The emerging role of antineoplastic agents in the treatment of keloids and hypertrophic scars: a review. Ann Plast Surg. 2010;64:355-361. [PMID: 20179490 DOI: 10.1097/sap.0b013e3181afaab0]

Strategies for Preventing Esophageal Stenosis After Endoscopic Submucosal Dissection and Progress in Stem Cell-Based Therapies

Endoscopic submucosal dissection (ESD) has been widely used in the early neoplasia of the esophagus. However, postoperative esophageal stenosis is a big problem, particularly when a large circumferential proportion of esophageal mucosa is resected. Currently, there are several methods available to prevent esophageal stenosis after ESD, including steroid administration, esophageal stent implantation, and endoscopic balloon dilation (EBD). However, the therapeutic effects of these are not yet satisfactory. Stem cell-based therapies has shown promising potential in reconstructing tissue structure and restoring tissue function. In this study, we discussed the current strategies for preventing esophageal stenosis after ESD and perspectives of stem cell-based therapies for the prevention of esophageal stenosis.

Hypertrophic Scars of the Hand: The Role of Electrophotobiomodulation Theory as a Recent Line of Treatment

BACKGROUND

A more enduring strategy for the treatment of hypertrophic scars of the hand is still a challenge facing restorative dermatologists and plastic surgeons. Nonetheless, with the use of nonablative devices, intense pulsed light and different types of lasers have started to yield promising outcomes and are close to becoming an effective and dependable technique. The advances in radiofrequency energy have brought new life to optical-based frameworks. Radiofrequency current delivers an unadulterated heat effect according to the electrical response characteristics of each tissue. The purpose of this study was to assess the patient satisfaction, safety, and clinical efficacy of the use of electrophotobiomodulation (combined intense pulsed light and radiofrequency energy) in the treatment of postburn hypertrophic scars of the hand.

METHODS

This was a prospective clinical study that was performed on 56 patients who presented with postburn hypertrophic scars on the hands between March of 2013 and January of 2020.

RESULTS

The clinical appraisal showed excellent results in 33 patients (58.9%), good results in 18 patients (32.2%), fair results in five patients (8.9%), and no poor results.

CONCLUSION

The use of radiofrequency energy combined with intense pulsed light was effective for the treatment of hand scars on people with various skin tones.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Surgical Considerations In Skin of Colour

For most clinicians undertaking surgery and patients undergoing surgery, the primary aim is the success of the operation being undertaken. The secondary aim is for optimal wound healing with minimal scar formation. The normal wound healing process involves four distinct but overlapping stages: Haemostasis, inflammation, proliferation and remodelling. In some patients the cellular process involved in the proliferation and remodelling stages can be deranged, resulting in the formation of hypertrophic or keloid scars. This is more frequently seen in skin of Colour. Excessive scarring is thought to be first described in the Smith papyrus about 1700 BC. Many years later Mancini (in 1962) and Peacock (in 1970) classified excessive scarring into hypertrophic and keloid scar formation. Clinicians can minimize the risk of these pathological scars developing with good pre-operative, peri-operative/intra-operative and post-operative surgical practices. We review the wound healing processes in association with good surgical principles and practice, discuss how implementing these principles in practice helps in prevention and management of pathological surgical scars such as hypertrophic scars and keloid scars. This review offers a practical step by step clinical guide that can be used by any clinician.

A patient-like swine model of gastrointestinal fibrotic strictures for advancing therapeutics

