Sensitization of keloid fibroblasts by quercetin through the PI3K/Akt pathway is dependent on regulation of HIF-1α

Keloids are raised, red, hard and irregular tumors that are prone to extend beyond the wound borders. Surgical excision is not sufficient to eradicate a keloid. Adjuvant therapy with radiation is a recommended treatment that reportedly achieves improved efficacy. However, radiation does not only kill cells in the keloid tissue but also stimulates their resistance, and intractable cases can display continuous recurrence. Quercetin was initially extracted from natural products and is used as a dietary supplement. The role of quercetin as an oxidant scavenger has been highlighted in many studies and has drawn interest to the application of ionizing radiation (IR) sensitization. In this study, we first demonstrate that keloid fibroblasts acquire resistance after IR treatment, and this can be relieved by treatment with quercetin. Further, we showed that hypoxia-inducible factor 1 (HIF-1), a prognostic marker used in clinical practice after radiation therapy, was associated with stronger radioresistance in keloid fibroblasts, which was downregulated after quercetin treatment. The inhibition of HIF-1 expression by quercetin was found to be dependent on the phosphatidylinositol-3-kinase (PI3K)/Akt pathway. Quercetin has been reported to reduce the phosphorylation of Akt. Taken together, we revealed one mechanism underlying the suppression of radioresistance by quercetin, which involved the regulation of HIF-1α by the PI3K/Akt pathway. Our study provides a molecular basis for the application of quercetin in radiation sensitization in the treatment of 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.

Reconstructed human keloid models show heterogeneity within keloid scars

Keloid scars are often described as having an actively growing peripheral margin with a regressing centre. The aim of this study was to examine the possible heterogeneity within keloids and the involvement of different regions within and around keloid scars in the pathogenesis, using an in vitro keloid scar model. In vitro skin models were constructed from keratinocytes and fibroblasts from normal skin and different regions within and around keloid scars: periphery, centre, and (adjacent) surrounding-normal-skin regions. Additionally, fibroblasts were isolated from the superficial-central and deep-central regions of the keloid and combined with central keratinocytes. All keloid regions showed increased contraction compared to normal skin models, particularly in central regions. Myofibroblasts were present in all keloid regions but were more abundant in models containing central-deep keloid fibroblasts. Secretion of anti-fibrotic HGF and extracellular matrix collagen IV gene expression was reduced in the central deep keloid compared to normal skin. No significant differences between peripheral and central regions within keloids were observed for inflammatory cytokine CCL20, CCL27, CXCL8, IL-6 and IL-18 secretion. Parameters for surrounding-normal-skin showed similarities to both non-lesional normal skin and keloids. In conclusion, a simple but elegant method of culturing keloid-derived keratinocytes and fibroblasts in an organotypic 3D scar model was developed, for the dual purpose of studying the underlying pathology and ultimately testing new therapeutics. In this study, these tissue engineered scar models show that the central keloid region shows a more aggressive keloid scar phenotype than the periphery and that the surrounding-normal-skin also shares certain abnormalities characteristic for keloids.

[Effects of N-(4-hydroxyphenyl) retinamide lipid microbubble combined with ultrasound on human keloid fibroblasts]

Objective: To explore the effects of N-(4-hydroxyphenyl) retinamide (4HPR), 4HPR liposome (4HPR-L), and 4HPR lipid microbubble (4HPR-LM) combined with ultrasound on proliferation, apoptosis, and cell cycle of human keloid fibroblasts (Fbs). Methods: (1) 4HPR-L and 4HPR-LM were prepared by hydration ultrasonic method. The appearance morphology, particle size distribution, Zeta potential, loading drug concentration, encapsulation efficiency, and drug loading rate of 4HPR-L were investigated by high performance liquid chromatography, dynamic light scattering, and transmission electron microscope. (2) Human keloid Fbs were cultured and divided into 13 groups by random number table (the same grouping method below), with 6 wells in each group. Cells in control group were given no treatment, while cells in 12 ultrasound groups including 0.5 W 30 s group, 0.5 W 60 s group, 0.5 W 120 s group, 0.7 W 30 s group, 0.7 W 60 s group, 0.7 W 120 s group, 1.0 W 30 s group, 1.0 W 60 s group, 1.0 W 120 s group, 1.5 W 30 s group, 1.5 W 60 s group, and 1.5 W 120 s group were treated by ultrasound with corresponding parameters. The cells viability was measured by a microplate reader after 24 hours of routine culture. Another batch of human keloid Fbs were divided into 5 groups, with 6 wells in each group. Cells in control group were given no treatment, while cells in 1, 10, 20, and 50 μg/mL blank lipid microbubble groups were treated with blank lipid microbubbles in corresponding mass concentration. The cells viability was measured as before after 24 hours of routine culture. Another batch of human keloid Fbs were divided into 6 groups, with 12 wells in each group. Cells in control group were given no treatment, while cells in 1, 10, 20, 50, and 100 μg/mL 4HPR-L groups were added with 4HPR-L carrying corresponding mass concentration of 4HPR. The cells viability in 6 wells of each group was detected after 24 and 48 hours of routine culture, respectively. Another batch of human keloid Fbs were divided into 4 groups, with 6 wells in each group. Cells in control group were given no treatment, while cells in 4HPR, 4HPR-L, and 4HPR-LM+ ultrasound groups were treated with 4HPR, 4HPR-L, and 4HPR-LM (all the mass concentration of 4HPR was 20 μg/mL), respectively, and cells in 4HPR-LM+ ultrasound group were given 0.5 W 60 s ultrasound treatment immediately after drug administration. The cells viability was measured as before after 24 hours of routine culture. (3) Another batch of human keloid Fbs were divided into control group, 4HPR group, 4HPR-L group and 4HPR-LM+ ultrasound group, with 3 wells in each group, and the cells in each group were treated as before. Apoptosis of the cells was detected by flow cytometer after 24 hours of routine culture. (4) Another batch of human keloid Fbs were grouped and treated as in (3), and then the cell cycle distribution was detected by flow cytometer after 24 hours of routine culture. Data were processed with one-way analysis of variance and t test. Results: (1) 4HPR-L particles had a spherical or spheroidal structure and were uniform in size, with particle size of (100.1±1.3) nm and Zeta potential of (-34.3±2.3) mV. The mass concentration of 4HPR in 4HPR-L solution was about 1 400 μg/mL, with the encapsulation efficiency of (95.8±1.2)% and drug loading rate of (8.3±0.4)%. (2) The viability of cells in the 12 ultrasound groups was higher than 93.0%, and the viability of cells in 1, 10, 20, and 50 μg/mL blank lipid microbubble groups was higher than 95.0%. The viability of cells in 1 μg/mL 4HPR-L group at administration hour 24 was similar to that at 48 (t=0.393, P>0.05). The viability of cells in 10, 20, 50, and 100 μg/mL 4HPR-L groups at administration hour 24 was significantly higher than that at administration hour 48 (t=44.593, 22.961, 32.224, 35.337, P<0.01). The viability of cells in 4HPR group, 4HPR-L group, and 4HPR-LM+ ultrasound group was (47.3±0.7)%, (42.3±1.7)%, and (38.6±0.8)%, respectively. The viability of cells in 4HPR group was significantly higher than that in 4HPR-L group and 4HPR-LM+ ultrasound group (t=4.551, 15.895, P<0.05 or P<0.01). The viability of cells in 4HPR-L group was significantly higher than that in 4HPR-LM+ ultrasound group (t=-3.360, P<0.05). (3) The percentages of total apoptotic cells in 4HPR group, 4HPR-L group, and 4HPR-LM+ ultrasound group were (32.8±2.4)%, (42.5±2.4)%, and (58.5±6.3)%, respectively, which were significantly higher than the percentage of control group [(14.9±1.6)%, t=8.748, 13.637, 9.500, P<0.01]. The percentages of total apoptotic cells in 4HPR-L group and 4HPR-LM+ ultrasound group were significantly higher than the percentage in 4HPR group (t=4.049, 5.393, P<0.05 or P<0.01), and the percentage of total apoptotic cells in 4HPR-LM+ ultrasound group was significantly higher than that in 4HPR-L group (t=3.371, P<0.01). (4) The percentage of G2/M phase cells in 4HPR group was higher than that in control group, but there was no statistically significant difference (t=2.107, P>0.05). The percentage of G2/M phase cells in 4HPR-L group was significantly higher than that in 4HPR group or control group (t=18.169, 30.026, P<0.01). The percentage of G2/M phase cells in 4HPR-LM+ ultrasound group was significantly higher than that in 4HPR-L group, 4HPR group, and control group (t=4.932, 25.854, 66.231, P<0.01). Conclusions: 4HPR can inhibit proliferation, induce apoptosis, and arrest G2/M phase of human keloid Fbs, and the effects of 4HPR-LM combined with ultrasound are better than those of 4HPR-L and free 4HPR.

