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Tahir SM, Ihebom D, Simman R. Compression Therapy for Keloid Scars: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5864. [PMID: 38841536 PMCID: PMC11150022 DOI: 10.1097/gox.0000000000005864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 04/08/2024] [Indexed: 06/07/2024]
Abstract
Background Keloid scars have a multitude of treatments with varying success rates. The purpose of this systematic review and meta-analysis is to study the different types of compression therapies used following surgical excision and their recurrence rates. Methods A literature search was conducted using the following databases: PubMed, Embase, and Cochrane Reviews. The following keywords were used in the search: "keloid" and "compression." The following inclusion criteria were used: (1) identifying lesion must be a keloid and (2) use of any type of compression therapy for keloid scar. Results A total of 27 articles were included in the final analysis, grouped into three treatment modalities for comparison. The three treatment modalities are (1) surgical excision and compression earring, (2) surgical excision and silicone gel sheeting, and (3) surgical excision, compression earring, and silicone gel sheeting. Based on our analysis, combination treatment with compression earring device and silicone gel sheeting had the lowest recurrence rate when compared with compression earring device or silicone gel alone, but the difference in recurrence rates between the three treatment modalities was not statistically significant. Conclusions There were too few studies included in each treatment modality with even fewer sample sizes, and there is a need for a greater number of studies with increased sample size to evaluate which therapy is the most efficacious in preventing keloid recurrence following surgical excision.
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Affiliation(s)
- Sadia M. Tahir
- From the College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio
| | - Diane Ihebom
- From the College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio
| | - Richard Simman
- College of Medicine and Life Sciences, Department of Surgery, University of Toledo, Toledo, Ohio
- ProMedica Health Network, Wound Care Program, Jobst Vascular Institute, Toledo, Ohio
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Kwon SH, Lee J, Yoo J, Jung Y. Artificial keloid skin models: understanding the pathophysiological mechanisms and application in therapeutic studies. Biomater Sci 2024. [PMID: 38812375 DOI: 10.1039/d4bm00005f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Keloid is a type of scar formed by the overexpression of extracellular matrix substances from fibroblasts following inflammation after trauma. The existing keloid treatment methods include drug injection, surgical intervention, light exposure, cryotherapy, etc. However, these methods have limitations such as recurrence, low treatment efficacy, and side effects. Consequently, studies are being conducted on the treatment of keloids from the perspective of inflammatory mechanisms. In this study, keloid models are created to understand inflammatory mechanisms and explore treatment methods to address them. While previous studies have used animal models with gene mutations, chemical treatments, and keloid tissue transplantation, there are limitations in fully reproducing the characteristics of keloids unique to humans, and ethical issues related to animal welfare pose additional challenges. Consequently, studies are underway to create in vitro artificial skin models to simulate keloid disease and apply them to the development of treatments for skin diseases. In particular, herein, scaffold technologies that implement three-dimensional (3D) full-thickness keloid models are introduced to enhance mechanical properties as well as biological properties of tissues, such as cell proliferation, differentiation, and cellular interactions. It is anticipated that applying these technologies to the production of artificial skin for keloid simulation could contribute to the development of inflammatory keloid treatment techniques in the future.
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Affiliation(s)
- Soo Hyun Kwon
- Center for Biomaterials, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea.
| | - Jongmin Lee
- Center for Biomaterials, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea.
- KU-KIST Graduate School of Converging Science and Technology, Korea University, Republic of Korea
| | - Jin Yoo
- Center for Biomaterials, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea.
| | - Youngmee Jung
- Center for Biomaterials, Korea Institute of Science and Technology, Seoul 02792, Republic of Korea.
