Keloids and Hypertrophic Scars Can Now Be Cured Completely: Recent Progress in Our Understanding of the Pathogenesis of Keloids and Hypertrophic Scars and the Most Promising Current Therapeutic Strategy

Comprehensive Insights into Keloid Pathogenesis and Advanced Therapeutic Strategies

Keloid scars, characterized by abnormal fibroproliferation and excessive extracellular matrix (ECM) production that extends beyond the original wound, often cause pruritus, pain, and hyperpigmentation, significantly impacting the quality of life. Keloid pathogenesis is multifactorial, involving genetic predisposition, immune response dysregulation, and aberrant wound-healing processes. Central molecular pathways such as TGF-β/Smad and JAK/STAT are important in keloid formation by sustaining fibroblast activation and ECM deposition. Conventional treatments, including surgical excision, radiation, laser therapies, and intralesional injections, yield variable success but are limited by high recurrence rates and potential adverse effects. Emerging therapies targeting specific immune pathways, small molecule inhibitors, RNA interference, and mesenchymal stem cells show promise in disrupting the underlying mechanisms of keloid pathogenesis, potentially offering more effective and lasting treatment outcomes. Despite advancements, further research is essential to fully elucidate the precise mechanisms of keloid formation and to develop targeted therapies. Ongoing clinical trials and research efforts are vital for translating these scientific insights into practical treatments that can markedly enhance the quality of life for individuals affected by keloid scars.

Recurrence and Complications of Peri-operative Steroid Injection of Keloids: A Systematic Review and Meta-analysis

Keloid scars are a particularly challenging fibroproliferative wound healing disorder with a variety of proposed management approaches including concurrent surgery and intralesional steroid injection. We aimed to identify the optimum time for triamcinolone injection of keloids, by comparing the recurrence and complication occurrence in patients who received pre-, intra- or post-operative injection. Studies reporting on the rate of recurrence and complication occurrence following treatment of keloid scarring with concurrent surgical excision and intralesional steroid injection were identified from the PubMed, Web of science and Embase databases. The I-squared (I2) statistic was used to quantify the variability in study estimates due to heterogeneity and to determine whether the fixed or random effect models will be employed. Publication bias was visualized through funnel plots and tested with the Egger's test. We found that the recurrence rate was significantly lower with post-operative injection compared to intra-operative injection (p < 0.001) and pre-operative injection (p = 0.009). A significant difference between intra-operative and pre-operative injection was not found (p = 0.46). In conclusion, post-operative steroid injection after surgical excision results in lower keloid recurrence compared to pre- and intra-operative injection.Level of Evidence IV "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 ."

In the face and neck, keloid scar distribution is related to skin thickness and stiffness changes associated with movement

Keloid scars tend to occur in high-tension sites due to mechanical stimuli that are involved in their development. To date, a detailed analysis of keloid distribution focused specifically on facial and neck areas has not been reported, and limited literature exists as to the related mechanical factors. To rectify this deficiency of knowledge, we first quantified the facial and neck keloid distribution observed clinically in 113 patients. Subsequently, we performed a rigorous investigation into the mechanical factors and their associated changes at these anatomic sites in healthy volunteers without a history of pathologic scarring. The association between keloid-predilection sites and sebaceous gland-dense and acne-prone sites was also examined. To assess skin stretch, thickness and stiffness, VECTRA, ultrasound and indentometer were utilised. Baseline skin stiffness and thickness were measured, as well as the magnitude of change in these values associated with facial expression and postural changes. Within the face and neck, keloids were most common near the mandibular angle (41.3%) and lateral submental (20.0%) regions. These areas of increased keloid incidence were not associated with areas more dense in sebaceous glands, nor linked consistently with acne-susceptible regions. Binomial logistic regression revealed that changes in skin stiffness and thickness related to postural changes significantly predicted keloid distribution. Skin stiffness and thickness changes related to prolonged mechanical forces (postural changes) are most pronounced at sites of high keloid predilection. This finding further elucidates the means by which skin stretch and tension are related to keloid development. As a more detailed analysis of mechanical forces on facial and neck skin, this study evaluates the nuances of multiple skin-mechanical properties, and their changes in a three-dimensional framework. Such factors may be critical to better understanding keloid progression and development in the face and neck.

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.

An approach to achieve tension-free closure and mitigate recurrence in the management of recurrent cervical keloids

Keloid is a burdensome condition that negatively affects patient's quality of life. It is influenced by a spectrum of risk factors, including tension. We propose an approach to address the tension-free closure and optimize surgical outcomes in neck keloid. A retrospective review of neck keloid patients who underwent surgical treatment between 2014 and 2022 was performed. Five patients underwent surgical interventions. Two patients had sufficient and three had insufficient tissue redundancy. The former underwent keloid excision with tension-free closure. The latter underwent keloid excision with full thickness skin graft for tension-free closure. One patient required re-excision with free flap coverage. All patients received postoperative low dose radiation. All patients were satisfied with the results and there were no signs of keloid recurrence during the follow-up period. Tension during closure following keloid excision is a modifiable risk factor. An appropriate algorithm providing tension-free closure can minimize the recurrence.

Effective keloid management using a combinatorial continuous-wave and repeat fractionated ablative CO2 laser regimen

BACKGROUND

Keloids are benign proliferative scars that form as a result of dysregulated growth and collagen deposition in response to cutaneous injury. Laser therapies have emerged as promising options for the treatment of keloids, with performance varying by laser type and lesion characteristics.

PURPOSE

To assess the combined continuous wave and repetitive fractionated CO2 laser treatment of keloids.

METHODS

A retrospective chart review of 22 cases of keloid scars treated with combined CO2 laser modes. A single session of continuous wave followed by five sessions of fractional delivery. Efficacy was assessed using the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale. The Numeric Rating Scale was used to assess patient satisfaction and pain.

RESULTS

Most patients were female (77.3%) with skin type IV (72.7%), age was 24.3 ± 9.3 years, most keloids were located on the earlobe (56.5%) or arm or hand (17.4%), size ranged from 5 to 10 cm, and time since injury ranged from 3 months to 35 years. No serious adverse events were reported. At 6 months, significant improvements from baseline occurred in all characteristics, scar color (4.8 ± 2.8 to 1.9 ± 1.1), rigidity (5.0 ± 2.8 vs. 5.4 ± 2.8), thickness (5.4 ± 2.8 vs. 2.0 ± 1.1), and irregularity (5.9 ± 2.4 vs. 1.9 ± 0.9). The Vancouver scores followed a similar trend. Patient-rated overall improvement from 37 ± 17.6 at baseline to 16.1 ± 8.5 at 6 months, and improvement in associated pain and pruritus.

CONCLUSION

Combination of two ablative laser delivery modes within a single laser platform provided for effective and safe keloid management and left patients highly satisfied.

