Results of a combination of bleomycin and triamcinolone acetonide in the treatment of keloids and hypertrophic scars

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.

Combining scar-modulating agents for the treatment of hypertrophic scars and keloids: A systematic review

Injury to the skin can cause abnormal wound healing and continuous inflammation that leads to the formation of hypertrophic scars and keloids. These lesions often cause significant negative impact on a patient's life due to aesthetic, physical, social, and psychological consequences. Numerous treatment modalities exist for these hypertrophic scars and keloids, which include silicone sheeting, pressure garments, intralesional injection/topical application of scar-modulating agents, laser therapy, and surgical excision. Due to increased efficacy, an evolving treatment paradigm encourages the use of multiple treatment modalities instead of one treatment modality. However, no gold standard treatment exists for these lesions, leaving many people with unsatisfactory results. Adding scar-modulating agents such as 5-Fluorouracil, bleomycin, or Botulinum Toxin A to triamcinolone monotherapy has emerged as a potential drug combination for treating hypertrophic scars and keloids. We sought to critically analyze the evidence that exists for the use of more than one scar-modulating agent. This was done by conducting a systematic review to determine the efficacy of these combined drug regimens. We found that many of these combinations show evidence of increased efficacy and fewer/similar adverse events to triamcinolone monotherapy. Triamcinolone and 5-Fluorouracil showed the strongest and most consistent evidence out of all combinations. With this review, we intend to encourage more research into unique drug combinations that may improve outcomes for patients with symptomatic hypertrophic scars or keloids.

Recurrence rates in the treatment of keloids and hypertrophic scars with intralesional triamcinolone combined with other intralesional agents

Hypertrophic scars (HTS) and keloids are pathologic scars that are products of a wound healing pathway error attributed to genetic and inflammatory causes (Leventhal et al., Arch Facial Plast Surg 8(6):362-368. https://doi.org/10.1001/archfaci.8.6.362 , 2006). Methods of pathologic scar treatment include intralesional agents, cryotherapy, surgical excision, pressure dressings, topical agents, laser resurfacing, radiotherapy, and other investigational therapies (Leventhal et al. 2006). The recurrence of pathologic scar is high across all treatment modalities, including the use of intralesional agents (Trisliana Perdanasari et al., Arch Plast Surg 41(6):620-629. https://doi.org/10.5999/aps.2014.41.6.620 , 2014). In the treatment of pathologic scar, combination approaches using intralesional agents, such as triamcinolone (TAC), 5-fluorouracil (5FU), verapamil (VER), bleomycin (BLM), and botulinum toxin (BTX), are superior therapies when compared to monotherapy (Yosipovitch et al., J Dermatol Treat 12(2):87-90. https://doi.org/10.1080/095466301317085363 , 2001; Yang et al., Front Med 8:691628. https://doi.org/10.3389/fmed.2021.691628 , 2021; Sun et al., Aesthetic Plast Surg 45(2):791-805. https://doi.org/10.1007/s00266-019-01570-8 , 2021). This review assesses recurrence and the reporting of recurrence in pathologic scar after treatment with intralesional triamcinolone (TAC) in combination with another intralesional agent. A literature review was conducted using research journals from PubMed using the following search terms: [(keloid) AND (triamcinolone) AND (combination) AND (intralesional)], as well as [(keloid) AND (triamcinolone) AND (combination)]. Articles were reviewed and included if the article analyzed  or compared intralesional agents for pathologic scar treatment within the last 10 years. The average follow-up period of included articles (n = 14) that utilized combination intralesional therapy (TAC-X) was approximately 11 months (range 1-24 months). Consistent recurrence rate reporting across studies was lacking. The combination agent with the highest recurrence rate was TAC-5FU (23.3%). The range of reported recurrence rates was 7.5-23.3%. Six studies using various intralesional combination regimens reported 0% recurrence over the follow-up period (TAC-5FU, TAC-BTX, TAC-BLM, TAC-CRY). Three studies did not report recurrence rates. While the efficacy of combination therapy is typically assessed via scar scales, the assessment of recurrence across studies of combination therapy is inconsistent and inadequate, with truncated follow-up periods. While scar recurrence can take place during 1-year post-treatment, long-term follow-up (18-24 months) is needed to characterize recurrence in the treatment of pathologic scar using various intralesional agents. Long-term follow-up periods allow patients to receive accurate prognostic information regarding recurrence after combination intralesional therapy. There are limitations to this review in that comparisons were made across studies with varying outcome variables, including scar size, injection concentration and interval, and follow-up period. Standardized follow-up periods and recurrence rate reporting are integral to furthering the understanding of these therapies and enhancing patient care.

