic scars and keloids; however, TAC has variable efficacy and safety in different individuals.

PURPOSE

To evaluate the efficacy and safety of intralesional TAC for treatment of hypertrophic scars and keloids.

DATA SOURCES

Searches of PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov prior to 25 March 2020.

STUDY SELECTION

Randomized controlled trials in English that compared TAC with a placebo or other medications that are commonly used for intralesional injection in hypertrophic scars and keloids.

DATA EXTRACTION

Primary outcomes were reduction in scar height, vascularity, pliability, pigmentation, total scores on the Vancouver Scar Scale (VSS) or patient and observer scar assessment scale (POSAS), telangiectasia, and skin atrophy. Secondary outcomes included overall scar improvement.

DATA SYNTHESIS

Fifteen trials met the inclusion criteria. In the short term, TAC was associated with a significant improvement in vascularity (MD: -0.22, 95% CI: -0.42 to -0.02) and pliability (MD: -0.25, 95% CI: -0.44 to -0.06) compared to verapamil. In the medium term, compared to TAC, 5-FU showed a significant improvement in scar height (SMD: 0.95, 95% CI: 0.15-1.75), while TAC led to a significant improvement in vascularity compared to 5-FU (MD: -0.45, 95% CI: -0.76 to -0.14). Compared to TAC, TAC+5-FU showed a significant improvement in pliability (SMD: 0.98, 95% CI: 0.17-1.78) and pigmentation (MD: 0.45, 95% CI: 0.12-0.78). Botulinum toxin type A resulted in significantly better pliability (SMD: 1.99, 95% CI: 0.98-3.00) compared to TAC. In the long term, compared to TAC, 5-FU led to a significant improvement in scar height (MD: 0.55, 95% CI: 0.17-0.93), but significantly less vascularity (MD: -0.35, 95% CI: -0.65 to -0.05). Compared to TAC, TAC+5-FU produced a significant improvement in scar height (MD: 1.50, 95% CI: 1.12-1.88), pliability (MD: 0.45, 95% CI: 0.10-0.80), and pigmentation (MD: 0.55, 95% CI: 0.24-0.86).

CONCLUSION

TAC may be beneficial for the short-term treatment of hypertrophic scars and keloids; however, 5-FU, 5-FU+TAC, and verapamil may produce superior results for medium- and long-term treatments. TAC injections at concentrations of 20 mg/ml or 40 mg/ml are more likely to result in skin atrophy compared to 5-FU or verapamil, and are more likely to cause telangiectasia than 5-FU, 5-FU+TAC, or bleomycin.

Intralesional cryotherapy with triamcinolone and onabotulinumtoxinA injections for umbilical keloid: A case report

Introduction

Keloid scars are therapeutically challenging and although many treatment options exist, there are no specific guidelines, and few reports have discussed keloids in the umbilical region.

Methods

Here, we present a successful treatment of a 31-year-old female with a history of a recurrent keloid in the umbilical region. The keloid was treated using intralesional cryotherapy followed by intralesional onabotulinumtoxinA and triamcinolone acetonide injections.

Discussion

The patient expressed high satisfaction, minimal side effects, and no recurrence.

Conclusion

Overall, due to the low rate of side effects, high patient satisfaction, and absence of recurrence, this treatment modality should be considered as an option for umbilical keloids.

Lay Summary

Background to subject: Keloids are a type of scar that are difficult to treat. There are many treatment options available, but there is no single best treatment for keloids that form around the belly button region. Question being asked: Is intralesional cryotherapy with intralesional onabotulinumtoxinA and triamcinolone acetonide injections effective at treating keloids in the belly button region? How the work was conducted: We treated a 31-year-old female with a keloid around the belly button region that returned after prior treatment. The keloid was treated using combination therapy of freezing the keloid from the inside out, which is called intralesional cryotherapy. This was followed by two types of injections, called onabotulinumtoxinA and triamcinolone acetonide, directly into the keloid. What we learned: Overall, due to the low rate of side effects, high patient satisfaction and the keloid not returning, this treatment plan should be considered as an option for keloids in the belly button region. What we did not learn: This treatment may or may not be effective and safe for all patients of all skin types and demographics as this treatment was performed for only one patient.

Alternative Clinical Indications of Botulinum Toxin

Botulinum toxin type A (BoNTA) is a powerful neurotoxin that inhibits acetylcholine release from presynaptic vesicles. The potency and safety profile of BoNTA grant the toxin vast therapeutic potential. It has been used off-label for a variety of dermatologic conditions. This review aims to analyze published literature regarding the benefits and risks of the off-label use of BoNTA beyond facial lines, including eccrine hidrocystomas, enlarged pores, keloids and hypertrophic scars, hidradenitis suppurativa, hyperhidrosis, masseter muscle hypertrophy, and salivary gland hypertrophy, among others. A MEDLINE search from January 2000 to December 2019 was conducted on the off-label uses of botulinum toxin in dermatology.

