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Sakhiya J, Sakhiya D, Kaklotar J, Hirapara B, Purohit M, Bhalala K, Daruwala F, Dudhatra N. Intralesional Agents in Dermatology: Pros and Cons. J Cutan Aesthet Surg 2021; 14:285-295. [PMID: 34908770 PMCID: PMC8611707 DOI: 10.4103/jcas.jcas_109_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Since introduced in 1961, intralesional (IL) agent has become an essential part of the dermatological practice. The term IL referred to the direct delivery of agent percutaneously into skin lesions. This therapeutic approach is relatively safe, easy to perform and applicable for a broad range of dermatological conditions. On the other hand, immediate side effects, including pain during administration, bleeding, high risk of infection and allergic reaction, and subsequent side effects involving skin changes such as atrophy, telangiectasia, pigmentary changes, and striae are usually associated with this modality. This review paper highlights the pros and cons of IL agents in modern dermatology practice.
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Affiliation(s)
- Jagdish Sakhiya
- Sakhiya Skin Clinic, 2nd Floor, Ayush Doctor House, Station-Lal Darwaja Road, Surat, Gujarat, India
| | - Dhruv Sakhiya
- B.J. Medical College, New Civil Hospital Asarwa, Ahmedabad, Gujarat, India
| | - Jitesh Kaklotar
- Sakhiya Skin Clinic, 2nd Floor, Ayush Doctor House, Station-Lal Darwaja Road, Surat, Gujarat, India
| | - Bansi Hirapara
- Sakhiya Skin Clinic, 2nd Floor, Ayush Doctor House, Station-Lal Darwaja Road, Surat, Gujarat, India
| | - Madhav Purohit
- Sakhiya Skin Clinic, 2nd Floor, Ayush Doctor House, Station-Lal Darwaja Road, Surat, Gujarat, India
| | - Krishna Bhalala
- Sakhiya Skin Clinic, 2nd Floor, Ayush Doctor House, Station-Lal Darwaja Road, Surat, Gujarat, India
| | - Feral Daruwala
- Sakhiya Skin Clinic, 2nd Floor, Ayush Doctor House, Station-Lal Darwaja Road, Surat, Gujarat, India
| | - Nimish Dudhatra
- Sakhiya Skin Clinic, 2nd Floor, Ayush Doctor House, Station-Lal Darwaja Road, Surat, Gujarat, India
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Yang HJ, Kang HJ, Lee WJ, Chang SE, Lee MW, Choi JH, Won CH. Case of infantile digital fibromatosis treated with topical tacrolimus. J Dermatol 2020; 47:e439-e440. [DOI: 10.1111/1346-8138.15599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hee Joo Yang
- Department of Dermatology University of Ulsan College of Medicine Asan Medical Center Seoul Korea
| | - Hyun Ji Kang
- Department of Dermatology Veterans Health Service Medical Center Seoul Korea
| | - Woo Jin Lee
- Department of Dermatology University of Ulsan College of Medicine Asan Medical Center Seoul Korea
| | - Sung Eun Chang
- Department of Dermatology University of Ulsan College of Medicine Asan Medical Center Seoul Korea
| | - Mi Woo Lee
- Department of Dermatology University of Ulsan College of Medicine Asan Medical Center Seoul Korea
| | - Jee Ho Choi
- Department of Dermatology University of Ulsan College of Medicine Asan Medical Center Seoul Korea
| | - Chong Hyun Won
- Department of Dermatology University of Ulsan College of Medicine Asan Medical Center Seoul Korea
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O Adegoke O, E Ajao A, H Ano-Edward G. Congenital infantile digital fibromatosis: a case report and review of the literature. Afr Health Sci 2020; 20:1865-1869. [PMID: 34394250 PMCID: PMC8351811 DOI: 10.4314/ahs.v20i4.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Infantile digital fibromatosis (IDF), also called inclusion body fibromatosis is an uncommon benign tumour occurring in the digits of young children. In about a third of cases, it is congenital and the diagnosis is based on the presence of peculiar intracytoplasmic inclusions on histology. Recurrence rate post-surgery is high. However, spontaneous regression has been reported. We present a case of a 5-month-old infant who had excision of a right second toe mass, which has been present from birth. Histological examination revealed this to be infantile digital fibromatosis. To the best of our knowledge, no report of this has been made in Nigeria. It is important that this diagnosis be entertained in young children with masses on the digits as this will influence the management instituted.