- School of Electrical and Electronic Engineering, YU-KIST Institute, Yonsei University, Seoul 03722, Republic of Korea
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3
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Huang Y, Ren S, Yang Q. Efficacy and Safety of Excision Combination Therapies for Earlobe Keloids: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2024:10.1007/s00266-024-04092-0. [PMID: 38789810 DOI: 10.1007/s00266-024-04092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/15/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Different combinations of excision and adjuvant therapies have been applied to improve outcomes for earlobe keloids, though evidence in this field is still lacking. OBJECTIVES This study sought to systematically investigate efficacy and safety of these treatments. METHODS We conducted a systematic search on PubMed, Embase, Web of Science, and Cochrane Library to find all relevant studies. Meta-analysis of recurrence rates (RRs) and adverse event rates with 95% confidence intervals, and individual participants data (IPD) were calculated for each intervention when possible. Otherwise, narrative syntheses were performed. RESULTS A total of 85 articles, covering 23 treatments for earlobe keloids, were included, indicating a preference for multiple combination therapy. The estimated RRs for 6 interventions (i.e., excision monotherapy, combinations of excision with imiquimod, pressure therapy, radiotherapy, steroids, and steroids with pressure therapy) appeared to be comparable. Electron radiotherapy was found to have potential advantages over X-ray treatment, contributing to the observed heterogeneity. Further meta-analysis using IPD revealed that both combination therapies of excision plus steroid therapy (p=0.003) and excision plus radiotherapy (p=0.003) yielded better recurrence-free survival compared to excision alone. The median recurrence-free interval for combination therapy was 10 months. Adverse event rates were similar among different intervention groups. CONCLUSIONS This study suggests that combining excision with radiotherapy or perioperative steroid therapy has the potential to improve prognosis of earlobe keloids without increasing the risk of adverse events. Overall evaluation of patients' conditions and further studies with sufficient follow-up are warranted for clinical practice. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Ying Huang
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Badachu Road 33, Beijing, People's Republic of China
| | - Shuofang Ren
- Department of Cardiac Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qinghua Yang
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Badachu Road 33, Beijing, People's Republic of China.
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Zaccardelli A, Harb JL, Papathanasiou E, Scott AR. Presentation, Management, and Outcomes of Pathologic Scars Within a Pediatric Otolaryngology Practice. Laryngoscope 2024. [PMID: 38308543 DOI: 10.1002/lary.31320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/08/2023] [Accepted: 01/17/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVES This study aims to review the spectrum of scarring that may present to an urban, pediatric otolaryngology practice and determine if associations exist between race, scar location, treatment modality, and outcomes following interventions for scarring. METHODS Retrospective cohort study among 115 pediatric patients with 138 unique keloids or hypertrophic scars (HTS), and 141 children presenting for tonsillectomy at Tufts Medical Center. Age at presentation and sex assigned at birth were collected for both populations. For those presenting for pathologic scars, income quintile, self-identified race/ethnicity, anatomical location, treatment number and type, and clinical outcome were also analyzed. Multivariate analyses calculated adjusted odds ratios (aORs) and 95% confidence intervals to assess associations between scar subsite, intervention type, and persistence after treatment. RESULTS Compared to individuals presenting for tonsillectomy, a disproportionate percentage of patients presenting for scarring identified as Black (26.6% vs. 13.5%) or Asian (17.4% vs. 7.1%, p = 0.016) or were male (61.7% vs. 49.7%, p = 0.053). Individuals identifying as Black or Asian were more likely to present with ear lobe and neck scars, respectively (50.0% vs. 45.5%, p = <0.001). Ear scars were significantly more likely to receive excision at initial treatment (aOR = 5.86 [1.43-23.96]) compared to other subsites, and were more likely to require >1 treatment (aOR = 5.91 [1.53-22.75]). CONCLUSION Among pediatric patients presenting with keloids or HTS, children who identified as Black or Asian were more likely to present with ear and neck scars, respectively. Ear scars were frequently treated with excision and appear more likely to require adjuvant treatments and multiple interventions. LEVEL OF EVIDENCE Level III Laryngoscope, 2024.