Gastrointestinal (GI) strictures are difficult to treat in a variety of disease processes. Currently, there are no Food and Drug Administration (FDA) approved drugs for fibrosis in the GI tract. One of the limitations to developing anti-fibrotic drugs has been the lack of a reproducible, relatively inexpensive, large animal model of fibrosis-driven luminal stricture. This study aimed to evaluate the feasibility of creating a model of luminal GI tract strictures. Argon plasma coagulation (APC) was applied circumferentially in porcine esophagi in vivo. Follow-up endoscopy (EGD) was performed at day 14 after the APC procedure. We noted high grade, benign esophageal strictures (n = 8). All 8 strictures resembled luminal GI fibrotic strictures in humans. These strictures were characterized, and then successfully dilated. A repeat EGD was performed at day 28 after the APC procedure and found evidence of recurrent, high grade, fibrotic, strictures at all 8 locations in all pigs. Pigs were sacrificed and gross and histologic analyses performed. Histologic examination showed extensive fibrosis, with significant collagen deposition in the lamina propria and submucosa, as well as extensive inflammatory infiltrates within the strictures. In conclusion, we report a porcine model of luminal GI fibrotic stricture that has the potential to assist with developing novel anti-fibrotic therapies as well as endoscopic techniques to address recurring fibrotic strictures in humans.

Emerging and Novel Therapies for Keloids: A compendious review

Keloids are abnormal fibroproliferative scars with aggressive dermal growth expanding beyond the borders of the original injury. Different therapeutic modalities, such as corticosteroids, surgical excision, topical silicone gel sheeting, laser therapy, cryotherapy, photodynamic therapy and radiotherapy, have been used to treat keloids; however, none of these modalities has proven completely effective. Recently, researchers have devised several promising anti-keloid therapies including anti-hypertensive pharmaceuticals, calcineurin inhibitors, electrical stimulation, mesenchymal stem cell therapy, microneedle physical contact and ribonucleic acid-based therapies. The present review summarises emerging and novel treatments for keloids. PubMed^® (National Library of Medicine, Bethesda, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands) and Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA) were searched for relevant literature published between January 1987 to June 2020. A total of 118 articles were included in this review. A deeper understanding of the molecular mechanisms underlying keloid scarring pathogenesis would open further avenues for developing innovative treatments.

Predictors of the recurrence of surgically removed previous caesarean skin scars at caesarean section: A retrospective cohort study

BACKGROUND

Caesarean skin scars (CSS; hypertrophic scars and keloids) are very stressful for women and treatment strategies vary. However, there is a lack of knowledge about the outcome of surgical excision of CSS during caesarean section (CS). The study aims to determine the rate of recurrence and risk factors of recurrence for surgically removed CSS.

METHOD

This is a retrospective cohort study that used STROBE guidelines. Pfannenstiel incisions of 145 patients were evaluated. Patients were divided into two groups: recurred (group 1, n = 19) and non-recurred group (group 2, n = 126). The groups were compared.

RESULTS

The rate of recurrence of CSS was 13% in the total cohort (19/145), one of the main outcomes of the study. While emergency CS was performed for 12 patients in group 1 (63%), CS was carried out in 25 patients in group 2 (20%); this difference was significant (P = 0.001). Before surgery, white blood cell and neutrophil counts were significantly higher in group 1 (P = 0.014 and P = 0.023, respectively). There were 11 dark-skinned women (26%; Fitzpatrick type 4) in group 1 and 31 (74%) in group 2. This difference was statistically significant (P = 0.031). As the other main outcome, emergency CS could be accepted as a risk factor for recurrence in the multivariate regression analysis (P = 0.060; odds ratio = 5.07; 95% confidence interval = 0.93-17.51).

CONCLUSION

The rate of recurrence of surgically removed previous CSS at CS is promising without adjunct therapy. Emergency CS was found to be a risk factor for recurrence.

LAY SUMMARY

Background Caesarean skin scars (CSS; hypertrophic scars and keloids) are very stressful and are generally itchy and painful for women. Treatment strategies vary. However, there is a lack of knowledge about the outcome of only surgical excision of CSS scars during caesarean section (CS). The issue being explored There are few data in the literature for CSS in the lower abdomen. These scars can be removed during the second or third CS, but the results are not known exactly. How was the work conducted? In our clinic, 145 patients with CSS were given a CS and their scars were removed at the same time. While most of these scars were reported as hypertrophic by pathological examination, some were reported as keloid. At the earliest, one year after surgery, the rate of recurrence was found to be 13%. What we learned from the study Asymptomatic patients who are planning another pregnancy and do not want to receive any other radiotherapy or steroid injection therapy can wait to remove their CSS at the next CS, especially elective CS with or without adjunct therapy. Emergency CS was found to be a risk factor for the recurrence of these scars.

