Keloids: Current and emerging therapies

Needle-Free Jet Injector-Assisted Triamcinolone Treatment of Keloids and Hypertrophic Scars is Effective and Well Tolerated in Children

BACKGROUND

Keloids and hypertrophic scars can cause severe pain, pruritus, and psychological distress. Conventional intralesional corticosteroid treatment with needle injections remains challenging, especially in children with needle phobia.

OBJECTIVE

We aimed to evaluate the effectiveness, tolerability, and patient satisfaction of intralesional treatment with triamcinolone acetonide using a needle-free electronic pneumatic jet injector in children with keloids and hypertrophic scars.

METHODS

A retrospective study was performed in children with keloids and hypertrophic scars who received intralesional triamcinolone acetonide treatments using an electronic pneumatic jet injector. Effectiveness was evaluated using the Patient and Observer Scar Assessment Scale and Global Aesthetic Improvement Score at follow-up versus baseline. Tolerability was assessed with reported adverse effects and injection-related pain using a visual analog scale. Satisfaction questionnaires were used to evaluate treatment-related patient satisfaction.

RESULTS

Six female patients and five male patients aged 5-17 years, with a total of >118 keloids or hypertrophic scars were included. Electronic pneumatic jet injector treatment led to a significant reduction in the total Patient and Observer Scar Assessment Scale observer and patient scores compared with baseline, with a median reduction of 28.9% and 23.8%, respectively (p = 0.005; p = 0.009). Median visual analog scale pain scores for electronic pneumatic jet injector treatment were significantly lower compared with needle injections, 3.0 versus 7.0, respectively (p = 0.027). No severe adverse effects were reported. Overall, 6 patients were 'satisfied' and five patients were 'very satisfied' with the treatment.

CONCLUSIONS

Electronic pneumatic jet injector-assisted intralesional triamcinolone acetonide is an effective and well-tolerated treatment for keloids and hypertrophic scars in children. It should be considered as an alternative non-traumatic delivery method, especially in children with needle phobia or severe pain during previous needle injections.

Microneedle Electroporation for Intralesional Administration of Corticosteroid Treatment of Keloid Scar

Abstract is missing (Short communication)

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.

Risk factors for recurrence after keloid surgery with electron radiotherapy

The aim of this study was to investigate the effect of postoperative electron radiotherapy (RT) on local control for keloids and to identify risk factors for recurrence. The clinical data of 82 patients treated at our institution from January 2015 to October 2019 were collected. The data included the general condition of the patients, clinical characteristics of the keloids, treatment plan, local control, and treatment side effects. A total of 82 patients (129 keloids) were included. The study included 23 men (28%) and 59 females (72%). The median patient age was 32 years (range, 18-67 years). Twenty-six recurrences were observed, and the 1-, 3-, and 5-year local control rates were 93%, 81%, and 73%, respectively. Univariate analysis revealed that age (P = .03), hypertension (P = .04), scar shape (P < .001), primary site (P = .02), maximum lesion diameter (P < .001), pain and itching (P = .005), local tension (P = .005), and infection (P < .001) were risk factors for local recurrence. Multivariable analysis revealed that maximum lesion diameter (P < .001), infection (P < .001), interval between surgery and RT (P = .02), and previous treatment (P = .02) were independent risk factors. Complete excision of keloids combined with electron RT is safe and seemingly effective. For keloids with a high risk of recurrence, more aggressive treatment should be chosen, and further prospective studies are needed to explore the optimal treatment.