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Karadağ AS, Koska MC, Cebeci Kahraman F, Bilgiç B, Bostan AB, Özkan K. Infantile digital fibromatosis successfully treated with topical imiquimod 5% combined with methylprednisolone aceponate 0.1. Dermatol Ther 2020; 33:e14012. [PMID: 32657516 DOI: 10.1111/dth.14012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/25/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Ayşe Serap Karadağ
- Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Göztepe Education and Research Hospital, Istanbul, Turkey
| | - Mahmut Can Koska
- Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Göztepe Education and Research Hospital, Istanbul, Turkey
| | - Filiz Cebeci Kahraman
- Department of Dermatology and Venereology, Istanbul Medeniyet University, School of Medicine, Göztepe Education and Research Hospital, Istanbul, Turkey
| | - Bilge Bilgiç
- Department of Pathology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey
| | - Ali Burak Bostan
- Department of Orthopedics and Traumatology, Istanbul Medeniyet University, School of Medicine, Göztepe Education and Research Hospital, Istanbul, Turkey
| | - Korhan Özkan
- Department of Orthopedics and Traumatology, Istanbul Medeniyet University, School of Medicine, Göztepe Education and Research Hospital, Istanbul, Turkey
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Congenital Lesion on the Hand of a Child: Answer. Am J Dermatopathol 2019; 41:75-76. [PMID: 30608264 DOI: 10.1097/dad.0000000000000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kramer A, Har-Shai Y, Metanes I, Harel H, Wollstein R. The Use of Cryotherapy to Treat Infantile Digital Fibromatosis with a Functional Deficit: A Case Report. J Hand Surg Asian Pac Vol 2018; 23:278-281. [PMID: 29734898 DOI: 10.1142/s2424835518720177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Infantile Digital Fibromatosis (IDF) is a rare benign lesion that can affect the fingers, often appearing at birth or early on in life. Treatment is controversial due to a high recurrence rate following surgical excision, and the tendency of the lesions to regress or resolve completely after the age of one year. Functional loss has rarely been described. We describe a case of IDF with joint contracture and significant functional deficit that was treated with cryotherapy and post procedural occupational therapy with an excellent result. Indications for treatment and cryotherapy as a therapeutic modality for IDF are discussed.
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Affiliation(s)
- Aviv Kramer
- * Department of Plastic Surgery, Carmel Lady Davis Medical Center, Israel
| | - Yaron Har-Shai
- * Department of Plastic Surgery, Carmel Lady Davis Medical Center, Israel.,† Departments of Orthopedic and Plastic Surgery, Division of Hand and Upper Extremity Surgery, Technion Israel Institute of Technology, School of Medicine, Haifa, Israel
| | - Isa Metanes
- * Department of Plastic Surgery, Carmel Lady Davis Medical Center, Israel
| | - Hani Harel
- * Department of Plastic Surgery, Carmel Lady Davis Medical Center, Israel
| | - Ronit Wollstein
- * Department of Plastic Surgery, Carmel Lady Davis Medical Center, Israel.,† Departments of Orthopedic and Plastic Surgery, Division of Hand and Upper Extremity Surgery, Technion Israel Institute of Technology, School of Medicine, Haifa, Israel.,‡ Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical School, Pittsburgh, PA, USA
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Abstract
Infantile digital fibroma is a rare benign lesion that usually occurs during the first 2 years of life. It can be multiple, but it is usually a single lesion. If it grows large enough it can cause joint deformities or interfere with everyday activities. Microscopically, the neoplastic cells usually have inclusion bodies that are best highlighted with a Masson trichrome stain but can often be seen on hematoxylin-eosin staining. Treatment for this entity is usually watchful waiting because of its ability to spontaneously regress, but excision is recommended if the lesion is symptomatic. More recently, fluorouracil or injectable steroids have shown great promise in inducing regression without the complications that accompany surgery.