Neuropathic Itch

Neurologic insults as varied as inflammation, stroke, and fibromyalgia elicit neuropathic pain and itch. Noxious sensation results when aberrantly increased afferent signaling reaches percept-forming cortical neurons and can occur due to increased sensory signaling, decreased inhibitory signaling, or a combination of both processes. To treat these symptoms, detailed knowledge of sensory transmission, from innervated end organ to cortex, is required. Molecular, genetic, and behavioral dissection of itch in animals and patients has improved understanding of the receptors, cells, and circuits involved. In this review, we will discuss neuropathic itch with a focus on the itch-specific circuit.

Botulinum toxin type A versus 5-Fluorouracil in treatment of keloid

Most therapeutic approaches for keloids remain clinically unsatisfactory. In the last years, intralesional botulinum toxin-A (IL BTX-A) was proposed for treatment of keloids. Our aim of the study was to compare the clinical efficacy of IL BTX-A and IL 5-Fluorouracil (IL 5-FU) in treatment of keloids. A total of 50 patients with keloids were included in the study, 22 patients (with 26 keloids) were treated with IL BTX-A monthly for up to 6 months and other 22 patients (with 27 keloids) were treated with IL 5-FU weekly for up to 6 weeks, while the remaining 6 patients, each having multiple keloids, were treated with both IL BTX-A for some lesions (8 keloids) and IL 5-FU for their remaining lesions (8 keloids). The clinical improvement was assessed according to flattening of the lesions. Side effects were recorded. A significantly better therapeutic response of keloids was detected after IL BTX-A than IL 5-FU (P = 0.041). IL BTX-A achieved excellent and good flattening of the lesions (58.8% and 20.6%) compared to (31.4% and 17.1%) after IL 5-FU, respectively. In BTX-A treated group, there was no statistically significant difference between the clinical response in small lesions compared to medium and large ones (P = 0.476). While in 5-FU treated group, small and medium lesions showed significantly better response than larger ones (P = 0.009). IL BTX-A caused fewer side effects than IL 5-FU, less pain, itching, no hyperpigmentation and less recurrence. Both IL BTX-A and IL 5-FU showed positive results in treatment of keloids. However, IL BTX-A showed higher clinical efficacy even in large size keloids with less side effects.

Assessment of laser-assisted delivery vs intralesional injection of botulinum toxin A in treatment of hypertrophic scars and keloids

Keloids and hypertrophic scars could impair the psychological, physical, and cosmetic aspects of the patient's quality of life. Unfortunately, there is no curative treatment available till now. This study aimed to evaluate the efficacy and safety of intralesional vs topical botulinum toxin A combined with Fractional CO₂ laser in the treatment of hypertrophic scars and keloids. Twenty patients with Keloids and hypertrophic scars were enrolled in the study. Each scar was divided into two halves, one subjected to intralesional injection of botulinum toxin type A once a month for 4 months and the other was subjected to four sessions of CO₂ laser therapy at 1 month interval followed by topical application of botulinum toxin A. Significant improvement was noted in Vancouver Scar Scale in hypertrophic scars in laser group than intralesional botulinum toxin A. In keloid cases, the improvement was significantly higher with intralesional botulinum toxin A. Clinical improvement showed significant negative correlation with scar duration and size. Botulinum toxin A is a promising treatment for hypertrophic scars and keloids. The use of fractional CO₂ laser as a mode of delivery enhanced the efficacy of botox in hypertrophic scars.

A Review of Current Keloid Management: Mainstay Monotherapies and Emerging Approaches

Commonly affecting those with skin of color, keloids are an aberrant wound response that leads to wound tissue expanding above and beyond the original cutaneous injury. Keloids are notoriously and particularly difficult to treat because of their tendency to recur after excision. The current standard of care is intralesional steroid (triamcinolone acetonide). However, because no therapy has yet proven to be fully curative, keloid treatments have expanded to include a number of options, from injections to multimodal approaches. This review details current treatment of keloids with injections (bleomycin, verapamil, hyaluronic acid and hyaluronidase, botulinum toxin, and collagenase), cryotherapy, laser, radiofrequency ablation, radiation, extracorporeal shockwave therapy, pentoxifylline, and dupilumab.

The use of botulinum toxin in keloid scar management: a literature review

INTRODUCTION

Administration of botulinum toxin is an increasingly popular procedure in the medical and aesthetic field. There is emerging evidence that it can influence fibroblast activity and minimise tension around the scar by virtue of muscular chemoimmobilisation. This review aims to explore the current evidence base behind the treatment of keloid scars with botulinum toxin.