The Efficacy of Intense Pulsed Light in the Treatment of Keloids and Hypertrophic Scars

Introduction: Different therapies have been applied to keloids and hypertrophic scars. Intense pulsed light (IPL) has recently been used but the evidence is limited. This study was to evaluate the effectiveness and safety of IPL as monotherapy for keloids and hypertrophic scars. Methods: This was a before-and-after interventional study on 16 patients with 50 scars who underwent IPL. Seven scars receive one IPL session, seven received two sessions, and 36 received three sessions. Outcomes were evaluated by the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), scar ultrasound, colorimeter for pigmentation and erythema, and side effects. Results: After the treatment, most outcomes significantly improved except that the pigmentation of the scars did not change. Scar thickness significantly reduced by nearly 10% after the first IPL session, 15% after the second session, and>20% after the third session. All side effects were mild with crust (33.3-46%), blisters (8.3-40%), and hyperpigmentation around the scar (0-14%); the pain was moderate as assessed by the patients. Conclusion: IPL is a safe and effective treatment for keloids and hypertrophic scars. More studies are required to confirm our results.

Immune cells and associated molecular markers in dermal fibrosis with focus on raised cutaneous scars

Raised dermal scars including hypertrophic, and keloid scars as well as scalp-associated fibrosing Folliculitis Keloidalis Nuchae (FKN) are a group of fibrotic raised dermal lesions that mostly occur following cutaneous injury. They are characterized by increased extracellular matrix (ECM) deposition, primarily excessive collagen type 1 production by hyperproliferative fibroblasts. The extent of ECM deposition is thought to be proportional to the severity of local skin inflammation leading to excessive fibrosis of the dermis. Due to a lack of suitable study models, therapy for raised dermal scars remains ill-defined. Immune cells and their associated markers have been strongly associated with dermal fibrosis. Therefore, modulation of the immune system and use of anti-inflammatory cytokines are of potential interest in the management of dermal fibrosis. In this review, we will discuss the importance of immune factors in the pathogenesis of raised dermal scarring. The aim here is to provide an up-to-date comprehensive review of the literature, from PubMed, Scopus, and other relevant search engines in order to describe the known immunological factors associated with raised dermal scarring. The importance of immune cells including mast cells, macrophages, lymphocytes, and relevant molecules such as cytokines, chemokines, and growth factors, antibodies, transcription factors, and other immune-associated molecules as well as tissue lymphoid aggregates identified within raised dermal scars will be presented. A growing body of evidence points to a shift from proinflammatory Th1 response to regulatory/anti-inflammatory Th2 response being associated with the development of fibrogenesis in raised dermal scarring. In summary, a better understanding of immune cells and associated molecular markers in dermal fibrosis will likely enable future development of potential immune-modulated therapeutic, diagnostic, and theranostic targets in raised dermal scarring.

Surgical Core Excision With Tongue Flap Closure in Combination With Electron Beam Radiotherapy in the Treatment of Ear Keloids

BACKGROUND

Ear keloids are disfiguring disorders resistant to various treatments.

OBJECTIVE

The authors aimed to assess the efficacy of surgical treatment of ear keloids in a Chinese population using a tongue flap with electron beam radiotherapy.

METHODS

The authors conducted a retrospective analysis of 41 patients treated at the Affiliated Hospital of Nantong University between January 2018 and May 2021. Core excision with a tongue flap was performed, followed by 3 days of electron beam radiotherapy and 3 to 6 months of pressure clip application. The Vancouver Scar Scale (VSS) and the Visual Analog Scale (VAS) were used to assess the results.

RESULTS

The mean age of the patients was 28.10 years (9-61 years). Postoperative follow-up ranged from 5 to 32 months (mean:12.07). The patients underwent 3 days of postoperative radiotherapy followed by pressure clips for 2 to 6 months. Thirty-seven patients had no recurrence, whereas 4 had a mild recurrence (<3 mm in height) with redness and itchiness. The VSS and VASscores significantly decreased. (p < .05).

CONCLUSION

Excision with a tongue flap and radiotherapy can be used as the primary treatment for ear keloids considering the good outcome and long-term management.

Current Research of Botulinum Toxin Type A in Prevention and Treatment on Pathological Scars

BACKGROUND

Dermatologists have been looking for ways to improve wound healing and postoperative scar appearance. The safety and efficacy of botulinum toxin type A (BTXA) in the prevention and treatment on pathological scars have become the current research hotspot since it was approved by the US FDA in medical cosmetology in 2002.

