Occupational dermatitis artefacta: a clinical case in a flight attendant

Dermatitis artefacta is a psychosomatic disorder characterized by cutaneous lesions that are self-inflicted by the patient, apparently due to itchy sensation. Usually, the patient denies any direct involvement with this condition and is rarely conscious of the underlying psychosomatic etiology. Authors report a case of a flight assistant with hypertrophic scars, symmetrically located on both upper arms. She referred chronic itchy sensation localized at the site where lesions were present; she referred relief only through continuous and forceful scratching. Considering the clinical history and after excluding other dermatological disorders, the diagnosis of dermatitis artefacta was made.

Current potential therapeutic strategies targeting the TGF-β/Smad signaling pathway to attenuate keloid and hypertrophic scar formation

Aberrant scar formation, which includes keloid and hypertrophic scars, is associated with a pathological disorganized wound healing process with chronic inflammation. The TGF-β/Smad signaling pathway is the most canonical pathway through which the formation of collagen in the fibroblasts and myofibroblasts is regulated. Sustained activation of the TGF-β/Smad signaling pathway results in the long-term overactivation of fibroblasts and myofibroblasts, which is necessary for the excessive collagen formation in aberrant scars. There are two categories of therapeutic strategies that aim to target the TGF-β/Smad signaling pathway in fibroblasts and myofibroblasts to interfere with their cellular functions and reduce cell proliferation. The first therapeutic strategy includes medications, and the second strategy is composed of genetic and cellular therapeutics. Therefore, the focus of this review is to critically evaluate these two main therapeutic strategies that target the TGF-β/Smad pathway to attenuate abnormal skin scar formation.

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.

Sumoylation enhances the activity of the TGF-β/SMAD and HIF-1 signaling pathways in keloids

Excessive fibrosis and extracellular matrix deposition resulting from upregulation of target genes expression mediated by transforming growth factor-beta (TGF-β)/SMAD and hypoxia inducible factor-1 (HIF-1) signaling pathways are the main mechanisms that drive keloid formation. Sumoylation is a protein posttranslational modification that regulates the function of proteins in many biological processes. In the present study, we aimed to investigate the mechanism underlying the effects of sumoylation on the TGF-β/SMAD and HIF-1 signaling pathways in keloids. We used 2-D08 to block sumoylation and silenced the expression of sentrin sumo-specific protease 1 (SENP1) to enhance sumoylation in human foreskin fibroblasts (HFFs) and human keloid fibroblasts (HKFs). We also reduced and increased intracellular SUMO1 levels by silencing SUMO1 and transfecting cells with a SUMO1 overexpression lentivirus, respectively. Sumoylation has the ability to amplify TGF-β/SMAD and HIF-1 signals in keloids, while SUMO1, especially the SUMO1-RanGAP1 complex, is the key molecule affecting the TGF-β/SMAD and HIF-1 signaling pathways. In addition, we also found that hypoxia promotes sumoylation in keloids and that HIF-1α is covalently modified by SUMO1 at Lys 391 and Lys 477 in HKFs. In summary, we elucidated the role and molecular mechanism of sumoylation in the formation of keloids, providing a new perspective for a potential therapeutic target of keloids.

[Clinical effect of Zhang's super tension-relieving suture for high-tension wound closure]

Objective: To investigate the clinical effect of Zhang's super tension-relieving suture applied in high-tension wound closure. Methods: From January to August 2019, 19 eligible patients with scar or black hairy nevus were treated with Zhang's super tension-relieving suture for outpatient operation in the Department of Plastic and Reconstructive Surgery of Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. The patients were composed of 6 males and 13 females, aged 10-68 years, with 8 keloids, 3 hypertrophic scars, 5 atrophic scars, and 3 black hairy nevus. The operation sites included lower jaw in 2 cases, neck in 3 cases, chest in 4 cases, abdomen in 2 cases, and limbs in 8 cases. The size of scars and black hairy nevus before surgery ranged from 1.4 cm×1.1 cm to 10.0 cm×4.0 cm. All the lesions underwent excision alone with both sides of the incision undermined for 1 to 2 cm, and the wound size ranged from 2.6 cm×2.6 cm to 12.6 cm×6.8 cm. Zhang's super tension-relieving suture was applied with barbed suture, and the wound edges were naturally jointed with relaxation and low tension by pushing normal skin on both sides to the middle. Two patients with keloids underwent superficial radiotherapy within 24-hour interval after the surgery, with a total of 20 Gy delivered in 4 times, once a day. All the patients were followed up at outpatient clinics, with tension-relieving duration and adverse effects recorded. Six months after operation, the Vancouver Scar Scale (VSS) was used to evaluate scar appearance, while scar width and recurrence were recorded. Results: All the wounds of 19 patients healed completely after surgeries. Two patients experienced transient hyperpigmentation at puncture points and recovered without intervention, and one of them had hypertrophic scar at the puncture point, which was relieved after intralesional injections of corticosteroids. One patient underwent transient erythema, dry desquamation, and hyperpigmentation after radiotherapy, which recovered without intervention. Follow-up time ranged from 7.1 to 13.6 months, with an average of 9.6 months. Tension-relieving duration ranged from 4 to 26 weeks, with an average of 11.2 weeks. Two patients underwent Zhang's super tension-relieving suture again 8 weeks after operation due to their short tension-relieving duration which lasted for only 4 weeks after the first suture. Six months after operation, liner scars were achieved in all the patients with an average width of 2.2 mm (0.8 to 7.0 mm) and an average VSS score of 2.1 points (1.0 to 4.3 points). Three keloid patients had local recurrence 3 months after surgery for not receiving radiotherapy, which was obviously relieved following laser treatment in combination with intralesional injections of corticosteroids and 5-fluorouracil, etc. Conclusions: Zhang's super tension-relieving suture technique with barbed suture is able to effectively relieve the tension on wound edges, extend the tension-relieving duration, and reduce the hypertrophic scar risk when applied in high-tension wound.

Topical delivery of 5-fluorouracil-loaded carboxymethyl chitosan nanoparticles using microneedles for keloid treatment

Keloids are induced by skin injuries such as surgeries, skin piercings, burns, and trauma. The intra-lesional injection of 5-fluorouracil (5-FU) is a promising therapy to treat keloid. However, local 5-FU injections have caused several side effects such as pain at administration and hyperpigmentation. This study suggests a safer and more effective 5-FU delivery system. We used microneedles to treat keloid because this method has the feasibility of self-administration without pain. In this study, 5-FU-loaded carboxymethyl chitosan (CMC) nanoparticles were prepared and characterized by various analytical methods and then coated on stainless solid microneedles. The blank CMC nanoparticles caused an increase in cell viability on human normal fibroblasts to 150%. In particular, the 5-FU-loaded CMC nanoparticles showed a significant inhibitory effect on the human keloid fibroblast to 16%. The intercellular uptake of the 5-FU-loaded CMC nanoparticles was observed on both human normal and keloid fibroblasts by using a confocal microscope. In addition, it was found that the nanoparticles showed an inhibition of TGF-β1 by ELISA. For topical drug delivery, it was confirmed that the nanoparticles coated onto the microneedles were dissolved and diffused at the administration site in the porcine dorsal skin model. According to these results, the suggested microneedle-mediated drug delivery system not only inhibits the human keloid fibroblasts by delivering drugs effectively into the keloids but also has the feasibility to self-administer without pain. Therefore, this new system including 5-FU-loaded CMC nanoparticles and microneedles has the potential to treat keloid scars. Graphical abstract.

TM4SF1 involves in miR-1-3p/miR-214-5p-mediated inhibition of the migration and proliferation in keloid by regulating AKT/ERK signaling

AIMS

Transmembrane 4 L six family member 1 (TM4SF1) is a small plasma membrane glycoprotein that is highly expressed in cancers. However, the role of TM4SF1 that plays in keloids remains unknown. We investigated the expression, function and the microRNA (miRNA) regulatory network of TM4SF1 in keloids.

MAIN METHODS

Small interfering RNAs and lentivirus were used to alter the expression of TM4SF1 in fibroblasts. Dual-luciferase reporter assays were applied to determine the miRNA targets. Immunohistochemistry, western blotting, qRT-PCR, wound healing assays, Transwell assays, cell count kit-8 assays and flow cytometry were also employed in this study.