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Affiliation(s)
- Etan Marks
- From the Department of Pathology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Gillooly ZD, Berry TM, Elwood HR, Zlotoff BJ. Recurrence of Two Nodules on the Toe of a 10-Year-Old Boy. Pediatr Dermatol 2016; 33:453-4. [PMID: 27396300 DOI: 10.1111/pde.12898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Zachary D Gillooly
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Tammy M Berry
- Department of Dermatology, University of New Mexico, Albuquerque, New Mexico
| | - Hillary R Elwood
- Department of Dermatology, University of New Mexico, Albuquerque, New Mexico.,Department of Pathology, University of New Mexico, Albuquerque, New Mexico
| | - Barrett J Zlotoff
- Department of Dermatology, School of Medicine, University of Virginia, Charlottesville, Virginia
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Mahajan BB, Singla M. Evaluation of intralesional 5% 5-fluorouracil in resistant localized plaque psoriasis. Indian Dermatol Online J 2014; 5:287-90. [PMID: 25165645 PMCID: PMC4144213 DOI: 10.4103/2229-5178.137779] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Psoriasis is a chronic, autoimmune, inflammatory papulosquamous disorder, the treatment of which remains challenging. A variety of therapeutic modalities have been used with varying degree of success. But, there is no such therapeutic modality till date that can prevent the relapse in psoriasis. Aims: The present study is being undertaken to evaluate the therapeutic efficacy of intralesional 5% 5-fluorouracil (5-FU) as well as its role in preventing relapse in resistant localized plaque psoriasis. Study Design: An open, prospective, randomized-controlled study. Materials and Methods: A total of 40 patients of resistant localized plaque psoriasis were enrolled for the study. Intralesional injection of 5% 5-FU was given in a dosage of 0.1 mL/cm2 of each plaque using an insulin syringe. In all patients, a single plaque was kept as control and was given intralesional injection of distilled water. A total of three injections were given in each plaque at weekly intervals. After that, patients were followed-up regularly at the interval of 2 weeks up to 12 weeks. All the lesions (both treated and control) were assessed clinically as well as photographically at each visit and graded using psoriasis severity index scoring. Results were analyzed statistically at the end of the follow-up period. Results: At 12 weeks follow-up, out of 40 patients treated, 4 (10%) patients had clearance (>90% resolution), 19 (47.5%) had excellent (70%-90%) improvement, whereas 12 (30%) patients were moderately (30%-70%) improved, and only 5 (12.5%) patients had mild or no improvement. Results were statistically significant in treated group in comparison to control group. Almost all patients complained of pain at the site of injection which subsided within 1-2 h. A total of 10 (25%) patients had necrosis after one or two injections which healed during the follow-up period within 6-8 weeks. Conclusion: Intralesional 5% 5-FU is found to be an effective therapeutic modality in resistant localized plaque psoriasis without much side effects.