PURPOSE

This article aims to provide an overview of the clinical research, limitations, and application prospects of BTXA in the prevention and treatment of traumatic or postoperative pathological scars, which can provide a reference and better understanding of relevant studies.

METHODS

The current research progress was summarized and discussed, with new problems and research ideas being proposed ranging from the molecular mechanism of BTXA in preventing and treating pathological scars to its clinical application via investigation and reference research.

RESULTS

BTXA is effective in relieving itching and pain associated with pathological scars, limiting scar hyperplasia along with preventing scar contracture, but the specific mechanism is still not clear.

CONCLUSION

Most of the clinicians have confirmed the clinical effectiveness of BTXA in the prevention and treatment of pathological scars, yet its mode of action and combination therapy need more research.

Safety and feasibility of autologous adipose-derived stromal vascular fraction in the treatment of keloids: a phase one randomized controlled pilot trial

INTRODUCTION

Autologous adipose-derived stromal vascular fraction (SVF) has been described to have therapeutic benefits in the treatment of keloids. However, most of the evidence on its efficacy is based on observational studies the majority of which are conducted in high-income countries and yet the highest burden of keloids is in low- and middle-income countries (LMICs).

OBJECTIVES

We set out to determine the safety and feasibility of using autologous adipose derived stromal vascular fraction in the treatment of keloids in LMICs.

METHODS

In this phase II randomized controlled pilot clinical trial conducted in the Plastic Surgery Unit of Kirruddu National Referral Hospital in Kampala Uganda, 8 patients were assigned a 1:1 ratio to either SVF or triamcinolone acetonide (TAC) arms. In the SVF arm, a median (Inter quartile range) amount of stromal cell infiltration of 2.7×10⁶ (11×10⁶) was administered, while the controls received 10 mg/ml TAC at a ratio of 1:1 TAC to keloid volume. Primary endpoints were adverse event development based on the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 tool and feasibility assessment based on ≥ 70% recruitment feasibility and ≥ 80% interventional feasibility rates.

RESULTS

The participants' mean age was 27.9 (±6.5) years, with a female predilection of 5 (63%). Overall, no adverse events were reported in the SVF arm, while ulceration in a single patient in the TAC arm, which was a grade II adverse event, was reported. Recruitment feasibility of 80% and interventional feasibility with 100% completion were reported.

CONCLUSION

Based on our findings, an autologous adipose-derived stromal vascular fraction is feasible and safe for the treatment of keloids in LMICs.

Could hyperbaric oxygen be an effective therapy option for pathological scars? A systematic review and meta-analysis

BACKGROUND

Hyperbaric oxygen (HBO) therapy involves breathing pure oxygen or a high oxygen concentration above atmospheric (ATM) pressure in an enclosed chamber. Studies on pathological scars have demonstrated that HBO can inhibit the formation of pathological scars.

OBJECTIVE

To evaluate the efficacy of HBO in the treatment of pathological scars via meta-analysis.

METHODS

Searches were run on various databases, including the Cochrane, Embase, PubMed, Web of Science, and CNKI databases. A comparative study was conducted on patients with pathological scars treated with or without HBO. We used RevMan 5.4 software to determine the recurrence rate, treatment satisfaction, and Vancouver Scar Scale(VSS) score in the pathological scar.

RESULTS

A total of 543 publications were identified; after screening, four were selected for review, including one randomized controlled trial (RCT), one controlled clinical trial (CCT), and two retrospective cohort studies. Meta-analysis results showed that HBO treatment reduced the pathological scar recurrence rate after surgery and radiotherapy (OR = 0.26, 95% CI: 0.13-0.52, p = 0.0001). Patients had higher satisfaction after HBO therapy (OR = 4.45, 95% CI: 1.49-13.30, p = 0.007). The Vancouver scar scale (VSS) score of patients with pathological scars was significantly improved in the HBO group (SMD: -3.82, 95% CI: -6.07to -0.49, p = 0.02).