KEY FINDINGS

TM4SF1 was frequently upregulated in human keloid fibroblasts (HKFs) compared with human normal skin fibroblasts (HSFs). The downregulation of TM4SF1 significantly inhibited proliferation and migration, and induced apoptosis in HKFs. Furthermore, si-TM4SF1 inhibited the AKT/ERK signaling. Meanwhile, the upregulation of TM4SF1 promoted proliferation, migration and the activation of AKT/ERK signaling in human foreskin fibroblasts (HFF-1). Moreover, TM4SF1 can be regulated by miRNAs, which have been validated to play important roles in keloids by posttranscriptional regulation of gene expression. After screening, we found miR-1-3p and miR-214-5p targeted TM4SF1, inhibited TM4SF1 expression, cell proliferation, migration, and induced apoptosis in HKFs. And the level of miR-1-3p and miR-214-5p were found lower in HKFs than in HSFs.

SIGNIFICANCE

Our study demonstrates a novel regulatory mechanism by which miR-1-3p, miR-214-5p, and TM4SF1 are involved in proliferation, cell motility, and apoptosis, suggesting that they may be potential targets in therapies for keloids.

Dumbbells for Dummies: A Simplified Approach to Managing Dumbbell-shaped Keloids of the Earlobe

BACKGROUND: Keloids are dense, fibrous tumors that arise from the dysregulation of normal wound healing, ultimately outgrowing the initial traumatic lesion. OBJECTIVE: We present a modified technique for the excision of dumbbell-shaped keloids on the earlobe using tools common to every dermatologist's office. METHODS: This was an observational report on the outcomes of dumbbell keloid excision using a #15 blade and punch biopsy. Eligible individuals were those with dumbbell-shaped keloids located on the earlobe. All procedures were conducted at an urban dermatology clinic. RESULTS: When combining the technique with continual compression earrings and intralesional corticosteroids, excellent cosmetic outcomes and minimal recurrence were achieved. CONCLUSION: The pairing of a #15 blade and punch biopsy has been demonstrated to produce a more user-friendly method for dumbbell keloid excision by dermatologists and clinicians without advanced surgical training.

Knockdown of fibronectin extra domain B suppresses TGF-β1-mediated cell proliferation and collagen deposition in keloid fibroblasts via AKT/ERK signaling pathway

Keloids represent a dermal fibrotic disease characterized by excess collagen deposition and invasion of normal skin beyond the wound boundary, similar to malignant tumor features. Fibronectin extra domain B (EDB) is highly expressed in many tumors but has not been studied in keloids. The present study aimed to investigate the expression and the influence of EDB on keloid and elucidate the putative signaling pathway. We examined expression of EDB and the effects of EDB on fibroblast proliferation, apoptosis and the expression of the related proteins and genes. The level of phosphorylation of Smad, ERK, and AKT was estimated to elucidate the signaling pathways. The results showed that EDB in human keloid tissues and fibroblasts was overexpressed. EDB knockdown suppressed the cell proliferation of keloid fibroblasts (KFs) treated by transforming growth factor-β1 (TGF-β1). Also, the phosphorylation of Smad, ERK, and AKT in TGF-β1-induced KFs was inhibited In addition, the low expression of pro-collagen-I (Col-I) and Col-III protein and mRNA level was observed in the siEDB group. EDB knockdown inhibited cell proliferation and suppressed collagen deposition in TGF-1-induced KFs. The underlying mechanism is the activation of TGF-β1/Smad, ERK, and AKT signaling pathways. Together, the results suggested that EDB is a promising therapeutic target for keloid clinical treatment.

Overexpression of miR-133a-3p inhibits fibrosis and proliferation of keloid fibroblasts by regulating IRF5 to inhibit the TGF-β/Smad2 pathway

AIM

Keloid is a benign dermal tumor with excessive hyperplasia and deposition of collagen. As a common tumor suppressor gene, miR-133a-3p has not been studied in keloid. This study will delve into the specific mechanism of miR-133a-3p in keloid.

METHODS

Normal skin fibroblasts and keloid fibroblasts (KFs) were first isolated from patients' normal skin and keloid, and cells were identified by morphological observation and immunofluorescence. The expressions of miR-133a-3p and extracellular matrix (ECM)-associated markers (Collagen I, III and α smooth muscle activin) were detected by Quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). Cell viability and apoptosis of KFs were examined by Cell Counting Kit-8 assay, flow cytometry, and Caspase-3 colorimetry. TargetScan predicted target gene for miR-133a-3p was verified by luciferase assay, qRT-PCR and Western Blot (WB). WB was used to study protein expression of TGFBR1, phosphorylated -Smad2 (p-Smad2) and Smad2. Finally, a series of rescue experiments were performed to verify the intervention of target genes on miR-133a-3p.

RESULTS

MiR-133a-3p was lowly expressed in keloid tissue and KFs. Overexpression of miR-133a-3p inhibited the expression of ECM-associated markers, reduced KFs viability, and promoted apoptosis. It was verified that interference regulator 5 (IRF5) is miR-133a-3p target gene. The rescue experiments showed that IRF5 reversed the effect of miR-133a-3p mimic on inhibiting fibrosis, and reversed the effects on promoting apoptosis and reducing cell proliferation.

CONCLUSION

Overexpressed miR-133a-3p inhibits fibrosis by down-regulating IRF5 and thus inhibiting the TGF-β/Smad2 pathway. And it also promotes KFs apoptosis and reduces proliferation.

Combined intralesional triamcinolone acetonide and platelet rich plasma versus intralesional triamcinolone acetonide alone in treatment of keloids

Background: Keloids are benign fibro-proliferative growths occurring after skin injury or spontaneously. Intralesional triamcinolone acetonide (TA) is their first-line therapy, but commonly associated with side effects or recurrence. Platelet rich plasma (PRP) is an autologous blood-derived product with promising results in improving wound healing with lower keloid occurrence.Objective: To compare the efficacy of combined intralesional TA and PRP versus TA alone in keloids treatment.Methods: Forty patients with keloids were divided randomly into two equal groups (A and B). Both groups received intralesional TA (20 mg/ml) for four sessions, 3 weeks apart. Group A patients received additional intralesional PRP 1 week after TA injections. Evaluation was done after 3 months of follow up by Vancouver scar scale (VSS) and verbal rating scale (VRS) for pain and itching.Results: Both groups showed significant improvement in all parameters of VSS and VRS in comparison with baseline. Significantly better improvement in height, pigmentation, and pliability and overall VSS was detected in patients of group A. A significantly higher incidence of post-TA atrophy and hypopigmentation was observed in group B.Conclusion: Combining intralesional PRP with TA could yield cosmetically better outcomes in keloid treatment with lower incidence of TA-induced side effects especially atrophy and hypopigmentation.

Identification and analysis of dysregulated lncRNA and associated ceRNA in the pathogenesis of keloid

Background

Keloid is an excessive fibrosis disease caused by the abnormal proliferation of collagen fibers following trauma. Previous studies have shown that genetic factors have been considered to play important roles in keloid formation. This study is aimed to investigate the regulatory network of messenger RNAs (mRNAs) microRNAs (miRNAs) and long non-coding RNAs (lncRNAs) in keloid, and identifying its key biomarkers.

Methods

We performed RNA-seq and miRNA-seq on keloid and normal skin samples. Sequencing datasets were analyzed by bioinformatics. Gene ontology (GO) and pathway analysis presented the characteristics of associated protein-coding genes. Differentially expressed ceRNAs were validated by quantitative reverse transcriptase-PCR (qRT-PCR).

Results

We identified a total of 319 lncRNAs, 1,533 mRNAs and 40 miRNAs as keloid-specific RNAs. Both the GO biological processes and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were analyzed for 1,219 specific genes with differentially expressed mRNAs. Then, with 509 key lncRNAs, 25 miRNAs, and 94 mRNAs, we constructed a ceRNA network and explored any potential underlying mechanisms. In the regulation of the actin cytokeleton pathway, we validated 2 pairs of ceRNAs EGFR/miR-370-3p/lnc-GLB1L-1 and ITGB5/ miR-204/ lnc-CASP9-3 in another sample size in keloid.

