Control of the skin scarring response

Roles of calcitonin gene-related peptide in the skin, and other physiological and pathophysiological functions

Skin immunity is regulated by many mediator molecules. One is the neuropeptide calcitonin gene-related peptide (CGRP). CGRP has roles in regulating the function of components of the immune system including T cells, B cells, dendritic cells (DCs), endothelial cells (ECs), and mast cells (MCs).

Herein we discuss actions of CGRP in mediating inflammatory and vascular effects in various cutaneous models and disorders.

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CGRP can help to recruit immune cells through endothelium-dependent vasodilation.

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CGRP plays an important role in the pathogenesis of neurogenic inflammation.

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Functions of many components in the immune system are influenced by CGRP.

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CGRP regulates various inflammatory processes in human skin by affecting different cell-types.

Pathologic Scarring after Eyebrow Micropigmentation: A Case Report and Systematic Review

BACKGROUND

Skin tattooing and cosmetic eyebrow definition and reshaping (micropigmentation) have been growing exponentially in popularity. The pigment used in these procedures can activate the skin's inflammatory response, promoting the formation of pathologic scars.

OBJECTIVE

To carry out a systematic review of the literature on this topic and report a case of pathologic scarring on the eyebrows after micropigmentation.

METHODS

A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline in the MEDLINE, Lilacs, and SciELO databases using the keywords "scar; scar, hypertrophic; eyebrows; pigmentation; skin pigmentation; coloring agents; tattooing" and their synonyms.

RESULTS

The systematic literature review did not identify any study reporting pathologic scarring on eyebrows after micropigmentation. This is likely because eyebrow pathology is uncommon, although these results are limited by the comprehensiveness of the systematic review. The case of a 50-year-old woman undergoing eyebrow micropigmentation who presented with hypertrophic scarring after the procedure is also reported.

CONCLUSIONS

Eyebrow micropigmentation may be a risk factor for pathologic scarring, but further research is needed.

Electric Factors in Wound Healing

Significance: Electric factors such as electric charges, electrodynamic field, skin battery, and interstitial exclusion permeate wound healing physiology and physiopathology from injury to re-epithelialization. The understanding of how electric factors contribute to wound healing and how treatments may interfere with them is fundamental for the development of better strategies for the management of pathological scarring and chronic wounds. Recent Advances: Angiogenesis, cell migration, macrophage activation hemorheology, and microcirculation can interfere and be interfered with electric factors. New treatments with various types of electric currents, laser, light emitting diode, acupuncture, and weak electric fields applied directly on the wound have been developed to improve wound healing. Critical Issues: Despite the basic and clinical development, pathological scars such as keloids and chronic wounds are still a challenge. Future Directions: New treatments can be developed to improve skin wound healing taking into account the influence of electrical charges. Monitoring electrical activity during skin healing and the influence of treatments on hemorheology and microcirculation are examples of how to use knowledge of electrical factors to increase their effectiveness.

High in situ mRNA levels of IL-22, TFG-β, and ARG-1 in keloid scars

Keloid scars are currently considered a chronic inflammatory process and no longer a benign skin tumor. Keloids are defined as highly inflamed, hyperproliferative pathological scars. Growth factors and cytokines have important functions in the keloid inflammatory etiopathogenesis. The aim of this study was to analyze the in situ expression of cytokines and growth factors in keloid scars in comparison with that in normal scars. Among them, we specifically assessed TGF-β, FGF, IL-33, IL-22, ARG-1, ARG-2, iNOS, VIP, VIP-R1, TAC, and TAC-R1. A total of 98 biopsies were evaluated, including of 53 keloid and 45 normal scars. The age of patients with keloids ranged from 11 to 73 years, with a mean age of 28 years and predominance of the female gender (58.5% of the total patients). Around 64.15% of the patients belonged to the black ethnic group. Evaluated keloids were most commonly located in the earlobe because of ear piercing, representing 73.6% of the cases. We found significantly greater expression of TGF-β, IL-22, and ARG-1 in keloids when compared with that in normal scars. As for IL-33, ARG-2, and VIP-R1, despite the higher number of mRNA copies found in keloids, this difference was not significant. Furthermore, FGF, iNOS, VIP, TAC, and TAC-R1 mRNA levels were not detectable, and therefore these results were inconclusive in this study. Considering these results, understanding the cellular and molecular mechanisms that control the inflammatory response during cutaneous healing may promote the development of strategies to improve the treatment of patients with keloids.