Early postoperative interventions in the prevention and management of thyroidectomy scars

Thyroidectomy scars, located on the exposed site, can cause distress in patients. Owing to the cosmetic importance of thyroidectomy scars, many studies have been conducted on its prevention and treatment. Scar formation factors mainly include inflammatory cell infiltration, angiogenesis, fibroblast proliferation, secretion of cytokines such as transforming growth factor (TGF)-β1, and mechanical tension on the wound edges. Anti-scar methods including topical anti-scar agents, skin tension-bearing devices, and local injections of botulinum toxin, as well as lasers and phototherapies, that target these scar formation factors have been developed. However, current studies remain fragmented, and there is a lack of a comprehensive evaluation of the impacts of these anti-scar methods on treating thyroidectomy scars. Early intervention is a crucial but often neglected key to control hyperplastic thyroidectomy scars. Therefore, we review the currently adopted early postoperative strategies for thyroidectomy scar reduction, aiming to illustrate the mechanism of these anti-scar methods and provide flexible and comprehensive treatment selections for clinical physicians to deal with thyroidectomy scars.

Efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids: A 13-year experience

BACKGROUND

Surgical excision combined with radiotherapy is considered an effective treatment for keloids, while the efficacy and safety of this regimen for huge keloids in patients who need reconstruction after excision is still unclear. Therefore, this study aimed to evaluate the efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids in a single center with 13 years of experience.

METHODS

All consecutive patients with huge keloids who underwent surgical excision and reconstruction combined with radiotherapy were identified. Demographic information, prior interventions for keloids, parameters and complications, and recurrence rates were documented.

RESULTS

Twenty-one patients (10 males; mean age, 43.19 ± 18.15 years) were included, 14 patients reconstructed with z-plasties, 5 with skin grafts, and 2 with skin flaps. During a mean follow-up of 75 months, one patient developed local necrosis without the need for revision surgery and two patients developed temporary hyperpigmentation. Two patients with the z-plasties suffered partial keloids recurrence, which was healed with corticosteroid injection. No wound infection, hematoma, telangiectasia, or new keloids at donor sites were observed. The overall appearance of reconstructed defects was aesthetically acceptable.

CONCLUSION

Surgical excision and reconstruction combined with radiotherapy may be safe and effective for huge keloids.

Identification and validation of CRLF1 and NRG1 as immune-related signatures in hypertrophic scar

BACKGROUND

Hypertrophic scar (HTS) is a prevalent chronic inflammatory skin disorder characterized by abnormal proliferation and extracellular matrix deposition and the precise mechanisms underlying HTS remain elusive. This study aimed to identify and validate potential immune-related genes associated with hypertrophic scar formation.

METHODS

Skin samples from normal (n = 12) and hypertrophic scar tissues (n = 12) were subjected to RNA-seq analysis. Differentially expressed genes (DEGs) and significant modular genes in Weighted gene Co-expression Network Analysis (WGCNA) were identified. Subsequently, functional enrichment analysis was performed on the intersecting genes. Additionally, eight immune-related genes were matched from the ImmPort database. Validation of NRG1 and CRLF1 was carried out using an external cohort (GSE136906). Furthermore, the association between these two genes and immune cells was assessed by Spearman correlation analysis. Finally, RNA was extracted from normal and hypertrophic scar samples, and RT-qPCR, Immunohistochemistry staining and Western Blot were employed to validate the expression of characteristic genes.

RESULTS

A total of 940 DEGs were identified between HTS and normal samples, and 288 key module genes were uncovered via WGCNA. Enrichment analysis in key module revealed involvement in many immune-related pathways, such as Th17 cell differentiation, antigen processing and presentation and B cell receptor signaling pathway. The eight immune-related genes (IFI30, NR2F2, NRG1, ESM1, NFATC2, CRLF1, COLEC12 and IL6) were identified by matching from the ImmPort database. Notably, we observed that activated mast cell positively correlated with CRLF1 expression, while CD8 T cells exhibited a positive correlation with NRG1. The expression of NRG1 and CRLF1 was further validated in clinical samples.

CONCLUSION

In this study, two key immune-related genes (CRLF1 and NRG1) were identified as characteristic genes associated with HTS. These findings provide valuable insights into the immune-related mechanisms underlying hypertrophic scar formation.

Autologous nanofat harvested from donor site of full-thickness skin or skin flap grafting for the treatment of early postburn scarring: a case series

Introduction

Postburn scarring often presents a specific reconstructive challenge from both functional and cosmetic perspectives. The purpose of this study was to investigate whether autologous nanofat harvested from the donor site of full skin or a skin flap can be reused for the treatment of early postburn scaring.

Methods

From July 2018 to April 2022, patients with early postburn scarring underwent scar reconstruction surgery with full-thickness skin or a skin flap for a contour deformity and/or scar contracture, and autologous nanofat grafting was performed during the same operation. The Vancouver Scar Score (VSS) and the itch and pain scores were evaluated at the preoperation time point as well as at 2-3 weeks and 3-months postoperation. A comparison was made among the same patients at different time points.

Results

A total of 17 patients, aged from 18 months to 62 years old were included in this analysis. The VSS was reduced from 10.00 ± 2.12 to 7.41 ± 1.277 at the 2-3-week postoperation time point, and to 5.53 ± 1.37 at the 3-month postoperation time point. The pain and itch score were reduced from 4.65 ± 1.37 and 6.35 ± 1.27, to 3.70 ± 1.10 and 4.94 ± 1.30 at the 2-3-week postoperation time point, and to 3.00 ± 1.28 and 3.94 ± 0.97 at the 3-month postoperation time point respectively. The VSS and pain and itch scores showed a statistically significant reduction (P < 0.05) at the 2-3-week and 3-month postoperative follow-ups compared with the preoperation time point.

Conclusion

Autologous nanofat grafting from donor sites of full thickness skin or skin flap may be a promising treatment for an early postburn scaring as it promotes scar softening, improves itching and pain within the scar. However, this is a small case series with only 17 patients. Further conclusions need to be drawn through expanded samples for randomized controlled clinical trials.

Lay Summary

Hypertrophic scarring is the most common complication after partial thickness burn injury, and the complex pathogenesis and prolonged dynamic process render treatments only marginally effective. In the past few decades, with the technological advances of liposuction and fat grafting, nanofat grafting has been used in a variety of surgical fields, including wound healing, scleroderma, facial rejuvenation, and neuralgia. However, the role of nanofat grafting is not well documented in the prevention and treatment of early postburn scarring. Full-thickness skin grafting or skin flap transplantation is the most common method for the reconstruction of a hypertrophic scaring until now. In the current study, we harvested subcutaneous fat during the preparation of the full-thickness skin or skin flap, prepared nanofat and injected it in the scar located at a nonsurgical site. Comparison of the pre- and postoperation scores for scar color, scar thickness, scar stiffness, and scar regularity showed that the postoperation scores were decreased significantly and that there was a significant improvement in scar pigmentation and thickness as well astheaesthetic outcome after treatment. Most importantly, reductions in the scores for pain and itching could be assessed objectively. It seems that the nanofat grafting is a potential method for prevention and treatment for early postburn scaring.