Conclusions

Through RNA-seq and miRNA-seq, we identified keloid-associated lncRNAs, mRNAs and miRNAs, which can be used as potential therapeutic targets and biomarkers for keloid. Our study may lay a foundation for future pathogenesis studies.

Inhibition of growth of Asian keloid cells with human umbilical cord Wharton's jelly stem cell-conditioned medium

Background

Keloid formation occurs in Caucasian, African, and Asian populations and is a severe psychosocial burden on patients. There is no permanent treatment for this problem as its pathogenesis is not properly understood. Furthermore, differences in keloid behavior between ethnic groups are not known. It has been hypothesized that keloids behave like benign tumors because of their uncontrolled growth. The present study evaluated the tumoricidal properties of human Wharton’s jelly stem cell-conditioned medium (hWJSC-CM) on fresh Asian keloid cells (AKCs).

Methods

Human Wharton’s jelly stem cells (hWJSCs) and AKCs were isolated based on our previous methods. hWJSCs and human skin fibroblasts (HSF) (controls) were used to collect hWJSC-CM and HSF-conditioned medium (HSF-CM). AKCs were treated with hWJSC-CM and HSF-CM in vitro and in vivo in a human keloid xenograft SCID mouse model. The inhibitory effect of hWJSC-CM on AKCs was tested in vitro using various assays and in vivo for attenuation/abrogation of AKC tumors created in a xenograft mouse model.

Results

qRT-PCR analysis showed that the genes FN1, MMP1, and VCAN were significantly upregulated in AKCs and ANXA1, ASPN, IGFBP7, LGALS1, and PTN downregulated. AKCs exposed to hWJSC-CM in vitro showed significant decreases in cell viability and proliferation, increases in Annexin V-FITC+ cell numbers, interruptions of the cell cycle at Sub-G1 and G2/M phases, altered CD marker expression, downregulated anti-apoptotic-related genes, and upregulated pro-apoptotic and autophagy-related genes compared to controls. When AKCs were administered together with hWJSC-CM into immunodeficient mice there were no keloid tumors formed in 7 mice (n = 10) compared to the untreated control mice. When hWJSC-CM was injected directly into keloid tumors created in mice there were significant reductions in keloid tumor volumes and weights in 30 days.

Conclusions

hWJSC-CM inhibited the growth of AKCs in vitro and in xenograft mice, and it may be a potential novel treatment for keloids in the human. The specific molecule(s) in hWJSC-CM that induce the anti-keloid effect need to be identified, characterized, and tested separately in larger preclinical and clinical studies.

Quantitative Assessment of Keloids Using Ultrasound Shear Wave Elastography

This study was aimed at investigating the value of shear wave elastography (SWE) in quantitative evaluation of keloids. A total of 87 patients with 139 keloids were enrolled. Vancouver scar scale (VSS) scores were recorded. Thickness and blood flow grade were evaluated using high-frequency ultrasound. Skin stiffness (mean speed of shear wave, C_mean) was evaluated using SWE in both transverse and longitudinal sections. All measurements were performed in both keloids and site-matched unaffected skin (normal controls). The reliability of measurements was evaluated using intra- and inter-class correlation coefficients by two observers. Inter- and intra-observer repeatability was excellent (correlation coefficient > 0.99, p < 0.01). The SWE results revealed a significant increase in C_mean in keloids (p < 0.001) compared with the normal controls. C_mean in the longitudinal section was greater than that in the transverse section for keloids (p < 0.001). C_mean was highly positively correlated with VSS score (r = 0.904, p < 0.001), moderately positively correlated with thickness (r = 0.490, p < 0.001) and less positively correlated with blood flow (r = 0.231, p < 0.01). This non-invasive, tolerable and convenient imaging technique could be an effective tool for objectively evaluating keloid stiffness in the future, thus laying a foundation for the treatment and evaluation of keloids.

Comparative Efficacy and Safety of Common Therapies in Keloids and Hypertrophic Scars: A Systematic Review and Meta-analysis

OBJECTIVES

At present, there are many therapies for treating keloids and hypertrophic scars, but there is still a lack of treatments that are relatively balanced in efficacy and safety. The study aims to evaluate comprehensively efficacy and safety of common therapies in keloids and hypertrophic scars.

METHODS

The literature search was conducted up to May 2019. The traditional meta-analysis was performed on 17 therapies. Bayesian network meta-analysis was conducted on the four most common treatments. The outcome indicators were the numbers of patients with good-to-excellent effect, Vancouver Scar Scale (VSS) and adverse events.

RESULTS

There was no significant difference in the efficacy of triamcinolone acetonide (TAC) compared with other monotherapies except for silicone gel sheet and neodymium-yttrium-aluminum-garnet in primary indicator. The combination therapies were superior to TAC, and the results were consistent after the pooled analysis (RR = 0.522, 95% CI 0.332-0.823). The level of VSS in TAC group was higher than that in 5-flurouracil (5-FU) and TAC + 5-FU group, but lower than that in verapamil (VER) group. And the patients treated with TAC were less safe than those treated with verapamil (P = 0.013). Surface under cumulative ranking ranked verapamil and TAC + 5-FU as the favorable efficacy therapies in terms of primary indicator and ranked TAC + 5-FU as the best therapy for VSS, while VER was ranked as the worst.

CONCLUSION

This meta-analysis showed that TAC + 5-FU may be the most effective therapy, while verapamil may be a better therapeutic strategy for safety.

LEVEL OF EVIDENCE III

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.

Laser management of hypertrophic burn scars: a comprehensive review

Hypertrophic scars often develop following burn-related injuries. These scars can be cosmetically unappealing, but associated symptoms of pruritus, pain and restricted range of motion can impair a person’s quality of life. Laser and light therapies offer a minimally invasive, low-risk approach to treatment, with a short postoperative recovery period. As laser technology developed, studies have shown decreased scar thickness, neuropathic pain and need for surgical excision, as well as improved scar pigmentation, erythema, pliability, texture, height and pruritus. In this review, we present the evolution of laser therapy for hypertrophic burn scars, how different types of lasers work, indications, perioperative considerations and guidelines for practice management.

Syndecan-1 regulates extracellular matrix expression in keloid fibroblasts via TGF-β1/Smad and MAPK signaling pathways

AIMS

The present study aimed to explore the effect of syndecan-1 on keloid fibroblasts.

MAIN METHODS

Immunohistochemistry and Western blot were employed to assess the expression of syndecan-1. Primary cultured keloid fibroblasts were transfected with syndecan-1 siRNA. The function of syndecan-1 on the proliferation of keloid fibroblasts was investigated through Cell Counting Kit-8 (CCK-8) and flow cytometry. Extracellular matrix, TGF-β1/Smad, and MAPK related proteins were evaluated by Western blot.

KEY FINDINGS

Syndecan-1 was significantly overexpressed in both keloid tissues and fibroblasts. Moreover, the knockdown of syndecan-1 remarkably attenuated the proliferation of keloid fibroblasts and reduced the content of the extracellular matrix. Importantly, syndecan-1 regulates the expression of the extracellular matrix in keloid fibroblasts via TGF-β1/Smad and mitogen-activated protein kinase (MAPK) signaling pathways.

SIGNIFICANCE

The current results revealed a crucial function for syndecan-1 in regulating the expression of extracellular matrix and cell proliferation, thereby designating syndecan-1 as a novel target for keloid.

Clinical efficacy of intermittent magnetic pressure therapy for ear keloid treatment after excision

BACKGROUND

Keloids are benign fibro-proliferative lesion, related to excessive inflammatory reactions in certain anatomical areas, including the auricles. Their specific etiology remains unclear; nonetheless they exhibit tumor-like characteristics of significant recurrence and cause emotional distress, even with various treatment strategies. We applied intermittent magnetic pressure therapy on ear keloids in combination with surgical excision, and present its effectiveness herein.

METHODS

Ear keloid patients were treated with surgical excision followed by magnetic pressure therapy. The keloid tissues underwent excision and keloid marginal flaps were utilized for wound closure. Intermittent magnetic pressure therapy was applied 2 weeks after the surgical procedure. The pressure therapy consisted of a 3-hour application and 2-hour resting protocol (9 hr/day), and lasted for 6 months. The results were analyzed 6 months after the therapeutic procedures, using the scar assessment scale.