CONCLUSIONS

HBO treatment decreased the recurrence rate of pathological scars after surgery and radiotherapy, increased patient satisfaction, and reduced the VSS score, thus providing a new way to treat pathological scar hyperplasia. However, evaluation of the longer-term effects of HBO treatment requires further comprehensive studies, including more RCTs.

A Review of Laser Therapies for the Treatment of Scarring and Vascular Anomalies

Significance: Laser use has become part of the gold standard of treatment as an effective adjuvant in multimodal therapy for pathologic scarring caused by burns, trauma, acne, and surgery, as well as vascular anomalies. Understanding indications and applications for laser therapy is essential for physicians to improve patient outcomes. Recent Advances: Since the 1980s, the medical use of lasers has continuously evolved with improvements in technology. Novel lasers and fractionated technologies are currently being studied in the hopes to improve treatment efficacy, while reducing complications. Recent advancements include acne treatment with novel picosecond lasers, new hypertrophic scar therapies with simultaneous laser and intense pulsed light use, and novel systems such as lasers with intralesional optical fiber delivery devices. In addition, optimizing the timing of laser therapy and its use in multimodal treatments continue to advance the field of photothermolysis. Critical Issues: Selecting the correct laser for a given indication is the fundamental decision when choosing a laser balancing effective treatment with minimal complications. This article covers the principles of laser therapy, the preferred lasers used for the treatment of scarring and vascular anomalies, and discusses the current evidence behind these laser choices. Future Directions: To optimize laser therapy, larger randomized control trials and split scar studies are needed. Continued advancement through better randomized controlled studies will help to improve patient outcomes on a broader scale.

Keloid Treatment Using Plasma Exeresis: A Pilot Trial Study

Introduction: Keloid scars and hypertrophic scars are more commonly seen after surgeries, suture placements, or other skin damages. Scars can be treated using a variety of methods, including topical compounds, surgery, and lasers. The aim of this study is to evaluate the effects of plasma exeresis on the treatment of keloid scars. Methods: This experimental study was conducted on patients with keloid scars, defined as a treatment-resistant subtype of scars with extension beyond the primary skin defect and cauliflower appearance, in different parts of the body. The patients were treated with 2-to-3-session plasma exeresis. Scars were examined based on the Vancouver scar scale (VSS) before and 5 months after the treatment. Results: A total number of 24 scars were enrolled in this study. The number of patients was 16. There was a decrease in the mean thickness of keloids from 2.20 to 0.54 (P=0.000). The mean pigmentation and pliability scores decreased from 1.54 and 2.16 to 0.375 and 0.541, respectively (P=0.001, 000). There was a significant reduction in the keloid scar vascularity score from 1.666 to 0.541 (P=0.000). There was a decrease from 0.708 to 0.00 (P=0.004) in the mean itchiness score. After the intervention, the mean pain score was 0.000, compared to 0.7500 before the intervention (P=0.003). There was a decrease in the total score from 8.958 to 2.000 (P=0.000). Conclusion: The plasma exeresis procedure is effective in destroying small keloid scars. Furthermore, results in less itching and pain, as well as no significant complications or recurrences.

Poly(l-lactic acid) Scaffold Releasing an α4β1 Integrin Agonist Promotes Nonfibrotic Skin Wound Healing in Diabetic Mice

Skin wound healing is a highly complex process that continues to represent a major medical problem, due to chronic nonhealing wounds in several classes of patients and to possible fibrotic complications, which compromise the function of the dermis. Integrins are transmembrane receptors that play key roles in this process and that offer a recognized druggable target. Our group recently synthesized GM18, a specific agonist for α4β1, an integrin that plays a role in skin immunity and in the migration of neutrophils, also regulating the differentiated state of fibroblasts. GM18 can be combined with poly(l-lactic acid) (PLLA) nanofibers to provide a controlled release of this agonist, resulting in a medication particularly suitable for skin wounds. In this study, we first optimized a GM18-PLLA nanofiber combination with a 7-day sustained release for use as skin wound medication. When tested in an experimental pressure ulcer in diabetic mice, a model for chronic nonhealing wounds, both soluble and GM18-PLLA formulations accelerated wound healing, as well as regulated extracellular matrix synthesis toward a nonfibrotic molecular signature. In vitro experiments using the adhesion test showed fibroblasts to be a principal GM18 cellular target, which we then used as an in vitro model to explore possible mechanisms of GM18 action. Our results suggest that the observed antifibrotic behavior of GM18 may exert a dual action on fibroblasts at the α4β1 binding site and that GM18 may prevent profibrotic EDA-fibronectin-α4β1 binding and activate outside-in signaling of the ERK1/2 pathways, a critical component of the wound healing process.