Gallic Acid Treats Hypertrophic Scar in Rabbit Ears via the TGF-β/Smad and TRPC3 Signaling Pathways

Hypertrophic scars (HSs) develop due to excessive collagen deposition and abnormal fibroblast proliferation during wound healing, significantly impacting patient quality of life. Three dosages of GA ointments were administered to rabbit ear HS models to investigate the potential efficacy and mechanism of gallic acid (GA) on HS. Daily application of ointment was performed on the matrix group, the GA ointment groups, and the silicone gel group for 28 days. (No drug treatment was performed on the skin and model groups as a blank group and vehicle group, and silicone gel ointment was topically administered to the silicone gel group as a positive control group.) Scar specimens were collected for histopathology analysis, RNA sequencing analysis, real-time quantitative polymerase chain reaction, and Western blot analysis at the first, second, and fourth weeks after the treatment. Low-dose and medium-dose GA effectively suppressed HS formation and markedly decreased fibroblast infiltration levels and scar thickness. Moreover, decreased expression of TRPC3 mRNA and TGF-β1, p-Smad2/3, and Smad2/3 protein was observed in the low- and medium-dose GA groups and the silicone gel group. This study provides evidence for the efficacy of GA in treating HS and sheds light on its potential underlying pharmacological mechanisms.

An Overview of Scaffolds and Biomaterials for Skin Expansion and Soft Tissue Regeneration: Insights on Zinc and Magnesium as New Potential Key Elements

The utilization of materials in medical implants, serving as substitutes for non-functional biological structures, supporting damaged tissues, or reinforcing active organs, holds significant importance in modern healthcare, positively impacting the quality of life for millions of individuals worldwide. However, certain implants may only be required temporarily to aid in the healing process of diseased or injured tissues and tissue expansion. Biodegradable metals, including zinc (Zn), magnesium (Mg), iron, and others, present a new paradigm in the realm of implant materials. Ongoing research focuses on developing optimized materials that meet medical standards, encompassing controllable corrosion rates, sustained mechanical stability, and favorable biocompatibility. Achieving these objectives involves refining alloy compositions and tailoring processing techniques to carefully control microstructures and mechanical properties. Among the materials under investigation, Mg- and Zn-based biodegradable materials and their alloys demonstrate the ability to provide necessary support during tissue regeneration while gradually degrading over time. Furthermore, as essential elements in the human body, Mg and Zn offer additional benefits, including promoting wound healing, facilitating cell growth, and participating in gene generation while interacting with various vital biological functions. This review provides an overview of the physiological function and significance for human health of Mg and Zn and their usage as implants in tissue regeneration using tissue scaffolds. The scaffold qualities, such as biodegradation, mechanical characteristics, and biocompatibility, are also discussed.

Close orthopedic surgery skin incision with combination of barbed sutures and running subcuticular suturing technique for less dermal tension concentration: a finite element analysis

BACKGROUND

Mechanical forces have an important role in the initiation and progression of orthopedic surgical incisions complications. To avoid incision complications with the reduction of dermal tension, surgeons may choose a buried continuous suture technique other than the traditional interrupted vertical mattress suture. Absorbable barbed sutures are widely used in orthopedics due to their convenience and reducing wound tension. The aim of this research is to compare and explain the advantages of running subcuticular suturing technique with absorbable barbed sutures for orthopedic surgical incisions closure.

METHODS

Finite element models of layered skin and two different suture techniques, running subcuticular suture and intradermal buried vertical mattress suture, ware constructed. The mechanical property difference between standard sutures and barbed sutures was modelled using different contact friction coefficient. Pulling the skin wound was simulated, and the sutures' pressure on the skin tissue was determined.

RESULTS

Compared with traditional smooth sutures, the barbed sutures effectively increased the contact force for subepidermal layers, which led the less force variation between different layers. The results also suggested that subcuticular suture caused less stress concentration compared with intradermal buried vertical mattress suture.

CONCLUSIONS

In conclusion, our study indicated that running subcuticular suturing technique with absorbable barbed sutures for orthopedic surgical incisions closure results in more uniform stress distribution in the dermis. We recommend this combination as the preferred method of skin closure in orthopedic surgery unless contraindicated.

Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies

Hypertrophic scars and keloids can have significant detrimental effects on patients both psychosocially and functionally. A careful identification of patient risk factors and a comprehensive management plan are necessary to optimize outcomes. Patients with a history of dystrophic scarring should avoid unnecessary procedures and enhance the wound-healing process using various preventive strategies. As there is no single, fully efficacious treatment modality, prevention remains the best approach in reducing aberrant scar formation. When prevention therapies fail, keloids have been shown to be respond to a variety of therapies including topical and injectable corticosteroids, 5-fluorouracil, radiotherapy, lasers, and surgical excision, all with varying efficacies. As such, management should be tailored to the individual patient's risk factors with the use of combination therapies to reduce recurrence rates. Still, keloid and hypertrophic scar therapies are widely diverse with novel treatment modalities providing alternatives for recurring lesions. Laser-assisted drug delivery, skin priming, and novel topical therapies may provide alternative options for the management of hypertrophic scars and keloids.

Treatment of Keloids with Surgery and Immediate Postoperative Radiotherapy: Knowledge Gained Over 17 Years

Background The treatment of keloidal scars with radiotherapy has been practiced for more than a century. Radiotherapy post-surgery has been deemed necessary and effective in preventing recurrence but still, no clear guidelines exist as to the best modality of radiotherapy, the ideal dose, and the time it should be given for keloidal scars. The purpose of this study is to confirm the effectiveness of this treatment and address these issues.

Methods Since 2004, 120 patients presenting with keloidal scars were seen by the author. Out of them, 50 were managed with surgery followed by HDR brachytherapy/electron beam radiotherapy delivering 2000 rads to the scar within 24 hours of surgery. Patients were followed up for at least 18 months to assess the scar status and the recurrence of keloids. Recurrence was defined as the appearance of a nodule or an obvious return of the keloid within 1 year of treatment.

Results Three patients developed a nodule in the scar, which was deemed a recurrence, making an incidence of 6%. There was no major problem after immediate postoperative radiotherapy. Five patients had delayed healing at 2 weeks and a hypertrophic scar was noted in five patients at 4 weeks that settled with conservative measures.

Conclusion Treating the vexing problem of keloids with surgery and immediate postoperative radiotherapy is safe and effective. We recommend that this be adopted as the standard treatment in keloid management.

An Updated Review of Hypertrophic Scarring

Hypertrophic scarring (HTS) is an aberrant form of wound healing that is associated with excessive deposition of extracellular matrix and connective tissue at the site of injury. In this review article, we provide an overview of normal (acute) wound healing phases (hemostasis, inflammation, proliferation, and remodeling). We next discuss the dysregulated and/or impaired mechanisms in wound healing phases that are associated with HTS development. We next discuss the animal models of HTS and their limitations, and review the current and emerging treatments of HTS.

Top cited publications for treatment of keloid with radiotherapy: A Bibliometric analysis

ABSTRACTS

The use of radiation to treat keloid scars has gained popularity during the last few decades. However, few bibliometric analyses have been performed on the published articles. This research aimed to demonstrate and evaluate the trends, top-cited articles, and frontier areas. In this cross-sectional study, Web of Science (WOS) and Scopus database literature was searched for all MESH terms related to "keloid" and "radiotherapy." The bibliometric analysis was carried out by VOSviewer 1.6.15. Articles with Web of Science-based citations of ≥20 were included. The citation per year index (CPYI) of articles was calculated for further inclusion of papers if they had CPYI higher than the mean value. There were 95 papers on keloid radiation that satisfied the inclusion criteria and were published between 1942 and 2019. The CPYI ranged from 0.38 to 11.3. Most studies were published in the "International Journal of Radiation Oncology, Biology, and Physics" (9 papers). The United States has the most papers (14), followed by Japan (9), the Netherlands (7), and Germany (5). To the best of our knowledge, this is the first bibliometric analysis of top-cited papers on keloid radiotherapy. From 2014 to the present, it seems that this title has resurfaced as a popular topic, with radiotherapy within 24 h of surgery being the most commonly recommended treatment plan. Since around 2011, high-dose-rate brachytherapy (HDR-BT) has been used as an effective treatment for keloid control. Individualization of therapy and dose/technique based on the location is strongly suggested.

