Hydration, not silicone, modulates the effects of keratinocytes on fibroblasts

Early postoperative interventions in the prevention and management of thyroidectomy scars

Thyroidectomy scars, located on the exposed site, can cause distress in patients. Owing to the cosmetic importance of thyroidectomy scars, many studies have been conducted on its prevention and treatment. Scar formation factors mainly include inflammatory cell infiltration, angiogenesis, fibroblast proliferation, secretion of cytokines such as transforming growth factor (TGF)-β1, and mechanical tension on the wound edges. Anti-scar methods including topical anti-scar agents, skin tension-bearing devices, and local injections of botulinum toxin, as well as lasers and phototherapies, that target these scar formation factors have been developed. However, current studies remain fragmented, and there is a lack of a comprehensive evaluation of the impacts of these anti-scar methods on treating thyroidectomy scars. Early intervention is a crucial but often neglected key to control hyperplastic thyroidectomy scars. Therefore, we review the currently adopted early postoperative strategies for thyroidectomy scar reduction, aiming to illustrate the mechanism of these anti-scar methods and provide flexible and comprehensive treatment selections for clinical physicians to deal with thyroidectomy scars.

Progress in the clinical treatment of keloids

Keloid is a pathological scar that is higher than the skin surface following skin damage. Its lesion range often extends beyond the original damage boundary and does not naturally subside over time. Its pathogenesis is very complex, currently the main causes include fibroblast excessive proliferation, collagen and extracellular matrix (Extracellular matrix, ECM) excessive deposition, excessive angiogenesis, and so on. The traditional treatment method primarily involves surgical intervention, but it is associated with a high recurrence rate post-surgery. Consequently, many treatment methods are derived according to the different clinical characteristics of keloid. This paper will review the therapeutic progress in recent years from surgical treatment, physiotherapy, drug therapy, and biological therapy, with the goal of offering valuable insights for the clinical treatment of keloids.

How to Promote Skin Repair? In-Depth Look at Pharmaceutical and Cosmetic Strategies

Skin repair encompasses epidermal barrier repair and wound healing which involves multiple cellular and molecular stages. Therefore, many skin repair strategies have been proposed. In order to characterize the usage frequency of skin repair ingredients in cosmetics, medicines, and medical devices, commercialized in Portuguese pharmacies and parapharmacies, a comprehensive analysis of the products' composition was performed. A total of 120 cosmetic products, collected from national pharmacies online platforms, 21 topical medicines, and 46 medical devices, collected from INFARMED database, were included in the study, revealing the top 10 most used skin repair ingredients in these categories. A critical review regarding the effectiveness of the top ingredients was performed and an in-depth analysis focused on the top three skin repair ingredients pursued. Results demonstrated that top three most used cosmetic ingredients were metal salts and oxides (78.3%), vitamin E and its derivatives (54.2%), and Centella asiatica (L.) Urb. extract and actives (35.8%). Regarding medicines, metal salts and oxides were also the most used (47.4%) followed by vitamin B5 and derivatives (23.8%), and vitamin A and derivatives (26.3%). Silicones and derivatives were the most common skin repair ingredients in medical devices (33%), followed by petrolatum and derivatives (22%) and alginate (15%). This work provides an overview of the most used skin repair ingredients, highlighting their different mechanisms of action, aiming to provide an up-to-date tool to support health professionals' decisions.

Epidermal Potentiation of Dermal Fibrosis: Lessons from Occlusion and Mucosal Healing

Fibrotic skin conditions, such as hypertrophic and keloid scars, frequently result from injury to the skin and as sequelae to surgical procedures. The development of skin fibrosis may lead to patient discomfort, limitation in range of motion, and cosmetic disfigurement. Despite the frequency of skin fibrosis, treatments that seek to address the root causes of fibrosis are lacking. Much research into fibrotic pathophysiology has focused on dermal pathology, but less research has been performed to understand aberrations in fibrotic epidermis, leading to an incomplete understanding of dermal fibrosis. The literature on occlusion, a treatment modality known to reduce dermal fibrosis, in part through accelerating wound healing and regulating aberrant epidermal inflammation that otherwise drives fibrosis in the dermis, is reviewed. There is a focus on epidermal-dermal crosstalk, which contributes to the development and maintenance of dermal fibrosis, an underemphasized interplay that may yield novel strategies for treatment if understood in more detail.

Silicones in dermatological topical drug formulation: Overview and advances

Silicones, more specifically those of the polydimethylsiloxane type, have been widely used in the pharmaceutical industry for decades, particularly in topical applications. In the dermatological field, in addition to provide undeniable textural and sensory benefits, they can play important functions in the physicochemical properties, stability and biopharmaceutical behavior of these formulations. However, despite the notable advances that can be attributed to the family of silicones, the reputation of these compounds is quite bad. Indeed, silicones, even if they derive from sand, are synthetic compounds. Moreover, they are not biodegradable. They flow into our wastewater and oceans, accumulating in the fauna and flora. This obviously raises many concerns in the common imagination. Do silicones represent a danger for our environment? Should the human species worry about long term toxic effects? Are the claimed benefits really that important? After exploring the various applications of silicone excipients in topical dermatological formulations with a special focus on recent advances which open breathtaking prospects for dermatological applications, this paper shed light on the specific challenges involved in preparation of silicone-based drug as well as, the in vivo behavior of these polymers, the toxicological and environmental risks associated with their application.