METHODS

A detailed literature review was conducted using PubMed Medline, Embase and Web of Science databases. Manuscripts were appraised and classified in accordance with the Joanna Briggs Institute Levels of Evidence by an independent consultant in evidence synthesis. The results of this search are presented in descending order of evidence for botulinum toxin as a primary management agent as well as a secondary adjunct following extralesional keloid excision.

DISCUSSION

On the basis of level 1 evidence, botulinum toxin appears to be equivalent to triamcinolone in producing a short-term reduction in keloidal volume, height and vascularity. A number of level 1 and 2 studies also suggest that botulinum toxin may be particularly helpful in alleviating symptoms of keloid associated pain and itch. There are currently limited studies appraising the value of botulinum toxin in the postoperative management of keloid scars.

CONCLUSION

Botulinum toxin may represent a promising agent in the management of keloid scars. However, further research involving large-scale studies with comparative designs and long-term follow-up is warranted to delineate the value of this therapeutic modality in scar management protocols.

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.

Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018

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.

New trends in botulinum toxin use in dermatology

Background: Recent studies have highlighted new botulinum neurotoxin (BoNT) applications in the field of dermatology. Objective: To review current knowledge of BoNT use in dermatology. Methods: The literature of the last 5 years has been reviewed. Results: We describe interesting protocols of BoNT treatment for hyperhidrosis (HH), hypertrophic scars and keloids, Raynaud phenomenon, facial flushing, oily skin, psoriasis, Hailey-Hailey disease, and cutaneous lesions like painful lesions and periorbital syringomas. Conclusions: Several skin conditions eligible for BoNT treatment have been described. After the wide application for HH treatment, scars as well as vascular and inflammatory skin disorders, oily skin and cutaneous lesions represent fields of application of BoNT.

Botulin Toxin Use in Scars/Keloids Treatment

Botulinum toxin (BTX) is a neurotoxin protein derived from the Clostridium botulinum bacterium that inhibits the release of acetylcholine at the neuromuscular junction level whose effects has been used for many years to treat a variety of muscular/neuromuscular conditions and more recently also for cosmetic use.

BTX has experimented in some dermatological conditions which include scar prevention and treatment with good results The complex mechanism underlying those results is not completely understood but several mechanisms were proposed release inhibition of different substances like (TGF)-β, substance P, calcitonin gene-related peptide (CGRP) and glutamate thus modulating cutaneous inflammation and wound healing.

We analysed the published data on BTX off label applications on scars and keloids retrieved from PubMed.

Alternative Therapies to Fat Grafting in the Craniofacial Region

Autologous fat grafting is a technique with various applications in the craniofacial region ranging from the treatment of wounds, scars, keloids, and soft tissue deformities. In this review, alternative therapies to fat grafting are discussed. These are composed of established therapies like silicone gel or sheeting, corticosteroids, cryotherapy, and laser therapy. Novel applications of negative pressure wound therapy, botulinum toxin A injection, and biologic agents are also reviewed.

Intralesional Injection of Botulinum Toxin Type A Compared with Intralesional Injection of Corticosteroid for the Treatment of Hypertrophic Scar and Keloid: A Systematic Review and Meta-Analysis

Background

The optimal treatment for hypertrophic scar and keloid remains controversial. Therefore, the aim of this systematic review and meta-analysis was to compare the effectiveness of intralesional injection of botulinum toxin type A compared with placebo and intralesional injection of corticosteroid compared with placebo in patients with hypertrophic scar and keloid.

Material/Methods

Six databases were searched using Medical Subject Headings (MeSH) keywords and included Web of Science, PubMed, EMBASE, the Cochrane Library, WanFang, and CNKI from their inception to March 1 2019, without language restriction. Randomized controlled trials (RCTs) and prospective controlled trials (PCTs) were identified that compared intralesional injection of botulinum toxin type A with placebo and corticosteroid with placebo in hypertrophic scar and keloid. The quality of controlled trials was assessed by the Newcastle-Ottawa Scale (NOS).

Results

Comparison of intralesional botulinum toxin type A and corticosteroid showed significant differences in the Visual Analog Scale (VAS) (P<0.001) (WMD, −4.30; 95% CI, −4.44 to −4.16) and effective rate (P=0.012) (RR=0.82; 95% CI, 0.70–0.96). Intralesional injection of botulinum toxin type A compared with placebo showed significant differences in the VAS (P<0.001) (WMD, 1.41; 95% CI, 1.21–1.62), the width of scar (P=0.00) (WMD, −0.15; 95% CI, −0.19 to −0.10) and Vancouver Scar Scale (VSS) (P=0.003) (WMD, −0.69; 95% CI, −1.14 to −0.23).

Conclusions

Systematic review and meta-analysis showed that injection of intralesional botulinum toxin type A was more effective in the treatment of hypertrophic scar and keloid than injection of intralesional corticosteroid or placebo.