RESULTS

Twenty-two ear keloids from 20 patients were finally reviewed. Among the keloids that completed the therapeutic course, 20 ear keloids out of 22 in total (90.9%) were successfully eradicated. Two patients (2 keloids) exhibited slight under-correction. Postoperative complications such as wound dehiscence or surgical site infection were not noted. The scar assessment scale demonstrated a significant improvement in each index. The intermittent pressure therapy led to patient compliance, and avoided pressure-related pain and discomfort.

CONCLUSION

Excision followed by intermittent pressure application using a magnet successfully reduced the burden of fibro-proliferative keloids, and had good patient compliance. The role of intermittent pressure application and resting should be studied with regard to keloid tissue remodeling.

Expression profile and bioinformatics analyses of circular RNAs in keloid and normal dermal fibroblasts

Increasing evidence indicates that circular RNAs (circRNAs) play a crucial regulatory role in the pathogenesis of multiple diseases. However, no study has examined the potential biological function and expression profile of circRNAs in keloid dermal fibroblasts (KDFs). Therefore, the aim of this study to investigate the expression profile of circRNAs and analyze their role in KDFs. Bioinformatic analyses and high-throughput RNA sequencing technology were applied to explore the expression profile of circRNAs in 3 human KDFs and normal dermal fibroblasts (NDFs). The differentially expressed circRNAs were verified by reverse transcription PCR (RT-PCR), quantitative real-time-PCR (qRT-PCR) and Sanger sequencing. A circRNA-microRNA (miRNA)-mRNA interaction network was created using bioinformatics tools. Hsa_circ_0008259, was selected to confirm its function by qRT-PCR and Western blot. Collectively, 411 circRNAs, of which 206 were upregulated and 205 decreased, were found to be differentially expressed in KDFs and could bind to 2532 miRNA response elements (MREs). GO and KEGG pathways enrichment analyses showed that differentially expressed circRNAs were mainly involved in apoptosis, focal adhesion, PI3K-Akt and metabolic pathway, and may regulate the pathogenesis and development of keloid. Two candidate circRNAs (hsa_circRNA_0008259, hsa_circRNA_0005480) were verified to be significantly reduced in KDFs, and one candidate circRNA (hsa_circRNA_0002198) was significantly elevated in accordance with RNA-Seq data analysis. Overexpression of hsa_circRNA_0008259 inhibited type I and Ⅲ collagen expression. Taken together, our study demonstrates for the first time that circRNAs exhibits differential expression in KDFs, and may be key players in the pathogenesis of keloid, or act as biomarkers of keloid.

The role of macrophages in the formation of hypertrophic scars and keloids

Numerous studies have shown that macrophages can orchestrate the microenvironment from the early stage of wound healing to the later stages of scar formation. However, few reviews have highlighted the significance of macrophages during the formation of abnormal scars. The purpose of this review was to outline the polarization of macrophages from early to late stage of pathological scar formation, focusing on spatiotemporal diversity of M1 and M2 macrophages. In this review, the role of macrophages in the formation of hypertrophic scars and keloids is summarized in detail. First, an increased number of M2 cells observed before injuries are significantly associated with susceptibility to abnormal scar pathogenesis. Second, decreased expression of M1 at the early stage and delayed expression of M2 at the late stage results in pathological scar formation. Third, M2 cells are highly expressed at both the margin and the superficial region, which is consistent with the invasive property of keloids. Finally, this review helps to characterize strategies for the prediction and prevention of pathological scar formation.

The effect of 5α-oleandrin on keloid fibroblast activities

Background

Keloids develop due to hyperactivity of keloid fibroblast (KF) in proliferation, migration, and collagen deposition along with low rates of collagen degradation. These are a result of the Wnt/β catenin signaling pathways under stimulation of TGF-β. 5α-oleandrin can suppress Wnt-targeted genes of osteosarcoma cells. We aimed to evaluate the anti-fibrotic effects of 5α-oleandrin on KF activities.

Methods

We collected the core of keloid materials from six patients who underwent keloid debulking surgery. Passage 4 of KF cells were then treated with mitomycin-C, 5α-oleandrin, and dilution medium as the negative control. To determine the effective dose of 5α-oleandrin, we diluted 5α-oleandrin into various concentrations. The incubation periods were 24 h, 48 h, and 72 h. The anti-proliferation and anti-fibrotic properties were measured using standard assay.

Results

Both the mitomycin-C and 5α-oleandrin treated groups indicated decrease in proliferation index (86.16 ± 4.20% and 73.76 ± 4.94%, respectively), collagen deposition index (90.26 ± 1.72% and 71.35 ± 4.26%, respectively), and migration capacity (33.51 ± 1.50% and 28.57 ± 1.58%, respectively). These were significant changes (p ≤ 0.05) compared to the non-treated group. Antifibrotic activities of 5α-oleandrin in cellular proliferation and collagen deposition were better than mitomycin-C.

Conclusions

The 5α-oleandrin has good antifibrotic effect in keloid fibroblast activities.

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.

Spontaneous symmetrical giant keloids at the bilateral labia majora: a case report

Keloids are caused by an imbalance between collagen matrix decomposition and production during wound repair. Spontaneous keloids are a rare type of keloid that arise without a significant history of trauma or surgery. We herein report a case involving a 59-year-old woman with symmetric neoplasms at the bilateral labia majora that had persisted for about 3 years and a >10-year history of pruritus and pain at the bilateral labia majora with folliculitis. The bilateral labia majora gradually swelled and lost their normal physiological morphology. The patient was diagnosed with keloids. Under general anesthesia, the keloids were resected. The right incision was sutured directly and the left was closed using an inguinal flap. Adjuvant radiotherapy was administered after the surgery. No recurrence of the keloids was observed at the 1-year follow-up, and the patient was satisfied with the appearance of the vulvar region. This is the first report of spontaneous symmetrical giant keloids at the bilateral labia majora, and it emphasizes the importance of the effect of abnormal inflammation on keloid formation. Repairing genital defects using an inguinal flap has only a minor effect on the patient’s postoperative movement, and an ideal vulvar appearance can be achieved.

[Use of Anterolateral Thigh Free Flap in the Treatment of a Sternal Keloid]

Hypertrophic and keloid scars represent hyperproliferative disorders that can have a significant impact on patients' lives. The authors present the case of a 53 years-old male with a sternal keloid after excision of a sebaceous cyst and multiple sessions of steroid infiltration, with worsening of the lesion. The patient underwent complete excision of the scar and reconstruction with an anterolateral thigh flap - ALT. The postoperative period was uneventful, with no signs of relapse. Keloid scar treatment in sternal area implies a reconstruction with no tension, in order to avoid relapse. Treatment of this type of scars is complex and a challenge to the plastic surgeon. In this case, a microvascular tissue transfer was used to reconstruct the large defect that ultimately resulted after scar excision, in a tension-free manner.

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.

Literature review and case report of post-circumcision keloid management

Keloid following circumcision has been described in the literature despite the rarity of its occurrence in penile skin. In this paper, we review the literature and report the successful management of post-circumcision keloid scarring in a 2-year-old boy. After circumcision a 2-year-old boy of African origin developed keloid scarring at the circumcision site. This was treated with three intralesional injections of triamcinolone acetate over 3 months, followed by surgical excision. There was no recurrence at 6 months after excision. To our knowledge this is the 12th case of keloid following paediatric circumcision described in the literature. There is a wide range of techniques described but all are recurrence free at 6 months following repeated intralesional triamcinolone acetate injection and surgical excision. While there is no current consensus in treating post-circumcision keloid, we find that intralesional injection followed by surgical excision provides an acceptable aesthetic result, which is recurrence free.