Comparison of three in vitro keratinocytes-fibroblasts wound healing models commonly used in pharmaceutical research

OBJECTIVES

Several common wound healing models have been used to evaluate wound healing agents and formulations, namely: conditioned media (CM), transwell co-cultures (TWCC) and co-cultures (CC) in a monolayer. However, no study has been conducted to compare the relevance of these models in the keratinocytes and fibroblasts interaction physiologically. Therefore, this study aimed to compare these models based on cell migration and proliferation, and matrix metalloproteinase (MMP) expression.

METHODS

Cell migration was analysed by scratch assay and MMP-7, while cell proliferation was analysed by (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) tetrazolium reduction assay.

KEY FINDINGS

Increased cell migration was observed in CM and TWCC models, while varied results were obtained in CC. Cell migration was increased due to upregulation of MMP-7 in CM and TWCC models, while it was downregulated in CC, which might have hindered migration of both cells in monolayers.

CONCLUSIONS

CM and TWCC are more suitable than CC for wound healing research and for evaluating wound healing agents or formulations, as they can better simulate the layered tissue constructs and paracrine interactions in the physiological environment.

A prospective randomized pilot study evaluating the scar outcome after gluteal dermis fat graft with and without kinesiotaping

Purpose

To compare gluteal wound healing after dermis fat graft (DFG) implantation in patients with and without local application of kinesiotapes.

Methods

In this prospective, single-center analysis, 16 patients who underwent DFG implantation were randomized in two groups. Wound healing was compared 4–6 weeks after therapy and 3 months later (after application of 2 cycles of kinesiotaping for 2–3 weeks in the case and no specific therapy in the control group). Demographic data, patient content and wound healing were assessed. Scarring was graded (0–3) by evaluation of photodocumentation by 2 blinded, independent observers.

Results

Mean scar grading by both observers decreased from 2.31 ± 0.48 to 1.13 ± 0.72 in the case and from 2.38 ± 0.52 to 1.44 ± 0.50 in the control group with interobserver agreement on scar grading being substantial to almost perfect in both groups. Scar length decreased significantly in both groups (p = 0.008). Scar prominence decreased in 2/3 of cases in the case and 1/3 in the control group. Scar coloring significantly improved in the case group alone (p = 0.031).

Conclusion

No functionally impairing or painful scar developed. No adverse effects occurred after kinesiotaping. Gluteal scars shortened significantly over time and were significantly paler in the case group. Kinesiotaping may improve scar elevation over no specific scar therapy.

Comparison of the effect of silicone gel sheets by thickness on excisional scars in pediatric and adolescent patients

Background Selecting effective products among the various types of silicone gel sheets can be challenging for surgeons. Therefore, we assessed the effect of silicone gel sheet thickness on surgical scars in pediatric and adolescent patients.Methods From December 2017 to May 2018, we identified patients aged 1–19 years who underwent excision. Among these patients, those who were prescribed 0.3-mm or 1.0-mm-thick silicone sheets were selected. Scars were subjectively evaluated using a questionnaire consisting of seven items. Objective evaluation was performed by two plastic surgeons using the Vancouver Scar Scale (VSS).Results The mean age of the 49 selected patients was 9.78 years. The patients were divided into two groups according to the thickness of the silicone gel sheet used (0.3 mm vs. 1.0 mm). Objective evaluation of the patients’ scars revealed more favorable results in the 0.3 mm group than in the 1.0 mm group (P=0.010). Multivariate analysis of VSS scores indicated that the resulting scars in cases involving the trunk were of poorer quality than those involving facial areas (P=0.015). Additionally, favorable (i.e., below-average) VSS scores were significantly less likely in patients with longer scars (odds ratio, 0.896; 95% confidence interval, 0.834–0.963; P=0.003) or thicker silicone sheets (odds ratio, 0.085; 95% confidence interval, 0.011–0.699; P=0.019).Conclusions The use of thinner silicone gel sheets in children and adolescents resulted in better scars according to subjective evaluations, underscoring the importance of compliance in pediatric patients. The type of operation and surgical lesion should also be considered when planning the management of surgical scars.

Bioinformatics study on different gene expression profiles of fibroblasts and vascular endothelial cells in keloids

Keloid is a benign fibroproliferative skin tumor. The respective functions of fibroblasts and vascular endothelial cells in keloid have not been fully studied. The purpose of this study is to identify the respective roles and key genes of fibroblasts and vascular endothelial cells in keloids, which can be used as new targets for diagnosis or treatment.The microarray datasets of keloid fibroblasts and vascular endothelial cells were obtained from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were screened out. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) were used for functional enrichment analysis. The search tool for retrieval of interacting genes and Cytoscape were used to construct protein-protein interaction (PPI) networks and analyze gene modules. The hub genes were screened out, and the relevant interaction networks and biological process analysis were carried out.In fibroblasts, the DEGs were significantly enriched in collagen fibril organization, extracellular matrix organization and ECM-receptor interaction. The PPI network was constructed, and the most significant module was selected, which is mainly enriched in ECM-receptor interaction. In vascular endothelial cells, the DEGs were significantly enriched in cytokine activity, growth factor activity and transforming growth factor-β (TGF-β) signaling pathway. Module analysis was mainly enriched in TGF-β signaling pathway. Hub genes were screened out separately.In summary, the DEGs and hub genes discovered in this study may help us understand the molecular mechanisms of keloid, and provide potential targets for diagnosis and treatment.

Scoping Review of Therapeutic Strategies for Keloids and Hypertrophic Scars

Background:

Keloids are an abnormal proliferation of scars that can involve large areas of tissue beyond the original injury site. Hypertrophic scars are similar clinically, but do not exceed the original scar limits. These scarring abnormalities can cause noxious symptoms such as pain, tenderness, itching, and ulcerations. The aim of this review is to discuss current therapies for both types of abnormal scarring, and to determine if guidelines can be provided for excisional treatment with adjuvant therapies versus non-excisional methods.