Impact of internal mammary artery perforator propeller flaps combined with radiotherapy in the treatment of large chest keloids: Our experience

Background

Keloids are benign skin hyperplasias but have a tumor-like appearance. Clinical management of keloids remains challenging.

Aims

We retrospectively evaluated the safety and efficacy of internal mammary artery perforator propeller flaps combined with timely radiotherapy in the treatment of large chest keloids.

Methods

From June 2017 to May 2020, 25 patients with large chest keloids (average size 4.82 cm ± 2.53 cm × 9.04 cm ± 4.86 cm) who received both radiotherapy and internal mammary artery perforator flaps transplantation in our department were included. After surgical removal of the keloids, various propeller flaps based on the unilateral internal mammary artery were designed and applied to repair the defects. Timely and full-dose radiotherapy was performed for these patients after the operation.

Results

After keloid resection, the dimensions of the defect area were 3 cm-15 cm × 4 cm-25 cm, and the sizes of the flaps were 3 cm-16 cm × 4 cm-27 cm. For all 25 patients, the flaps survived, and the incisions healed in one stage. During the follow-up (median 18 months), no local recurrence was observed, and the itching and pain symptoms in the scar area were significantly relieved. Both physicians and patients were satisfied with the results.

Conclusions

The application of internal mammary artery perforator propeller flaps combined with radiotherapy in the treatment of chest keloids can effectively reduce the recurrence of keloids and relieve the related symptoms. It also has advantages including minimized donor site damage, short operation time and speedy postoperative recovery, suggesting its great clinical value.

The objective evaluation of triamcinolone acetonide efficacy in keloids management using Antera3D® imaging system

Background

Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. These lesions do not spontaneously regress and can cause cosmetic disfigurements and functional disabilities. IntraLesional Injection of Triamcinolone Acetonide (ILITA), alone or in combination with other therapy, is one of the first-line treatment modalities. In this study the authors evaluated the objective efficacy of ILITA treatment in keloids management using this new imaging system.

Materials and Methods

37 patients with 45 keloid scars were treated with intralesional injection of triamcinolone acetonide (TAC) 20 mg/ml at an interval of three weeks. Antera3D® camera took the images and dates of the treated area in each patient, before the treatment (T0) and at three weeks after the last injection (T1). The system processed the levels of color, elevations, melanin and hemoglobin expression. All the scars were also evaluated, at the same times, by validated Vancouver Scar Scale (VSS). Comparison of the variables was performed using a Wilcoxon signed-rank test with a p < 0.05.

Results

At T0, mean VSS score was 8.67 ± 1.35 which reduced to 3.62 ± 1.72 at final follow up. Antera3D® scores were statistically significant differences in color (8.14 ± 2.41 vs 9.54 ± 1.81), protrusion (381.3 ± 15.6 vs 198.6 ± 21.3), melanin (0.53 ± 0.02 vs 0.62 ± 0.2) and hemoglobin (1.26 ± 0.41 vs 2.21 ± 0.41) expression levels after the treatment.

Conclusions

In our clinical trial, the data results demonstrated that ILITA seems to be effective in reducing keloid dimensions and symptoms such as itching and pain, even if the treatment has local minimal adverse effects such as pain, telangiectasias and atrophy.

Lay Summary

Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. Large keloids can cause cosmetic disfigurements and functional disabilities that affect quality of life. In literature, several treatment approaches have been described but, to date, no single method is considered superior. The International Advisory Panel on Scar Management recommended the use of intralesional steroid injections for keloids treatment. The efficacy of treatment may be evaluated with subjective scale; as no one can guarantee an objective evaluation. To eliminate the observer and/or patient factors, and to obtain a reliable, consistent, feasible, valid and objective evaluation a skin analysis camera system called Antera3D® (Miravex, Dublin, Ireland) can be used.In this study the authors evaluated the objective efficacy of triamcinolone acetonide treatment in keloids management using this imaging system. In this series, for Antera3D® scores there were statistically significant differences in color, protrusion, melanin and hemoglobin expression levels before and after treatment. The device directly shows the treatment changes, measured objectively and accurately, without bias of traditional evaluation scoring scale.Antera3D® system guarantees an objective evaluation of effectiveness of scar treatment enabling clinicians to modulate the therapy according to the scores registered.

A Nomogram with the Keloid Activity Assessment Scale for Predicting the Recurrence of Chest Keloid after Surgery and Radiotherapy

BACKGROUND

Patients with chest keloids undergoing surgery and adjuvant radiotherapy still have a high recurrence rate, which is a critical problem. The level of keloid activity has not been studied, and a nomogram model for predicting keloid recurrence has not been established in previous studies.

METHODS

A total of 145 patients with chest keloids who underwent surgery and radiotherapy between January 2015 and January 2019 at Peking Union Medical College Hospital were included in our study. Demographic and clinical features and the score of KAAS were analyzed. We compared the area under the curve (AUC) and decision curve analysis (DCA) between KAAS and the Vancouver scar scale (VSS) and established a nomogram model for predicting the risk of recurrence. We used bootstrap and calibration plots to evaluate the performance of the nomogram.

RESULTS

The KAAS can predict recurrence in patients with chest keloids after surgery and radiotherapy. Areas under the curve (AUCs) of KAAS and VSS were 0.858 and 0.711, respectively (p < 0.001). Decision curve analysis (DCA) demonstrated that the KAAS was better than the VSS. Complications after treatment may be risk factors for keloid recurrence. We created a nomogram by using complications and KAAS. The AUC was 0.871 (95% CI 0.812-0.930). The ROC of the model's bootstrap was 0.865 and was well calibrated.

CONCLUSIONS

The KAAS can be used to predict the recurrence and we developed a nomogram for predicting the recurrence of chest keloids after surgery and adjuvant radiotherapy.

LEVEL OF EVIDENCE IV

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 .

Traditional Chinese medicine for hypertrophic scars—A review of the therapeutic methods and potential effects

Hypertrophic scar (HS) is a typical pathological response during skin injury, which can lead to pain, itching, and contracture in patients and even affect their physical and mental health. The complexity of the wound healing process leads to the formation of HS affected by many factors. Several treatments are available for HS, whereas some have more adverse reactions and can even cause new injuries with exacerbated scarring. Traditional Chinese Medicine (TCM) has a rich source, and most botanical drugs have few side effects, providing new ideas and methods for treating HS. This paper reviews the formation process of HS, the therapeutic strategy for HS, the research progress of TCM with its relevant mechanisms in the treatment of HS, and the related new drug delivery system of TCM, aiming to provide ideas for further research of botanical compounds in the treatment of HS, to promote the discovery of more efficient botanical candidates for the clinical treatment of HS, to accelerate the development of the new drug delivery system and the final clinical application, and at the same time, to promote the research on the anti-HS mechanism of multiherbal preparations (Fufang), to continuously improve the quality control and safety and effectiveness of anti-HS botanical drugs in clinical application.