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Affiliation(s)
- Alessandra Zaccardelli
- Department of Otolaryngology-Head and Neck, Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Jennifer L Harb
- Division of Pediatric Otolaryngology and Facial Plastic and Reconstructive Surgery, Boston, Massachusetts, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Evangelos Papathanasiou
- Department of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts, U.S.A
| | - Andrew R Scott
- Department of Otolaryngology-Head and Neck, Tufts University School of Medicine, Boston, Massachusetts, U.S.A
- Division of Pediatric Otolaryngology and Facial Plastic and Reconstructive Surgery, Boston, Massachusetts, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A
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5
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Maria R, Kok YO, Teoh KH. A Fully Digital Auricular Splint Workflow for Post-Keloid Excision. Arch Plast Surg 2023; 50:563-567. [PMID: 38143839 PMCID: PMC10736199 DOI: 10.1055/s-0043-1771271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/15/2023] [Indexed: 12/26/2023] Open
Abstract
Ear keloids are challenging lesions to treat due to high recurrence rates postexcision. Conservative compression techniques as adjunct treatment have been reported to be effective. An innovative technique of using computer-aided design/computed-aided manufacturing to print a customized auricular splint improves efficiency and comfort level for patients compared with conventional methods. The ear is scanned using an intraoral scanning 2 weeks postsurgery. A two-piece auricular splint is designed on the digital model, incorporating perforated projections for three nylon screws for retention of the splint. The splint is printed with clear acrylic material, postprocessed, and finished. The patient is taught to assemble the components of the splint and instructed to wear for at least 8 hours daily. The surgery site reviewed for any ulceration, pain, or recurrence of keloid for 6 months. During the 6-month review, the excision scar remained flat and pink. The patient also reports unrestricted daily activities. The digital workflow increases comfort for the patient and reduces the number of hours required to produce a customized auricular splint compared with conventional methods. A fully digital workflow for a printed auricular splint should be considered for adjunctive treatment to excision of ear keloids.
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Affiliation(s)
- Rahmat Maria
- Department of Restorative Dentistry, National Dental Centre of Singapore, Singapore, Republic of Singapore
| | - Yee Onn Kok
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore, Republic of Singapore
| | - Khim Hean Teoh
- Department of Restorative Dentistry, National Dental Centre of Singapore, Singapore, Republic of Singapore
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Biazus Soares G, Mahmoud O, Yosipovitch G. Pruritus in keloid scars: mechanisms and treatments. Ital J Dermatol Venerol 2023; 158:401-407. [PMID: 37916400 DOI: 10.23736/s2784-8671.23.07554-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Keloids occur after cutaneous injury and can cause distress due to physical appearance and associated symptoms such as pain and pruritus. Keloid-associated pruritus is a common manifestation and has negative impacts on quality of life. The mechanism underlying this type of pruritus is multifactorial and thought to involve small nerve fiber damage, neurogenic inflammation, and a Th2-predominant inflammatory response. Various agents have been shown to reduce keloid pruritus, including intralesional corticosteroids, botulinum toxin A, 5-fluorouracil, and bleomycin. Other treatment modalities such as cryotherapy and hyperbaric oxygen therapy are also effective. Future treatments targeting the mechanisms involved in keloid-associated itch could provide improvements in pruritus and quality of life in these patients, but further studies on the efficacy of these agents are needed.
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Affiliation(s)
- Georgia Biazus Soares
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Omar Mahmoud
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gil Yosipovitch
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Miami Itch Center, University of Miami Miller School of Medicine, Miami, FL, USA -
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Nejat AH, Hamdan S, Abrego I, Lindsey JT, Vitter R. Fully Digital Workflow for Fabrication of A 3D Printed Ear Stent for Auricular Keloids: A Technique Article. J Prosthodont 2021; 31:266-270. [PMID: 34811842 DOI: 10.1111/jopr.13455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2021] [Indexed: 11/28/2022] Open
Abstract
Keloids are skin lesions which result from an aberration in the physiological healing process marked with overgrowth of collagen fibers. Keloid of the ear is cosmetically challenging and has an increased chance of re-growth. To minimize recurrence, pressure therapy in combination with other treatment forms has been used. Various techniques have been used to fabricate a passive or active stent. This report presents a fully digital workflow to fabricate an ear stent after intralesional excision and skin autografting of an extensive recurrence of a keloid lesion of the left ear involving the helix, antihelix, scapha and conchal bowl. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Amir H Nejat
- Assistant Professor, Prosthodontics Department, Louisiana State University Health Science Center, School of Dentistry, New Orleans, LA
| | - Suleiman Hamdan
- Associate Professor, Prosthodontics Department, Louisiana State University Health Science Center, School of Dentistry, New Orleans, LA
| | | | - John T Lindsey
- Clinical Associate Professor of Surgery, Division of Plastic and Reconstructive Surgery, Tulane University School of Dentistry
| | - Roger Vitter
- Assistant Professor, Prosthodontics Department, Louisiana State University Health Science Center, School of Dentistry, New Orleans, LA
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Zawadiuk LRR, Van Slyke AC, Bone J, Redfern B, Carr NJ, Arneja JS. What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2021; 30:49-58. [PMID: 35096693 PMCID: PMC8793758 DOI: 10.1177/2292550321995746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids. Methods: We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality. Results: A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found. Conclusions: Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.