Methods:

A systematic literature search was performed through the Web of Science database. The search revolved around keywords such as “keloid,” “hypertrophic scars,” and “treatment.” Articles were reviewed and screened for inclusion and exclusion criteria. The review focuses on an analysis and summarization of randomized control trials regarding keloid or hypertrophic scar treatments.

Results:

The original searches produced 1161 and 1275 articles for keloid and hypertrophic scars, respectively. In total, 316 duplicates were found. After accounting for 2014–2019 publication time, 655 keloid and 893 hypertrophic scar articles were reviewed. This resulted in 15 articles that pertained to treatment and randomized control trials.

Conclusions:

Keloids and hypertrophic scars present a clinical challenge. Based on qualitative review of recurrence, neither excision plus adjuvant therapy or nonsurgical treatments can be recommended preferentially at this time. More research is needed to determine if recurrence rate bias exists between the treatment regimens, as excisional treatment plus adjuvant therapy is reserved for refractory scars.

Surgical scar revision using silicone gel sheet as an adjunct

Introduction:

Scar is often referred to as an unattractive mark after healing of a wound. An undesirable scar may have negative social, emotional, and functional impact on the patient. It is our job as surgeons to adequately understand the expectations of the patient and counsel them for a successful procedure.

Materials and Methods:

Twelve patients were randomly chosen for the study, of which five were males and seven were females. The scar tissue was removed surgically, and silicone gel sheets (SGSs) were applied on the 14^th postoperative day, and the dimensions of the new scar was measured periodically up to 12 months.

Results:

The study comprised of 12 patients- 5 males and 7 females. The descriptive statistics were calculated as median and interquartile range and comparison between time intervals was done using Wilcoxon signed rank test. Out of the 12 patients, 10 showing complete resolution of the scar and 2 patients had partial relapse of scar. However, they were satisfied with the final outcome.

Conclusion:

Our study found that SGSs applied to surgically revised scars significantly improves their appearance. The ease of use of the SGSs also makes it patient friendly. We observed almost complete resolution of the scar in ten patients and two patients exhibited partial relapse of the scar. However, there was a significant improvement in the overall appearance of the scar, and the patients were satisfied with the results of the procedure.

Nonsurgical Management of Hypertrophic Scars: Evidence-Based Therapies, Standard Practices, and Emerging Methods

Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.

Interplay Between Keratinocytes and Fibroblasts: A Systematic Review Providing a New Angle for Understanding Skin Fibrotic Disorders

Background/Objective: Skin fibrosis is the result of aberrant processes leading to abnormal deposition of extracellular matrix (ECM) in the dermis. In healthy skin, keratinocytes participate to maintain skin homeostasis by actively crosstalking with fibroblasts. Within the wide spectrum of fibrotic skin disorders, relatively little attention has been devoted to the role of keratinocytes for their capacity to participate to skin fibrosis. This systematic review aims at summarizing the available knowledge on the reciprocal interplay of keratinocytes with fibroblasts and their soluble mediators in physiological states, mostly wound healing, and conditions associated with skin fibrosis.

Methods: We performed a systematic literature search on PubMed to identify in vitro and ex vivo human studies investigating the keratinocyte characteristics and their interplay with fibroblasts in physiological conditions and within fibrotic skin disorders including hypertrophic scars, keloids, and systemic sclerosis. Studies were selected according to pre-specified eligibility criteria. Data on study methods, models, stimuli and outcomes were retrieved and summarized according to pre-specified criteria.

Results: Among the 6,271 abstracts retrieved, 73 articles were included, of which 14 were specifically dealing with fibrotic skin pathologies. Fifty-six studies investigated how keratinocyte may affect fibroblast responses in terms of ECM-related genes or protein production, phenotype modification, and cytokine production. Most studies in both physiological conditions and fibrosis demonstrated that keratinocytes stimulate fibroblasts through the production of interleukin 1, inducing keratinocyte growth factor (KGF) and metalloproteinases in the fibroblasts. When the potential of keratinocytes to modulate collagen synthesis by healthy fibroblasts was explored, the results were controversial. Nevertheless, studies investigating keratinocytes from fibrotic skin, including keloids, hypertrophic scar, and scleroderma, suggested their potential involvement in enhancing ECM deposition. Twenty-three papers investigated keratinocyte proliferation differentiation and production of soluble mediators in response to interactions with fibroblasts. Most studies showed that fibroblasts modulate keratinocyte viability, proliferation, and differentiation. The production of KGF by fibroblast was identified as key for these functions.

Conclusions: This review condenses evidence for the active interaction between keratinocytes and fibroblasts in maintaining skin homeostasis and the altered homeostatic interplay between keratinocytes and dermal fibroblasts in scleroderma and scleroderma-like disorders.

Effect of poly(dimethylsiloxane)-block-poly(oligo (ethylene glycol) methacrylate) amphiphilic block copolymers on dermal fibroblast viability and proliferation

In this work, well-defined poly(dimethylsiloxane)-b-poly(oligo (ethylene glycol) methacrylate) (PDMS-b-POEGMA) amphiphilic block copolymers were synthesized and their effect on human dermal fibroblast were investigated. Anionic ring opening polymerization (ROP) and atom transfer radical polymerization (ATRP) were used to synthesis the block copolymers. The molecular weight of synthesized copolymers ranged from 1000 to 2300 Da by changing the number of both PDMS and POEGMA units. It was found that the copolymer having low molecular weight decreased the fibroblast viability and proliferation by inducing apoptosis. It was proved by flow cytometry and TUNEL assay that human dermal fibroblast experienced apoptosis after exposure to synthesized amphiphilic copolymers. The results of this work suggest the use of PDMS-b-POEGMA amphiphilic copolymers with low molecular weight for hypertrophic scars remediation.