The integrative regulatory network of circRNA and microRNA in keloid scarring

Circular RNA (circRNA), a novel type of non-coding RNA that consists of a circular loop, has been demonstrated to act as a "sponge" for microRNAs (miRNAs). However, the role of circRNAs in keloid remains unknown. In this study, we investigated circRNA expression profiles in keloid to identify potential diagnostic and therapeutic circRNAs. We performed a circRNA microarray assay to determine circRNA expression in keloid and paired normal skin tissues. Quantitative reverse transcription polymerase chain reaction was used to evaluate the expression levels of candidate circRNAs. The most significantly over-expressed circRNA was used to predict putative miRNA targets and the binding sites of miRNAs with this circRNA. Finally, we constructed a circRNA-miRNA interaction network and carried out gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses. We found 52 significantly upregulated and 24 downregulated circRNAs in keloid compared with normal skin tissue. We confirmed that hsa_circ_0057452, hsa_circ_0007482, hsa_circ_0020792, hsa_circ_0057342, and hsa_circ_0043688 were significantly upregulated in keloid tissues. Analysis of the circRNA-miRNA interaction network revealed that circRNAs could interact with miRNAs, including miRNA-29a, miRNA-23a-5p and miRNA-1976. GO and KEGG analyses indicated that these target genes were involved in biological functions and signaling pathways that may play vital roles in the pathogenesis of keloid. This study revealed that circRNAs are potentially implicated in the development of keloid and could serve as novel diagnostic and therapeutic targets.

Demographic and clinical characteristics of keloids in an urban center in Sub-Sahara Africa

Background

Keloid is a major complication of wound healing. The clinical spectrum ranges from unaesthetic lesions minimally invading the adjacent skin to large grotesque lesions sometimes associated with contractures.

Subjects and Methods

The patients were seen over 2 years in a tertiary hospital setting. The following information was obtained with a proforma: the biodata, etiology of keloid, region affected, symptoms, and treatment prior to presentation. The keloids were examined and the sizes were grouped into small, medium, and large keloids; the severities of symptoms were determined using the visual analog scale.

Results

159 patients with 224 keloids were seen over 2-year period with male-to-female ratio of 1:1.24. The most common causes of keloid were trauma and acne (27.0% and 20.1%, respectively). The trunk had a statistically significant higher number of symptomatic keloid compared with other regions keloids. The larger keloids were more symptomatic compared with the smaller ones, P = 0.000. There were more pruritic keloids than painful ones. About 25% of patients had positive family history in first-degree relative, 16% in second-degree relative, and their keloid are more symptomatic than those without family history.

Conclusion

In view of the burden of keloids, early treatment is advised. Unnecessary trauma and extra piercing should be avoided; elective surgeries that are deferrable should be postponed until when necessary.

[Giant right post-traumatic retroauricular keloid]

Keloid is a benign fibroblastic tumor which is most often secondary to a scar, but it can occur spontaneously in a subject with black skin. We report the case of a 19-year old patient, electrician, presenting with giant right retroauricular mass evolving over two years. For some time, the patient has experienced a feeling of heaviness on the pavilion of the right ear. The lesion had manifested as a hard, pruritic, non-painful patch gradually increasing in size. The patient had received several topical and antiseptics treatments without any effect. He had a history of traumatic injury in the right retroauricular sulcus. A month after, pruritic hypertrophic scar occurred. Physical examination showed voluminous hard, fixed, retroauricular tumor (10 × 6 cm) with normal skin color, non-painful on movement (A). Its base was sessile. The remainder of the physical examination was normal. Ultrasound showed little vascularized skin tumor of the right retroauricular sulcus with more or less sharp margins, measuring 9 x 5 cm. Two diagnoses were suspected: post-traumatic keloid (most likely) and Darier Ferrand dermatofibrosarcoma. Biopsy was performed and histological examination showed keloid. The patient underwent intramarginal excision (B). The surgical specimens weighed 75 grams (C). The postoperative course was simple with disappearance of the feeling of heaviness.

Keloid-associated lymphoid tissues in keloid lesions express vitamin D receptor

Objectives: Vitamin D receptor (VDR) may play a role in keloid disorder. This study investigated the expression of VDR by the embryonic stem cell (ESC)-like population within keloid-associated lymphoid tissues (KALTs) which expresses components of the renin-angiotensin system (RAS). Methods: 11 formalin-fixed paraffin-embedded sections of keloid lesions (KLs) underwent 3,3-diaminobenzidine (DAB) immunohistochemical (IHC) staining for VDR. Immunofluorescence (IF) dual IHC staining of CD34/VDR and OCT4/VDR was performed on two representative KLs. Transcriptional activation of VDR was investigated in four representative snap-frozen KLs using reverse-transcriptase-quantitative polymerase chain reaction (RT-qPCR). Results: DAB IHC staining demonstrated the presence of VDR on the KALTs within the keloid tissue samples. RT-qPCR confirmed transcriptional activation of VDR. IF IHC staining demonstrated expression of VDR on the CD34⁺ and the OCT4⁺ endothelium of the microvessels, and the OCT4⁺ perivascular cells, within the KALTs. Conclusions: This study demonstrated the expression of VDR by the ESC-like population within the KALTs in KLs. Further work is needed to elucidate the precise interaction between VDR and the RAS in regulating the primitive population within the KALTs.

A dose-ranging, parallel group, split-face, single-blind phase II study of light emitting diode-red light (LED-RL) for skin scarring prevention: study protocol for a randomized controlled trial

BACKGROUND

Skin fibrosis is a significant global health problem that affects over 100 million people annually and has a profoundly negative impact on quality of life. Characterized by excessive fibroblast proliferation and collagen deposition, skin fibrosis underlies a wide spectrum of dermatologic conditions ranging from pathologic scars secondary to injury (e.g., burns, surgery, trauma) to immune-mediated diseases. Effective anti-scarring therapeutics remain an unmet need, underscoring the importance of developing novel approaches to treat and prevent skin fibrosis. Our in vitro data show that light emitting diode-red light (LED-RL) can modulate key cellular and molecular processes involved in skin fibrosis. In two phase I clinical trials (STARS 1 and STARS 2), we demonstrated the safety and tolerability of LED-RL at fluences of 160 J/cm² up to 480 J/cm² on normal human skin.

METHODS/DESIGN

CURES (Cutaneous Understanding of Red-light Efficacy on Scarring) is a dose-ranging, randomized, parallel group, split-face, single-blind, mock-controlled phase II study to evaluate the efficacy of LED-RL to limit post-surgical skin fibrosis in subjects undergoing elective mini-facelift surgery. Thirty subjects will be randomly allocated to three treatment groups to receive LED-RL phototherapy or temperature-matched mock irradiation (control) to either periauricular incision site at fluences of 160 J/cm², 320 J/cm², or 480 J/cm². Starting one week post-surgery (postoperative days 4-8), treatments will be administered three times weekly for three consecutive weeks, followed by efficacy assessments at 30 days, 3 months, and 6 months. The primary endpoint is the difference in scar pliability between LED-RL-treated and control sites as determined by skin elasticity and induration measurements. Secondary outcomes include clinical and photographic evaluations of scars, 3D skin imaging analysis, histological and molecular analyses, and adverse events.

DISCUSSION

LED-RL is a therapeutic modality of increasing importance in dermatology, and has the potential to limit skin fibrosis clinically by decreasing dermal fibroblast activity and collagen production. The administration of LED-RL phototherapy in the early postoperative period may optimize wound healing and prevent excessive scarring. The results from this study may change the current treatment paradigm for fibrotic skin diseases and help to pioneer LED-RL as a safe, non-invasive, cost-effective, portable, at-home therapy for scars.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03795116 . Registered on 20 December 2018.

Interleukin-6 serum level and gene polymorphism in keloid patients

The formation of keloid is associated with accumulation of extracellular matrix (ECM) formed mainly of collagen and fibronectin. Persistent deregulated IL-6 synthesis causes the development of various diseases. This study aim to investigate interleukin 6 (IL-6) serum level and gene polymorphism in a sample of Egyptian patients having keloid. This study was carried out on 90 subjects; 60 patients with keloid, and 30 age and sex matched apparently healthy control. All subjects underwent full history taking, clinical examinations, weight and length measuring to calculate BMI, dermatological examination, analysis of IL6-572 gene polymorphism using REFLP- PCR and IL-6 serum level using ELISA.IL-6 serum levels were significantly higher in keloid patients than control group (75.54±39.18) vs (19.17±6.06), (p &lt;0.001). The higher serum levels of IL-6 were associated with GG genotype (104.84±19.12) followed by CG (57.64±35.38) genotype (P&lt;0.001). GG genotype was significantly higher in keloid patients and increased the risk for keloid development by nearly14 folds (p&lt;0.001, OR (95%CI) =13.81).  CG genotype was significantly observed in keloid patients and increased the risk for keloid development by about 4 times (p=0.010, OR (95%CI) =4.27). G Allele significantly increased the risk for keloid development by about 5 folds (P &lt;0.001 OR =5.11). In conclusion, there was a great association between IL-6 572 gene polymorphism and its serum level in patients with keloid specifically who have family history.