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Affiliation(s)
- Luke R. R. Zawadiuk
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aaron C. Van Slyke
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baillie Redfern
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas J. Carr
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jugpal S. Arneja
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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9
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The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis. Dermatol Surg 2021; 46:1054-1059. [PMID: 32224709 DOI: 10.1097/dss.0000000000002362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective. OBJECTIVE To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy). MATERIALS AND METHODS Systematic literature review and meta-analysis of combination treatment for keloids. RESULTS After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099). CONCLUSION Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.
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10
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3d printed custom made pressure clips for ear keloid treatment after surgical excision. Am J Otolaryngol 2020; 41:102516. [PMID: 32381347 DOI: 10.1016/j.amjoto.2020.102516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of this study is to introduce the efficacy of our 3D printer custom made pressure adjustable clips for preventing keloid recurrence after ear keloid surgical excision. Mechanical pressure is increasingly applied as a means to prevent or treat keloid scars. METHODS 10 patients were included in the study, and were treated for six months with the 3D custom printed pressure clips after ear keloid excision surgery. The mean follow-up was one year. The primary outcome assessed was the degree of recurrence of keloids, with patient satisfaction as the secondary outcome assessed by subjective history. RESULTS Keloid scars were reduced in the treated patient group. Patient scarring was decreased. There were no negative side effects observed after the therapy. CONCLUSION Our 3d printed custom pressure-adjustable earclip model is an effective tool in the prevention of ear keloid recurrence and is associated with high patient satisfaction. The benefits should prompt further study on its value as an adjuvant therapy to surgery in keloid treatment. LEVEL OF EVIDENCE Level III on the Evidence Rating Scale for Therapeutic Studies.
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Jun D, Shin D, Choi H, Lee M. Clinical efficacy of intermittent magnetic pressure therapy for ear keloid treatment after excision. Arch Craniofac Surg 2020; 20:354-360. [PMID: 31914489 PMCID: PMC6949498 DOI: 10.7181/acfs.2019.00465] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/21/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Keloids are benign fibro-proliferative lesion, related to excessive inflammatory reactions in certain anatomical areas, including the auricles. Their specific etiology remains unclear; nonetheless they exhibit tumor-like characteristics of significant recurrence and cause emotional distress, even with various treatment strategies. We applied intermittent magnetic pressure therapy on ear keloids in combination with surgical excision, and present its effectiveness herein. METHODS Ear keloid patients were treated with surgical excision followed by magnetic pressure therapy. The keloid tissues underwent excision and keloid marginal flaps were utilized for wound closure. Intermittent magnetic pressure therapy was applied 2 weeks after the surgical procedure. The pressure therapy consisted of a 3-hour application and 2-hour resting protocol (9 hr/day), and lasted for 6 months. The results were analyzed 6 months after the therapeutic procedures, using the scar assessment scale. RESULTS Twenty-two ear keloids from 20 patients were finally reviewed. Among the keloids that completed the therapeutic course, 20 ear keloids out of 22 in total (90.9%) were successfully eradicated. Two patients (2 keloids) exhibited slight under-correction. Postoperative complications such as wound dehiscence or surgical site infection were not noted. The scar assessment scale demonstrated a significant improvement in each index. The intermittent pressure therapy led to patient compliance, and avoided pressure-related pain and discomfort. CONCLUSION Excision followed by intermittent pressure application using a magnet successfully reduced the burden of fibro-proliferative keloids, and had good patient compliance. The role of intermittent pressure application and resting should be studied with regard to keloid tissue remodeling.