Local application of triamcinolone acetonide-conjugated chitosan membrane to prevent benign biliary stricture

Benign biliary stricture (BBS) is the proliferation of fibrous tissue of the biliary tract caused by the biliary operation, bile duct stones, cholangitis, trauma, and other etiologies due to scar contracture. Recent therapeutic strategies to suppress stenosis are insufficient. Here, we developed a sustained-release membrane (SM) of triamcinolone acetonide (TA) with N-succinyl hydroxypropyl chitosan (TASM) for inhibiting fibroblast proliferation in vitro and bile duct hyperplasia in the rabbit model for benign biliary stricture formation. The TASM were successfully placed in 45 of 50 rabbits. Evaluation of subcutaneous stimulation and acute liver injury confirms the safety of TASM in vivo. Compared to the control group, the TASM can significantly inhibit the proliferation of scar muscle fibroblasts in vitro. ELISA and immunofluorescence showed TASM could increase bFGF level and inhibit expression of TGFβ1 and αSMA. Cholangiographic and histologic examinations demonstrated significantly decreased tissue hyperplasia in the TASM groups compared with the model group. The immunohistochemical staining showed that TASM could reduce the level of cytokine-induced scars and inhibit the proliferation of myofibroblasts. Taken together, the chitosan membrane chemically conjugated with TA can effectively inhibit the benign biliary stricture. Further clinical usage of this membrane may effectively reduce the occurrence of benign biliary stricture.

Dual drug delivery collagen vehicles for modulation of skin fibrosisin vitro

Single molecule drug delivery systems have failed to yield functional therapeutic outcomes, triggering investigations into multi-molecular drug delivery vehicles. In the context of skin fibrosis, although multi-drug systems have been assessed, no system has assessed molecular combinations that directly and specifically reduce cell proliferation, collagen synthesis and transforming growth factor β1 (TGFβ1) expression. Herein, a core-shell collagen type I hydrogel system was developed for the dual delivery of a TGFβ trap, a soluble recombinant protein that inhibits TGFβ signalling, and Trichostatin A (TSA), a small molecule inhibitor of histone deacetylases. The antifibrotic potential of the dual delivery system was assessed in an in vitro skin fibrosis model induced by macromolecular crowding (MMC) and TGFβ1. SDS-PAGE and HPLC analyses revealed that ~ 50 % of the TGFβ trap and ~ 30 % of the TSA were released from the core and shell compartments, respectively, of the hydrogel system after 10 days (longest time point assessed) in culture. As a direct consequence of this slow release, the core (TGFβ trap) / shell (TSA) hydrogel system induced significantly (p < 0.05) lower than the control group (MMC and TGFβ1) collagen type I deposition (assessed via SDS-PAGE and immunocytochemistry), α smooth muscle actin (αSMA) expression (assessed via immunocytochemistry) and cellular proliferation (assessed via DNA quantification) and viability (assessed via calcein AM and ethidium homodimer-I staining) after 10 days in culture. On the other hand, direct TSA-TGFβ supplementation induced the lowest (p < 0.05) collagen type I deposition, αSMA expression and cellular proliferation and viability after 10 days in culture. Our results illustrate the potential of core-shell collagen hydrogel systems for sustained delivery of antifibrotic molecules.

Treatment of Keloids: A Meta-analysis of Intralesional Triamcinolone, Verapamil, and Their Combination

Keloids are skin lesions of abnormal and excessive scar proliferation that have no agreed upon gold standard of therapy. Extensive research in this area has shown that both intralesional triamcinolone and verapamil are effective in their treatment.

The effectiveness of long Pulsed Nd:YAG Laser alone for treatment of keloids and hypertrophic scars versus its combination with bleomycin

BACKGROUND AND OBJECTIVES

Pathological scars are benign hyper-proliferative growths of dermal collagen that causes severe psychological and physical problems. This study was performed to assess and compare safety and clinical efficiency of combined pulsed Nd-YAG laser and intralesional bleomycin versus pulsed Nd-YAG laser alone to treat the hypertrophic scars and keloids.

PATIENTS AND METHODS

Randomly, 40 patients with hypertrophic scars or keloids were divided into two groups A and B. Group A were handled by pulsed Nd:YAG laser and intralesional bleomycin while group B were handled by pulsed Nd:YAG laser only. Response was assessed subjectively by clinical imaging and modified Vancouver Scar Scale (mVSS). While for objective evaluation, skin biopsies were taken from volunteer patients before and after treatment, and were examined by Hematoxylin and eosin staining (H&E) and Masson trichrome staining.