Randomized, single-blinded, crossover study of a novel wound dressing vs current clinical practice after percutaneous collagen induction therapy

INTRODUCTION

Skin rejuvenation procedures have become common with sophisticated technologies with reduced downtime and related risks. Recently, microneedling has been paired with radiofrequency to create Fractional Radiofrequency Microneedling (FRFM) to induce neocollagenesis. Frequently, topical products are applied immediately after the needling. This procedure is known as percutaneous collagen induction therapy (PCIT). Postoperative topical wound care is critical for prompt rapid and safe healing, with moist wound healing deemed of primary importance for fast and correct scarring process. An ideal dressing enables a moist environment while reducing postprocedural inflammatory responses in the first stages of wound healing.

OBJECTIVE

To evaluate whether an innovative silicone-based wound dressing is superior than standard of care therapy in decreasing severity and duration of treatment-site acute inflammatory reactions post PCIT.

MATERIALS AND METHODS

Endymed PRO Intensif Handpiece (Endymed, Israel) was used for the full-face FRFM procedure. Subjects (n = 20) applied treatment (Stratacel^® -Stratpharma SG, Switzerland) and control (Aquaphor^® -Beiersdorf Inc, USA) immediately after the procedure and daily; they were evaluated immediately postprocedure (baseline assessment), at 2, 3 and 7 days postprocedure. Digital and 3D pictures (Antera 3D Camera for Skin Analysis-Miravex, Ireland) were taken at each assessment.

RESULTS

All patients healed properly without reporting adverse reactions to any of the studied products. Erythema at each study visit was significantly reduced with the use of the novel wound dressing (P < 0.001). A statistically significant difference in favor of the innovative wound dressing also emerged with respect to the patient-rated product properties (P = 0.008), such as feel on skin, drying time and stickiness.

CONCLUSIONS

The novel wound dressing reduced signs of acute inflammation following PCIT when compared to standard of care, without reporting adverse events and resulting in a more favorable outcome from a patient perspective.

Mechanical Forces in Cutaneous Wound Healing: Emerging Therapies to Minimize Scar Formation

Significance: Excessive scarring is major clinical and financial burden in the United States. Improved therapies are necessary to reduce scarring, especially in patients affected by hypertrophic and keloid scars. Recent Advances: Advances in our understanding of mechanical forces in the wound environment enable us to target mechanical forces to minimize scar formation. Fetal wounds experience much lower resting stress when compared with adult wounds, and they heal without scars. Therapies that modulate mechanical forces in the wound environment are able to reduce scar size. Critical Issues: Increased mechanical stresses in the wound environment induce hypertrophic scarring via activation of mechanotransduction pathways. Mechanical stimulation modulates integrin, Wingless-type, protein kinase B, and focal adhesion kinase, resulting in cell proliferation and, ultimately, fibrosis. Therefore, the development of therapies that reduce mechanical forces in the wound environment would decrease the risk of developing excessive scars. Future Directions: The development of novel mechanotherapies is necessary to minimize scar formation and advance adult wound healing toward the scarless ideal. Mechanotransduction pathways are potential targets to reduce excessive scar formation, and thus, continued studies on therapies that utilize mechanical offloading and mechanomodulation are needed.

Piercing Ear Keloid: Excision Using Loupe Magnification and Topical Liquid Silicone Gel as Adjuvant

Background

Keloid is an abnormal growth of scar at the site of skin injury, which usually does not regress. It proliferates beyond the original scar. The ear keloid usually develops after piercing injury to wear ornaments. A patient usually asks for removal of keloid, as it is aesthetically unpleasant. Patient may sometimes complain of itching and pain.

Aim

The study was conducted to analyze results following excision of keloid with its tract and topical silicone gel as the postsurgical adjuvant.

Materials and Methods

Ear keloids measuring less than 0.5cm or more than 5cm in maximum dimension were excluded from the study. Nonpiercing causes such as burns, trauma, and recurrent keloid were excluded from the study. The study was carried out on 22 patients who had keloid because of piercing injury, including 4 cases with both ear keloids. Of 26 ear keloids, 19 had the tract or connecting tissue. The lesion was excised under anesthesia using magnification. For all the operated cases, topical liquid silicone gel was used as postsurgical adjuvant therapy. The method of application of topical silicone gel was taught to each patient and was considered significant.

Result

The magnification helped in identification of tract in 73% of the cases in this study. Twenty patients had successfully responded to proposed treatment, and two patients developed recurrence while using topical silicone gel as the adjuvant. These two patients were managed with conventional triamcinolone injection.

Conclusion

The topical silicone gel as postsurgical adjuvant therapy avoided the use of painful postsurgical injection or radiotherapy for the 1-3cm primary ear keloids. The advantages of magnification were better clearance of keloid tissue, easier identification of tract and removal of keloid pseudopods, meticulous suturing, and comfortable elevation of a small local flap.