Effect of hydrogen intervention on refractory wounds after radiotherapy: A case report

BACKGROUND

Patients with keloids who receive radiotherapy (RT) after surgery can develop refractory wounds that cannot be healed by the patient's own repair system. Such chronic wounds are uneven and complex due to persistent abscess and ulceration. Without external intervention, they can easily result in local tissue necrosis or, in severe cases, large area tissue resection, amputation, and even death.

CASE SUMMARY

This article describes the use of hydrogen to treat a 42-year-old female patient with a chronic wound on her left shoulder. The patient had a skin graft that involved implanting a dilator under the skin of her left shoulder, and then transferring excess skin from her shoulder onto scar tissue on her chest. The skin grafting was followed by two rounds of RT, after which the shoulder wound had difficulty healing. For six months, the patient was treated with 2 h of hydrogen inhalation (HI) therapy per day, in addition to application of sterile gauze on the wound and periodic debridement. We also performed one deep, large, sharp debridement to enlarge the wound area. The wound healed completely within 6 mo of beginning the HI treatment.

CONCLUSION

After HI therapy, the patient showed superior progress in reepithelialization and wound repair, with eventual wound closure in 6 mo, in comparison with the previous failures of hyperbaric oxygen and recombinant bovine basic fibroblast growth factor therapies. Our work showed that HI therapy could be a new strategy for wound healing that is cleaner, more convenient, and less expensive than other therapies, as well as easily accessible for further application in clinical wound care.

Controlling Inflammation Pre-Emptively or at the Time of Cutaneous Injury Optimises Outcome of Skin Scarring

Inflammation plays an active role during the wound healing process. There is a direct association between the extent of injury as well as inflammation and the amount of subsequent cutaneous scarring. Evidence to date demonstrates that high levels of inflammation are associated with excessive dermal scarring and formation of abnormal pathological scars such as keloids and hypertrophic scars. In view of the multiple important cell types being involved in the inflammatory process and their influence on the extent of scar formation, many scar therapies should aim to target these cells in order to control inflammation and by association help improve scar outcome. However, most current treatment strategies for the management of a newly formed skin scar often adopt a watch-and-wait approach prior to commencing targeted anti-inflammatory therapy. Moreover, most of these therapies have been evaluated in the remodelling phase of wound healing and the evaluation of anti-inflammatory treatments at earlier stages of healing have not been fully explored and remain limited. Taken together, in order to minimise the risk of developing a poor scar outcome, it is clear that adopting an early intervention prior to skin injury would be optimal, however, the concept of pre-emptively priming the skin prior to injury has not yet been thoroughly evaluated. Therefore, the aim of this review was to evaluate the available literature regarding scar therapies that aim to target inflammation which are commenced prior to when a scar is formed or immediately after injury, with a particular focus on the role of pre-emptive priming of skin prior to injury in order to control inflammation for the prevention of poor scarring outcome.

Role of Inflammasomes in Keloids and Hypertrophic Scars-Lessons Learned from Chronic Diabetic Wounds and Skin Fibrosis

Keloids and hypertrophic scars are pathological cutaneous scars. They arise from excessive wound healing, which induces chronic dermal inflammation and results in overwhelming fibroblast production of extracellular matrix. Their etiology is unclear. Inflammasomes are multiprotein complexes that are important in proinflammatory innate-immune system responses. We asked whether inflammasomes participate in pathological scarring by examining the literature on scarring, diabetic wounds (also characterized by chronic inflammation), and systemic sclerosis (also marked by fibrosis). Pathological scars are predominantly populated by anti-inflammatory M2 macrophages and recent literature hints that this could be driven by non-canonical inflammasome signaling. Diabetic-wound healing associates with inflammasome activation in immune (macrophages) and non-immune (keratinocytes) cells. Fibrotic conditions associate with inflammasome activation and inflammasome-induced transition of epithelial cells/endothelial cells/macrophages into myofibroblasts that deposit excessive extracellular matrix. Studies suggest that mechanical stimuli activate inflammasomes via the cytoskeleton and that mechanotransduction-inflammasome crosstalk is involved in fibrosis. Further research should examine (i) the roles that various inflammasome types in macrophages, (myo)fibroblasts, and other cell types play in keloid development and (ii) how mechanical stimuli interact with inflammasomes and thereby drive scar growth. Such research is likely to significantly advance our understanding of pathological scarring and aid the development of new therapeutic strategies.

Identification and validation of HOXD3 and UNC5C as molecular signatures in keloid based on weighted gene co-expression network analysis

BACKGROUND

Keloid is a benign proliferative disease characterized by excessive deposition of extracellular matrix collagen during skin wound healing. The mechanisms of keloid formation have not been fully elucidated, and the current treatment methods are not effective for all keloid patients. Therefore, there is an urgent need to find more effective therapies, and our research focused on identifying characteristic molecular signatures of keloid to explore potential therapeutic targets.

METHODS

Gene expression profiles of keloid and control group samples were retrieved from the GEO database. Taking the GSE113619 dataset as the training set, the dataset collected skin tissues from non-lesion sites of healthy and keloid-prone individuals, denoted as Day0. The second sampling was performed 42 days later at the original sampling site of control and keloid groups, denoted as Day42.The 'limma' package and Venn diagram identified differentially expressed genes (DEGs) specific to keloid day42 versus day0 samples. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), Reactome pathway functional enrichment, and annotation of the characteristic genes were conducted on the Metascape website. Ingenuity canonical pathways, disease & function enrichment analysis and gene interaction network were performed and predicted in Ingenuity Pathway Analysis (IPA) software. Key module genes related to keloid were filtered out by Weighted Gene Co-expression Network Analysis (WGCNA). We utilized the Least Absolute Shrinkage and Selection Operator (LASSO) algorithm to screen the characteristic genes in keloid by the 'glmnet' package. The area under the curve (AUC) of receiver operating characteristic (ROC) was utilized to determine the effectiveness of potential signatures in discriminating keloid samples from normal samples and performed by using the 'pROC' package. The enrich scores of 24 immune cells in each sample were calculated by the single-sample gene set enrichment analysis (ssGSEA) algorithm， and then the Gene Set Variation Analysis (GSVA) was performed. Finally, RNA from 4 normal and 6 keloid samples was extracted, and RT-qPCR and Western Blot validated the expression of characteristic genes.

RESULTS

A total of 640 DEGs specific to keloid day42 versus day0 samples were detected. 69 key module genes were uncovered and implicated in 'NCAM signaling for neurite out-growth', 'oncogenic MAPK signaling', 'transmission across chemical synapses' pathways, and the mitotic cell cycle-related processes. Five characteristic genes (MTUS1, UNC5C, CEP57, NAA35, and HOXD3) of keloid were identified by LASSO, and among which UNC5C and HOXD3 were validated by ROC plot in external dataset, RT-qPCR and Western Blot in validation samples. The result of ssGSEA indicated that the infiltration of neutrophils showed a relatively higher abundance and natural killer cells with relatively low enrichment in the keloid group compared to the control group. UNC5C was correlated with more immune cells compared with other characteristic genes.