Long-Term Results of a Multimodal Treatment Regimen in Patients With Auricular Keloids

Objectives: The treatment of auricular keloids is challenging, as they tend to recur; further, the treatment may impact quality of life and implies cosmetic and functional impairment for each patient. There is no standardized therapeutic concept established, and the literature is lacking long-term results of available treatment modalities. Methods: Patients suffering from auricular keloids were included in the study. All patients had undergone surgical resection, intralesional injection of triamcinolone acetonide (TAC), and the application of an individual pressure splint. Quality of life (QoL) was assessed using the keloid intervention benefit inventory 21 (KIBI-21). Further analysis was carried out for patients without (group 1) and with (group 2) recurrence of the keloid. Results: In total, 50 keloids with a mean follow-up period of 59 months (range 6-137 months) could be analyzed. In nine cases (18%), a keloid recurrence was found during the observation period. The assessment of QoL differed significantly between study groups at P = 0.04, as well as for the subcategories General Health (GH) and Physical Health (PH). No differences were found for the categories Social Impact (SI) and Self-Esteem (SE). Conclusions: The multimodal subsequent treatment regimen consisting of surgical resection, intralesional TAC injection, and the application of an individual magnetic pressure splint shows good results concerning long-term recurrence rates. The treatment method shows positive effects on the QoL, especially in the measured categories GH and PH.

Single-cell RNA-seq reveals the communications between extracellular matrix-related components and Schwann cells contributing to the earlobe keloid formation

Keloid is a major type of skin fibrotic disease, with one prominent feature of extensive accumulation of extracellular matrix (ECM) components, and another feature of pain/itching, which is closely related to the peripheral nervous system (PNS). However, the molecular pathogenesis of these two prominent features still needs to be further explored. In the present study, we performed single-cell RNA sequencing (scRNA-seq) on clinical earlobe keloid samples and adjacent normal skin samples and constructed a keloid atlas of 31,379 cells. All cells were clustered into 13 major cell types using cell-type-specific markers. Among them, fibroblast, vascular endothelial cells, and smooth muscle cells were defined as the ECM-related populations according to their ECM-associated functions. Also, we found that Schwann cells (SCs) were the main neuron cells of PNS in the skin. Interestingly, the cell proportions of ECM-related populations, as well as SC were increased significantly in the earlobe keloid compared to the adjacent normal tissues, suggesting an important role of these cell types in the development of the earlobe keloid. Comprehensive cell-cell interaction analysis at the single-cell level revealed a strong interaction between SC and ECM-related subgroups which might be mediated by SEMA3C signaling pathways and MK/PTN gene family, which are found to be mainly involved in promoting cell proliferation and migration. Moreover, further exploration of the interactions of ECM-related populations and SC in different keloids, including earlobe keloid, back keloid, and chest keloid revealed an increasing amount of TGFβ-TGFβ receptor interactions in chest/back keloids as compared to earlobe keloid, which suggested the anatomic site-specific pathogenesis in different keloids. Altogether, these findings suggested the interactions between ECM-related populations and SC contributing to the earlobe keloid formation and helped us to better understand the pathogenesis of keloids.