Current and Emerging Treatments for Postsurgical Cleft Lip Scarring: Effectiveness and Mechanisms

Cleft lip with or without cleft palate is the most common congenital malformation of the head and the third-most common birth defect. Surgical repair of the lip is the only treatment and is usually performed during the first year of life. Hypertrophic scar (HTS) formation is a frequent postoperative complication that impairs soft tissue form, function, or movement. Multiple lip revision operations are often required throughout childhood, attempting to optimize aesthetics and function. The mechanisms guiding HTS formation are multifactorial and complex. HTS is the result of dysregulated wound healing, where excessive collagen and extracellular matrix proteins are deposited within the wound area, resulting in persistent inflammation and resultant fibrosis. Many studies support the contribution of dysregulated, exaggerated inflammation in scar formation. Fibrosis and scarring result from chronic inflammation that interrupts tissue remodeling in normal wound healing. Failure of active resolution of inflammation pathways has been implicated. The management of HTS has been challenging for clinicians, since current therapies are minimally effective. Emerging evidence that specialized proresolving mediators of inflammation accelerate wound healing by preventing chronic inflammation and allowing natural uninterrupted tissue remodeling suggests new therapeutic opportunities in the prevention and management of HTS.

Treating Scars to the Neck

Scarring of the neck affects millions of people every year. The appearance of neck scarring can be disturbing both physically and psychologically. Scarring of the neck can be accompanied by morbidities because of the limitation of functional motion of the neck. Treatment options and modalities for reduction and prevention of scar formation include topical steroids, intralesional steroids, interferon, 5-fluorouracil, silicone gel, radiation, laser therapy, and surgeries. There is no general consensus in the literature as to the optimal treatment of neck scarring. Patients should understand that the scar is likely to be improved but not eliminated by treatment.

Keloids: The paradigm of skin fibrosis - Pathomechanisms and treatment

Keloids, fibroproliferative dermal tumors with effusive accumulation of extracellular matrix (ECM) components, particularly collagen, result from excessive expression of growth factors and cytokines. The etiology of keloids is unknown but they occur after dermal injury in genetically susceptible individuals, and they cause both physical and psychological distress for the affected individuals. Several treatment methods for keloids exist, including the combination therapy of surgical excision followed by intralesional steroid therapy, however, they have high recurrence rate regardless of the current treatment method. Improved understanding of the pathomechanisms leading to keloid formation will hopefully identify pathways that serve as specific targets to improve therapy for this devastating, currently intractable, disorder.

A comprehensive evidence-based review on the role of topicals and dressings in the management of skin scarring

Wound healing after dermal injury is an imperfect process, inevitably leading to scar formation as the skin re-establishes its integrity. The resulting scars have different characteristics to normal skin, ranging from fine-line asymptomatic scars to problematic scarring including hypertrophic and keloid scars. Scars appear as a different colour to the surrounding skin and can be flat, stretched, depressed or raised, manifesting a range of symptoms including inflammation, erythema, dryness and pruritus, which can result in significant psychosocial impact on patients and their quality of life. In this paper, a comprehensive literature review coupled with an analysis of levels of evidence (LOE) for each published treatment type was conducted. Topical treatments identified include imiquimod, mitomycin C and plant extracts such as onion extract, green tea, Aloe vera, vitamin E and D, applied to healing wounds, mature scar tissue or fibrotic scars following revision surgery, or in combination with other more established treatments such as steroid injections and silicone. In total, 39 articles were included, involving 1703 patients. There was limited clinical evidence to support their efficacy; the majority of articles (n = 23) were ranked as category 4 LOE, being of limited quality with individual flaws, including low patient numbers, poor randomisation, blinding, and short follow-up periods. As trials were performed in different settings, they were difficult to compare. In conclusion, there is an unmet clinical need for effective solutions to skin scarring, more robust long-term randomised trials and a consensus on a standardised treatment regime to address all aspects of scarring.

Scarless wound healing: chasing the holy grail

Over 100 million patients acquire scars in the industrialized world each year, primarily as a result of elective operations. Although undefined, the global incidence of scarring is even larger, extending to significant numbers of burn and other trauma-related wounds. Scars have the potential to exert a profound psychological and physical impact on the individual. Beyond aesthetic considerations and potential disfigurement, scarring can result in restriction of movement and reduced quality of life. The formation of a scar following skin injury is a consequence of wound healing occurring through reparative rather than regenerative mechanisms. In this article, the authors review the basic stages of wound healing; differences between adult and fetal wound healing; various mechanical, genetic, and pharmacologic strategies to reduce scarring; and the biology of skin stem/progenitor cells that may hold the key to scarless regeneration.

New insights on keloids, hypertrophic scars, and striae

This article presents an overview of the literature regarding treatments for keloid disease, hypertrophic scars, and striae distensae in dark pigmented skin. Striae, keloid, and hypertrophic scarring present a challenging problem for both the clinician and patient. No single therapy is advocated for hypertrophic scars, keloid scars, or striae distensae. New therapies have shown promise in the treatment of hypertrophic and keloid scars, and in patients with dark pigmented skin. This article provides guidance on the assessment and determination of patients' suitability for certain treatment options, as well as advice on the follow-up of patients affected with problematic scarring and striae.

Reliability of Repeated Measurements on Post-Burn Scars with Corneometer CM 825(®)

BACKGROUND/PURPOSE

The water content in burn scars, the parameter of stratum corneum water holding capacity, is an important feature in evaluation of biophysical properties of scars. Nevertheless, quantifiying this parameter is a challenge. In this study, the reliability of repeated water content measurements with Corneometer CM825(®) on (burn) scars was investigated.

METHODS

Intra-observer reliability, inter-observer reliability and day-by-day variability were examined on 30 scars by means of intra-class correlation coefficient (ICC) and within-subject coefficient of variation (WSCV). Bland-Altman plots with '95% limits of agreement' were constructed.