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Affiliation(s)
- Bharat Bhushan Mahajan
- Department of Dermatology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Monika Singla
- Department of Dermatology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
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Recurrent infantile digital fibromatosis. ANNALS OF PEDIATRIC SURGERY 2014. [DOI: 10.1097/01.xps.0000438125.55523.4f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Diagnosis and treatment of digitocutaneous dysplasia, a rare infantile digital fibromatosis: a case report. Hand (N Y) 2013; 8:473-8. [PMID: 24426970 PMCID: PMC3840752 DOI: 10.1007/s11552-013-9515-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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12
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Willard KJ, Cappel MA, Kozin SH, Abzug JM. Congenital and infantile benign skin lesions affecting the hand and upper extremity, part 2: nonvascular neoplasms. J Hand Surg Am 2013; 38:2284-92. [PMID: 24206996 DOI: 10.1016/j.jhsa.2013.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 04/03/2013] [Accepted: 04/04/2013] [Indexed: 02/02/2023]
Abstract
This article is part 2 of a 2-part series presented to aid the hand surgeon in becoming familiar with dermatological lesions that may be present on the upper extremity during infancy. The discussion focuses on nonvascular neoplasms grouped into the following categories: epithelial, melanocytic, histiocytic, dermal, fibroblastic, and adipocytic neoplasms. Diagnostic tips are offered, including clinical photographs, to help differentiate between these lesions. In addition, the recommended treatment for each is discussed.
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Affiliation(s)
- Katherine J Willard
- Department of Dermatology, Mayo Clinic Florida, Jacksonville, Florida; Shriners Hospital for Children of Philadelphia, Philadelphia, Pennsylvania; and Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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Liu B, Xu ZC, Bao PQ, Hu TZ, Li Y. A case of infantile digital fibromatosis: differential diagnosis and treatment. Int J Dermatol 2013; 53:e16-8. [PMID: 23330824 DOI: 10.1111/j.1365-4632.2011.05406.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Bin Liu
- Department of Pediatric Surgery, Sichuan University, West China Hospital, Chengdu, Sichuan Province, China E-mail:
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Holmes WJM, Mishra A, McArthur P. Intra-lesional steroid for the management of symptomatic Infantile Digital Fibromatosis. J Plast Reconstr Aesthet Surg 2011; 64:632-7. [PMID: 20937573 DOI: 10.1016/j.bjps.2010.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 09/06/2010] [Accepted: 09/09/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Infantile Digital Fibromatosis (IDF) is a benign, often asymptomatic nodular proliferation of fibrous tissue occurring almost exclusively on the extremities. Conventional treatment has included radical surgery but this is associated with a high level of recurrence. Whilst some authors suggest a strictly conservative approach, this is unacceptable when lesions become symptomatic from pain, contracture formation or functional deformity METHODS We present a retrospective analysis of 12 symptomatic lesions of which 7 were treated with a novel technique of intra-lesional steroid. From 2004-2009, a total of ten patients received treatment for symptomatic IDFs. Patients were followed-up for an average of 5 years 9 months (range 8-131 months). RESULTS Corticosteroid was well tolerated with no significant complications and was associated with lower morbidity that compared with surgery. There was no significance difference between rate of recurrence (1/7 vs. 5/10) for those treated with corticosteroid than compared to those patients who underwent surgery (p = 0.3) but the study is underpowered. CONCLUSIONS This is the first ever study to look at the role of intra-lesional steroid in the management of IDF. Whilst the majority of asymptomatic Infantile Digital Fibromatoses can be safely observed until natural resolution, intra-lesional corticosteroid is a safe and well-tolerated alternative to surgery for all symptomatic digital fibromatoses of infancy. We suggest it replaces surgery as first-line treatment but look forward to a large multicentre trial to allow comparison.
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Affiliation(s)
- W J M Holmes
- Department of Plastic Surgery, Alder Hey Children's Hospital, Eaton Road, Liverpool L12 2AP, UK.