The potential of functionalized dressing releasing flavonoids facilitates scar-free healing

Scars are pathological marks left after an injury heals that inflict physical and psychological harm, especially the great threat to development and aesthetics posed by oral and maxillofacial scars. The differential expression of genes such as transforming growth factor-β, local adherent plaque kinase, and yes-related transcriptional regulators at infancy or the oral mucosa is thought to be the reason of scarless regenerative capacity after tissue defects. Currently, tissue engineering products for defect repair frequently overlook the management of postoperative scars, and inhibitors of important genes alone have negative consequences for the organism. Natural flavonoids have hemostatic, anti-inflammatory, antioxidant, and antibacterial properties, which promote wound healing and have anti-scar properties by interfering with the transmission of key signaling pathways involved in scar formation. The combination of flavonoid-rich drug dressings provides a platform for clinical translation of compounds that aid in drug disintegration, prolonged release, and targeted delivery. Therefore, we present a review of the mechanisms and effects of flavonoids in promoting scar-free regeneration and the application of flavonoid-laden dressings.

Circular RNA hsa_circ_0043688 serves as a competing endogenous RNA for microRNA-145-5p to promote the progression of Keloids via Fibroblast growth factor-2

Background

Keloids are benign fibroproliferative skin tumors. Circular RNA (circRNA) hsa_circ_0043688 has been exhibited to the freakishly expressed in keloid tissues. Here, we aimed to investigate the regulatory network of hsa_circ_0043688 in the pathological process of keloid.

Methods

Hsa_circ_0043688, microRNA‐145‐5p (miR‐145‐5p), and Fibroblast growth factor‐2 (FGF2) level were detected using RT‐qPCR. Cell viability, proliferation, apoptosis, invasion, and migration were investigated using Cell Counting Kit‐8 (CCK‐8), 5‐ethynyl‐2′‐deoxyuridine (EdU), flow cytometry, transwell, and wound healing assays, respectively. Western blot analysis of protein levels of FGF2, CyclinD1, Collagen I, and Collagen III. After the prediction of Circinteractome and Starbase, their interaction was verified based on a dual‐luciferase reporter and RIP assays.

Results

Increased hsa_circ_0043688 and FGF2, and decreased miR‐145‐5p in keloids samples and fibroblasts were found. Also, hsa_circ_0043688 absence hindered proliferation, invasion, migration, and boost apoptosis of keloid fibroblasts. In mechanism, hsa_circ_0043688 modulated FGF2 content via sponging miR‐145‐5p.

Conclusion

Hsa_circ_0043688 knockdown inhibited cell growth and metastasis of keloid fibroblasts via miR‐145‐5p/FGF2, providing a new mechanism to understand the keloid progression.

FBXL6 is dysregulated in keloids and promotes keloid fibroblast growth by inducing c-Myc expression

C-MYC-mediated keloid fibroblasts proliferation and collagen deposit may contribute to the development of keloids. F-box and leucine-rich repeat protein 6 (FBXL6) is reported to be involved in tumour progression, while the role of FBXL6 in keloid fibroblasts is not deciphered. Normal control skins, hypertrophic scars and keloid tissues were collected and prepared for FBXL6 detection. FBXL6 short hairpin RNAs (shRNAs) or FBXL6 over-expression plasmids were transfected into keloid fibroblasts, and then c-MYC plasmids were further transfected. Cell viability was assayed with a Cell-Counting Kit-8 kit. The relative expression of FBXL6, Cyclin A1, Cyclin D2, Cyclin E1 and Collagen I was detected with real-time PCR and Western blot. Elevated FBXL6 expression could be observed in keloid tissues and hypertrophic scars. FBXL6 shRNAs transfection could inhibit the viability of keloid fibroblasts with diminished c-MYC expression and down-regulated Cyclin A1, Cyclin D2, Cyclin E1 and Collagen I expression. At the same time, overexpressed FBXL6 could promote the proliferation of keloid fibroblasts. Overexpression of c-MYC could promote the proliferation of keloid fibroblasts reduced by FBXL6 shRNAs with up-regulated Cyclin A1 and Collagen I expression. FBXL6 could promote the growth of keloid fibroblasts by inducing c-MYC expression, which could be targeted in keloids treatment.