Facial Plastic Surgery Controversies: Keloids

There are more than 11 million people in the world affected with keloids. Nevertheless, there is a lack of agreement in keloid management. Moreover, keloid research has left gaps in the understanding of its pathogenesis. Six questions are answered by 3 clinical scientists in an attempt to address common keloid controversies.

[Mutations in A((8)) and A((9)) loci of exon 8 of retinoblastoma protein-interacting zinc finger gene of keloid patients]

Objective: To study the situation of the mutations in the A((8)) and A((9)) loci of exon 8 of retinoblastoma protein-interacting zinc finger gene (RIZ) of keloid patients. Methods: From January 2003 to December 2007, 19 outpatient and hospitalized keloid patients of our hospital were conforming to the inclusion criteria. Both 3-5 g keloid tissue and 3 mL peripheral venous blood were collected from each patient to extract their genomic DNA, and the concentration was determined. The A((8)) and A((9)) loci fragments of exon 8 of RIZ were amplified by polymerase chain reaction (PCR). The length of product was detected by agarose gel electrophoresis, and DNA sequencing was performed after column chromatography. The mutations of A((8)) and A((9)) loci fragments were searched, and the types of mutations were determined. The consistency of genetic mutations of the keloid tissue and peripheral venous blood were compared. Data were processed with McNemar test. Results: The DNA concentrations of the extracted keloid tissue and peripheral venous blood were 0.54 and 0.37 μg/μL, respectively, which were above 0.10 μg/μL. The lengths of PCR products of A((8)) locus fragment DNA of exon 8 of RIZ from keloid tissue and peripheral venous blood were 235 and 238 bp, respectively, and those of A((9)) locus were 242 and 244 bp, respectively, which were basically the same as the designed DNA fragments. PCR products purity of A((8)) locus fragment DNA of exon 8 of RIZ from keloid tissue and peripheral venous blood were 1.81 and 1.75, respectively, and those of A((9)) locus were 1.82 and 1.78, respectively, which were above 1.50. Mutations in the A((8)) locus of exon 8 of RIZ were observed in keloid tissue of 18 patients, totally 6 gene mutations, including 4 point mutations and 2 frameshift mutations. Mutations in the A((9)) locus of exon 8 of RIZ were observed in keloid tissue of 9 patients, totally 9 gene mutations, including 7 point mutations and 2 frameshift mutations. No patient had a mutation in the A((8)) or A((9)) locus of exon 8 of RIZ in peripheral venous blood. Compared with those of peripheral venous blood, the mutations in the A((8)) and A((9)) loci of exon 8 of RIZ in keloid tissue of patients were statistically significant (χ(2)=16.06, 7.11, P<0.05). Conclusions: Point mutations and frameshift mutations occur in the A((8)) and A((9)) loci of exon 8 of RIZ in keloids of patients, which may be associated with the occurrence of keloids.

[Effectiveness of internal mammary artery perforator propeller flap repair combined with radiotherapy for chest keloid in female patients]

Objective

To investigate the effectiveness of internal mammary artery perforator (IMAP) propeller flap repair combined with radiotherapy for chest keloid in female patients.

Methods

Between January 2015 and December 2016, 15 female patients with chest keloids were treated, aged 28-75 years (mean, 45.2 years). The keloid disease duration was 1-28 years (median, 6 years). The causes of disease included secondary keloid caused by folliculitis in 7 cases, cardiac surgery in 4 cases, skin abrasion in 2 cases, mosquito bite in 1 case, and unknown etiology in 1 case. The size of keloid ranged from 5 cm×3 cm to 17 cm×6 cm. The IMAP propeller flaps were used to repair the defects after chest keloid excision. The size of flaps ranged from 7 cm×5 cm to 14 cm×8 cm. The donor sits were sutured directly. The routine radiotherapy was performed after operation.

Results

All IMAP propeller flaps survived well, and the donor site healed by first intention. All 15 patients were followed up 12-24 months (mean, 16 months). No telangiectasia or incision dehiscence occurred. No radiation-related carcinogenesis occurred during follow-up. The patients were satisfied with the breast shape and symmetry after operation. The symptoms of pain and itching were relieved at keloid area in 13 cases (86.7%), with no obvious recurrence of keloid at the donor site and the primary site. Only 2 cases (13.3%) recurred and were treated with continuously conservative treatment.

Conclusion

IMAP propeller flap is an ideal reconstruction method for repairing the wounds after chest keloid excision in female patients, which can preserve the good breast shape. The IMAP propeller flap repair combined with early postoperative radiotherapy can effectively reduce the recurrence rate, and the effectiveness is satisfactory.

Treatment of keloid scars with intralesional triamcinolone and 5-fluorouracil injections - a randomized controlled trial

Keloids have high recurrence rates. Current first-line therapy is triamcinolone (TAC) injection, but it has been suggested that approximately 50% of keloids are steroid resistant. We compared the efficacy of intralesional 5-fluorouracil (5-FU) and triamcinalone injections in a double-blind randomized controlled trial. Forty-three patients with 50 keloid scars were treated with either intralesional TAC or 5-FU-injections over 6 months. There was no statistically significant difference in the remission rate at 6 months between the 5-FU and TAC groups (46% vs 60%, respectively). Local adverse effects were higher in the TAC group compared to the 5-FU group. Occurrence of skin atrophy in TAC group was 44% and in the 5-FU group 8% (p < 0.05). Also the occurrence of telangiectasia in the TAC group was 50% and in the 5-FU 21% (p < 0.05). Vascularity of the keloids, assessed by spectral imaging and immunohistochemical staining for blood vessels, after treatment decreased in the TAC group, but not in the 5-FU group (p < 0.05). Fibroblast proliferation evaluated by Ki-67 staining significantly decreased in the TAC group (p < 0.05) but increased in the 5-FU group (p < 0.05). TAC and 5-FU injections did not differ in their clinical effectivity in this randomized study, but 5-FU injections lead to increased proliferation rate and did not affect vascular density in histological assessment. Due to the greater number of adverse effects observed after TAC treatment, 5-FU injections may be preferable for cosmetically sensitive skin areas.

Identification of a novel mutation in the mechanoreceptor-encoding gene CXCR1 in patients with keloid

Keloids are skin fibroproliferative tumors characterized by locally invasive growth of fibroblasts and excessive collagen deposition. The objective of this study is to investigate the molecular basis of the keloid scar by studying the mutation of related genes. We performed gene screening of mechanoreceptors by quantitative polymerase chain reaction (qPCR), Sanger sequencing to detect the CXCR1gene mutation, and immuno-histochemistry to determine CXCR1 protein expression. Among the genes encoding mechanoreceptors, the expression of CXCR1 mRNA was significantly higher in keloid scar tissues than in the surrounding tissues of normal controls (P < 0.05). Sequencing analysis identified a novel missense mutation, c.574G > A (p.Gly192Glu). Immunohistochemistry showed heightened protein expression of CXCR1 in keloid scars as compared to controls. Our findings indicate that CXCR1 gene mutation and altered protein expression are associated with keloid scar development. Identification of the CXCR1 gene mutation might provide insights into the molecular mechanism underlying keloid scar and underscores the potential importance of mechanoreceptors in keloid scar pathogenesis.