Keloid negatively affects body image

BACKGROUND/OBJECTIVES

Keloid is a healing disorder that occurs exclusively in humans. This pathology is considered a benign cicatricial neoplasm, whose physiopathogenesis has not yet completely clarified. Its disfiguring appearance often could potentially cause a disturbance in the patient regarding his/her body image. The objective is to evaluate the impact of keloid on body image.

METHODS

61 patients with keloid in socially exposed regions of the body were included. The participants were submitted to clinical evaluation, composed of anamnesis and physical examination, and answered two questionnaires: the Body Dysmorphic Symptoms Scale (BDSS) questionnaire and the Rosenberg Self-Esteem Scale - Unifesp/EPM.

RESULTS

Forty percent of the patients had negative aspects of body image (BDSS score≥6). The scores of these patients on the Rosenberg Scale reached an average of 10.5 (p<0.03).

CONCLUSIONS

The presence of a keloid negatively affects body image.

Gene Expression of Neurotrophins and Their Receptors in Keloids

The aim of this study was to assess gene expression of neurotrophins and their receptors in keloids. Skin samples of normal skin and keloids were obtained from patients in the control (n = 12) and keloid (n = 12) groups, respectively. Ribonucleic acid was extracted from the skin specimens, purified, evaluated by spectrophotometry, and used to synthesize complementary DNA. Real-time quantitative polymerase chain reaction analysis of 84 human neurotrophin genes and their receptors was performed. Twelve genes, including heat shock 27-kDa protein 1, gastrin-releasing peptide receptor, corticotropin-releasing hormone receptor 2, neuropeptide Y Y2 receptor, interleukin 6 signal transducer, nerve growth factor, metallothionein 3, B-cell chronic lymphocytic leukemia/lymphoma 2, cholecystokinin A receptor, persephin, galanin receptor 2, and fibroblast growth factor receptor 3, were down-regulated in keloid tissue compared with normal skin. The genes 27-kDa heat shock protein 1, gastrin-releasing peptide receptor, corticotropin-releasing hormone receptor 2, nerve growth factor, metallothionein 3, B-cell chronic lymphocytic leukemia/lymphoma 2, and persephin protein were considered priority genes associated with keloid formation.

Are the skin scar characteristics and closure of the parietal peritoneum associated with pelvic adhesions?

Objective:

To assess whether the abdominal scar characteristics and closure of the peritoneum were associated with pelvic adhesions.

Materials and Methods:

Patients who had undergone cesarean section between December 2015 and February 2016 were assessed prospectively in terms of age, gravida, body mass index, number of living children, number of cesarean sections, time passed since the last cesarean section, closure status of the peritoneum in the last cesarean section, presence of other diseases, smoking status, location of incision in the abdomen (medial, pfannenstiel) scar dimensions (length, width), scar status with respect to skin (hypertrophic, flat, depressive), scar color [color change/no color change (hyperpigmented/hypopigmented)], adhesion of bowel-omentum-uterus, omentum-anterior abdominal wall, uterus-anterior abdominal wall, uterus-bladder, bladder-anterior abdominal wall, fixed uterus, and uterus-omentum-anterior abdominal wall in abdominal exploration.

Results:

One hundred five pregnant women who had undergone previous ceserean section surgery by the same physician, were at least in their 30th gestational week, had surgery notes about their previous operation, and had no chronic diseases were included in the study. Age, gravida, body mass index, number of children, number of cesarean sections, time passed since the previous cesarean section, closure/non-closure of peritoneum in the previous cesarean section, and smoking status had no effect on pelvic adhesions. Intraabdominal adhesion was not found to be associated with scar length [odds ratio (OR): 1.54, 95% confidence interval (CI): 1.1-2.2; p=0.02], depressive scar (OR: 9.3, 95% CI: 3.2-27.2; p<0.001), or hypopigmented scar [OR: 0.01, 95% CI: 0.003-0.11; p<0.001].

Conclusion:

Adhesions following surgical operations are of great importance due to complications for the patient, complications in relaparotomy, and high costs. Depressive and hypopigmented abdominal scars may be associated with pelvic adhesions. We believe that closure or non-closure of the parietal peritoneum is not associated with pelvic adhesions.

