A role for vitamin D and the vitamin D receptor in keloid disorder

Keloids are disfiguring fibroproliferative lesions that can occur in susceptible individuals following any skin injury. They are extremely challenging to treat, with relatively low response rates to current therapies and high rates of recurrence after treatment. Although several distinct genetic loci have been associated with keloid formation in different populations, there has been no single causative gene yet identified and the molecular mechanisms guiding keloid development are incompletely understood. Further, although it is well known that keloids are more commonly observed in populations with dark skin pigmentation, the basis for increased keloid risk in skin of colour is not yet known. Because individuals with dark skin pigmentation are at higher risk for vitamin D deficiency, the role of vitamin D in keloid pathology has gained interest in the keloid research community. A limited number of studies have found lower serum vitamin D levels in patients with keloids, and reduced expression of the vitamin D receptor (VDR) in keloid lesions compared with uninjured skin. Vitamin D has documented anti-inflammatory, anti-proliferative and pro-differentiation activities, suggesting it may have a therapeutic role in suppression of keloid fibrosis. Here we review the evidence supporting a role for vitamin D and VDR in keloid pathology.

Evaluating Symptomatic and Psychosocial Well-being After Keloid Treatment With SCAR-Q

BACKGROUND

Many patients with keloids experience symptoms, such as pain and pruritus, and may present with significant psychosocial burdens. However, no single therapeutic regimen has been firmly established for treatment of keloids.

OBJECTIVES

The aim of this study was to assess patients' perspectives on their keloids after treatment by comparing preoperative and postoperative surveys.

METHODS

All patients seen at the keloid clinic, both preoperatively and postoperatively, were contacted by telephone call. Information about demographics, keloid characteristics, and levels of pain and pruritus were recorded. Participants also completed all 3 parts (appearance, symptoms, and psychosocial impact) of the SCAR-Q, a validated patient-reported outcome measure questionnaire. Statistical analysis was performed with SPSS version 23 (IBM Corp., Armonk, NY).

RESULTS

Of the 60 patients who participated in the study, 35 preoperative and 34 postoperative surveys were completed. Patients experienced significant reductions in mean [standard deviation] pain levels (from 5.6 [4.0] to 0.1 [0.4], P < 0.001) and pruritus (from 6.5 [3.0] to 0.8 [1.5], P < 0.001) postintervention. Significant improvements in all 3 parts of the SCAR-Q were noted. Appearance improved from 26.5 [22.3] to 73.4 [23.0] (P < 0.001); symptoms from 44.0 [15.7] to 81.4 [16.7] (P < 0.001); and psychosocial impact from 27.7 [30.7] to 82.6 [26.3] (P < 0.001).

CONCLUSIONS

Patients with keloids experience significant improvement in their symptomatic and psychosocial burden after treatment. Although management modalities are not well established, it is essential that plastic surgeons do not overlook the therapeutic benefits for their patients' well-being.

Quality-of-life of people with keloids and its correlation with clinical severity and demographic profiles

Though the impairment of quality of life in individuals with keloids is profound, it has neither been well quantified nor correlated with severity in people with skin of colour. This cross-sectional, questionnaire-based study comprised 110 patients with keloid(s). A physician measured the severity of keloids using the Vancouver Scar scale and impairment of quality of life using the patient-filled Hindi version of Dermatology Life Quality Index questionnaire. The relationship among QoL and severity score as well as with components of demographic data was analysed using SPSS. Our study found the severity of keloid(s) to be moderately but significantly correlated with the quality of life of its sufferers. Individuals with multiple keloids were found to be significantly younger than those with solitary ones. Itching, pain, along with restricted mobility significantly impacted the quality of life as well as severity of keloids. Individuals who had undergone prior treatment were found to have a worse quality of life than the treatment naive. Recurrence was found to be associated with lower scar severity, multiple keloids, and younger age. Increasing age, though associated with greater scar severity, lacked any relationship with the quality of life. Our study also found that individuals with bigger keloids sought treatment earlier and more often. Hyperpigmented keloid(s), more common in individuals with skin of colour, were associated with a significantly worse quality of life as well as a higher scar severity.