Assessment of laser-assisted delivery vs intralesional injection of botulinum toxin A in treatment of hypertrophic scars and keloids

Keloids and hypertrophic scars could impair the psychological, physical, and cosmetic aspects of the patient's quality of life. Unfortunately, there is no curative treatment available till now. This study aimed to evaluate the efficacy and safety of intralesional vs topical botulinum toxin A combined with Fractional CO₂ laser in the treatment of hypertrophic scars and keloids. Twenty patients with Keloids and hypertrophic scars were enrolled in the study. Each scar was divided into two halves, one subjected to intralesional injection of botulinum toxin type A once a month for 4 months and the other was subjected to four sessions of CO₂ laser therapy at 1 month interval followed by topical application of botulinum toxin A. Significant improvement was noted in Vancouver Scar Scale in hypertrophic scars in laser group than intralesional botulinum toxin A. In keloid cases, the improvement was significantly higher with intralesional botulinum toxin A. Clinical improvement showed significant negative correlation with scar duration and size. Botulinum toxin A is a promising treatment for hypertrophic scars and keloids. The use of fractional CO₂ laser as a mode of delivery enhanced the efficacy of botox in hypertrophic scars.

Kefir Accelerates Burn Wound Healing Through Inducing Fibroblast Cell Migration In Vitro and Modulating the Expression of IL-1ß, TGF-ß1, and bFGF Genes In Vivo

Kefir is a natural probiotic compound with a long history of health benefits which can improve wound healing. This study investigated the regeneration potential of kefir in vitro scratch assay and in vivo burn wound in rat model. Cytotoxicity of different concentrations of kefir was evaluated by colorimetric methylthiazoltetrazolium assay. A scratch wound experiment was performed to investigate the ability of kefir in reducing the gap of wounds in a dose-dependent manner, in vitro. The standardized kefir was incorporated into silver sulfadiazine (SSD) and applied on burn wounds in vivo, and was compared with the SSD and negative control groups after 7, 14, and 28 days of treatment. The wound sites were then removed for histopathological and morphometric analyses, assessment of interleukin-1β (IL-1β), transforming growth factor-β1 (TGF-β1), basic fibroblast growth factor (bFGF), dry weight, and hydroxyproline contents. Kefir enhanced proliferation and migration of human dermal fibroblast (HDF) cells and 12.50, 6.25, and 3.12 μL/mL concentrations showed better effects on the scratch assay. Kefir resulted in reduction of IL-1β and TGF-β1 expression at day 7 compared to the negative control. Kefir also reduced the expression of IL-1β at days 14 and 28 and stimulated bFGF at day 28. It significantly improved the dry matter and hydroxyproline contents in the burn wounds. Kefir also resulted in enhanced angiogenesis and elevated migration and proliferation of fibroblasts and improved fibrous connective tissue formation in the wound area. The morphometric results indicated significant global contraction values in the kefir-treated wounds compared to other groups. Taken together, the findings suggest that kefir has considerable ability to accelerate healing of the burn wounds. Therefore, kefir may be a possible option to improve the outcomes of severe burns.

Histopathology and immunohistochemical analysis of 5-fluorouracil and triamcinolone treated keloids in double-blinded randomized controlled trial

Keloids are a major complication related to surgical wound healing and very challenging condition to treat. Many treatment options are available, but the efficacy of the treatment is poor in most of cases and some keloids do not respond to the treatment at all. We compared the efficacy of intralesional 5-fluorouracil (5-FU) and triamcinolone (TAC) injections in a double-blind randomized controlled trial (RCT). Forty-three patients with 50 keloid scars were treated with either intralesional TAC or 5-FU-injections over 6 months. We wanted to find out whether biological features (cell density, cell proliferation rate, vascular density, myofibroblast numbers, steroid hormone receptor expression) in keloids could be used to predict the response to therapy and define the biological changes that take place in patients receiving a response. As there was no statistically significant difference in the remission rate between TAC and 5-FU treatments, all patients were combined and analyzed as responders and nonresponders. Although responders have slightly more myofibroblasts than the nonresponders in their keloids in the pretreatment biopsy samples, we could not identify a single predictive factor that could identify those patients that respond to drug injections. The good clinical response to therapy is associated with the simultaneous reduction of myofibroblasts in the keloid. This study demonstrates that myofibroblasts are reduced in number in those keloids that were responsive to therapy, and that both 5-FU and TAC injections are useful for keloid treatment.