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Affiliation(s)
- Dongkeun Jun
- Department of Plastic and Reconstructive Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Donghyeok Shin
- Department of Plastic and Reconstructive Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Hyungon Choi
- Department of Plastic and Reconstructive Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Myungchul Lee
- Department of Plastic and Reconstructive Surgery, Konkuk University School of Medicine, Seoul, Korea
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12
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Abstract
Keloids are pathological scars that grow over time and extend beyond the initial site of injury after impaired wound healing. These scars frequently recur and rarely regress. They are aesthetically disfiguring, can cause pain, itching, discomfort as well as psychological stress, often affecting quality of life. Many treatment modalities, including surgical and non-surgical, have been explored and have been reported to be beneficial; however, none have been absolutely satisfactory or optimal for the treatment of all keloid subtypes to date. This poses a major challenge to clinicians. Often, a combinational therapeutic approach appears to offer the best results with higher patient satisfaction compared to monotherapy. The aetiopathogenesis of keloids is not fully elucidated; however, with recent advances in molecular biology and genetics, insight is being gained on the complex process of scar formation and hence new therapeutic and management options for keloids. In this paper, we explore the literature and summarise the general concepts surrounding keloid development and review both current (corticosteroids, surgical excision, silicone-based products, pressure therapy, radiotherapy, cryotherapy, laser therapy, imiquimod and 5-fluorouracil) and emerging (stem cell therapy, mitomycin C, verapamil, interferons, bleomycin, botulinum toxin type A and angiotensin-converting enzyme inhibitors) treatments. Increased knowledge and understanding in this area may potentially lead to the discovery and development of novel therapeutic options that are more efficacious for all keloid types. LAY SUMMARY Keloids are problematic scars that are difficult to treat and manage. The aetiopathogenesis of keloids is not clear; however, recent advances in molecular biology and genetics are beginning to shed light on the underlying mechanisms implicated in keloid scar formation which will hopefully lead to the development of treatment options for all keloid types. This review summarises current and emerging therapies.
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Affiliation(s)
- Nkemcho Ojeh
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Ambadasu Bharatha
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Uma Gaur
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Andrew LeRoy Forde
- Pine Medical Centre, 3rd Avenue Belleville, St. Michael, Barbados, West Indies
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Coentro JQ, Pugliese E, Hanley G, Raghunath M, Zeugolis DI. Current and upcoming therapies to modulate skin scarring and fibrosis. Adv Drug Deliv Rev 2019; 146:37-59. [PMID: 30172924 DOI: 10.1016/j.addr.2018.08.009] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 07/08/2018] [Accepted: 08/26/2018] [Indexed: 12/12/2022]
Abstract
Skin is the largest organ of the human body. Being the interface between the body and the outer environment, makes it susceptible to physical injury. To maintain life, nature has endowed skin with a fast healing response that invariably ends in the formation of scar at the wounded dermal area. In many cases, skin remodelling may be impaired, leading to local hypertrophic scars or keloids. One should also consider that the scarring process is part of the wound healing response, which always starts with inflammation. Thus, scarring can also be induced in the dermis, in the absence of an actual wound, during chronic inflammatory processes. Considering the significant portion of the population that is subject to abnormal scarring, this review critically discusses the state-of-the-art and upcoming therapies in skin scarring and fibrosis.
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Affiliation(s)
- João Q Coentro
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Eugenia Pugliese
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Geoffrey Hanley
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Michael Raghunath
- Center for Cell Biology and Tissue Engineering, Institute for Chemistry and Biotechnology (ICBT), Zurich University of Applied Sciences (ZHAW), Wädenswil, Switzerland
| | - Dimitrios I Zeugolis
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland.