[Advances in the research of drug intralesional injection therapy in keloid]

Keloid is characterized by tumor-like invasive growth, high incidence, and low remission rate. The pathogenesis of keloid is still unknown. Keloids can not only affect appearance, but also cause severe itching and pain, which may affect physical and mental health of patients. Previous treatments for keloids include surgery, drugs, lasers and so on. Due to the high recurrence rate of surgical treatment accompanied by keloid enlargement, drug therapy has gradually become a hot topic. Among various methods of administration, intralesional injection is widely accepted as it can promote drug absorption to achieve better results. The progress of several drugs used in intralesional injection therapy for keloid is reviewed in this paper.

Comparison of intralesional verapamil versus intralesional corticosteroids in treatment of keloids and hypertrophic scars: A randomized controlled trial

BACKGROUND

Keloids and hypertrophic scars are due to overgrowth of dermal collagen following trauma to the skin that usually cause major physical, psychological and cosmetic problems.

METHODS

In this randomized controlled trial, with a paired design, 50 patients with 2 or more keloids were included. In the control group (50 lesions), intralesional triamcinolone acetonide (40mg/mL) was injected at three-week intervals for a total of 18weeks. In the other group (50 lesions), lesions were treated by verapamil (2.5mg/mL) with the same therapeutic sessions. Scar evaluation at each stage and at the end of 3months follow up was done by serial photographic records as well as by Vancouver Scar Scale (VSS).

RESULTS

Mean zero VSS scores were achieved with only triamcinolone in respect of scar height (week 15th) and pliability (week 15th). No therapeutic event (parameter=0) or significant improvement was seen in verapamil group.

CONCLUSION

Our results did not support verapamil's capability in treatment of keloid nor hypertrophic scars.

Is Striae Gravidarum related to Cesarean Scar and Peritoneal Adhesions?

Objective

To evaluate the relationship between striae gravidarum (SG) score and abdominal scar characteristics together with intraperitoneal adhesion (IPA) grades of patients who were hospitalized for second cesarean delivery.

Methods

A total of 145 consecutive women undergoing scheduled cesarean section (CS) in a tertiary level maternity hospital between November 2013 and January 2014 were included in the study. All women had transverse suprapubic skin incision due to the previous CS and none of them had a history of vaginal delivery. Patients were classified according to the SG status, as women with no SG: Group-1(n=53), mild SG: Group-2(n=27) and severe SG: Group 3(n=65). Groups were compared between themselves with regard to various sociodemographic properties, cesarean scar characteristics and IPA scores.

Results

No significant difference in the length, width and color of the scar was detected among groups. While flat scar was the most prominent form of scar, the elevated scar was significantly more frequent in Group-1 compared to other groups (p=0.009). IPA grades were 0 or 1 in 77.3% of Group-1, 81.3% of Group-2 and 76% of Group-3. There was no significant difference in IPA scores between groups (p=0.884). After combining CS scar characteristics (flat, depressed and elevated) and SG status [SG (+) or SG (-)], we found no significant difference between the groups in terms of IPA severity.

Conclusion

Striae gravidarum (SG) was found to be associated with scar characteristics, but not associated with the severity of intraperitoneal adhesion (IPA).

AMF siRNA treatment of keloid through inhibition signaling pathway of RhoA/ROCK1

A keloid (KD) is a benign dermal fibrotic tumor. Treatment of KDs is challenging and the recurrence rate is high; thus, there is an unmet need to explore new target sites and new treatment methods. As a tumor-associated cytokine, autocrine motility factor (AMF) can effectively stimulate the random and directional movement of cells. We first found that AMF was overexpressed in keloid fibroblasts (KFs) and the proliferation and migration of KFs were promoted by AMF stimulation. After treatment with Y-27632, RhoA kinase inhibitor, the proliferation and migration capacity of KFs declined significantly, and type I collagen protein, active RhoA and ROCK1 also were downregulated. In addition, a KD transplantation model was established under the skin of nude mice, with KD intramural injection AMF siRNA, we found that the weight of the KD was smaller than in the control group (P < 0.05), KD tissue sections stained by HE and Masson showed that fibers became loose and the blood vessels were visibly reduced. In conclusion, AMF siRNA is expected to be a novel strategy to treat KD by inhibiting signaling pathway of RhoA/ROCK1.

Comparison of Intralesional Triamcinolone Acetonide, 5-Fluorouracil, and Their Combination in Treatment of Keloids

BACKGROUND

Despite the myriad options available, there is no universally accepted treatment for keloids. This study has compared intralesional triamcinolone acetonide, 5-fluorouracil, and their combination in treatment of keloids.

METHODS

In this randomized parallel group study, 60 patients were enrolled and randomly allocated to three groups. Patients received intralesional injections of triamcinolone acetonide (TAC) in Group TAC, 5-fluorouracil (5FU) in Group 5FU and a combination in Group T+F every 3 weeks till 24 weeks or till the keloid resolved.

RESULTS

There was a reduction in all parameters at every successive assessment in all three groups. Improvement in terms of height, vascularity and pliability was fastest with 5FU, TAC and T+F group, respectively, which was statistically significant. Decrease in pigmentation was significantly faster with T+F. Reduction in pruritus, however, was significantly faster with 5FU than the other groups, but the difference in reduction of pain among the three groups was not significant. Telangiectasias and skin atrophy were seen most commonly in TAC group, while skin ulceration was a common problem in 5FU group.

CONCLUSION

TAC, 5FU and their combination are all effective in keloid scars. A combination of TAC+5FU seems to offer the balanced benefit of faster and more efficacious response with lesser adverse effects when compared to individual drugs.

The fortune cookie flap for aesthetic reconstruction after chest keloid resection: a small case series

Background

Generally, the recurrence rate of keloids is unacceptably high after surgical excision alone. Nevertheless, surgical reduction of keloids is inevitable in many cases. The reconstruction of extensive soft tissue defects following complete keloid resection is challenging to surgeons. In this study, we present our clinical experience using a novel fortune cookie flap for treating chest keloids. This flap provides an excellent surgical option that maintains natural appearance with minimal donor-site morbidity.

Methods

We retrospectively reviewed the data from 3 consecutive cases of reconstruction using the fortune cookie flap following resection of chest keloids between March and December, 2017.

Results

Successful reconstructions were performed without any major complications. The mean dimensions of the reconstructed defect were 5.0 × 4.2 cm, while the mean dimensions of the flap were 7.7 × 5.7 cm.

Conclusions

Owing to its simplicity, reliability, versatility, minimal morbidity and excellent aesthetics, the fortune cookie flap is as an excellent option for reconstruction following complete keloid resection on the chest.

Electronic supplementary material

The online version of this article (10.1186/s13019-018-0713-x) contains supplementary material, which is available to authorized users.

Rare experience of keloidal dermatofibroma of forehead

Dermatofibromas most commonly occur on limbs and rarely occur on the face. Dermatofibroma occurring on the face is associated with unusual clinicopathologic features and a more aggressive clinical course in comparison to typical cases. Additionally, the most common subtype found in previous studies was benign fibrous histiocytoma, with the keloid type being very rare (about 1% of reported cases). The aim of this study was to present our experience with a keloidal dermatofibroma of the face, which is usually missed clinically, and to discuss the treatment of a keloidal dermatofibroma in this location.