A research design for the quantification of the neuropeptides substance p and calcitonin gene-related Peptide in rat skin using Western blot analysis

OBJECTIVE

To describe and standardize a protocol that overcomes the technical limitations of Western blot (WB) analysis in the quantification of the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) following nociceptive stimuli in rat skin.

DESIGN

Male Wistar rats (Rattus norvegicus albinus) weighing 250 to 350 g were used in this study. Elements of WB analysis were adapted by using specific manipulation of samples, repeated cycles of freezing and thawing, more thorough maceration, and a more potent homogenizer; increasing lytic reagents; promoting greater inhibition of protease activity; and using polyvinylidene fluoride membranes as transfer means for skin-specific protein. Other changes were also made to adapt the WB analysis to a rat model.

SETTING

University research center.

MAIN OUTCOME MEASURE

Western blot analysis adapted to a rat model.

RESULTS

This research design has proven effective in collecting and preparing skin samples to quantify SP and CGRP using WB analysis in rat skin.

CONCLUSION

This study described a research design that uses WB analysis as a reproducible, technically accessible, and cost-effective method for the quantification of SP and CGRP in rat skin that overcomes technical biases.

Transcriptome Analysis of Ullrich Congenital Muscular Dystrophy Fibroblasts Reveals a Disease Extracellular Matrix Signature and Key Molecular Regulators

Background

Collagen VI related myopathies encompass a range of phenotypes with involvement of skeletal muscle, skin and other connective tissues. They represent a severe and relatively common form of congenital disease for which there is no treatment. Collagen VI in skeletal muscle and skin is produced by fibroblasts.

Aims & Methods

In order to gain insight into the consequences of collagen VI mutations and identify key disease pathways we performed global gene expression analysis of dermal fibroblasts from patients with Ullrich Congenital Muscular Dystrophy with and without vitamin C treatment. The expression data were integrated using a range of systems biology tools. Results were validated by real-time PCR, western blotting and functional assays.

Findings

We found significant changes in the expression levels of almost 600 genes between collagen VI deficient and control fibroblasts. Highly regulated genes included extracellular matrix components and surface receptors, including integrins, indicating a shift in the interaction between the cell and its environment. This was accompanied by a significant increase in fibroblasts adhesion to laminin. The observed changes in gene expression profiling may be under the control of two miRNAs, miR-30c and miR-181a, which we found elevated in tissue and serum from patients and which could represent novel biomarkers for muscular dystrophy. Finally, the response to vitamin C of collagen VI mutated fibroblasts significantly differed from healthy fibroblasts. Vitamin C treatment was able to revert the expression of some key genes to levels found in control cells raising the possibility of a beneficial effect of vitamin C as a modulator of some of the pathological aspects of collagen VI related diseases.

Does dexamethasone act in neuropeptides SP and CGRP in neurogenic inflammation of the skin? An experimental study

PURPOSE

To investigate the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) after subcutaneous injection of dexamethasone prior to skin incision in rats.

METHODS

Twenty seven Wistar-EPM-1 rats were randomly divided into three groups. The sham group (SG) of rats was injected with 0.9 % saline. The second group (Dexa) was injected with 1.0 mg/kg dexamethasone, and the third group (Dexa+) was injected with 10.0 mg/kg dexamethasone. In all groups, the three subcutaneous injections were performed 30 minutes prior to the surgical skin incision and tissue collection. SP and CGRP (15 kDa pro-CGRP and 5 kDa CGRP) were quantified by Western Blotting.

RESULTS

No statistically significant differences (p>0.05) were found in pro-CGRP, CGRP and SP values in all three groups.

CONCLUSION

The anti-inflammatory effect of dexamethasone did not occur when the substance P and calcitonin gene-related peptide levels were altered during the neurogenic inflammation process of skin wound healing in rats.

Does ear keloid formation depend on the type of earrings or piercing jewellery?

The ear is one of the most common sites of keloid formation, usually associated with the wearing of earrings. However, although this is a small perforating lesion that is equal on both sides, keloids are bigger and more prevalent on the posterior surface. In this study, 141 keloids were evaluated, most of which were located on the posterior surface of the earlobe and caused by the piercing of the ear. Most of the earrings and piercing jewellery used had metallic backs. The more frequent occurrence of earlobe keloids on the posterior surface of the ear therefore may be associated with the exacerbation of local neurogenic inflammation caused by the metallic backs.