CONCLUSION

In this study, characteristic genes associated with keloid were identified by bioinformatic approaches and verified in clinical validation samples, providing potential targets for the diagnosis and treatment of keloid.

Hemodynamics and Vascular Histology of Keloid Tissues and Anatomy of Nearby Blood Vessels

Keloids are red' invasive scars that are driven by chronic inflammation in the reticular dermis. The role of blood vessels in keloid behavior remains poorly understood. In the present study with 32 keloid patients, we examined the hemodynamics of keloid tissue, the anatomy of the blood vessels feeding and draining the keloids, and the vascular histology of keloids.

Methods

Ten patients with large anterior chest keloids underwent near-infrared spectroscopy, which measured regional saturation of oxygen and total hemoglobin index in the keloid and surrounding skin. Another 10 patients with large chest keloids and three healthy volunteers underwent multidetector-low computed tomography. The extirpated chest keloids of 12 patients were subjected to histology with optical, CD31 immunohistochemical, and electron microscopy.

Results

All keloids had a low regional saturation of oxygen and a high total hemoglobin index, which is indicative of blood congestion. Multidetector-low computed tomography revealed dilation of the arteries and veins that were respectively feeding and draining the keloid leading edge. Hematoxylin-eosin staining and CD31 immunohistochemisty revealed considerable neovascularization in the keloid leading edge but not in the center. Electron microscopy showed that the lumens of many vessels in the keloid center appeared to be occluded or narrowed.

Conclusions

Keloids seem to be congested because of increased neovascularization and arterial inflow at the leading edge and blocked outflow due to vascular destruction in the center. The surrounding veins seem to expand in response to this congested state. Methods that improve the blood circulation in keloids may be effective therapies.

Surgical Considerations In Skin of Colour

For most clinicians undertaking surgery and patients undergoing surgery, the primary aim is the success of the operation being undertaken. The secondary aim is for optimal wound healing with minimal scar formation. The normal wound healing process involves four distinct but overlapping stages: Haemostasis, inflammation, proliferation and remodelling. In some patients the cellular process involved in the proliferation and remodelling stages can be deranged, resulting in the formation of hypertrophic or keloid scars. This is more frequently seen in skin of Colour. Excessive scarring is thought to be first described in the Smith papyrus about 1700 BC. Many years later Mancini (in 1962) and Peacock (in 1970) classified excessive scarring into hypertrophic and keloid scar formation. Clinicians can minimize the risk of these pathological scars developing with good pre-operative, peri-operative/intra-operative and post-operative surgical practices. We review the wound healing processes in association with good surgical principles and practice, discuss how implementing these principles in practice helps in prevention and management of pathological surgical scars such as hypertrophic scars and keloid scars. This review offers a practical step by step clinical guide that can be used by any clinician.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago

BACKGROUND

In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.

METHODS

All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.

RESULTS

Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.

CONCLUSIONS

Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.

A Case of Erythema Elevatum Diutinum (EED) Exhibiting A Keloid-Like Appearance

Introduction

Most severe-appearing keloids tend to occur around joints because of the increased extensional stimulation of the scar in those areas. However, erythema elevatum diutinum (EED) appears more commonly on friction sites including extensor surfaces of the extremities and dorsal surfaces of joints. EEDs also presents as red-brown and elevated lesions.

Case Presentation

In this report, we describe a 42-year-old female who presented with firm, sporadic, brown-colored raised nodules on her bilateral lower extremities. As the appearance of these nodules resembled keloids, resection of the affected area with subsequent radiation therapy was initiated. However, histopathologic examination performed after treatment revealed tuberous lesions in the dermis, increased wired collagen fibers, neutrophilic infiltrate with nuclear dust, and edematous endothelial cells in the small vessels. Consequently, the patient was later diagnosed with EED. Post-surgery, no recurrence or abnormal scars appeared.

Discussion

Whereas clinical findings of EED are similar to that of keloids, the mechanisms of the two conditions differ considerably, leading to varying management strategies. EEDs can be misdiagnosed as keloids on several grounds; they can both appear morphologically similar, exhibit as stiff lesions, demonstrate chronic inflammation of the reticular dermis, and appear anywhere on the body. The only definitive method of differentiating between the two is through histopathologic examination.

Conclusion

EED should be considered as one of the differential diagnoses for any patients presenting with keloid-like lesions on friction sites and biopsy should be performed prior to resection and radiotherapy.

Bioflavonoid Galangin Suppresses Hypertrophic Scar Formation by the TGF-β/Smad Signaling Pathway

Background

Hypertrophic scar (HS) is a benign fibroproliferative skin disease resulting from an aberrant wound healing process and can cause aesthetic and functional damage to patients. Currently, there is no ideal treatment to treat this disease. Galangin, a natural active bioflavonoid compound, is suggested to inhibit fibrosis and proliferation in certain cells.

Methods

In this study, we found Galangin could attenuate abnormal scar formation in an HS rabbit ear model. Additionally, the HE staining shows Galangin reduced scar elevation index (SEI) and Masson's trichrome staining changed collagen deposition.

Results

The expressions of type I collagen, type III collagen, and TGF-β1 were much lower under a proper dose of Galangin treatment, and Smad7 expression was also enhanced, which are examined by real-time PCR, immunohistochemistry, and western blot.

Conclusion

Our data indicated that Galangin can alleviate dermal scarring via the TGF-β/Smad signaling pathway probably by upregulating Smad 7 expression and, thus, suppressing the expression of type I and type III collagens and TGF-β1.

Mechanical and Immunological Regulation in Wound Healing and Skin Reconstruction

In the past decade, a new frontier in scarless wound healing has arisen because of significant advances in the field of wound healing realised by incorporating emerging concepts from mechanobiology and immunology. The complete integumentary organ system (IOS) regeneration and scarless wound healing mechanism, which occurs in specific species, body sites and developmental stages, clearly shows that mechanical stress signals and immune responses play important roles in determining the wound healing mode. Advances in tissue engineering technology have led to the production of novel human skin equivalents and organoids that reproduce cell–cell interactions with tissue-scale tensional homeostasis, and enable us to evaluate skin tissue morphology, functionality, drug response and wound healing. This breakthrough in tissue engineering has the potential to accelerate the understanding of wound healing control mechanisms through complex mechanobiological and immunological interactions. In this review, we present an overview of recent studies of biomechanical and immunological wound healing and tissue remodelling mechanisms through comparisons of species- and developmental stage-dependent wound healing mechanisms. We also discuss the possibility of elucidating the control mechanism of wound healing involving mechanobiological and immunological interaction by using next-generation human skin equivalents.

Corilagin alleviates hypertrophic scars via inhibiting the transforming growth factor (TGF)-β/Smad signal pathway

AIMS

Exploring the effects of corilagin on hypertrophic scar (HS) and its underlying mechanisms.

MAIN METHODS

Human HS-derived fibroblasts (HSFs) were isolated and treated with corilagin. To investigate the effects of corilagin on HSFs, quantitative real time polymerase chain reaction (qRT-PCR), western blotting, wound healing, and immunofluorescence assays were performed. These effects were confirmed in a rabbit ear scar model by histological and immunohistochemical studies. Lastly, western blot assay was performed to detect the protein levels of several components of the transforming growth factor (TGF)-β/Smad signaling pathway, as well as the protein levels of matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs).