Challenges in the Management of Upper Lid Keloid

A middle-aged lady presented with a firm, nontender mass on the left upper lid and area behind the left ear following lid reconstruction with postauricular graft for cicatricial ectropion 11 months prior. She had a similar mass on the right shin. She was diagnosed as a case of multiple keloids. Intralesional injection of triamcinolone acetonide suspension and 5-Fluorouracil (5-FU) in the upper lid keloid resulted in ulceration of its surface. Surgical excision, injection of 5-FU in the keloid bed with temporal forehead flap reconstruction, was performed. Occurrence of inadvertent postoperative wound infection with Acinetobacter baumannii was treated with local dressing with colistimethate sodium. Adjuvant therapy with topical imiquimod cream 5% was given subsequently for 24 weeks with no recurrence of the lid keloid after 16 months. The patient was managed using a combination of conservative and surgical therapy and multidisciplinary team work and kept on a long term follow-up.

TREATMENT WITH THERESIENöL OF SURGICAL DISEASES OF THE SKIN

Theresienöl is a 100 % natural product representing a mixture of animal and vegetable raw materials from Tyrol. Its exact recipe has been preserved untouched and in deep secret for more than six centuries yet, and has been passed down from generation to generation. Six patients were included in this case series one patient with malignant melanoma of the skin after re-excision with subsequent non-free skin surgical plastic, two patients with III degree skin burning and three patients with infected wound successfully treated with Theresienöl. All of them - before the application of Theresienöl - were treated with different operative methods. The treatment of scars from operative interventions with Theresienöl is very effective. That is why it must start directly after the operative intervention. The therapeutic effect of Theresienöl for postoperative scars is commensurable with and even better than the one of all applied until now local medicines, which makes it an agent of choice in those cases. Theresienöl represents a good alternative to the free skin surgical plastic for small burns of III degree. The local treatment of infected wounds with Theresienoil is more effective and economically sound than the treatment with all the rest types of dressings. The effects from the treatment of different surgical diseases with Theresienöl occur very rapidly, while there is a very good response to local hematomas, pain, and itchiness by the medicine, and there are no side effects from its administration.

Immediate Postoperative Treatment of Keloids with Intraoperative Radiation Therapy Technology: A Pilot Study

Background

The combination of surgery and postoperative radiotherapy allows for the most effective results with keloids. In this trial, surgery and intraoperative radiation therapy (IORT) technology were used-the hypothesis being that the earlier the application of postoperative radiotherapy, the better the wound healing evolution.

Methods

The study included 16 patients with 21 keloids. The keloids were radically excised and repaired with direct suture or local skin flaps. Collimated electron radiotherapy was applied within 45 minutes of surgery. The outcomes were assessed according to the modified Patient and Observer Scar Assessment Scale; the modified Vancouver Scar Scale; and the modified Common Terminology Criteria for Adverse Events v. 4.0 for skin and subcutaneous tissue disorders.

Results

Recurrences were observed in one out of 16 patients, and in two out of 21 keloids (9.5%). The modified Patient and Observer Scar Assessment Scale demonstrated a statistically significant improvement in pain, itching, color, stiffness, thickness, and irregularity after the treatment. The modified Patient and Observer Scar Assessment Scale displayed a statistically significant improvement in the scar vascularity, pigmentation, thickness, and pliability after the treatment. The modified Vancouver Scar Scale demonstrated a statistically significant improvement in 90.48% of the scars after the treatment. The modified Common Terminology Criteria for Adverse Events v. 4.0 for skin and subcutaneous tissue disorders demonstrated an improvement in erythema multiforme and skin pain across the whole sample, with a temporary hyperpigmentation in 19% of the scars after the treatment.

Conclusion

The combination of surgery and collimated electron radiotherapy with IORT technology demonstrated favorable results in 90.5% of the cases.