Mechanical forces in skin disorders

Mechanical forces are known to regulate homeostasis of the skin and play a role in the pathogenesis of skin diseases. The epidermis consists of keratinocytes that are tightly adhered to each other by cell junctions. Defects in keratins or desmosomal/hemidesmosomal proteins lead to the attenuation of mechanical strength and formation of intraepidermal blisters in the case of epidermolysis bullosa simplex. The dermis is rich in extracellular matrix, especially collagen, and provides the majority of tensile force in the skin. Keloid and hypertrophic scar, which is the result of over-production of collagen by fibroblasts during the wound healing, are associated with extrinsic tensile forces and changes of intrinsic mechanical properties of the cell. Increasing evidences shows that stiffness of the skin environment determines the regenerative ability during wound healing process. Mechanotransduction pathways are also involved in the morphogenesis and cyclic growth of hair follicles. The development of androgenetic alopecia is correlated to tensile forces generated by the fibrous tissue underlying the scalp. Acral melanoma predominantly occurs in the weight-bearing area of the foot suggesting the role of mechanical stress. Increased dermal stiffness from fibrosis might be the cause of recessive dystrophic epidermolysis bullosa associated squamous cell carcinoma. Strategies to change the mechanical forces or modify the mechanotransduction signals may lead to a new way to treat skin diseases and promote skin regeneration.

Intralesional cryotherapy versus excision with corticosteroid injections or brachytherapy for keloid treatment: Randomised controlled trials

BACKGROUND

Keloids are a burden for patients due to physical, aesthetic and social consequences. Treatment remains a challenge due to therapy resistance and high recurrence rates. The main goals of treatment are to improve scar appearance and symptoms and patients' quality of life (QoL).

METHODS

Two multicentre, randomised controlled open trials that compared 1) intralesional cryotherapy with excision and corticosteroid injections for primary keloids, and 2) intralesional cryotherapy with excision and brachytherapy for therapy resistant keloids. Primary outcome was scar appearance assessed with the Patient and Observer Scar Assessment Scale. Secondary outcomes were patient reported QoL (Skindex-29, SF-36, EQ-5D-5L), recurrence rates and scar volume reduction. For analysis, a linear mixed model was used. Power analysis indicated 33 patients in each group were needed.

RESULTS

The trial was prematurely terminated after inclusion of 26 patients due to unexpectedly inferior outcomes after intralesional cryotherapy. For primary keloids no convincing difference between treatments was found, but surgery improved scar appearance while cryotherapy did not. For resistant keloids, excision followed by brachytherapy improved scar appearance (POSAS) and scar symptoms (itch and pain) significantly (p < 0.001, p < 0.001 and p = 0.006 respectively) while cryotherapy did not. Neither of the treatments caused indisputable improvements in QoL.

CONCLUSIONS

Intralesional cryotherapy is inferior to keloid excision followed by brachytherapy for resistant keloids. In primary keloids, intralesional cryotherapy reduced keloid volume and, therefore, may be used in these patients and specific cases. Primary keloid group size was too small to draw valid conclusions, further research on the efficacy of intralesional cryotherapy for primary keloids is warranted.

[Advances in the research of relationship between CD26 and hypertrophic scar and keloid]

In recent years, researchers have found that CD26 (dipeptidyl peptidase 4) is closely related to the formation and development of many fibrotic diseases. Hypertrophic scar, keloid, and other skin fibrosis diseases are major problems nowadays, which may affect the patient's appearance and cause joints deformity and dysfunction due to scar contracture. This article briefly reviews the relationship between CD26 and hypertrophic scar and keloid to provide new insights into the treatment of skin fibrotic diseases.

Corneal Myofibroma (Keloid) in a Young Patient with Neurofibromatosis Type 2

We present a 27-year-old male patient with neurofibromatosis type 2 (NF2), facial palsy, and lagophthalmos following acoustic neuroma removal and an impressing vascularized corneal tumor, which was excised. Histology showed a fibrous tumor with small vessels, and immunohistochemistry was positive for vimentin and negative for smooth muscle actin, S100, and GFAP. We assume a corneal myofibroma (keloid), which in this case rather represents a reactive lesion. This entity has not been described before in NF2 or in facial palsy-associated lagophthalmos in general.

Efficacy and the toxicity of the interstitial high-dose-rate brachytherapy in the management of recurrent keloids: 5-year outcomes

PURPOSE

Recurring keloids are a clinical challenge. Interdisciplinary treatments are required in most cases. Owing to the wide variety of concepts, the optimal treatment regime remains unclear. Our clinic established a protocol of perioperative interstitial high-dose-rate brachytherapy with three fractions of 6 Gy and achieved an excellent 2-year local control rate of 94% (In search of the optimal treatment of keloids: Report of a series and a review of the literature). This report is an update on our long-term results of prospective study. Twenty-nine patients were included with a median followup of 5 years.

METHODS AND MATERIALS

From 2009 to 2015, 29 patients with 37 recurrent keloids were treated with perioperative interstitial high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiotherapy and presented with recurrences in the pretreated area. Brachytherapy was given in three fractions with a single dose of 6 Gy in 5-mm tissue depth and covered the scar in total length. Followup visits were scheduled at 6 weeks, 3 months, 6 months, 1 year, and annually thereafter. Therapeutic outcome was assessed in terms of recurrence, acute and late complications, and cosmetic results.

RESULTS

No procedure-related complications occurred. Improvement of keloid-related symptoms was noticed in all patients after treatment. After a median followup of 49.7 months (range: 7.9-91.9 months), three keloid recurrences and two hypertrophied scars were observed.

CONCLUSIONS

Our results suggest that brachytherapy may be advantageous in the management of high-risk keloids, even after failure of external beam radiotherapy and other treatment procedures. Our three-fraction treatment schedule reduces the treatment period to 2 days and is therefore convenient for the patients.

Macrophages in keloid are potent at promoting the differentiation and function of regulatory T cells

The mechanistic details of keloid formation are still not understood. Given that the immune system is engaged in skin lesion repair, we examined the CD14⁺ macrophages and CD3⁺ T cells in keloid tissues and in the normal skin. Compared to the normal skin, keloid tissues presented significantly elevated infiltration by CD14⁺ macrophages. Moreover, the transcription and protein expression of iNOS, IL-12, IL-10, and TGF-β were significantly higher in keloid macrophages than in normal skin macrophages, in which the expression of M2-associated genes were further elevated compared to M1-associated genes in keloid. We also observed that keloid tissues presented higher infiltration by CD3⁺ T cells, of which the majority was CD4⁺ T cells. Notably, the frequency of Foxp3⁺ regulatory T cells (Tregs) in keloid tissues was significantly higher compared to that in the peripheral blood. Furthermore, macrophages from keloid tissues possessed potent capacity to induce Foxp3 expression in circulating CD3⁺ T cells. Together, this study suggested that macrophages in keloid tissues presented high activation status and were polarized toward the M2 subtype; moreover, these macrophages could promote Treg differentiation by upregulating Foxp3 expression.