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Failla V, Wauters O, Nikkels-Tassoudji N, Carlier A, André J, Nikkels AF. Congenital infantile digital fibromatosis: a case report and review of the literature. Rare Tumors 2009; 1:e47. [PMID: 21139926 PMCID: PMC2994462 DOI: 10.4081/rt.2009.e47] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Revised: 10/20/2009] [Accepted: 10/21/2009] [Indexed: 12/02/2022] Open
Abstract
Infantile digital fibromatosis (IDF) is a rare benign fibroproliferative tumor of early childhood. IDF preferentially affects the fingers and the toes. Malignant transformation or metastases have never been reported. Surgical treatment has been advocated previously but local recurrences were observed frequently. Recent literature supports clinical surveillance without any medical or surgical intervention as spontaneous regression usually occurs after two to three years. A six-month-old Caucasian girl with IDF on the left fourth digit is presented here. The tumor progressively increased in size after birth. Topical imiquimod cream and diflucortolone valerate cream, both displaying antifibrotic properties, had no effect on tumor growth. Currently the lesion size remains stable without any treatment. Early recognition of IDF is important in order to avoid unnecessary surgical intervention that may prove to be potentially aggravating, unless serious functional or cosmetic concerns intervene. Parents should be reassured concerning the benign nature of IDF and be informed that spontaneous involution of IDF might be expected.
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Abstract
Dysregulated wound healing and pathologic fibrosis cause abnormal scarring, leading to poor functional and aesthetic results in hand burns. Understanding the underlying biologic mechanisms involved allows the hand surgeon to better address these issues, and suggests new avenues of research to improve patient outcomes. In this article, the authors review the biology of scar and contracture by focusing on potential causes of abnormal wound healing, including depth of injury, cytokines, cells, the immune system, and extracellular matrix, and explore therapeutic measures designed to target the various biologic causes of poor scar.
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Affiliation(s)
- Peter Kwan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 2D2.28 WMC, University of Alberta, 8440-112 Street, Edmonton, AB T6G 2B7, Canada
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Amini S, Baum B, Weiss E. A novel treatment for rheumatoid nodules (RN) with intralesional fluorouracil. Int J Dermatol 2009; 48:543-6. [DOI: 10.1111/j.1365-4632.2009.03894.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Click J, Fastenberg M, Burkhart CN, Morrell DS. Small tumor on the toe of a 10-month-old. Pediatr Dermatol 2009; 26:347-8. [PMID: 19706104 DOI: 10.1111/j.1525-1470.2009.00929.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- James Click
- The University of Virginia School of Medicine, Charlottesville, VA, USA
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Prevention and management of hypertrophic scars and keloids after burns in children. J Craniofac Surg 2008; 19:989-1006. [PMID: 18650721 DOI: 10.1097/scs.0b013e318175f3a7] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hypertrophic scars and keloids are challenging to manage, particularly as sequelae of burns in children in whom the psychologic burden and skin characteristics differ substantially from adults. Prevention of hypertrophic scars and keloids after burns is currently the best strategy in their management to avoid permanent functional and aesthetical alterations. Several actions can be taken to prevent their occurrence, including parental and children education regarding handling sources of fire and flammable materials, among others. Combination of therapies is the mainstay of current burn scar management, including surgical reconstruction, pressure therapy, silicon gels and sheets, and temporary garments. Other adjuvant therapies such as topical imiquimod, tacrolimus, and retinoids, as well as intralesional corticosteroids, 5-fluorouracil, interferons, and bleomycin, have been used with relative success. Cryosurgery and lasers have also been reported as alternatives. Newer treatments aimed at molecular targets such as cytokines, growth factors, and gene therapy, currently in developing stages, are considered the future of the treatment of postburn hypertrophic scars and keloids in children.
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21
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Heymann WR. Infantile digital fibromatosis. J Am Acad Dermatol 2008; 59:122-3. [PMID: 18571599 DOI: 10.1016/j.jaad.2007.11.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 10/19/2007] [Accepted: 11/25/2007] [Indexed: 10/21/2022]
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Fernández-Jorge B, Vicente A, Zurinaga MM, Capella MS, De Caba LDS, González-Enseñat A. An unusual congenital presentation of infantile digital fibromatosis. J Paediatr Child Health 2007; 43:505-6. [PMID: 17535189 DOI: 10.1111/j.1440-1754.2007.01125.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- Lisa B Campbell
- Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania 17822, USA
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24
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Mohs Micrographic Surgery for a Problematic Infantile Digital Fibroma. Dermatol Surg 2007. [DOI: 10.1097/00042728-200703000-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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