Strategies to prevent stricture after esophageal endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) has been widely applied as a less invasive and more effective method for treating early esophageal cancers such as squamous cell carcinoma and dysplasia of Barrett's esophagus. However, post-ESD esophageal stricture often occurs if patients suffer circumferential mucosal defects of more than three-quarters of the circumference of the esophagus, which makes it difficult for patients to swallow and greatly reduces their quality of life. Moreover, there is currently no standard method to treat post-ESD esophageal stricture, even though it is extraordinarily important to prevent its formation. In recent years, several strategies to prevent esophageal stricture have emerged. These strategies can be classified into pharmacological, mechanical, tissue engineering, and other novel strategies, with each strategy having its own strengths and weaknesses. Although the pharmacological prophylaxis and mechanical strategies are relatively mature, they still have their drawbacks like high time-consumption, the occurrence of re-stricture, and significant side effects. Tissue engineering strategies and other novel strategies have shown promising preliminary results, but more clinical trials are needed. In this review, we discuss these strategies, with a particular focus on tissue engineering strategies and other novel strategies. It is hoped that this discussion will aid in finding more effective and safer strategies to prevent esophageal stricture.

Extracorporeal shock wave therapy with low-energy flux density inhibits hypertrophic scar formation in an animal model

Hypertrophic scar is characterized by excessive deposits of collagen during skin wound healing, which could become a challenge to clinicians. This study assessed the effects of the extracorporeal shock wave therapy (ESWT) on hypertrophic scar formation and the underlying gene regu-lation. A rabbit ear hypertrophic scar model was generated and randomly divided into three groups: L-ESWT group to receive L-ESWT (energy flux density of 0.1 mJ/mm2), H-ESWT (energy flux density of 0.2 mJ/mm2) and sham ESWT group (S-ESWT). Hypertrophic scar tissues were then collected and stained with hematoxylin and eosin (H&E) and Masson's trichrome staining, respectively, to assess scar elevation index (SEI), fibroblast density and collagen fiber arrangement. Expression of cell proliferation marker proliferating cell nuclear antigen (PCNA) and α-smooth muscle actin (α-SMA) were assessed using RT-PCR and immunohistochemistry in hypertrophic scar tissues. H&E staining sections showed significant reduction of SEI and fibroblast density in both ESWT treatment groups compared to S-ESWT, but there was no dramatic difference between L-ESWT and H-ESWT groups. Masson's trichrome staining showed that collagen fibers were more slender and broader and oriented in parallel to skin surface after administration of ESWT compared to control tissues. At the gene level, PCNA‑positive fibroblasts and α-SMA-positive myofibroblasts were significantly decreased after L-ESWT or H-ESWT compared to the controls. Furthermore, there was no significant difference in expression of PCNA mRNA between L-ESWT or H-ESWT and S-ESWT, whereas expression of α-SMA mRNA significantly decreased in L-ESWT compared to that of H-ESWT and S-ESWT (P=0.002 and P=0.030, respectively). In conclusion, L-ESWT could be effective on suppression of hypertrophic scar formation by inhibition of scar elevation index and fibroblast density as well as α-SMA expression in hypertrophic scar tissues of the rabbit model.

A Comparison of Gene Expression of Decorin and MMP13 in Hypertrophic Scars Treated With Calcium Channel Blocker, Steroid, and Interferon: A Human-Scar-Carrying Animal Model Study

BACKGROUND

The formation of hypertrophic scaring (HSc) is an abnormal wound-healing response. In a previous study, an animal model with human scar tissue implanted into nude mice (BALB/c) has been successfully established. The effects of verapamil as well as combination therapy with verapamil and kenacort have been studied and compared.