RESULTS

Our study demonstrated almost complete improvement in 4 (20%) patients, partial improvement in 16 (80%) patients and 0 patient with no improvement in group A. Furthermore, in group B, we demonstrated almost complete improvement in 2 (10%) patients, partial in 14 (70%) patients and no improvement in 4 (20%) patients. Modified Vancouver Scar Scale reduced from 10.15 to 3.5 in group A and from 11.05 to 4.95 in group B. Elastica Masson-Goldner staining and Hematoxylin and eosin staining showed that treatment in both groups structurally changed tissue collagen.

CONCLUSION

Long-pulsed Nd-YAG laser combined with intralesional bleomycin could be a promising way for treatment of keloids or hypertrophic scars.

Treatment of Small Keloids Using Intralesional 5-fluorouracil and Triamcinolone Acetonide versus Intralesional Bleomycin and Triamcinolone Acetonide

BACKGROUND: The aberration of wound healing leads to scar formation in the form of hypertrophic scars and keloids. Various modalities with variable results have been used in the treatment of keloids. OBJECTIVE: We sought to evaluate outcomes in the treatment of small keloids with the combination of intralesional 5-fluorouracil (5-FU) and triamcinolone acetonide versus intralesional bleomycin and triamcinolone acetonide. DESIGN: Sixty clinically diagnosed keloid lesions in 40 patients aged 18 to 60 years were divided equally into Groups A (n=30) and B (n=30). The combination of intralesional 5-FU and triamcinolone acetonide (TAC) was given to Group A and the combination of intralesional bleomycin and triamcinolone acetonide was given to Group B. Treatment was repeated in both groups at three-week intervals until keloid flattening was achieved or a maximum of 10 treatments were completed. Before treatment, the lesions were assessed using the Vancouver Scar Scale and their size was measured using vernier calipers. RESULTS: In Group A, 15 (50%) keloids showed an excellent response, 10 (33.33%) keloids showed a good response, three (10%) keloids showed a fair response, and two (6.66%) keloids showed a poor response. In Group B, 23 (76%) keloids showed an excellent response, three (10%) keloids showed a good response, two (6.66%) keloids showed a fair response, and two (6.66%) keloids showed a poor response. CONCLUSION: Patient response regarding treatment duration, flattening of lesions, improvements in the Vancouver Scar Scale score, and recurrence rates were statistically significant in Group B. A greater improvement in the signs and symptoms of keloids (with respect to cosmetic problems, restriction of movement, and tenderness) was observed in the patients treated with a combination of intralesional bleomycin and triamcinolone acetonide compared to those treated with a combination of intralesional 5-FU and triamcinolone acetonide.

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

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

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.

Autologous adipose tissue grafting for the management of the painful scar

BACKGROUND AIMS

There is currently no definitive treatment for the painful scar. Autologous adipose tissue grafting (AATG) as a treatment option for scars has become increasingly popular and there is now an abundance of evidence in the literature that supports its application. Some studies suggest that human adipose tissue is a rich source of multipotent mesenchymal stromal cells. To our knowledge, there is currently no systematic literature review to date that examines the effectiveness of AATG for reducing pain in scars. Our novel systematic review aims to examine clinical studies on the use of AATG in the treatment of the painful scar.

METHODS

A literature search was performed using the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Medline, Cochrane library and Embase. The following key words and search terms were used: adipose stem cells, scar, pain, autologous fat grafting, scar management and neuropathic pain. Human interventional studies using autologous adipose tissue grafting for the treatment of painful scars including case series, case-control, cohort studies and randomized controlled trials were reviewed.

RESULTS

A total of 387 studies were found and 18 studies from January 1990 to January 2019 were identified as relevant for the purpose of this systematic review. Two studies were evidence level V, seven were evidence level IV, six were evidence level III, two were evidence level II and one was level I. A total of 337 scars were assessed in 288 patients for improvement in pain after scar treatment using adipose tissue grafting. An improvement in the analgesic effect was recorded in 12 of the 18 studies with adipose tissue grafting. A total of 233 of the 288 treated subjects responded with reduction in pain, whereas the rest did not. We carried out a pooled analysis of the studies and observed an odds ratio of 3.94 (P = 0.00001) when comparing pain reduction to no change in pain.

CONCLUSIONS

We conclude that AATG is a promising and safe modality for the treatment of the painful scar. There is an abundance of low-level evidence to support its use as an alternative treatment but there is a lack of high-level evidence at present to support its standard use. Future long-term randomized controlled trials with analgesic scores as the primary outcome measures are required to assess long-term efficacy.