KEY FINDINGS

Corilagin showed multiple effects on HSFs, including does-dependent inhibition of collagen production, cell proliferation, and migration, besides suppression of the activation of HSFs. Moreover, corilagin suppressed HS formation and collagen deposition in a rabbit ear scar model. Corilagin also inhibited fibroblast proliferation and α-smooth muscle actin (α-SMA) expression in vivo. Finally, western blot analysis revealed that corilagin downregulated the protein levels of TGF-β1 and TGF-β receptor type I (TGFβRI), thus lowering the level of p-smad2/3, also affected the protein levels of MMPs and TIMP1.

SIGNIFICANCE

Corilagin could be a potential agent for HS treatment through the inhibition of extracellular matrix (ECM) deposition and multiple functions of fibroblasts.

Assessment of various intralesional injections in keloid: Comparative analysis

AIM

Intralesional triamcinolone is a gold standard in treating the keloids to comparation its effectiveness versus intralesional 5-fluorouracil intralesional verapamil and intralesional platelet-rich plasma.

PATIENTS AND METHODS

Several 160-cases were categorized into four groups of each Group-Containing 40 cases. Group-A (control) treated with intralesional triamcinolone and Group-B intralesional verapamil, Group-C intralesional 5-fluorouracil, and Group-D intralesional platelet-rich plasma. Patients were assessed for clinical response based on a decrease in the patient and observer scar assessment scale (POSAS) at baseline and the end of treatment.

RESULTS

The mean base-line POSAS score was 91 ± 10.98 SD check-in Group-A, 90 ± 10.85 in Group-B, 89 ± 10.06 in Group-C, and 92 ± 10.84 in Group-D.POSAS score after 24 weeks 36 ± 12.74 in Group-A, 29 ± 10.91 in Group-B, 39 ± 13.74 in Group-C, 36 ± 12.74 in Group-D. Statistically, a significant difference was observed between groups.

CONCLUSION

Intralesional verapamil reported to be the most effective therapy and platelet-rich plasma was effective as intralesional triamcinolone acetonide with no serious side effects and 5-fluorouracil was less effective in treating the keloids.

The Roles of Inflammation in Keloid and Hypertrophic Scars

The underlying mechanisms of wound healing are complex but inflammation is one of the determining factors. Besides its traditional role in combating against infection upon injury, the characteristics and magnitude of inflammation have dramatic impacts on the pathogenesis of scar. Keloids and hypertrophic scars are pathological scars that result from aberrant wound healing. They are characterized by continuous local inflammation and excessive collagen deposition. In this review, we aim at discussing how dysregulated inflammation contributes to the pathogenesis of scar formation. Immune cells, soluble inflammatory mediators, and the related intracellular signal transduction pathways are our three subtopics encompassing the events occurring in inflammation associated with scar formation. In the end, we enumerate the current and potential medicines and therapeutics for suppressing inflammation and limiting progression to scar. Understanding the initiation, progression, and resolution of inflammation will provide insights into the mechanisms of scar formation and is useful for developing effective treatments.

Candidate rejuvenating factor GDF11 and tissue fibrosis: friend or foe?

Growth differentiation factor 11 (GDF11 or bone morphogenetic protein 11, BMP11) belongs to the transforming growth factor-β superfamily and is closely related to other family member-myostatin (also known as GDF8). GDF11 was firstly identified in 2004 due to its ability to rejuvenate the function of multiple organs in old mice. However, in the past few years, the heralded rejuvenating effects of GDF11 have been seriously questioned by many studies that do not support the idea that restoring levels of GDF11 in aging improves overall organ structure and function. Moreover, with increasing controversies, several other studies described the involvement of GDF11 in fibrotic processes in various organ setups. This review paper focuses on the GDF11 and its pro- or anti-fibrotic actions in major organs and tissues, with the goal to summarize our knowledge on its emerging role in regulating the progression of fibrosis in different pathological conditions, and to guide upcoming research efforts.

Tomotherapy as an Alternative Irradiative Treatment for Complicated Keloids

The aim of this study was to investigate the treatment of complicated keloids with helical tomotherapy (HT) and electron beam radiotherapy. From July 2018 to September 2018, 11 patients with 23 keloid lesions treated with HT were enrolled. Additionally, 11 patients with 20 lesions treated with electron beam radiotherapy in the same period were enrolled. Patients in both groups were treated within 24 h after surgical excision of the keloid lesion with 13.5 Gy in three consecutive daily fractions. The median follow-up period was 15 months. The local control rate was 91.3% and 80% in the HT group and the electron beam group, respectively. No acute adverse effects were observed in either group, but most patients exhibited pigmentation. No radiation-induced cancer occurred in these patients up to the time of this report. Pain and pruritus improved for all patients and more obviously for three patients with complicated keloids treated with HT. The measured surface dose was 103.7–112.5% and 92.8–97.6% of the prescribed dose in the HT group and the electron beam group, respectively. HT can be considered an alternative in cases where it is not feasible to use multiple electron fields, due to encouraging clinical outcomes.

Combination Therapy Composed of Surgery, Postoperative Radiotherapy, and Wound Self-management for Umbilical Keloids

A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection.

[Multicenter study of the effectiveness of antiscar therapy in patients at different age periods]

OBJECTIVE

Was to evaluate the effectiveness of anti-scar treatment with Contractubex gel in children and adults.

MATERIAL AND METHODS

A group of researchers based on clinical hospitals and university medical clinics carry out the multicenter study to evaluate the effectiveness of anti-scar treatment with Contractubex gel containing cepalin, allantoin and heparin, with its early appointment in groups of children from 12 to 18 years old and adults from 21 to 35 years old. The study included data from 216 patients. Patients of both age groups were initially divided into two: the main and control ones with an equal distribution according to the type of surgical intervention (hernia repair and appendectomy), age, gender, and anamnestic data. The dynamic observation was carried out using two rating scales - filled out by a doctor (Vancouver scale) and a patient (author's rating scale in the Scar Diary mobile application).

RESULTS

Based on the results of the analysis of the data obtained, a high efficiency of the use of Contractubex gel at the early stages of scar formation among patients of the main group in comparison with the control was revealed. By 90 days, the treatment result according to the Vancouver scale was 0,16±0,1 points in the main group and 0,39±0,2 points in the control group. At the same time, with a dynamic scale for assessing the cicatricial process, there was a significant (p<0.05) improvement in the main group (0,2±0,06 points) compared with the control group (0,6±0,17 points). In addition, was noticed the strong commitment to anti-scar treatment in pediatric patients.

CONCLUSIONS

The work confirms the undoubted need for anti-scar treatment in the early stages of scar formation after surgical interventions, which accelerates the psychophysical rehabilitation of patients after surgery and improves the quality of life.