RESULTS

Results revealed excellent ICC values (ICCintra  = 0.985; ICCinter  = 0.984) with relatively low WSCV (WSCVintra  = 6.3%; WSCVinter  = 10.6%) for respectively intra- and inter-observer reliability. However, the Bland-Altman plot showed that more than 5% of differences were expected to exceed 4 a.u., the limit of what has been defined as a clinically acceptable difference. Results for day-by-day variability showed good ICC value (ICCday-by-day  = 0.849) and higher WSCV (WSCVday-by-day  = 20.5%).

CONCLUSION

The Corneometer CM825(®) is an objective and sensitive instrument for water content measurements. On the basis of our results, we concluded that the instrument can be used in clinical trials, but only under very strict conditions with standardized test protocol, preferably in combination with the evaluation of other physiological parameters.

Topical verapamil as a scar modulator

BACKGROUND

Skin injuries and the consequent loss of tissue integrity triggers a sequence of cellular and biochemical events that lead to a healed wound. Any failure during this rather sophisticated process may result in pathological scarring.

METHODS

To evaluate the efficacy of topical verapamil as a modulator of the healing process, a group of five observers (plastic surgeon, dermatologist, physiotherapist, biologist, and layman) analyzed pictures of 120 patients 3 months after abdominoplasty (60 patients) and mammoplasty (60 patients). Half of each group of patients used the topical verapamil scar modulator. Pictures were rated using the Stony Brook Scale.

RESULTS

According to the classification established by us, the scars in patients who used topical verapamil scar modulator showed better results than those who did not (p < 0.05). Patients treated with verapamil presented good-quality scarring (80 % of mammoplasty scars and 75.2 % abdominoplasty scars), while patients who did not use healing modulators showed 48 and 51.2 % satisfaction for mammoplasty and abdominoplasty scars, respectively. No adverse reactions were observed or reported after the use of topical verapamil.

CONCLUSIONS

This is the first clinical trial that reports the use of topical verapamil as a modulator in the healing process in the postoperative period. Based on clinical results and on the high level of reliability and statistical significance, we concluded that verapamil at a concentration of 50 µM is an excellent choice as a scar modulator; its use avoids the development of keloids and hypertrophic scars after plastic surgery.

Overview of surgical scar prevention and management

Management of incisional scar is intimately connected to stages of wound healing. The management of an elective surgery patient begins with a thorough informed consent process in which the patient is made aware of personal and clinical circumstances that cannot be modified, such as age, ethnicity, and previous history of hypertrophic scars. In scar prevention, the single most important modifiable factor is wound tension during the proliferative and remodeling phases, and this is determined by the choice of incision design. Traditional incisions most often follow relaxed skin tension lines, but no such lines exist in high surface tension areas. If such incisions are unavoidable, the patient must be informed of this ahead of time. The management of a surgical incision does not end when the sutures are removed. Surgical scar care should be continued for one year. Patient participation is paramount in obtaining the optimal outcome. Postoperative visits should screen for signs of scar hypertrophy and has a dual purpose of continued patient education and reinforcement of proper care. Early intervention is a key to control hyperplastic response. Hypertrophic scars that do not improve by 6 months are keloids and should be managed aggressively with intralesional steroid injections and alternate modalities.

Strategic management of keloid disease in ethnic skin: a structured approach supported by the emerging literature

Keloid disease (KD) is a common, benign, dermal fibroproliferative growth of unknown aetiology. Lesions tend to grow over time; they often recur following therapy and do not regress spontaneously. KD causes considerable discomfort due to pain, pruritus and inflammation, and a significant psychosocial impact with reduced quality of life. It is unique to humans and occurrence is higher in individuals with dark, pigmented, ethnic skin. There is a strong familial heritability, with a high ethnic predisposition in individuals of African, Asian and Hispanic descent. High recurrence rates and unknown resolution rates present a major problem for both the patient and clinician. Many treatment modalities exist; however, there is no single advocated therapy. Therefore, the aim of this review was to explore the most current literature regarding the range of treatment options for KD and to offer a structured approach in the management of KD, based on evidence and experience, to aid clinicians in their current practice. A focused history involving careful evaluation of the patient's symptoms, signs, quality of life and psychosocial well-being should direct targeted therapy, complemented with regular follow-up and re-evaluation. Many treatment modalities, such as intralesional steroid injection, silicone gel application, cryotherapy, lasers, 5-fluorouracil and, relatively recently, photodynamic therapy, are currently being used in clinical practice for the management of KD. Combination therapies have also been shown to be beneficial. However, there is a lack of robust, randomized, level-one, evidence-controlled trials evaluating these treatment options. Management of KD in ethnic pigmented skin remains a clinical challenge. Thus, a strategic approach with structured assessment, targeted therapy and focus on prevention of recurrence is highly recommended. Quality evidence is essential in order to tailor treatment effectively for the ethnic patient presenting with KD.

The effect of topical scar treatment on postoperative scar pain and pruritus after total knee arthroplasty

INTRODUCTION

The surgical wound of total knee arthroplasty (TKA) needs continuous flexion and extension movement. Silicone gel treatment is widely used to treat hypertrophic scars and keloids since it is easily applied and prevents scar pain and itching. The aim of this study was to evaluate the clinical efficacy and safety of silicone gel applied to surgical scars of TKA on postoperative scar pain and pruritus.

MATERIALS AND METHODS

One hundred TKAs were randomized into a silicone gel group (silicone gel was applied to the wound after stitch-out for 1 month) or a placebo group. The postoperative scar pain and pruritus were evaluated with the use of a visual analog scale (VAS) at postoperative 3 months, 6 months and 1 year. Scar assessment was done using the Vancouver scar scale by evaluating scar pigmentation, vascularity, pliability, and height.

RESULTS

Although silicone gel group showed better pigmentation and height scales than placebo group (P < 0.05), there were no significant differences in the postoperative scar pain and pruritus VAS scores between the groups (P > 0.05).