A comparison of apoptosis levels in keloid tissue, physiological scars and normal skin

Apoptosis is a process of programmed cell death that occurs in multicellular organisms. The mitochondrial pathway plays a paramount role in apoptosis. In this study, the expression levels of key factors in the mitochondrial pathway and the cell proliferation factor (PCNA) were measured to evaluate the level of apoptosis and proliferation in keloid scars, physiological scars and normal skin tissue. Thirty samples were taken from 30 patients: 10 keloid patients, 10 physiological scar patients and 10 patients without obvious scarring. All 30 patients were selected randomly from the Department of Plastic Surgery at Peking Union Medical College Hospital from June 2016 to December 2016. Hematoxylin and eosin staining and Masson staining were used to observe the differences in histology and fiber tissue content. Mitochondrial pathway factors (caspase-3, caspase-8, caspase-9, Bcl-2, Bax, cytochrome-c) and PCNA expression levels were detected by immunohistochemistry and were analyzed as the percentage of positively stained cells in the epidermis and dermis. Relative protein expression levels were measured by western blotting. Compared with physiological scars and normal skin tissue, keloid tissue had an increase in fiber number and decrease in cell content. In our immunohistochemical and western blot analyses, all tissue types showed similar expression levels of the mitochondrial pathway factors. However, the percentage of PCNA-positive cells and the relative protein expression level of PCNA were significantly higher in keloid tissue. Keloid has a similar apoptosis level as physiological scars and normal skin but has a higher expression of PCNA, indicating that keloid scars have high levels of proliferation and normal apoptosis.

[Therapy of scars with lasers]

Scar formation is the consequence of trauma to the skin that affects the deep parts of the dermis. Different scar types like immature, mature, atrophic, hypertrophic, or keloid scars can develop depending on factors like age, anatomic localization, cause of trauma, the course of the healing process, and individual predispositions. Keloids and hypertrophic scars are often associated with itching, pain, tautness of the skin, and functional impairments, thus, leading to significantly reduced quality of life in some patients. However, even seemingly physiologically healed scars can cause tremendous psychological strain as is the case with self-harm scars. Despite increased research efforts, the exact pathomechanisms of excessive scarring are still scarcely understood, and dependably effective treatment options are often lacking. However, through continually improving scientific progress, scar treatment paradigms for a variety of scar types, thus far often dominated by conventional treatment methods, are increasingly complemented by new laser technologies and wavelengths.

Status of M1 and M2 type macrophages in keloid

Macrophages, differentiation from monocytes infiltrated in the wound, have been suggested to be involved and to play an important role in the pathogenesis of wound healing. Nevertheless, no evidence has been established regarding M1 and M2 type macrophages in Keloid. To understand the status of M1 and M2 type macrophages in keloid, immunohistochemistry was performed on 30 cases of Keloid tissues and normal controls, with CD68, typical surface marker for M1 and CD163, well-accepted marker for M2 being immunostained. Meanwhile, the glucocorticoid receptor NR3C1 was also detected. As further confirmation, quantitative real-time PCR was utilized to verify the expression of CD68, CD163 and NR3C1 on mRNA level. It was consistently shown that infiltrated M2 macrophages pronouncedly outnumbered M1 macrophages in the dermis of keloids; and that NR3C1 expression was significantly up-regulated in keloids than that in normal controls. In addition, there was a marked correlation between CD163 and NR3C1 expression. Our results suggest that the number of infiltrated M2 macrophages in the dermis of keloids may be linked to the responsiveness to glucocorticoids in the pathogenesis of keloid.

A novel model of humanised keloid scarring in mice

Treatments for keloid scarring are a major challenge to scientists and physicians for their unknown aetiology. Although several models, including monolayer cell culture to tissue-engineered models, were developed, further research on keloid has more or less been hindered by the lack of appropriate animal models. Because these aberrant scars are specific to humans, we obtained human normal and keloid skin tissues and isolated dermal fibroblasts from them. Cell morphology, growth and immunohistochemical staining of myofibroblastmarker α-SMA were examined, and the cell medium of 2-hour culture and 24-hour culture was implanted on the back of nude mice. The cell medium of 2-hour culture and 24-hour culture was also analysed by a protein array for the detection of distinction in inflammatory factors. We showed that keloid fibroblasts had similar morphology and growth compared to normal skin fibroblasts, but the α-SMA expression was obviously up-regulated. After 6 weeks, mice of the 2-hour keloid-derived culture medium group exhibited keloid-like hypertrophic nodules macroscopically, while mice of 24-hour keloid-derived culture medium group were similar to normal skin. Histological findings confirmed that the reconstituted skin tissues had the typical features of human keloids. The protein array data revealed that RANTES were involved in humanised fibrotic occurrence in mice, also suggesting they were important modulators of this inflammatory event. This novel model might help to understand the key events that result in the formation of these abnormal scars and provide new therapeutic options.

[Advances in the research of treatment of angiogenesis inhibitor on pathological scars]

Angiogenesis inhibitors are a class of agents that prevent the angiogenesis by inhibiting the activation, migration, and proliferation of endothelial cells. In recent years, studies have found that there was a close relationship between the occurrence of pathological scars and angiogenesis. The vascular density in pathological scars is significantly higher than that in normal skin and scars. Neovascularization supports the fibroblasts growth and collagen production, which contribute to the development of pathological scars. Therefore, the angiogenesis inhibitor may become a possible agent for prevention and treatment of pathological scars. This review explores the relationship between pathological scars and angiogenesis inhibitor.

Treatment of keloid scars using light-, laser- and energy-based devices: a contemporary review of the literature

Keloid scars are common and have a predilection for young, ethnic skin often with a family history. Keloids can be painful and pruritic and cause significant emotional distress when particularly visible or prominent. In this article, we review the evidence underlying the use of laser- and energy-based devices for treatment of keloid scars, either as monotherapy or in conjunction with other therapies such as corticosteroids, surgery and silicone gel in the treatment of keloid scars.

Human adipose tissue-derived stem cells inhibit the activity of keloid fibroblasts and fibrosis in a keloid model by paracrine signaling

BACKGROUND

Human adipose tissue-derived mesenchymal stem cells (ASCs) have potential utility as modulators of the regeneration of tissue that is inflamed or scarred secondary to injuries such as burns or trauma. However, the effect of ASCs on one particular type of scarring, keloidal disease, remains unknown. The absence of an optimal model for investigation has hindered the development of an effective therapy using ASCs for keloids.

OBJECTIVE

To investigate the influence of ASCs on angiogenesis, extracellular matrix deposition, and inflammatory cell influx in keloids.

METHODS

We analyzed the proliferation, migration, and apoptosis of human keloid-derived fibroblasts treated with a starvation-induced, conditioned medium from ASCs (ASCs-CM). This was achieved by Brdu proliferation assay, a validated co-culture migration assay, and flow cytometry, respectively. To assess the change in phenotype to a pro-fibrotic state, fibroblasts were analyzed by real-time PCR and contraction assay. A keloid implantation animal model was used to assess the paracrine effect of ASCs histochemically and immunohistochemically on scar morphology, collagen deposition, inflammatory cell composition, and blood vessel density. In tandem, an antibody-based array was used to identify protein concentration in the presence of ASCs-CM at time point 0, 24, and 48h.

RESULTS

ASCs-CM inhibited the proliferation and collagen synthesis of human keloid-derived fibroblasts. ASCs-CM was associated with reduced inflammation and fibrosis in the keloid implantation model. Thirty-four cytokines were differentially regulated by ASCs-CM at 24h. These included molecules associated with apoptosis, matrix metalloproteases, and their inhibitors. The same molecules were present at relatively higher concentrations at the 48h timepoint.

CONCLUSION

These results suggest that ASCs are associated with the inhibition of fibrosis in keloids by a paracrine effect. This phenomenon may have utility as a therapeutic approach in the clinical environment.

Effects of Topical Tamoxifen on Wound Healing of Burned Skin in Rats

Background

This study aimed to assess the effects of the topical application of tamoxifen on wound healing of burned skin in Wistar rats by evaluating 3 healing characteristics: fibrotic tissue thickness (FTT), scar surface area (SSA), and angiogenesis in the healed scar tissue.

Methods

Eighteen male Wistar rats were used in this study. A third-degree burn wound was made on the shaved animals’ back, measuring 2×2×2 cm. In the first group, a 2% tamoxifen ointment was applied to the wound twice daily for 8 weeks. The second group received a placebo ointment during the same period. The third group did not receive any treatment and served as the control group.