Novel targets and therapies for keloid

Keloids are the result of aberrant tissue scarring typically occurring in injured skin, and are caused by the overgrowth of granulation tissue or collagen type III during the healing process. There is a genetic component, thus a predisposition can be genetically transmitted. Keloids are difficult to treat because of their postexcisional recurrence, and they have an impact on patient quality of life due to psychological distress caused by cosmetic concerns and functional disability. Treatment ranges from classic corticosteroid therapy to multimodal approaches such as injections, cryotherapy, laser, radiation, radiofrequency ablation and extracorporeal shockwave therapy. Recent discoveries into the pathogenesis of keloid have enabled clinicians to expand the therapeutic options for treatment. The aim of this paper was to review the literature, clarify the general concept of keloid development, and assess emerging treatment options such as stem cell therapy, mitomycin C, bleomycin, interferon, botulinum toxin type A, calcium channel blockers, angiotensin-converting enzyme inhibitors and fat grafting, and the evolutionary advancement towards epigenetic modifications and gene therapy.

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.

Postinflammatory Medial Meatal Fibrosis: Histopathologic Features and Outcomes of Surgical Management

OBJECTIVES

The aims of our study were to investigate the clinical and audiometric outcome of the surgical treatment of postinflammatory medial meatal fibrosis (PIMMF) and to review the histopathologic changes in the specimens of the fibrotic plug, in order to try to shed light on the pathogenesis of the disease.

MATERIALS AND METHODS

The clinical records and the histopathologic specimens of all patients who underwent tympanomeatoplasty for PIMMF at the ENT Clinic of the University of Erlangen between 2006 and 2020 were evaluated retrospectively.

RESULTS

Thirty-four patients (41 primary surgical procedures) made up our study cohort. Of this, 28 cases were managed by means of meatoplasty and 13 cases with tympanomeatoplasty. The mean preoperative air-bone gap (ABG) was 27.8 dB (10-44 dB). Postoperative ABG was significantly improved compared to preoperative values at both short- and long-term follow-ups (P < .001 for both). No significant difference was noted between short-term and long-term ABG (P = .240). An ABG ≤20 dB was achieved in 65.8% of patients (short term) and 50% (long term). The overall rate of revision surgery for restenosis was 29.3% (12/41). Histopathologic reevaluation of the fibrotic plugs revealed a mosaic of patterns with frequent occurrence of secondary cholesteatoma-like lesions and keloid-like tissue changes. Lichenoid submucosal inflammation and increased ectopic ceruminous gland lobules were seen less frequently.

DISCUSSION

The moderate long-term outcome of surgical management and the identification of histologic changes with therapeutic implications might pave the way for alternative nonsurgical treatment options.

Localized temporal co-delivery of interleukin 10 and decorin genes using amediated by collagen-based biphasic scaffold modulates the expression of TGF-β1/β2 in a rabbit ear hypertrophic scarring model

Hypertrophic scarring (HS) is an intractable complication associated with cutaneous wound healing. Although transforming growth factor β1 (TGF-β1) has long been documented as a central regulatory cytokine in fibrogenesis and fibroplasia, there is currently no cure. Gene therapy is emerging as a powerful tool to attenuate the overexpression of TGF-β1 and its signaling activities. An effective approach may require transferring multiple genes to regulate different aspects of TGF-β1 signaling activities in a Spatio-temporal manner. Herein we report the additive anti-fibrotic effects of two plasmid DNAs encoding interleukin 10 (IL-10) and decorin (DCN) co-delivered via a biphasic 3D collagen scaffold reservoir platform. Combined gene therapy significantly attenuated inflammation and extracellular matrix components' accumulation in a rabbit ear ulcer model; and suppressed the expressions of genes associated with fibrogenesis, including collagen type I, as well as TGF-β1 and TGF-β2, while enhancing the genes commonly associated with regenerative healing including collagen type III. These findings may serve to provide a non-viral gene therapy platform that is safe, optimized, and effective to deliver multiple genes onto the diseased tissue in a wider range of tissue fibrosis-related maladies.