Efficacy of surgical excision and sub-dermal injection of triamcinolone acetonide for treatment of keloid scars after caesarean section: a single blind randomised controlled trial protocol

Background

One of the first-line options to treat keloid scars is corticosteroid injection after excision of the existing scar. A thorough literature search has shown a lack of research on the injection of corticosteroid injection immediately after the excision of the existing caesarean section keloid scars. Therefore, in the proposed study, we aim to investigate the effect of surgical excision and corticosteroid (triamcinolone acetonide) injection immediately after surgical removal of old caesarean section keloid scars on the recurrence of the scars. This is a protocol for a randomised controlled trial.

Methods/design

Pregnant women (n = 150), who attend antenatal clinics at Westmead Hospital in New South Wales, Australia, have a keloid scar from a previous caesarean section, meet the inclusion criteria and sign the consent form, will be randomised to either the control or the intervention group. The control group will receive surgical excision of the keloid scar at the beginning of the procedure during skin incision. The baby will be delivered according to normal procedures, and routine wound closure will be performed in accordance with National Institute for Health and Care Excellence guidelines. The intervention group will receive surgical excision of the keloid scar after the delivery of the baby, and closure of the uterus layers, rectus sheath and the fat layer will be completed as explained above. Then, triamcinolone acetone will be injected sub-dermally at the time of wound closure. Two ampules of triamcinolone acetonide will be administered at a single dose; each ampule contains 10 mg/1 ml active medication. The surgeon will inject one ampule along the entire length of the upper edge of the skin incision and one ampule along the entire length of the lower edge of the skin incision, using a 25 G needle. After the procedure is completed, the surgeon will fill in the post-operation survey.

The participants will be followed up post-operation, daily on the ward and then at 6 weeks, 6 months and 12 months post-partum. Main outcomes are (1) keloid formation after caesarean section and (2) changes in the appearance and specification of the keloid scar after the intervention.

Discussion

We anticipate that surgical excision and steroid injection will be a safe, lasting and cost-effective treatment in the management of caesarean keloid scars which will be useful for patients unable to undergo cosmetic surgery due to clinical or financial reasons.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618000984291. Registered on 12 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3465-6) contains supplementary material, which is available to authorized users.

Monocytes co-cultured with reconstructed keloid and normal skin models skew towards M2 macrophage phenotype

Several abnormalities have been reported in the peripheral blood mononuclear cells of keloid-forming patients and particularly in the monocyte cell fraction. The goal of this in vitro study was to determine whether monocytes from keloid-prone patients contribute to the keloid phenotype in early developing keloids, and whether monocyte differentiation is affected by the keloid microenvironment. Therefore, keloid-derived keratinocytes and fibroblasts were used to reconstruct a full thickness, human, in vitro keloid scar model. The reconstructed keloid was co-cultured with monocytes from keloid-forming patients and compared to reconstructed normal skin co-cultured with monocytes from non-keloid-formers. The reconstructed keloid showed increased contraction, dermal thickness (trend) and α-SMA+ staining, but co-culture with monocytes did not further enhance the keloid phenotype. After 2-week culture, all monocytes switched from a CD11c^high/CD14^high/CD68^low to a CD11c^high/CD14^low/CD68^high phenotype. However, only monocytes co-cultured with either reconstructed keloid scar or normal skin models skewed towards the more fibrotic M2-macrophage phenotype. There was negligible fibroblast and fibrocyte differentiation in mono- and co-cultured monocytes. These results indicate that monocytes differentiate into M2 macrophages when in the vicinity of early regenerating and repairing tissue, independent of whether the individual is prone to normal or keloid scar formation.

Dermatologic Conditions in Transgender Populations

Transgender persons receiving gender-affirming hormone therapy and procedures may face specific skin conditions. Skin diseases in transgender patients often are underdiagnosed and underrecognized despite their important impact on quality of life and mental health. This article discusses pathophysiology, diagnosis, and treatment of common skin diseases in the transgender populations. For transmasculine patients, conditions include acne vulgaris and male pattern hair loss. For transfeminine patients, conditions include hirsutism, pseudofolliculitis barbae, and melasma. Postprocedural keloids and other cutaneous complications are discussed. Unique aspects of skin health in transgender persons should be considered in the context of multidisciplinary gender-affirming care.

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.

Role of Hypoxia Inducible Factor-1 Alpha (HIF-1α) in Cytoglobin Expression and Fibroblast Proliferation of Keloids

BACKGROUND

Keloids are characterized by an overabundance of collagen deposition due to elevated activity and proliferation of fibroblasts, which lead to hypoxic conditions. Adaptation to these conditions is regulated by the transcription factor hypoxia inducible factor-1α (HIF-1α). Cytoglobin (Cygb), a reactive oxygen species scavenger, is a target gene of HIF-1α. In our previous study, we showed that Cygb expression in keloid tissue was correlated with HIF-1α expression. However, whether HIF-1α regulates Cygb expression and the proliferation of keloid fibroblasts remained unclear. Therefore, this study aimed to determine the role of HIF-1α in Cygb expression and fibroblast proliferation of keloids.

METHODS

This was an in vitro study using a primary culture of keloid fibroblasts in which ibuprofen was used to inhibit HIF-1α expression. The expression of HIF-1α and Cygb mRNA were analyzed using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) methods, and their protein levels were analyzed using an enzyme-linked immunosorbent assay (ELISA). Fibroblast proliferation was analyzed using a Trypan blue exclusion assay.

RESULTS

Inhibition of HIF-1α by ibuprofen decreased Cygb mRNA expression but not in all the samples, followed by a decrease in the protein level of Cygb. There was a positive correlation between the HIF-1α protein and Cygb mRNA, probably due to the regulation of Cygb by HIF-1α at the mRNA level, but not the protein level. The proliferation of keloid fibroblasts was significantly decreased and positively correlated with the HIF-1α protein.

CONCLUSION

HIF-1α regulates Cygb expression and fibroblast proliferation in keloids.

The Scar Bane, Without the Pain: A New Approach in the Treatment of Elevated Scars: Thermomechanical Delivery of Topical Triamcinolone Acetonide and 5-Fluorouracil

Introduction

Keloids are challenging to treat due to their inadequate response to treatment and high recurrence rate. Intralesional triamcinolone acetonide (TAC) injection with or without 5-fluorouracil (5FU) is considered the first-line treatment for keloids. Three significant disadvantages of intralesional injections are the pain associated with the procedure, the uneven topography, and epidermal atrophy. Fractionated ablative carbon dioxide (CO₂) laser-assisted drug delivery (LADD) of the topical solution can help facilitate transdermal drug delivery and shows promise in scar remodeling. This study examined the use of a thermomechanical device (Tixel, Novoxel) to facilitate the transdermal delivery of TAC and 5-FU in the treatment of keloid scars.

Methods

Seven patients each received eight topical thermal ablations, with one ablation performed every 2–3 weeks. TAC and 5FU were applied after each ablation. Outcomes were evaluated using the Vancouver Scar Scale (VSS), and pain was assessed using the Visual Analog Scale (VAS).

Results

Mean keloid VSS reduced from 8.6 ± 1.2 to 5 ± 2.7 after the eight treatments. Mean treatment pain VAS score was 2.4 ± 0.7. Patients rated their satisfaction level as moderate–high. No severe adverse reactions were noted.

Conclusion

Thermomechanical drug delivery of TAC and 5-FU is safe and effective. This is a promising option for the treatment of keloid scars, particularly in the pediatric population.

Retrospective study of immediate postoperative electron radiotherapy for therapy-resistant earlobe keloids

Keloid resection followed by adjuvant radiotherapy is the most efficacious treatment for keloids. However, for earlobe keloids, an optimal protocol for the total dose and fractions of adjuvant radiation has not yet been established. We retrospectively analyzed the efficacy and safety of immediate three-fraction electron radiotherapy after operation for resistant earlobe keloids. From 2011 to 2017, three-fraction electron radiotherapy with single dose of 5 Gy was given postoperatively to 23 patients with 30 keloids in our hospital. The first fraction of adjuvant radiotherapy was administered within 2 h of surgery, and the other two sessions were completed within the next day or two. Five (16.7%) primary keloids and 25 (83.3%) recurrent keloids were examined in this study. The primary endpoint was the local control rate, which was 86.7% after a median follow-up of 26 months (14–93 months). Secondary endpoints were acute and late procedure-related complications, and no severe complications were observed after combination therapy. Our results suggest that three-fraction electron radiotherapy after excision within 2 days of surgery is a safe and effective protocol for the prevention of earlobe keloid recurrence that can also improve patient compliance and comfort.