Results

The median (interquartile range=[Q1, Q3]) FTT was 1.35 (1.15, 1.62) mm, 1.00 (0.95, 1.02) mm, and 1.25 (0.8, 1.5) mm in the control, tamoxifen, and placebo groups, respectively (P=0.069). However, the FTT in the tamoxifen group was less than in the placebo and control groups. The median angiogenesis was 3.5 (3.00, 6.25), 8.00 (6.75, 9.25), and 7.00 (5.50, 8.25) vessels per high-power field for the control, tamoxifen, and placebo groups, respectively (P=0.067). However, the median angiogenesis was higher in the tamoxifen group than in the control group. No significant difference was observed in the mean SSA between the tamoxifen group and the control group (P=0.990).

Conclusions

Local application of tamoxifen increased angiogenesis and decreased the FTT, with no change in the SSA in burned skin areas. These effects are expected to expedite the wound healing process, reducing contracture and preventing hypertrophic scar and keloid formation.

Intralesional excision with topical intralesional cryotherapy improves the treatment of keloid scarring in a paediatric patient

Recurrent keloid scarring has a significant impact on quality of life. Management is complex, particularly for scars resistant to conventional treatments and in paediatric cases where radiotherapy is not a suitable adjunct to surgical excision. We present the case of a nine-year-old African Caribbean girl with multiple large and recurrent keloid scars on both ears and bilateral sensorineural deafness. Following repeated intralesional excisions, corticosteroid and botulinum toxin injections, she continued to experience rapid recurrence of her keloids, worsening pain and pruritus. She was no longer able to wear her hearing aids because of the large size of the keloids. We employed a novel technique using topical intralesional cryotherapy, applying liquid nitrogen intraoperatively to the inside of the skin flaps immediately post-intralesional keloid excision and before wound closure. At 26-month follow-up a good aesthetic and symptomatic result was achieved, with minimal hypopigmentation, significantly reduced scar volume and significantly slowed recurrence. We discuss this case and review the current literature on the use of topical intralesional cryotherapy for keloid scarring.

Inhibiting function of human fetal dermal mesenchymal stem cells on bioactivities of keloid fibroblasts

BACKGROUND

Keloid is one kind of benign skin disease caused by hyperplasia of fibroblasts and collagen fibrils. It is refractory due to the lack of an effective treatment at present, which puts pressure on seeking a new therapeutic regimen. Mesenchymal stem cells (MSCs) from fetal skin are considered to play a crucial role in scarless healing. Nevertheless, the efficacy of them in keloid disorders remains poorly understood.

METHODS

Keloid fibroblasts (KFs), human adult dermal fibroblasts (ADFs), and human fetal dermal mesenchymal stem cells (FDMSCs) were isolated to single cells and cultured in Dulbecco's modified Eagle's medium (DMEM). ADFs and FDMSCs were used to generate ADF-conditioned medium (A-CM) and FDMSC-conditioned medium (F-CM). The effects of A-CM and F-CM on KFs were tested using MTT assay, BrdU assay, TUNEL assay, quantitative polymerase chain reaction, Western blot, and annexin V-FITC/PI binding assay,.

RESULTS

FDMSCs inhibited the bioactivity of KFs, downregulated the expression of the antiapoptotic protein BCL-2, and upregulated the expression of the proapoptotic protein BAX of KFs by secreting some soluble substances, thus accelerating the apoptosis of KFs.

CONCLUSION

F-CM induces apoptosis of KFs, providing a novel treatment strategy for keloid disorders.

Downregulation of β-catenin blocks fibrosis via Wnt2 signaling in human keloid fibroblasts

Keloid is a disorder of fibroproliferative diseases that occurs in wounds, characterized by an exaggerated response to injury. The key factor responsible for the disease process has not been identified. This study sought to elucidate the role of β-catenin in the regulation of keloid phenotypes and signaling. Expression of β-catenin in keloid and normal non-keloid samples was measured by real-time polymerase chain reaction. Knockdown of β-catenin was achieved by delivering small interfering RNA to target β-catenin. Cell proliferation, cell cycle progression, and apoptosis of keloid cells were measured by functional assays in vitro. The proteins related to keloid fibrosis were measured by Western blotting. β-catenin expression was significantly upregulated in keloid tissue samples compared with the normal non-keloid age-adjusted skin sample counterparts. Functionally, targeting β-catenin with lipofection-delivered small interfering RNA oligonucleotide inhibited the proliferation and cell cycle arrest in G0/G1 phase and increased apoptosis of fibroblast cells, accompanied by downregulation of Wnt2 and cyclin D1 as well as the phosphorylation level of glycogen synthase kinase 3 beta in the keloid fibrosis. Our study supports a crucial role of β-catenin in the regulation of fibroproliferation and extracellular matrix deposition. Targeting β-catenin using small interfering RNA oligonucleotide may be a promising approach for preventing excessive fibroproliferative development after wound healing and may lead to the development of novel strategies for restoring keloid diseases.

Bilateral breast keloids in an elderly woman associated with bilateral breast cancers and high concentration of serum tumor growth factor-β

We report a case of bilateral annular breast keloids in a 72-year-old woman who had been suffering from bilateral breast cancers. Histopathologically, the keloids showed unique distribution of α-SMA+, CD34- myofibroblasts and α-SMA-, CD34+ fibroblasts depending on the region. High serum levels of tumor growth factor-β were detected at 6 months after the development of the breast keloids, but not at 10 months. CD163-positive cells were abundantly detected in the skin of the elevated portion of the keloids. In contrast, these cells were considerably less numerous in the skin of the central healing portion compared with the skin of the elevated expanding portion. One interesting idea based on these results is that high levels of tumor growth factor-β released from CD163-positive cells played a crucial role in the formation of breast keloids through active induction of fibroblast differentiation into myofibroblasts. The present case strongly supports the previously proposed idea that keloids can form as a paraneoplastic phenomenon in breast cancer patients with keloid constitution.

Histological analysis of hyalinised keloidal collagen formation in earlobe keloids over time: collagen hyalinisation starts in the perivascular area

Keloids grow and do not regress. They are characterised histologically by hyalinised keloidal collagen (HKC). HKC amounts vary, and the mechanism by which they form is unclear. To clarify how HKCs form and whether their formation associates with specific clinical features, we studied the histological findings of earlobe keloids and compared them with respective clinical features. A total of 50 earlobe keloids from 43 patients were used for histological analysis of keloid size (mm² ), HKC area (mm² ) and HKC area ratio (%). As a result, keloid durations ranged from 3 months to >13 years. Early-stage keloids exhibited little HKC and a tendency for the HKCs to locate in perivascular regions. In later-stage keloids, the HKCs were extremely interconnected and formed a thick bitten donut-shaped region. HKC area ratios correlated positively with keloid duration (r² = 0·58, P<0·05). HKC area ratios and keloid durations did not correlate with keloid sizes. These patterns of HKC formation and growth may explain why local therapies, which effectively remove fibroblasts and accumulated collagen but not HKCs, are ineffective in older keloids. Keloids should be promptly treated after diagnosis, and older keloids with extensive HKCs may require surgical excision followed by radiotherapy.

Expansion of CD26 positive fibroblast population promotes keloid progression

BACKGROUND

Keloid is a skin fibrosis disease that characterised by invasive growth of fibroblasts and aberrant deposition of extracellular matrix. Studies indicated that keloid fibroblasts (KFs) is a class of 'activated' fibroblasts, which show accelerated proliferation and excessive extracellular matrix formation as compared with normal fibroblasts (NFs). However, the mechanism underlying keloid fibroblasts dysfunction is still unknown.

OBJECTIVE

To verify CD26 expression difference between KFs and NFs, and investigate the function of CD26 positive fibroblasts in keloid progression.