Analysis of HOX gene expression and the effects of HOXA9 overexpression in fibroblasts derived from keloid lesions and normal skin

Keloids are fibroproliferative lesions resulting from an abnormal wound healing process due to pathological mechanisms that remain incompletely understood. Keloids tend to occur more frequently in anterior versus posterior body regions (e.g., ears, face, upper torso); this has been attributed to higher skin tension in those areas, although this has not yet been conclusively proven. Previous studies reported reduced expression of multiple homeobox (HOX) genes in keloid versus normal fibroblasts, suggesting a role for HOX genes in keloid pathology. However, HOX genes are differentially expressed along the anterior-posterior axis. Hypothetically, differential HOX expression may be due to differences in body sites, as matched donor sites are often unavailable for keloids and normal skin. To better understand the basis for differential HOX gene expression in cells from keloids compared with normal skin, we compared HOXA7, HOXA9, HOXC8 and HOXC11 expression in keloid and normal skin-derived fibroblasts from various body sites. When keloid (N = 20) and normal (N = 12) fibroblast cell strains were evaluated, expression of HOXA7, HOXA9 and HOXC8 was significantly lower in keloid versus normal fibroblasts. However, HOX gene expression was lower in fibroblasts from more anterior versus posterior body sites. When keloid and normal cells from similar body sites were compared, differential HOX expression was not observed. To investigate the phenotypic relevance of HOX expression, HOXA9 was overexpressed in keloid and normal fibroblasts. HOXA9 overexpression did not affect proliferation but significantly reduced fibroblast migration and altered gene expression. The results suggest that differential HOX expression may be due to differences in positional identity between keloid and normal fibroblasts. However, HOX genes can potentially regulate fibroblast phenotype, suggesting that differential HOX gene expression may play a role in keloid development in anterior body sites.

Efficacy of adjuvant radiotherapy for treatment of adrenocortical carcinoma: a retrospective study and an updated meta-analysis

Background

Adrenocortical carcinoma (ACC) is a rare and highly aggressive malignancy. Surgical resection is the standard treatment for localized ACC, but the local recurrence remains high. Adjuvant radiation (ART) has been proposed as a means to reduce recurrence rates in ACC after surgery with conflicting results from nonrandomized studies. We performed a retrospective study and a meta-analysis to determine the impact of ART on survival outcomes.

Methods

A retrospective study of the adrenocortical cancer database in Peking Union Medical College was conducted. We selected postoperative ACC patients with or without ART. A meta-analysis is also performed to compare the outcomes between ART and only surgical resection in ACC patients. The obtained data were analyzed using SPSS 23.0 and Stata 15.0 statistical software. Differences between two groups were compared using the log-rank test for retrospective analysis and estimated by calculating the odds ratio (OR) and 95% confidence interval (CI) for meta-analysis.

Results

Of a total of 75 patients available in the database, 12 patients underwent postoperative ART and were matched one to one to patients with only surgical resection. There was no significant difference on overall survival between ART group and control group (log-rank P = 0.149). Locoregional recurrence was diagnosed in 2 of the ART group, and in 4 of the control group (P = 0.64). A total of 238 participants were selected for the meta-analysis, of which 111 and 127 patients underwent ART after surgical resection and only surgical resection, respectively. Overall survival is significantly higher in ART group, with an odds ratio (OR) of 2.41 (95% CI of 1.33, 4.38; P = 0.004). Besides, meta-analysis significantly favored ART for locoregional recurrence-free survival and disease-free survival, with an OR of 4.08 and 2.27, respectively.

Conclusions

Our results show that compared to only surgical resection, ART is an effective postoperative treatment for ACC.