Surgery for scar revision and reduction: from primary closure to flap surgery

Scars are the final result of the four processes that constitute cutaneous wound healing, namely, coagulation, inflammation, proliferation, and remodeling. Permanent scars are produced if the wounds reach the reticular dermis. The nature of these scars depends on the four wound healing processes. If the remodeling process is excessive, collagen degradation exceeds collagen synthesis and atrophic scars are produced. If the inflammation phase is prolonged and/or more potent for some reason, inflammatory/pathological scars such as keloids or hypertrophic scars can arise. If these pathological scars are located on joints or mobile regions, scar contractures can develop. When used with the appropriate timing and when selected on the basis of individual factors, surgical techniques can improve mature scars. This review paper focuses on the surgical techniques that are used to improve mature scars, burn scars, and scar contractures. Those methods include z-plasties, w-plasties, split-thickness skin grafting, full-thickness skin grafting, local flaps (including the square flap method and the propeller flap), and expanded flaps, distant flaps, regional flaps, and free flaps.

Keloid formation after pediatric male genital surgeries: an uncommon and difficult problem to manage

INTRODUCTION

Penile and genital keloids are uncommon despite frequent surgeries in the genital area. Keloid scar pathogenesis is not well understood, and a uniform effective therapeutic regimen for keloids has not yet been established. In the present study, the clinical features and subsequent management in cases of severe keloid formation after pediatric genital surgery are described.

METHODS

A retrospective review of keloid cases that had developed after genital procedures between 2000 and 2017 was conducted. Pre-operative characteristics, operative procedures, postoperative management, and follow-up were reviewed for each case. All cases were managed by a multidisciplinary team that included plastic surgeons and dermatologists.

RESULT

Six cases developed genital keloids. The mean age at surgery was 5.6 years (± standard deviation 4.6 years). Procedures included phalloplasties, penile curvature correction, penoscrotal transposition, redo hypospadias repair, and circumcision. Treatment options included excision of the keloid ± topical steroid injections and postoperative use of silicone gel. Two cases of severe keloid lesions developed after using posterior auricular grafts. Ultimately, a successful outcome was achieved in all cases.

CONCLUSION

Genital keloids are rare and difficult to treat. Many therapeutic options are available with varying degrees of proven clinical success. As a result, pediatric urologists must be aware of advances in other fields such as plastic surgery and dermatology to treat and ideally prevent the occurrence of this serious complication.

Successful Treatment of Intralesional Bleomycin in Keloids of Vietnamese Population

BACKGROUND:

Keloid is an overactive condition of the skin tissue to early lesions characterised by proliferation of fibroblasts, excessive collagen production in the lesion. Treatment of keloids is a big challenge because of the poor response rate and high risk of recurrence after treatment. We found that bleomycin offers promise in the treatment of keloids.

AIM:

To evaluate the efficacy of bleomycin injected in the injury for keloids treatment.

METHODS:

The treatment was carried out in 55 patients having 120 keloids of different sizes and locations. Average treatments were 4 times.

RESULTS:

Complete flattening was 70.8%, highly significant flattening was 8.3%, no patient of minimal flattening. Systemic side-effects of bleomycin were not evaluated, but local side-effects were mainly pains (100%), blisters (78.3%), ulceration (5.8%), and hyperpigmentation (56.7%).

CONCLUSION:

The percentage of patients recurring 6, 12, 15, 18 months after the last treatment were 3.8, 15.4, 45.5, 50%, respectively.

Successful Treatment of Intralesional Triamcilonon Acetonide Injection in Keloid Patients

AIM:

Evaluation the effect of intralesional corticosteroid injection on keloid, at the National Hospital of Dermatology and Venereology from 1/2009 to 12/2009.

METHODS:

A group of 65 patients with keloid were randomly assigned into three groups. In the studied group, 33 patients were intralesionally injected 7.5 mg/1 cm² of TCA. In the control group, TAC 32 patients were intralesionally injected 15 mg/1 cm² of TCA. The result was evaluated basing on the criteria of Henderson (1998) and El-Tonsy (1996).

RESULTS:

In comparison between 2 groups, good to excellent improvement in the studied group was statistically higher than the control group (90.7% versus 68.7%; p < 0.05). After each injection, the thickness of the scar was reduced 1.24 ± 0.53 mm in the studied group and 0.81 ± 0.39 mm in the control group. The disappearance of pain and itching after treatment were 86.6% and 95.5% in the studied group and 78.1% and 80% in the control group (p > 0.05). Ulceration, acne and troublesome with menstrual cycles were sometimes were noted more frequently in the control group than in the studied group.

CONCLUSION:

Intralesional triamcinolone acetonide injection had a good result, and 7.5 mg/1 cm² scar is the best dose for treatment of keloid.

Keloid Formation due to Repetitive Mammographies

A keloid is the result of an abnormal wound healing response to a variety of skin injuries, characterized by a well-circumscribed, firm, irregular, mildly tender, and pink to purple hyperpigmented lump with a glossy surface. The present case reports on excessive formation of keloid due to repetitive mammographies causing symptomatic, cosmetically disturbing symptoms.

Surgical excision and postoperative radiotherapy for keloids

Keloids can be treated in a number of ways, including by surgery. Multiple studies now show that while surgical monotherapy associates with extremely high rates of recurrence (50%-80%), postoperative radiotherapy can significantly reduce these recurrence rates. Ongoing improvements in radiation technology have further increased the safety and efficacy of this combination protocol. Of the various radiotherapies that have been used in this setting, electron beam (β-ray) irradiation is currently the best due to its excellent dose distribution and safety. The maximal biologically effective dose (BED) for keloids is 30 Gy (using an estimated α / β ratio of 10); increasing the dose has no further benefits and elevates side effects. Over the last two decades, we have modified and then fine-tuned our radiotherapy protocol for keloid excision wounds. Thus, our early protocol was used for all body sites and consisted of 15 Gy/3 fr/3 days. We then customised the radiotherapy protocol so that body sites that are highly prone to recurrence (e.g. the anterior chest) receive higher doses while low recurrence sites like the earlobe receive a much smaller dose. More recently, we tweaked this body site-customised protocol so that fewer fractions are employed. Therefore, we currently apply 18 Gy/3 fr/3 days to high-recurrence sites, 8 Gy/1 fr/1 day to earlobes and 15 Gy/2 fr/2 days to other body sites. These radiotherapy protocol changes were accompanied by the evolution of body site-customised surgical approaches. As a result of these developments, our overall keloid recurrence rate is now below 10%.

Efficacy of 5-aminolevulinic acid-based photodynamic therapy against keloid compromised by downregulation of SIRT1-SIRT3-SOD2-mROS dependent autophagy pathway

Keloids exhibit cancer-like properties without spontaneous regression and usually recur post excision. Although photodynamic therapy (PDT) is a promising treatment, details of the mechanisms remain to be elucidated. In this study, we investigated mechanisms involved in 5-Aminolevulinic Acid (5-ALA)-based PDT against keloid. Found that 5-ALA-PDT induced superoxide anion-dependent autophagic cell death. Application of autophagy inhibitor 3-Methyladenine (3-MA) significantly prevented the effect that 5-ALA-PDT induced keloid-derived fibroblasts death, but Z-VAK-FMK (apoptotic inhibitor) did not. Interestingly, 5-ALA-PDT promoted the SIRT3 protein expression and the activity of mitochondrial superoxide dismutase 2 (SOD2), but SIRT1 protein expression level was decreased. SOD2 as a key enzyme can decrease mitochondrial ROS (mROS) level, Deacetylation of SOD2 by SIRT3 regulates SOD2 enzymatic activity has been identified. Then we explored SOD2 acetylation level with immunoprecipitation, found that 5-ALA-PDT significantly increased the acetylation levels of SOD2. In order to confirm deacetylation of SOD2 regulated by SIRT3, 3-TYP (SIRT3 inhibitor) was used. Found that inhibition of SIRT3 by 3-TYP significantly increased the level of SOD2 acetylation level compared with control group or 5-ALA-PDT group. To explore the connection of SIRT1 and SIRT3, cells were treated with EX527(SIRT1 inhibitor) or SRT1720 (SIRT1 activator), and EX527 increased SIRT3 protein level, however, SRT1720 displayed the opposite effect in the present or absence of 5-ALA-PDT. Moreover SIRT1-inhibited cells are more resistant to 5-ALA-PDT and showing decreased ROS accumulation. These results may demonstrate that 5-ALA-PDT induced SIRT1 protein level decreased, which promoted the effect of SIRT3 increased activity of SOD2 that can reduce mROS level, and then compromised 5-ALA-PDT induced autophagic cell death.