New approach to the understanding of keloid: psychoneuroimmune-endocrine aspects

The skin is a dynamic and complex organ that relies on the interrelation among different cell types, macromolecules, and signaling pathways. Further, the skin has interactions with its own appendages and other organs such as the sebaceous glands and hair follicles, the kidney, and adrenal glands; systems such as the central nervous system; and axes such as the hypothalamic–pituitary–adrenal axis. These continuous connections give the skin its versatility, and when an injury is caused, some triggers start a cascade of events designed to restore its integrity. Nowadays, it is known that this psychoneuroimmune–endocrine intercommunication modulates both the homeostatic condition and the healing process. In this sense, the skin conditions before a trauma, whether of endogenous (acne) or exogenous origin (injury or surgical incision), could regulate the process of tissue repair. Most skin diseases such as psoriasis and atopic dermatitis, among others, have in their pathophysiology a psychogenic component that triggers integrated actions in the nervous, immune, and endocrine systems. However, fibroproliferative disorders of wound healing, such as hypertrophic scar and keloid, are not yet included in this listing, despite showing correlation with stress, especially with the psychosocial character. This review, by understanding the “brain–skin connection”, presents evidence that allows us to understand the keloid as a psychomediated disease.

Psychological stress as a risk factor for postoperative keloid recurrence

OBJECTIVE

To investigate psychological stress on the prognosis of the postoperative recurrence of keloids.

METHODS

Patients with keloids (n=25), candidates for surgical resection and postoperative radiotherapy, had their psychological stress evaluated on the day before the surgical procedure. The parameters evaluated were pain and itching (Visual Numerical Scale), quality of life (Questionnaire QualiFibro/Cirurgia Plástica-UNIFESP), perceived stress (Perceived Stress Scale), depression and anxiety (Hospital Depression and Anxiety Scale), salivary cortisol and minimum and maximum galvanic skin responses (GSR) at rest and under stress (i.e., while the questionnaires were being filled out). Patients were evaluated during the 3rd, 6th, 9th and 12th months of postoperative care. During each return visit, two experts classified the lesions as non-recurrent and recurrent.

RESULTS

The recurrence group presented the greatest values in GSR during a stressful situation. The chance of recurrence increased by 34% at each increase of 1000 arbitrary units in maximum GSR during stress.

CONCLUSION

Psychological stress influenced the recurrence of keloids.

Evaluating keloid recurrence after surgical excision with prospective longitudinal scar assessment scales

INTRODUCTION

Evaluation tools are used to quantify scar evolution and determine treatment effectiveness. In clinical practice, scar assessment scales are less costly, tend to cover a greater number of aspects related to scar characteristics and can incorporate a patient's opinion in the assessment. However, the scales have not yet been used as an evaluation method for the postoperative recurrence of keloids.

OBJECTIVE

The study aims to evaluate the effectiveness of scar rating scales for keloid recurrence after surgical excision.

METHODS

Patients (n = 25) with keloids on the trunk were treated by surgical resection and postoperative beta radiation therapy. On the 3rd, 6th, 9th and 12th postoperative months, two specialists classified the lesions qualitatively in recurrent and non-recurrent cases. Furthermore, in the objective evaluation, the items on the Seattle Scar Scale (SSS) and the Stony Brook Scar Evaluation Scale (SBSES) were assessed by specialists, and the patients assessed items on the Patient Scar Assessment Scale (PSAS) for the pre- and postoperative periods. The scars were classified qualitatively as "good" or "poor."

RESULTS

Recurrence was observed in 18 patients (72%), according to the specialists' qualitative assessments. The best scores on the SSS and SBSES were given to the non-recurrent (p < 0.001) scars. The highest PSAS values were for the scars classified as "poor" (p < 0.001). There were no differences in the PSAS values for the preoperative period and outcomes for the recurrent scars (p = 0.519). The outcomes showed that the non-recurrent scars had lower values on the PSAS compared to the recurrent scars (p = 0.001) and compared to the preoperative period (p = 0.004).

CONCLUSIONS

The PSAS, SSS and SBSES scales were effective methods in distinguishing keloid postoperative recurrence. It is necessary to establish the recurrence cut-off scores for each of the scales according to the treatment used.