METHODS

KFs and NFs were isolated from Keloid tissues and normal skin tissues respectively. Flow cytometry was performed to isolate CD26+/CD26- fibroblasts from KFs and NFs. Proliferation of different fibroblasts were analyzed by CCK8 assay and Ki 67 straining. Profibrotic phenotype difference was detected by qRT-PCR, western blot, ELISA and immunofluorescence. Scratching experiment and transwell assay were used to assess invasion ability of CD26+/CD26- fibroblasts. Diprotin A was used as a CD26 inhibitor to further investigated the function of CD26 fibroblasts in keloid disease.

RESULT

CD26 expression was increased in KFs, and the proportion of CD26+ fibroblasts was significantly increased in KFs. Cell viability analysis showed that CD26+ fibroblasts was more active in proliferation. Furthermore, the expression of profibrotic genes were increased in CD26+ fibroblasts, including TGF-β1, IGF-1, IL6, collagen 1, collagen 3 and fibronectin. And meanwhile, CD26+ fibroblasts showed stronger invasion ability as compared to CD26- fibroblasts. Moreover, Diprotin A significantly suppressed proliferation and extracellular matrix secretion of CD26+ fibroblasts isolated from keloid tissues.

CONCLUSION

Our findings suggest that CD26+ fibroblasts possess proliferation advantage in compare to CD26- fibroblasts, and the advantage caused expansion of CD26 positive fibroblast population promotes keloid progression.

Autologous fat grafting in keloids and hypertrophic scars: a review

Keloid and hypertrophic scars are unique human dermal fibroproliferative disorders of the injured skin and are associated with pain, itch and can cause functional limitations. A number of genetic, systemic and local factors have been identified in the formation of keloids and hypertrophic scars. Studies have shown that adipose-derived stem cells have angiogenic and antiapoptotic properties which has effects on wound healing, soft-tissue restoration and scar remodelling, and thus may have a role in managing keloid scaring. However, this role is not well described in the literature. A systemic review of available literature was thus undertaken, regarding the use of fat grafting in treatment of keloids and hypertrophic scarring. In total, 858 articles were identified, with ten studies ultimately fulfilling inclusion criteria. There were no studies specifically isolating the keloids and hypertrophic group of patients, and thus quantitative data were completely lacking from the literature. There were, however, individual cases described, and qualitatively encouraging clinical results were reported for the use of fat grafting on keloids and hypertrophic scars. Combined with the current theoretical and immunohistochemical understanding through other laboratory and animal studies, fat grafting may play a role in the treatment of keloids and hypertrophic scaring; however, specific evidence is currently lacking. The role for further research is clear.

Keloid and hypertrophic scars are difficult to treat conditions. Some studies have suggested that fat cells may have a role in managing these scars although this role is not well described in the literature. We perform a systematic review of available literature, examining the evidence for this.

A Selenium-Enriched Ziyang Green Tea Polysaccharide Induces Bax-Dependent Mitochondrial Apoptosis and Inhibits TGF-β1-Stimulated Collagen Expression in Human Keloid Fibroblasts via NG2 Inactivation

Keloids are fibroproliferative disorders characterized by the overabundant deposition of extracellular matrix (ECM), especially collagen and overgrowth of scar tissue in response to cutaneous injury. In this study, we isolated a selenium (Se)-containing polysaccharide (Se-ZGTP-I) from Ziyang green tea and explored its potential therapeutic effects on keloid fibroblasts formation. 3-(4,5-Dimethyl-thiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and annexin V/propidium iodide (PI) staining assays demonstrated that Se-ZGTP-I or neuron-glia 2 (NG2) short hairpin RNA (shRNA) significantly inhibited proliferation of human keloid fibroblasts via induction of apoptosis. Besides, the activation of caspase-3 and the subsequent cleavage of poly (ADP-ribose) polymerase (PARP) were observed in keloid fibroblasts following Se-ZGTP-I (200 and 400 μg/ml) or NG2 shRNA treatment. Moreover, Western blotting analysis showed that treatment of keloid fibroblasts with Se-ZGTP-I (200 and 400 μg/ml) or NG2 shRNA resulted in an increase of pro-apoptotic protein Bax expression and a decrease in expression levels of anti-apoptotic protein Bcl-2 and NG2. In addition, type I collagen biosynthesis and protein expression in keloid fibroblasts following TGF-β1 stimulation were decreased by Se-ZGTP-I (200 and 400 μg/ml) or NG2 shRNA management. Current findings imply that Se-ZGTP-I has a therapeutic potential to intervene and prevent keloid formation and other fibrotic diseases.

Donor site morbidities resulting from conchal cartilage harvesting in rhinoplasty

OBJECTIVE

Conchal cartilage is frequently used in rhinoplasty, but donor site morbidity data are seldom reported. This study aimed to investigate the complications of conchal cartilage harvesting in rhinoplasty.

METHODS

A retrospective chart review of 372 patients who underwent conchal cartilage harvesting for rhinoplasty was conducted. Data regarding patient demographics, types of nasal deformities, graft usage and complications were analysed.

RESULTS

A total of 372 patients who underwent conchal cartilage harvesting for rhinoplasty were enrolled. The harvested conchal cartilage tissues were used in a variety of applications: tip graft, dorsal graft, septal reinforcement and correction of nostril asymmetry. Nine cases (2.4 per cent) with donor site morbidities were identified, including four cases (1.1 per cent) with keloids and five cases (1.3 per cent) with haematomas.

CONCLUSION

Conchal cartilage harvesting is a safe and useful technique for rhinoplasty, with a low complication rate. However, patients should be informed about the possibility of donor site morbidities such as keloids and haematomas.

[Recombinant human bone morphogenetic protein 7 inhibits the proliferation and extracellular matrix secretion of fibroblast of urethral scars]

Objective: To study the effect and its mechanism of recombinant human bone morphogenetic protein 7 (rhBMP-7) on urethral keloid fibroblast. Methods: Urethral fibroblasts were extracted and cultured, and the fourth-generation fibroblasts were used for experiment. Urethral fibroblasts were treated with rhBMP-7. Proliferation rate was detected by CCK-8 method. RT-PCR was applied to test changes of mRNA in α smooth muscle actin (α-SMA) and type Ⅰ collagen protein (COL-1) of each group. Western blot was used to measure α-SMA protein expression and the effect of rhBMP-7 on signaling pathway of urethral keloid fibroblasts. Results: With the increase of rhBMP-7 concentrations, the proliferation rate of urethral keloid fibroblast was generally decreased. Cells kept proliferating with time at the same concentration of rhBMP-7. mRNA level of COL-1 and α-SMA in rhBMP-7-treated (>20 ng/ml) urethral keloid fibroblasts was greatly reduced with statistical significance (P<0.05) and dose dependency. It was found rhBMP-7 inhibited the overexpression of p-smad2/3 and α-SMA mediated by transforming growth factor beta 1 (TGF-β(1)) signaling pathway. Conclusion: rhBMP-7 could adjust TGF-β(1) signaling pathway to inhibit gene expression of COL-1 and a-SMA in urethral keloid fibroblast, which provided evidences for further animal experiments or clinical trials.