CONCLUSIONS

Application of silicone gel had no beneficial effects on scar pain and itching relief during the early postoperative period of TKA.

LEVEL OF EVIDENCE

I-Randomized Controlled Trial.

The effects of topical agent (kelo-cote or contractubex) massage on the thickness of post-burn scar tissue formed in rats

Background

We conducted an experimental study to compare the effect of massage using topical agents (Kelo-cote or Contractubex) on scar formation by massaging the healed burn wound on the dorsal area of Sprague-Dawley (SD) rats.

Methods

Four areas of second degree contact burn were made on the dorsal area of each of 15 SD rats, using a soldering iron 15 mm in diameter. After gross epithelialization in the defect, 15 SD rats were randomly divided into four groups: the Kelo-cote group, Contractubex group, Vaseline group, and control group. Rats in three of the groups (all but the Control group) were massaged twice per day for 5 minutes each day, while those in the Control group were left unattended. For histologic analysis, we performed a biopsy and evaluated the thickness of scar tissue.

Results

In the Kelo-cote and Contractubex groups, scar tissue thicknesses showed a significant decrease, compared with the Vaseline and control groups. However, no significant differences were observed between the Kelo-cote and Contractubex groups. In the Vaseline group, scar tissue thicknesses showed a significant decrease, compared with the control groups.

Conclusions

The findings of this study suggest that massage using a topical agent is helpful in the prevention of scar formation and that massage only with lubricant (no use of a topical agent) also has a considerable effect, although not as much as the use of a topical agent. Thus, we recommend massage with a topical agent on the post-burn scar as an effective method for decreasing the scar thickness.

Epidermal impedance sensing sheets for precision hydration assessment and spatial mapping

This paper presents a class of hydration monitor that uses ultrathin, stretchable sheets with arrays of embedded impedance sensors for precise measurement and spatially multiplexed mapping. The devices contain miniaturized capacitive electrodes arranged in a matrix format, capable of integration with skin in a conformal, intimate manner due to the overall skin-like physical properties. These "epidermal" systems noninvasively quantify regional variations in skin hydration, at uniform or variable skin depths. Experimental results demonstrate that the devices possess excellent uniformity, with favorable precision and accuracy. Theoretical models capture the underlying physics of the measurement and enable quantitative interpretation of the experimental results. These devices are appealing for applications ranging from skin care and dermatology, to cosmetology and health/wellness monitoring, with the additional potential for combined use with other classes of sensors for comprehensive, quantitative physiological assessment via the skin.

Scar management by means of occlusion and hydration: a comparative study of silicones versus a hydrating gel-cream

Despite the worldwide use of silicones in scar management, its exact working mechanism based on a balanced occlusion and hydration, is still not completely elucidated. Moreover, it seems peculiar that silicones with completely different occlusive and hydrating properties still could provide a similar therapeutic effect. The objective of the first part of this study was to compare the occlusive and hydrating properties of three fluid silicone gels and a hydrating gel-cream. In a second part of the study these results were compared with those of silicone gel sheets. Tape stripped skin was used as a standardized scar like model on both forearms of 40 healthy volunteers. At specific times, trans epidermal water loss (TEWL) and the hydration state of the stratum corneum were measured and compared with intact skin and a scar-like control over a 3-4h period. Our study clearly demonstrated that fluid silicone gels and a hydrating gel-cream have comparable occlusive and hydrating properties while silicone gel sheets are much more occlusive, reducing TEWL values far below those of normal skin. A well-balanced, hydrating gel-cream can provide the same occlusive and hydrating properties as fluid silicone gels, suggesting that it could eventually replace silicones in scar treatment.

Influence of silicone gel on standardized postoperative scars

BACKGROUND

Silicone gel is one therapeutic approach in the treatment and prevention of excessive scarring. The likely mechanism of action is the hydration of the tissue. This should lead to reduced angiogenesis and capillary blood flow. The efficacy is still controversial and the evidence base, insufficient. The aim of this prospective and standardized study is to investigate silicone gel in the preventive treatment of scars.

PATIENTS AND METHODS

Included in the study were 20 patients with costal cartilage harvest. Half of a standard chest scar was treated for three months with a silicone gel. The other half served as an internal control. After three months both scar sides were compared subjectively by visual analog scale and objectively by elasticity, moisture and color measurements.

RESULTS

Of 19 patients 8 had a better subjective result in the treated half. In one subject, no difference was seen. A worse subjective result in the treated half was seen in 10 out of 19. The objective measurements showed no significant difference. A correlation between the different results was not seen.

CONCLUSIONS

The use of silicone gel caused subjective differences within the same scar (worsening as well as improvement of the appearance). Positive effects were not detectable in the investigated parameters.

A review of the effects of moisturizers on the appearance of scars and striae

Scars are well known to have a stratum corneum (SC) that is malfunctional. Increases in transepidermal water loss and decreases in SC capacitance and conductance have been reported. Occlusion therapy is a well-known route to improving the signs and symptoms of scarring. Until recently that has been assumed to be totally pressure related. However, studies have demonstrated that the direct effects of hydration on keratinocytes and fibroblasts contribute to the reduction in hypertrophic scarring. Now it is well known that occlusion can regulate epidermal cytokine and growth factor production; changes in profibrotic and anti-fibrotic factors have been established. As a result, it is to be expected that moisturizers may improve the signs and symptoms of scars. As striae have been suggested to be anatomically similar to scars and as it is well established that paracrine signalling occurs in skin, it is expected that striae have similar SC issues. While one cannot exclude the effects of some of the ingredients used in the products, several studies are reported in this review that demonstrates that moisturization is a key component to reducing the clinical signs and symptoms of scars and striae. This is a good example of how knowledge of corneobiology leads to corneotherapies for these skin condition problems. The review is being written in memory of Professor Johann Wiechers who, before he died tragically in November 2011, performed two of the reported studies together with colleagues.