Keloids: a review of therapeutic management

Keloid scar formation arises from a disorganized fibroproliferative collagen response that extends beyond the original wound margins because of excessive production of extracellular matrix (ECM). Despite treatment options for keloid scars including medical and surgical therapies, such as intralesional steroid injection and surgical excision, the recurrence rate remains high. Herein we consolidate recently published narrative reviews, systematic reviews, and meta-analyses to provide an overview of updated treatment recommendations for keloidal scar formation. PubMed search engine was used to access the MEDLINE database to investigate updates regarding keloid incidence and treatment. More than 100 articles were reviewed. Keloid management remains a multimodal approach. There continues to be no gold standard of treatment that provides a consistently low recurrence rate; however, the increasing number of available treatments and synergistic combinations of these treatments (i.e., laser-based devices in combination with intralesional steroids, or 5-fluorouracil (5-FU) in combination with steroid therapy) is showing favorable results. Future studies could target the efficacy of novel treatment modalities (i.e., autologous fat grafting or stem cell-based therapies) for keloid management. This review article provides updated treatment guidelines for keloids and discusses insight into management to assist patient-focused, evidence-based clinical decision making.

The Latest Strategy for Keloid and Hypertrophic Scar Prevention and Treatment: The Nippon Medical School (NMS) Protocol

In 2006, we established a scar/keloid-specialized unit in the Department of Plastic, Reconstructive, and Aesthetic Surgery at Nippon Medical School (NMS) in Tokyo, Japan. In the ensuing 15 years, we treated approximately 2,000 new scar/keloid patients annually. This extensive experience has greatly improved the efficacy of the treatments we offer. Therefore, we discuss here the latest NMS protocol for preventing and treating keloids and hypertrophic scars. While this protocol was optimized for Japanese patients, our experience with a growing body of non-Japanese patients suggests that it is also effective in other ethnicities. The extensive evidence-based experience underlying the NMS protocol suggests that it may be suitable as the foundation of a standard international prevention/treatment algorithm for pathological scars.

Where do you insert a drain tube during breast reconstruction?

PURPOSE

A drain tube is commonly inserted during breast reconstruction surgery. This leads to a scar in addition to the scar on the breast. This study was performed to investigate how patients feel about the drain scar and to clarify its ideal location.

METHODS

A questionnaire survey about the drain scar was distributed to 38 consecutive breast reconstruction patients and a total of 104 female doctors and nurses engaged in breast reconstruction. The drain scars were evaluated using the Japan Scar Workshop (JSW) Scar Scale.

RESULTS

A total of 32% of the patients expressed some anxiety about the drain scar. Patients who were anxious about the drain scar had higher scores on the JSW Scar Scale than those who were not anxious. Younger doctors and nurses preferred the drain scar to be on the side of the chest, while older doctors and nurses preferred the drain scars to be at the axilla.

CONCLUSIONS

About a third of the patients had some anxiety associated with their drain scar after breast reconstruction surgery, and this anxiety level was correlated with objective assessment of the scar. Thus, more patient involvement or the provision of more information regarding drain placement is required.

Hypertrophic scars and keloids: a review and current treatment modalities

Hypertrophic scars (HTS) are raised, red, rigid, inflexible cell-like, and cosmetic problems precipitated due to multiple underlying dermal injuries such as burn, surgery, and trauma during which aberrant wound healing with more pathological deposition of the extracellular matrix than degradation leads to their spawning. Till date, well established and specific treatments for HTS have not been reported; hence, the need of recent developments is thrusted with novel drug delivery vision. This review will try to encompass all the agogs to HTS, definition, pathophysiology, mechanism of hypertrophic scar formation, the role of growth factors in hypertrophic scarring, and their difference with keloids. Further, it will illuminate the available medicaments and recent advances in novel topical drug delivery systems such as ethosomes, transethosomes, liposomes, solid lipid nanoparticles, and microsponges for treatment of HTS.

The Immunosuppressant Fingolimod (FTY720) for the Treatment of Mechanical Force-Induced Abnormal Scars

Aim

Abnormal scars such as hypertrophic scars (HSs) and keloids are excessively growing scars that exhibit chronic inflammation and capillary vasculogenesis. The lipid mediator sphingosine-1-phosphate (S1P) is important in inflammatory cell recruitment and angiogenesis. Fingolimod (FTY720) is an analog of S1P and thus functionally antagonizes S1P receptors and inhibits the enzyme that produces S1P. We examined the effects of topical FTY720 injections on mechanical force-induced HS progression.

Methods

Mechanical force-induced HSs were generated in C57BL6/J mice by suturing a dorsal incision and applying a stretching device on Days 6, 8, 10, and 12. On Days 8, 10, and 12, intracutaneous FTY720 (10 μM) or control vehicle injections were performed. On Day 14, scar tissues and blood were procured and subjected to histology and flow cytometry.

Results

Flow cytometry showed that FTY720 decreased the frequencies of macrophages with M2 predominance in the scars but had no effect on total, CD4⁺, or CD8a⁺ T cell frequencies. FTY720 also decreased the vascular endothelial cell frequencies in the scar along with the microvessels, as determined by immunohistochemistry. Compared to the vehicles, FTY720 treatment significantly reduced the gross scar area and the cross-sectional scar area on histology. On the other hand, FTY720 tended to reduce white blood cells and significantly reduced the lymphocyte frequencies in the blood.

Conclusion

Topical FTY720 induces M2 predominance and impairs angiogenesis. Therefore, its local immunosuppressive mechanisms differ from those of conventional immunosuppressive agents. Topical FTY720 can be a novel therapeutic option for abnormal scars that are difficult to control with corticosteroids. Its lymphocytopenic effects may be limited by careful optimization of the treatment regimen.

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.

Sex Differences in Keloidogenesis: An Analysis of 1659 Keloid Patients in Japan

INTRODUCTION

Keloids are a cutaneous fibroproliferative disorder. Despite the fact that keloids are relatively common lesions, the statistics of patient with keloids especially sex difference remain unknown. To better understand it, we conducted an extensive cross-sectional analysis of a large cohort of patients with keloids (n = 1659). The study showed for the first time that female sex may be an inherent keloid risk factor.

METHODS

This cross-sectional study of 1659 consecutive patients with keloids who attended a plastic surgery outpatient clinic in Japan in 2014 analyzed age at keloid onset, age at the first medical examination for keloid, and the influence of sex on these variables.

RESULTS

In both male and female patients, the keloids were most likely to start in puberty and there was no significant difference in the mode value for age of onset (16 vs. 20 years). Though female patients were twice as prevalent as male patients at nearly all onset ages, female patients predominated over male patients with a gender ratio of 2.7:1 in cases of onset before the age of 15 years. Moreover male and female patients did not differ in terms of the mean ± SD duration between keloid onset and the first medical examination. This finding shows that female patients do not get their keloids examined earlier than male patients. These observations together suggest that female sex may promote early keloid development due to physiological, not social, reasons.

CONCLUSION

This is the first report to suggest that female sex may drive keloidogenesis because of physiological reasons. Individuals were most likely to seek a medical examination almost 10 years after onset, regardless of sex. These findings provide new insight into the importance of sex in the development and progression of keloids. Future studies should address the influence of sex hormones on the keloid.

Z-plasty and Postoperative Radiotherapy for Upper-arm Keloids: An Analysis of 38 Patients

Therapies for upper arm keloids include surgical excision followed by postoperative radiotherapy, silicone tape stabilization, and steroid plaster. However, a universally accepted therapeutic strategy for upper-arm keloids is lacking.