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14
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Tan A, Glass nd DA. Patient-reported outcomes for keloids: a systematic review. GIORN ITAL DERMAT V 2019; 154:148-165. [DOI: 10.23736/s0392-0488.18.06089-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Intralesional Steroids and Compression Devices for Keloids. Dermatol Surg 2018; 45:1203-1207. [PMID: 30585850 DOI: 10.1097/dss.0000000000001704] [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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16
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da Cunha Colombo Tiveron LR, da Silva IR, da Silva MV, Peixoto AB, Rodrigues DBR, Rodrigues V. High in situ mRNA levels of IL-22, TFG-β, and ARG-1 in keloid scars. Immunobiology 2018; 223:812-817. [PMID: 30146129 DOI: 10.1016/j.imbio.2018.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/18/2018] [Accepted: 08/19/2018] [Indexed: 12/21/2022]
Abstract
Keloid scars are currently considered a chronic inflammatory process and no longer a benign skin tumor. Keloids are defined as highly inflamed, hyperproliferative pathological scars. Growth factors and cytokines have important functions in the keloid inflammatory etiopathogenesis. The aim of this study was to analyze the in situ expression of cytokines and growth factors in keloid scars in comparison with that in normal scars. Among them, we specifically assessed TGF-β, FGF, IL-33, IL-22, ARG-1, ARG-2, iNOS, VIP, VIP-R1, TAC, and TAC-R1. A total of 98 biopsies were evaluated, including of 53 keloid and 45 normal scars. The age of patients with keloids ranged from 11 to 73 years, with a mean age of 28 years and predominance of the female gender (58.5% of the total patients). Around 64.15% of the patients belonged to the black ethnic group. Evaluated keloids were most commonly located in the earlobe because of ear piercing, representing 73.6% of the cases. We found significantly greater expression of TGF-β, IL-22, and ARG-1 in keloids when compared with that in normal scars. As for IL-33, ARG-2, and VIP-R1, despite the higher number of mRNA copies found in keloids, this difference was not significant. Furthermore, FGF, iNOS, VIP, TAC, and TAC-R1 mRNA levels were not detectable, and therefore these results were inconclusive in this study. Considering these results, understanding the cellular and molecular mechanisms that control the inflammatory response during cutaneous healing may promote the development of strategies to improve the treatment of patients with keloids.
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Affiliation(s)
| | - Isabela Rios da Silva
- Federal University of Triângulo Mineiro (UFTM) ICBN and CEFORES, Uberaba, MG, Brazil
| | | | - Alberto Borges Peixoto
- Laboratory of Biopathology and Molecular Biology, University of Uberaba (UNIUBE), Uberaba, MG, Brazil
| | - Denise Bertulucci Rocha Rodrigues
- Federal University of Triângulo Mineiro (UFTM) ICBN and CEFORES, Uberaba, MG, Brazil; Laboratory of Biopathology and Molecular Biology, University of Uberaba (UNIUBE), Uberaba, MG, Brazil
| | - Virmondes Rodrigues
- Federal University of Triângulo Mineiro (UFTM) ICBN and CEFORES, Uberaba, MG, Brazil.
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Lyu A, Xu E, Wang Q. A retrospective analysis of surgical resection of large ear keloids. Australas J Dermatol 2018; 60:29-32. [PMID: 29962005 DOI: 10.1111/ajd.12872] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 09/16/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate surgical methods for the removal of larger ear keloids. METHODS Two different surgical techniques were used: Method A, tumour excision followed by in situ scar flap repair; and Method B, wedge resection of an auricular lesion followed by primary closure or local flap repair. After the treatment, patients received postoperative, local radiotherapy. Follow-up was for 1-3 years (median 28.9 months). RESULTS Twenty patients with 35 large ear keloids were reviewed. In Method A, six ears were cured, three ears improved, five ears relapsed after 1 year and one ear recurred within 1 year. In Method B, 17 ears were cured, two ears improved and one ear recurred within 1 year. CONCLUSION Keloid scars can be effectively treated with a combination of radiotherapy and surgical excision.
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Affiliation(s)
- Anqi Lyu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Erwei Xu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Qiying Wang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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18
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The Effects of Postoperative Intralesional Corticosteroids in the Prevention of Recurrent Earlobe Keloids: A Multispecialty Retrospective Review. Dermatol Surg 2018; 44:865-869. [DOI: 10.1097/dss.0000000000001474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Treatment of ear keloids: algorithm for a multimodal therapy regimen. Eur Arch Otorhinolaryngol 2017; 274:3859-3866. [DOI: 10.1007/s00405-017-4714-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/10/2017] [Indexed: 10/19/2022]
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20
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In Situ Cytokine Expression and Morphometric Evaluation of Total Collagen and Collagens Type I and Type III in Keloid Scars. Mediators Inflamm 2017. [PMID: 28638180 PMCID: PMC5468593 DOI: 10.1155/2017/6573802] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Keloids are characterized by excessive collagen deposition and growth beyond the edges of the initial injury, and cytokines may be related to their formation. The objective of this study was to evaluate the collagen fibers, analyze in situ expression of cytokines in keloid lesions, and compare to the control group. Results showed that there was a predominance of women and nonwhite and direct black ancestry. Keloid showed a significant increase in total and type III collagen. Significantly, the expression of mRNA for TGF-β in keloid was increased, the expressions of IFN-γ, IFN-γR1, and IL-10 were lower, and IFN-γR1 and TNF-α had no statistical difference. Correlations between collagen type III and TGF-β mRNA expression were positive and significant, IFN-γ, IFN-γR1, and IL-10 were negative and significant, and TNF-α showed no statistical difference. We conclude that there was a significant increase of total collagen in keloid and predominance of collagen type III compared to the controls, showing keloid as an immature lesion. There is a significant increase in TGF-β mRNA in keloid lesions, and a significant decrease in IFN-γ and IL-10, suggesting that these cytokines are related to keloid lesions.