OBJECTIVE

To treat persistent hypertrophic scars, local injection of drugs composed of steroids, calcium channel blockers (CCBs), and interferon might be a good method. What is the best dose of the regimen and what are the mechanisms are also a worthwhile study.

MATERIALS AND METHODS

Scar specimens were harvested from patients with HSc or Keloid resulting from burn injury, and then implanted to BALB/c-nu nude mice for 4 weeks. Before implantation, the specimen was either injected with or without drugs such as steroids (kenacort), CCBs (verapamil), and interferons (INFα2b), respectively. After the removal of implants, quantitative gene expressions of decorin and collagenase (MMP13) were measured using a real-time polymerase chain reaction to detect their mRNAs. Two way-ANOVA and Post Hoc were used for statistical analysis using the software SPSS 15.0.

RESULTS

All drug-treated groups increased the expressions of decorin and MMP13 in comparison with those in noninjected group (p < .001) in a dose-dependent manner. Comparing equal amounts of individual drugs, gene expression of decorin was increased with increasing injection amount, and the best result in low amount of injection (0.02 mL of each) was shown in the group injected with INFα2b followed by kenacort and verapamil. However, the results were changed while injection amount was up to 0.04 mL and the strongest decorin gene expression was found in kenacort injection. Regarding MMP-13 expression, low-amount injection (0.02 mL) of INFα2b has strongest gene expression followed by kenacort and verapamil, but in the large-amount regimes (0.04 mL), verapamil had strongest gene expression followed by INFα2b and kenacort.

CONCLUSION

This study showed that the kenacort, verapamil, and INFα2b all inhibited HSc in a dose-dependent manner through the evidence of gene expression of decorin and MMP13. In comparison with the injections between small amounts of drugs, INFα2b potentiated the strongest decorin and MMP13 expression. On the contrary, among the large-amount injection regimes, kenacrot was more effective on decorin expression as verapamil to MMP13 expression. To decrease side effects from the drugs and produce promising results for the clinical practice, it is suggested to maintain the dose of INFα2b along with an increased dose of verapamil for HSc improvement.

Dermatologic conditions in patients of color who are pregnant

Certain dermatoses that present during pregnancy have a predilection for populations with skin of color (SOC). Additionally, certain systemic diseases such as systemic lupus erythematosus tend to be more aggressive during pregnancy and confer worse prognoses in women with SOC. The purpose of this review is to highlight the unique implications of selected diseases during pregnancy as it relates to SOC. Dermatologists should be vigilant for the unique clinical variations of dermatological conditions in patients of color who are pregnant to ensure correct diagnoses and optimize treatment outcomes.

The therapy with ethosomes containing 5-fluorouracil for laryngotracheal stenosis in rabbit models

The aim of this study is to evaluate the efficacy of ethosomes encapsulated with 5-fluorouracil (5-FU) in treatment of laryngotracheal stenosis in rabbit models. The 5-FU ethosome was prepared by the thin film hydration method, and the amorphous, size distribution and the encapsulation efficiency was investigated. The tracheal mucosa were scraped about 0.5 cm with a nylon brush to induce the scar in airway grow, then models were divided into three groups: 5-FU ethosome group, 5-FU group and saline group, drug were injected into scar of every group by paracentesis guided under endoscope, respectively. The stenosis states were observed under laryngo fiberscope immediate, 7, 14 and 21 days after administrated. Airway stenosis of 5-FU ethosome group has no significant difference when compared with 5-FU group at 7 days after administration, but 5-FU ethosome significantly reduced the airway stenosis after 21-day administration when compared with 5-FU group again and has no restenosis during the period under observation. The fact that ethosomes encapsulated with 5-FU were effective for laryngotracheal stenosis suggests that it has potential as a new method for ameliorating airway stenosis originating from granulation tissue.