Keloid research: current status and future directions

INTRODUCTION

Keloids and hypertrophic scars are fibroproliferative disorders of the skin that result from abnormal healing of injured or irritated skin. Multiple studies suggest that genetic, systemic and local factors may contribute to the development and/or growth of keloids and hypertrophic scars. A key local factor may be mechanical stimuli. Here, we provide an up-to-date review of the studies on the roles that genetic variation, epigenetic modifications and mechanotransduction play in keloidogenesis.

METHODS

An English literature review was performed by searching the PubMed, Embase and Web of Science databases with the following keywords: genome-wide association study; epigenetics; non-coding RNA; microRNA; long non-coding RNA (lncRNA); DNA methylation; mechanobiology; and keloid. The searches targeted the time period between the date of database inception and July 2018.

RESULTS

Genetic studies identified several single-nucleotide polymorphisms and gene linkages that may contribute to keloid pathogenesis. Epigenetic modifications caused by non-coding RNAs (e.g. microRNAs and lncRNAs) and DNA methylation may also play important roles by inducing the persistent activation of keloidal fibroblasts. Mechanical forces and the ensuing cellular mechanotransduction may also influence the degree of scar formation, scar contracture and the formation/progression of keloids and hypertrophic scars.

CONCLUSIONS

Recent research indicates that the formation/growth of keloids and hypertrophic scars associate clearly with genetic, epigenetic, systemic and local risk factors, particularly skin tension around scars. Further research into scar-related genetics, epigenetics and mechanobiology may reveal molecular, cellular or tissue-level targets that could lead to the development of more effective prophylactic and therapeutic strategies for wounds/scars in the future.

Tension enhances cell proliferation and collagen synthesis by upregulating expressions of integrin αvβ3 in human keloid-derived mesenchymal stem cells

AIMS

Keloids are a dermal fibrotic disease whose etiology remains totally unknown and for which there is no successful treatment. Mechanical tension, in addition, is closely associated with the germination and development of keloids. In this study, we investigated the influence of human keloid-derived mesenchymal stem cells (KD-MSCs) on cell proliferation, collagen synthesis, and expressions of integrin αvβ3 under tension.

MAIN METHODS

KD-MSCs and human normal skin-derived mesenchymal stem cells (NS-MSCs) were isolated and cultured in stem cell medium with a gradual increase in the serum concentration. Cell proliferation and collagen synthesis were detected by Cell Counting Kit-8 (CCK-8) assay and hydroxyproline content analysis under tension respectively. We investigated the messenger RNA expressions of nine integrin subunits, including integrin units α2, α3, α5, αv, α8, α10, α11, β1, and β3, in KD-MSCs stimulated with tension. Identification of differentially expressed genes was performed by Western blot analysis and immunocytochemistry staining.

KEY FINDINGS

We obtained high-purity KD-MSCs and NS-MSCs using the culture method of decreasing serum concentration gradient gradually. Furthermore, we found that tension enhances cell proliferation and collagen synthesis and promotes expressions of integrin αvβ3 in KD-MSCs. In addition, blocking experiments showed that increased integrin αvβ3 expression affects cell proliferation and collagen synthesis of KD-MSCs under tension.

SIGNIFICANCE

Our results suggest that integrin αvβ3 receptor may be sensitive molecules of mechanical tension and could contribute to the occurrence and development of keloids. It could lead to novel targets for therapeutic intervention, treatment, and prevention of recurrence for keloid disorders.

Helical rim advancement - A technique to avoid keloid recurrence

Introduction

Helical rim keloids occur commonly following ear piercings, trauma and previous surgeries and can be disfiguring. Many techniques have been developed to treated these disfiguring lesions with varying successes, however, individuals prone to developing keloids inadvertently recur despite best efforts.

Objective

To determine whether helical rim advancement flap reconstruction following helical rim keloid excision can reduce recurrences.

Design

Case series followed up to 2 years.

Setting

Single Centre Tertiary Hospital Facial Plastics Service.

Participants

All patients who consented to helical rim advancement reconstruction after keloid excision.

Results

The authors report a series of 7 patients with helical rim keloids ranging from 1.2 cm to 5 cm in widest diameter treated with keloid excision and reconstruction with helical rim advancement flap technique. There were no recurrences within a mean of about 19 months post-operatively. Most patients report satisfaction with the cosmetic end-result.

Discussion

From the authors’ experience, helical rim advancement reconstruction following excision of keloids about 2.5 cm in widest diameter is an excellent tension-free option to avoid recurrence of helical rim keloids. Wound tension is a key risk factor for keloid formation. We hypothesise that the reason why there was no recurrence is because in helical rim advancement flap reconstruction, the underlying helical rim takes all the tension of closure off the dermis, resulting in tension-free skin closure.

Conclusion

Helical rim advancement flap reconstruction is a viable technique to avoid recurrence and minimise cosmetic deformities of the pinna for selected helical rim keloids.

2-Methoxyestradiol improves the apoptosis level in keloid fibroblasts through caspase-dependent mechanisms in vitro

Apoptosis is a form of programmed cell death that occurs in multicellular organisms. Fibroblasts are the main cellular ingredients in keloid tissue, which has a relatively low apoptosis level. A natural metabolite of estradiol, 2-Methoxyestradiol (2ME2) exerts a pro-apoptotic effect on tumor cells. In this study, the expression levels of key factors in the apoptosis pathway and the expression level of the proliferating cell nuclear antigen (PCNA) were measured to assess the levels of apoptosis and proliferation in both normal skin fibroblasts and keloid fibroblasts. Twelve samples were obtained from 12 patients: 6 keloid patients and 6 non-keloid patients. All 12 of the patients were randomly selected from the Department of Plastic Surgery at Peking Union Medical College Hospital from June 2016 to December 2016. After cell culture, fibroblasts were divided into the following 6 groups: normal skin fibroblasts (S); keloid fibroblasts (K); keloid fibroblasts treated with 2ME2 (2ME2); keloid fibroblasts treated with DMSO (DMSO); keloid fibroblasts treated with the caspase inhibitor Ac-DEVD-CHO (IN); and keloid fibroblasts treated with both Ac-DEVD-CHO and 2ME2 (IN+2ME2). Fibroblasts at up to passage 3 were used for analysis. Cell activity was measured by the cell counting kit-8. TUNEL staining was used to observe the cell apoptotic morphology. The key apoptosis factors (caspase-3, caspase-8, caspase-9, Bcl-2, Bax, and cytochrome-c) and PCNA expression levels were detected by immunofluorescence analysis and Western blotting. A certain concentration of 2ME2 was also used in group S to evaluate the toxicity. Compared with that in the other groups, 2ME2 significantly inhibited cell activity and led to apoptotic appearance of fibroblasts. In protein analysis, 2ME2 remarkably increased the expression of apoptosis factors and decreased the PCNA expression. Apoptosis levels were reduced by both the caspase inhibitor and 2ME2; thus indicating that the pro-apoptosis effect of 2ME2 was achieved through a caspase-dependent mechanism in keloid fibroblasts. Toxicity assessment showed that 2ME2 had a very low influence on normal skin fibroblasts. 2ME2, considered to be a new promising type of chemotherapy drug, exerts a pro-apoptosis effect by regulating the caspase family and an anti-proliferation effect towards keloid fibroblasts, and it presents low toxicity towards normal fibroblasts in vitro.