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Abstract
This article provides a review of the surgical and nonsurgical options available to manage a variety of auricular scars. The basics of wound healing are discussed in addition to the etiology of keloids and the cauliflower ear. Many auricular scars can be revised with scar excision techniques, but separate discussions for the treatment of keloids and the cauliflower ear are provided. The management plan for auricular scarring requires appropriate patient counseling regarding the risk of recurrence in keloids, regrowth of scar tissue in cauliflower ears, scar hypertrophy at the line of closure, widening of the scar, and persisting ear contour deformities.
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Affiliation(s)
- Deborah Watson
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, 3350 La Jolla Village Drive, 112-C, San Diego, CA 92161, USA
| | - Bharat Panuganti
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, 3350 La Jolla Village Drive, 112-C, San Diego, CA 92161, USA.
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22
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Maderal AD, Berman B. Updates on Keloidal Wound Healing. CURRENT DERMATOLOGY REPORTS 2016. [DOI: 10.1007/s13671-016-0155-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Tirgan M. Massive ear keloids: Natural history, evaluation of risk factors and recommendation for preventive measures - A retrospective case series. F1000Res 2016; 5:2517. [PMID: 28529690 PMCID: PMC5428534 DOI: 10.12688/f1000research.9504.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 01/02/2023] Open
Abstract
Keloid disorder (KD) is an inherited wound healing ailment, frequently seen among Africans /African Americans and Asians. Genetics of this disorder continues to be obscure and poorly understood. Clinical manifestation of KD is quite variable and very diverse, spanning from individuals with one or very few small keloidal lesions, to those with numerous and very large lesions covering large portion of their skin. Ears are common locations for development of keloids. Ear piercing is by far the leading triggering factor for ear keloid formation in genetically predisposed individuals. Although there are numerous publications about ear and earlobe keloids, there is a void in medical literature about massive ear keloids. This paper focuses on the natural history of massive ear keloids and risk factors that lead to formation of these life-changing and debilitating tumors and recommendations for prevention.
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Goder M, Kornhaber R, Bordoni D, Winkler E, Haik J, Tessone A. Cutaneous basal cell carcinoma arising within a keloid scar: a case report. Onco Targets Ther 2016; 9:4793-6. [PMID: 27536142 PMCID: PMC4976908 DOI: 10.2147/ott.s113724] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Basal cell carcinomas (BCCs) are one of the most frequent cutaneous malignancies. The majority of BCCs are reported to occur on the auricular helix and periauricular region due to ultraviolet light exposure. Despite the frequency of BCCs, those that develop within scar tissue are rare, and the phenomenon of keloid BCCs has rarely been reported in the literature. Keloid collagen within BCCs is associated with morphoeiform characteristics, ulceration, or necrosis. Extensive keloid collagen is often seen in BCCs of the ear region, a site prone to keloid scarring. This article presents a rare case of a secondary tumor (BCC) which arose on top of a primary tumor (keloid scar) on the right auricle region in a healthy 23-year-old female after an ear piercing 2 years prior. To our knowledge, the tumor described in this case, in contrast to keloidal BCCs, has never been reported in the literature.
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Affiliation(s)
- Maya Goder
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Rachel Kornhaber
- School of Health Sciences, Faculty of Health, University of Tasmania, Sydney, NSW, Australia
| | - Daniele Bordoni
- Department of Senology, Ospedale Santa Maria della Misericordia Urbino, Urbino, Italy
| | - Eyal Winkler
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Josef Haik
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Ariel Tessone
- Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel Hashomer, Israel
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