Upregulation of microRNA-205 suppresses vascular endothelial growth factor expression-mediated PI3K/Akt signaling transduction in human keloid fibroblasts

Keloid is one of the most frustrating problems related to wounding healing and presents a great challenge in clinic. MicroRNAs (miRs) have shown their potential as a novel therapy for the prevention and treatment of keloid. Vascular endothelial growth factor (VEGF) plays a critical role in the regulation of scar development. In the current study, it was hypothesized that miR-205-5p was capable of suppressing keloid formation by inhibiting the VEGF-mediated wound healing cascade. The expression statuses of miR-205-5p and VEGF in clinical keloid tissues and keloid cell line human keloid fibroblasts (HKF) were detected. Then the direct action of miR-205-5p on VEGF gene was assessed using dual-luciferase assay. Thereafter, orchestrated administrations on HKF with miR-205-5p mimic, specific VEGF siRNA, PI3K agonist (740 Y-P), and PI3K inhibitor (LY294002) were performed to reveal the roles of miR-205-5p and VEGF in keloid formation and further explain the mechanism through which miR-205-5p affected the VEGF-mediated signaling transductions. Our results showed that there was significant low expression of miR-205-5p in keloid tissue specimens and the cell line while the expression of VEGF in keloid tissues was augmented. Moreover, miR-205-5p overexpression dramatically impaired the cell viability, induced the cell apoptosis, and inhibited the cell invasion and migration ability in HKF. Based on the detection of dual luciferase assay and detection at protein level, miR-205-5p antagonized the keloids by directly targeting VEGF expression and subsequently inhibiting PI3K/Akt pathway. The current study is the first one demonstrating that miR-205-5p inhibits the pathogenesis of keloids, indicating the potential of miR-205-5p in the development of therapies for prevention and treatment of keloids.

Intratracheal Keloid

BACKGROUND

Keloidal scarring can complicate surgical procedures.

CASE REPORT

This 21-month-old African-American child developed a keloid around his tracheostomy that extended into the trachea.

CONCLUSION

Keloidal formation from a tracheostomy site can extend into the trachea.

Brachytherapy in the adjuvant management of keloid scars: literature review

INTRODUCTION

Radiation therapy is a well-recognised modality for the adjuvant treatment of keloid scars. It can be conventionally delivered as external beam using a large apparatus at a distance from the lesion or as brachytherapy with specialised equipment to enable the delivery of treatment in the immediate vicinity of the keloidal tissue.

METHODS

An English literature review was performed with keywords 'brachytherapy' and 'keloid' using the databases PubMed, Embase and Web of Science from their individual dates of inception until June 2017. Studies pertinent to the field are presented in a chronological manner to depict the evolution of different brachytherapy strategies over the last decades. We also discuss considerations relating to the risk of secondary carcinogenesis, which are relevant to shared decision-making in the clinical setting.

DISCUSSION

Low dose rate interstitial brachytherapy was first introduced in the English literature in 1976 and currently appears to have been superseded by more modern approaches, including high dose rate interstitial brachytherapy. This modality compares favourably to more traditional modes of radiotherapy in terms of recurrence as well as rates of symptomatic relief from keloidal symptoms. Superficial brachytherapy was introduced more recently in the relevant literature and appears to be associated with favourable therapeutic outcomes compared to external beam radiation therapy.

CONCLUSION

Brachytherapy is a valid modality of radiotherapy for the adjuvant treatment of keloid scars, with high dose rate interstitial and surface regimens gaining in popularity over recent years. Further research needs to focus on randomised controlled trials to further establish the role of different radiotherapy modalities in keloid scar management.

Keloid progression: a stiffness gap hypothesis

Keloids are fibroproliferative skin disorders characterised clinically by continuous horizontal progression and post-surgical recurrence and histologically by the accumulation of collagen and fibroblast ingredients. Till now, their aetiology remains clear, which may cover genetic, environmental and metabolic factors. Evidence in the involvement of local mechanics (e.g. predilection site and typical shape) and the progress in mechanobiology have incubated our stiffness gap hypotheses in illustrating the chronic but constant development in keloid. We put forward that the enlarged gap between extracellular matrix (ECM) stiffness and cellular stiffness potentiates keloid progression. Matrix stiffness itself provides organisational guidance cues to regulate the mechanosensitive resident cells (e.g. proliferation, migration and apoptosis). During this dynamic process, the ECM stiffness and cell stiffness are not well balanced, and the continuously enlarged stiffness gap between them potentiates keloid progression. The cushion factors, such as prestress for cell stiffness and topology for ECM stiffness, serve as compensations, the decompensation of which aggravates keloid development. It can well explain the typical shape of keloids, their progression in a horizontal but not vertical direction and the post-surgical recurrence, which were evidenced by our clinical cases. Such a stiffness gap hypothesis might be bridged to mechanotherapeutic approaches for keloid progression.

Can intralesional cryotherapy reshape the management of difficult keloid scars?

Keloid scars are notoriously difficult to treat with very high recurrence rates despite a range of treatment options. We present a case report of a 43-year-old man with a resistant keloid scar on his left ear from a piercing. After 15 years of multimodal treatments including surgery, steroid and 5-fluorourcil injections, the keloid persisted. It has responded very well to a single treatment of intralesional cryotherapy (trademark: CryoShape, Etgar Group International Ltd). The authors would now consider intralesional cryotherapy as a useful tool in their armamentarium for prominent, resistant or recurrent keloids. Future experience will guide its clinical applications.

There is limited evidence of efficacy, more research is required.

Background: Keloid scars grow outside of the initial wound margins. They can be itchy and very unsightly. They are difficult to treat. Whether treated by surgical removal, injections, or radiotherapy, there is a high recurrence rate.

Question: Can a new technique be used to successfully treat resistant keloid scars?

How the work was conducted: A technique of freezing the scar to cause frostbite and auto-amputation of the scar has been developed. This report describes 15 years of multi-modality treatment for a patient who had a large keloid scar on his ear. It recurred after all conventional treatments and had started growing very aggressively despite treatments. A new technique of intralesional cryotherapy was used to freeze the keloid scar. This has had excellent initial results and although the follow-up time is relatively short at six months, there has been no aggressive regrowth yet which is very promising.

What have we learnt: The procedure went smoothly and was very well-tolerated by the patient. The scar resolved with no early evidence of recurrence. We do not yet know whether this scar will recur in the future and if so how quickly. The scar was however very troublesome to the patient before the treatment and his symptoms have now resolved with no sign of regrowth to date. We need a larger case series with long term follow up before any firm conclusions can be drawn from this.

Novel Insights on Understanding of Keloid Scar: Article Review

Keloid scar, dermal benign fibro-proliferative growth that extends outside the original wound and invades adjacent dermal tissue due to extensive production of extracellular matrix, especially collagen, which caused by over expression of cytokines and growth factors. Although many attempts were made to understand the exact pathophysiology and the molecular abnormalities, the pathogenesis of keloid scar is yet to be determined. Even though there are several treatment options for keloid scars include combination of medical and surgical therapies like combination of surgical removal followed by cryotherapy or intralesional steroid therapy, the reoccurrence rate is still high despite the present treatment. In this review, PubMed, clinical key and Wright State Library web site have been used to investigate any update regarding Keloid disease. We used Keloid, scar formation, hypertrophic scar and collagen as key words. More than 40 articles have been reviewed. This paper reviews literature about keloid scar formation mechanism, the most recent therapeutic options including the ones under research.

Can subphysiological cold application be utilized in excessive dermal scarring prophylaxis and treatment?: A promising hypothetical perspective

Excessive dermal scarring (EDS) is a wound healing complication, characterized by protruded erythematous and inelastic 'proliferative scar tissue' which is associated with increased and prolonged inflammation process within the wound microenvironment. As inflammation plays a key role in this process, methods to contain or attenuate excessive inflammation hold promise in treatment and prophylaxis of EDS conditions. While cold exposure is notorious as the causative agent a wide array of morbidities and fatalities, its tempered use is exploited in medicine for ablative and therapeutic applications. "Subphysiological cold" has been administered for its antiinflammatory effects which act via decreasing vascular permeability and downregulating proliferation of cells in the wound environment; this knowledge supports our hypothesis that "subphysiological cold application" can also be utilized in human EDS prophylaxis and treatment. In this study, we are reviewing the mechanisms of its both deleterious and therapeutic actions and suggesting another possible application for prevention and/or treatment of human EDS conditions.