New trends in botulinum toxin use in dermatology

Background

Recent studies have highlighted new botulinum neurotoxin (BoNT) applications in the field of dermatology.

Objective

To review current knowledge of BoNT use in dermatology.

Methods

The literature of the last 5 five years has been reviewed.

Results

We describe interesting protocols of BoNT treatment for hyperhidrosis (HH), hypertrophic scars and keloids, Raynaud phenomenon, facial flushing, oily skin, psoriasis, Hailey-Hailey disease, and cutaneous lesions like painful lesions and periorbital syringomas.

Conclusions

Several skin conditions eligible for BoNT treatment have been described. After the wide application for HH treatment, scars as well as vascular and inflammatory skin disorders, oily skin and cutaneous lesions represent fields of application of BoNT.

The Cellular Response of Keloids and Hypertrophic Scars to Botulinum Toxin A: A Comprehensive Literature Review

BACKGROUND

Keloids and hypertrophic scars are conditions of pathologic scarring characterized by fibroblast hyperproliferation and excess collagen deposition. These conditions significantly impact patients by causing psychosocial, functional, and aesthetic distress. Current treatment modalities have limitations. Clinical evidence indicates that botulinum toxin A (BoNT-A) may prevent and treat keloids and hypertrophic scars.

OBJECTIVE

To examine investigated cellular pathways involved in BoNT-A therapeutic modulation of keloids and hypertrophic scars.

METHODS

The authors searched PubMed, Embase, and Web of Science for basic science articles related to botulinum toxin therapy, scarring, fibroblasts, keloids, and hypertrophic scars.

RESULTS

Eleven basic science articles involving keloids and hypertrophic scars were reviewed.

DISCUSSION

BoNT-A may reduce skin fibrosis by decreasing fibroblast proliferation, modulating the activity of transforming growth factor-β, and reducing transcription and expression of profibrotic cytokines in keloid-derived and hypertrophic scar-derived dermal fibroblasts. BoNT-A may modulate collagen deposition, but there is a paucity of evidence regarding specific mechanisms of action.

CONCLUSION

Overall, BoNT-A has the potential to prevent or treat pathologic scars in patients with a known personal or family history of keloids and hypertrophic scars, which may improve patient psychosocial distress and reduce clinic visits and health care costs. Variability in keloid and hypertrophic scar response to BoNT-A may be due to interexperiment differences in dosing, tissue donors, and assay sensitivity.

The Efficacy and Safety of Early Postoperative Botulinum Toxin A Injection for Facial Scars

BACKGROUND

Scars widen when the underlying musculature pulls apart suture lines, and scars oriented against relaxed skin tension lines are especially susceptible to these distraction forces. Because botulinum toxin A (BTA) induces complete muscle paralysis, the purpose of the current study was to evaluate the effects of BTA using both observer-dependent qualitative assessments and quantitative measurements to verify its beneficial effects on facial scarring.

METHODS

Patients with vertical forehead lacerations, treated by primary closure, were randomly assigned to two groups: one (n = 15) received BTA injections within 5 days of primary closure and the other (n = 15) received no further treatment. Vancouver scar scale (VSS) scores and wound width were determined at the 1-month and 6-month follow-up visits. Quantitative color differences between the scar and surrounding normal skin, using the Commission International d'Eclairage L*a*b* color coordinates, were measured and compared by analyzing photographs.

RESULT

Improved VSS scores, less increase in wound width, and less scar discoloration were noted among patients treated with BTA injections compared with the control group. These differences were observed at the 6-month visit, but not at the 1-month visit.

CONCLUSION

BTA injection improves scar quality when injected during the early postoperative days.

LEVEL OF EVIDENCE I

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

Antipruritic Effects of Botulinum Neurotoxins

This review explores current evidence to demonstrate that botulinum neurotoxins (BoNTs) exert antipruritic effects. Both experimental and clinical conditions in which botulinum neurotoxins have been applied for pruritus relief will be presented and significant findings will be highlighted. Potential mechanisms underlying antipruritic effects will also be discussed and ongoing challenges and unmet needs will be addressed.

Recent Understandings of Biology, Prophylaxis and Treatment Strategies for Hypertrophic Scars and Keloids

Hypertrophic scars and keloids are fibroproliferative disorders that may arise after any deep cutaneous injury caused by trauma, burns, surgery, etc. Hypertrophic scars and keloids are cosmetically problematic, and in combination with functional problems such as contractures and subjective symptoms including pruritus, these significantly affect patients’ quality of life. There have been many studies on hypertrophic scars and keloids; but the mechanisms underlying scar formation have not yet been well established, and prophylactic and treatment strategies remain unsatisfactory. In this review, the authors introduce and summarize classical concepts surrounding wound healing and review recent understandings of the biology, prevention and treatment strategies for hypertrophic scars and keloids.