Topical modalities for treatment and prevention of postsurgical hypertrophic scars

There is no universally accepted treatment regimen and no evidence-based literature to guide management of hypertrophic scars. This article summarizes the existing literature regarding topical treatments such as silicone gel sheeting and ointment, onion extract, vitamin E, pressure garment therapy, massage therapy, and topical imiquimod 5% cream in the management of hypertrophic scars.

Epithelial regulation of mesenchymal tissue behavior

Fibroproliferative scars are an important clinical problem, and yet the mechanisms that regulate scar formation remain poorly understood. This study explored the hypothesis that the epithelium has a critical role in dictating scar formation, and that these interactions differ in skin and mucosa. Paired skin and vaginal mucosal wounds on New Zealand white (NZW) rabbits diverged significantly; the cutaneous epithelium exhibited a greater and prolonged response to injury when compared with the mucosa. Microarray analysis of the injured epithelium was performed, and numerous factors were identified that were more strongly upregulated in skin, including several proinflammatory cytokines and profibrotic growth factors. Analysis of the underlying mesenchymal tissue demonstrated a fibrotic response in the dermis of the skin but not the mucosal lamina propria, in the absence of a connective tissue injury. To determine if the proinflammatory factors produced by the epidermis may have a role in dermal fibrosis, an IL-1 receptor antagonist was administered locally to healing skin wounds. In the NZW rabbit model, blockade of IL-1 signaling was effective in preventing hypertrophic scar formation. These results support the idea that soluble factors produced by the epithelium in response to injury may influence fibroblast behavior and regulate scar formation in vivo.

Scar tissue

PURPOSE OF REVIEW

To examine the place of surgery and other modes of treating scar tissue given the plethora of measures that are advocated on the internet.

RECENT FINDINGS

There is good evidence to support the use of silicone sheets, pulsed dye laser (PDL), intralesional triamcinolone and dermabrasion in reducing hypertrophic scars, but each needs qualifying in terms of their timing and the type of scar tissue that they are used for.

SUMMARY

The surgical revision of scars should be delayed for at least 12 months unless there is webbing when redistributing skin tension forces with a Z-plasty or multiple Z-plasties or other local flaps negates the need to wait for the scar to mature. In a posttraumatic 'horse shoe' shaped, or a very oblique, cut an irregular contour is likely to occur. Under these circumstances a triamcinolone injection into any raised area can help and this needs to be re-evaluated after 6 weeks. With a less irregular contour dermabrasion can help if used 8 weeks after surgery. With hypertrophic scarring both silicone gel sheeting and PDL may help reduce the prominence of the scar. Most of all time helps scars to settle and fade and typical scar maturation takes 18-24 months. The role of stem cells, particularly from adipose tissue, warrants further study.

Strategies for prevention of scars: what can we learn from fetal skin?

Fetal wound healing occurs rapidly and without scar formation early in gestation. Studying the mechanisms of scarless repair can lead to novel scar-preventive approaches. In fetal wounds, collagen is deposited early and is fine and reticular with less cross-linking. Several important differences of fetal vs. postgestational wound-healing response have been determined, such as the presence of less inflammation, higher hyaluronic acid concentration and a greater ratio of collagen type III to type I. Compared with typical wounds, there are also altered ratios of signaling molecules, such as higher ratios of transforming growth factor (TGF)-β3 to TGF-β1 and -β2, and matrix metalloproteinases to tissue inhibitors of metalloproteinases. Furthermore, fetal fibroblasts do not exhibit TGF-β1-induced collagen production compared with their mature counterparts. Patterning genes (homeobox genes) involved in organogenesis are more active in the fetal period and are believed to be the "first domino" in the fetal cutaneous wound repair regulatory cascade. The recommended scar-preventive agents, such as Scarguard MD®, silicone gel and sheet, Seprafilm® Bioresorbable Membrane, topical hyaluronan, onion extract, oral tamoxifen and 585-nm pulsed dye laser are reviewed in this study. Despite the lack of supporting evidence, there is a widespread false presumption that the acceleration of healing with the widely assumed scar-preventive commercial agents is associated with decreased scar formation. Humans are erroneously inclined to make a negative correlation between the healing rate and the degree of scar formation, while such a correlation does not exist in reality. Despite the importance of scar prevention, no FDA-approved therapy for this purpose is available in the 21st century, which reflects the important challenges, such as the presence of redundant pathways, that these approaches are facing.

Silicone-based scar therapy: a review of the literature

Hypertrophic and keloid scars still are among the banes of plastic surgery. In the treatment arsenal at the disposal of the plastic surgeon, topical silicone therapy usually is considered the first line of treatment or as an adjuvant to other treatment methods. Yet, knowledge concerning its mechanisms of action, clinical efficacy, and possible adverse effects is rather obscure and sometimes conflicting. This review briefly summarizes the existing literature regarding the silicone elastomer's mechanism of action on scars, the clinical trials regarding its efficacy, a description of some controversial points and contradicting evidence, and possible adverse effects of this treatment method. Topical silicone therapy probably will continue to be the preferred first-line treatment for hypertrophic scars due to its availability, price, ease of application, lack of serious adverse effects, and relative efficacy. Hopefully, future randomized clinical trials will help to clarify its exact clinical efficacy and appropriate treatment protocols to optimize treatment results.