Current and upcoming therapies to modulate skin scarring and fibrosis

Skin is the largest organ of the human body. Being the interface between the body and the outer environment, makes it susceptible to physical injury. To maintain life, nature has endowed skin with a fast healing response that invariably ends in the formation of scar at the wounded dermal area. In many cases, skin remodelling may be impaired, leading to local hypertrophic scars or keloids. One should also consider that the scarring process is part of the wound healing response, which always starts with inflammation. Thus, scarring can also be induced in the dermis, in the absence of an actual wound, during chronic inflammatory processes. Considering the significant portion of the population that is subject to abnormal scarring, this review critically discusses the state-of-the-art and upcoming therapies in skin scarring and fibrosis.

Managing Pathologic Scars by Injecting Auto-Cross-linked Hyaluronic Acid: A Preliminary Prospective Clinical Study

BACKGROUND

Pathological scars are unattractive and may significantly impair the patient's quality of life. Current treatments provide inconsistent results, and none may be regarded as definitive. Recently, an auto-cross-linked hyaluronic acid (HA) formulation, IAL-SYSTEM ACP, featuring a long residence time and an enhanced safety profile, has been successfully used to prevent surgical adhesions, treat tendon lesions and rejuvenate the face and the décolletage. This study aims to preliminarily investigate whether IAL-SYSTEM ACP may also be effective in treating pathological scars resulting from burns, trauma or iatrogenic causes.

METHODS

Patients presenting one pathological scar were prospectively recruited and treated with two IAL-SYSTEM ACP injections carried out two weeks apart. Scar improvement was measured comparing the patient and observer scar assessment scale (POSAS) scores collected before treatment (T0) and 90 days after the second injection (T90) using nonparametric tests. The effect of age and scar type over score variation was investigated through quantile regression analysis.

RESULTS

Forty-one patients, 10 women and 31 men (median age, 34 years) were recruited. No patient dropped out, and no significant adverse event was observed. At T90, the median observer total score decreased by 11 units (- 77.5%) and the median patient total score decreased by 15 units (- 73.7%). The difference was significant (p < 0.001) in both cases. Traumatic injuries and young patient's age were the most significant predictors of a positive treatment outcome.

CONCLUSIONS

Treatment of pathological scars by two IAL-SYSTEM ACP injections, carried out two weeks apart, may provide significant clinical benefits. These findings should be the subject of further investigations.

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 .

Managing keloid scars: From radiation therapy to actual and potential drug deliveries

The aetiology of keloids is becoming clearer, but many questions remain, including about the most optimal treatment. Current therapies include surgical excision, radiotherapy, and various pharmaceutical drugs. However, none of these drugs are keloid-specific. Moreover, all current interventions are associated with high recurrence rates. Here, we review the pharmaceutical interventions that are currently available. All are based on the fact that keloids are an expanding solid mass with intense chronic inflammation at its advancing edges. Consequently, current pharmaceuticals aim to reduce the mass and/or symptoms of keloids, similar to surgery and radiotherapy. They include chemotherapies, immunotherapies, volume-reducing therapies, and anti-inflammatory therapies. We also describe new advances in keloid pharmaceuticals. They include drugs that were designed to treat systemic diseases such as hypertension or breast cancer but were found to also treat keloids. Furthermore, recent progress in genetic, epigenetic, and stem cell therapies suggests that they could become useful in the keloid field. This review of pharmaceutical advances will hopefully promote additional research and the development of effective and specific pharmaceuticals for keloids.

Keloids and Hypertrophic Scars: A Spectrum of Clinical Challenges

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

Recent developments in the use of intralesional injections keloid treatment

Keloid scars are often considered aesthetically unattractive and frustrating problems that occur following injuries. They cause functional and cosmetic deformities, displeasure, itching, pain, and psychological stress and possibly affect joint movement. The combination of these factors ultimately results in a compromised quality of life and diminished functional performance. Various methods have been implemented to improve keloid scars using both surgical and non-surgical approaches. However, it has proven to be a challenge to identify a universal treatment that can deliver optimal results for all types of scars. Through a PubMed search, we explored most of the literature that is available about the intralesional injection treatment of hypertrophic scars and keloids and highlights both current (corticosteroid, 5-fluorouracil, bleomycin, interferon, cryotherapy and verapamil) and future treatments (interleukin-10 and botulinum toxin type A). The reference lists of retrieved articles were also analysed. Information was gathered about the mechanism of each injection treatment, its benefits and associated adverse reactions, and possible strategies to address adverse reactions to provide reliable guidelines for determining the optimal treatment for particular types of keloid scars. This article will benefit practitioners by outlining evidence-based treatment strategies using intralesional injections for patients with hypertrophic scars and keloids.