Enhanced in vivo delivery of 5-fluorouracil by ethosomal gels in rabbit ear hypertrophic scar model

Applying Ethosomal Gels (EGs) in transdermal drug delivery systems has evoked considerable interest because of their good water-solubility and biocompatibility. However, there has not been an explicit description of applying EGs as a vehicle for hypertrophic scars treatment. Here, a novel transdermal EGs loaded with 5-fluorouracil (5-FU EGs) was successfully prepared and characterized. The stability assay in vitro revealed that 5-FU EGs stored for a period of 30 days at 4 ± 1 °C had a better size stability than that at 25 ± 1 °C. Furthermore, using confocal laser scanning microscopy, EGs labeled with Rhodamine 6 G penetrated into the deep dermis of the hypertrophic scar within 24 h in the rabbit ear hypertrophic model suggested that the EGs were an optional delivery carrier through scar tissues. In addition, the value of the Scar Elevation Index (SEI) of 5-FU EGs group in the rabbit ear scar model was lower than that of 5-FU Phosphate Buffered Saline gel and Control groups. To conclude, these results suggest that EGs delivery system loaded 5-fluorouracil is a perfect candidate drug for hypertrophic scars therapy in future.

Update on hypertrophic scar treatment

Scar formation is a consequence of the wound healing process that occurs when body tissues are damaged by a physical injury. Hypertrophic scars and keloids are pathological scars resulting from abnormal responses to trauma and can be itchy and painful, causing serious functional and cosmetic disability. The current review will focus on the definition of hypertrophic scars, distinguishing them from keloids and on the various methods for treating hypertrophic scarring that have been described in the literature, including treatments with clearly proven efficiency and therapies with doubtful benefits. Numerous methods have been described for the treatment of abnormal scars, but to date, the optimal treatment method has not been established. This review will explore the differences between different types of nonsurgical management of hypertrophic scars, focusing on the indications, uses, mechanisms of action, associations and efficacies of the following therapies: silicone, pressure garments, onion extract, intralesional corticoid injections and bleomycin.

Follicular and scarring disorders in skin of color: presentation and management

Skin of color, also known as ethnic skin, is described as skin of individuals of African, Asian, Hispanic, Native-American, Middle Eastern, and Pacific Island backgrounds. Differences in hair morphology, hair grooming, cultural practices, and susceptibility to keloid scarring exist within these populations and have been implicated in hair, scalp, and skin disorders. Acne keloidalis (AK), central centrifugal cicatricial alopecia (CCCA), dissecting cellulitis of the scalp (DCS), pseudofolliculitis barbae (PFB), traction alopecia (TA), and keloids are the most prevalent follicular and scarring disorders in skin of color. They have been associated with disfigurement, permanent hair loss, emotional distress, and decreased quality of life. Hair grooming practices, such as the use of chemical relaxers, heat straightening, and tight braiding and weaving can cause scalp irritation and follicular damage and are linked to the pathogenesis of some of these conditions. Consequently, patient education and behavior modifications are integral to the prevention and management of these disorders. Scarring disorders are also of concern in ethnic populations. Keloid scarring is more prevalent in individuals of African, Asian, and Hispanic descent. The scarring alopecia CCCA is almost exclusively seen in patients of African descent. Therapeutic regimens such as intralesional corticosteroids, surgical excision, and laser therapy can be effective for these follicular and scarring disorders, but carry a risk of dyspigmentation and keloid scarring. Ethnic skin and hair may present unique challenges to the clinician, and knowledge of these differences is essential to providing quality care.

Ablative laser assisted topical delivery of antifibrotics in the management of cicatricial ectropion

A variety of surgical techniques have traditionally been used to manage cicatricial ectropion. These techniques primarily aim at vertical lengthening of the anterior lamella and include a variety of skin flaps and grafts. Alternative techniques such as dermal filler injection to support the eyelid margin may also be used in the management of select patients with cicatricial ectropion. The application of different types of laser for scar revision throughout the body has rapidly evolved; similar mechanisms, principles and treatment rationale can be applied to the use of lasers in the management of cicatricial ectropion. Additionally, ablative lasers, such as Carbon Dioxide and Erbium:yttrium-aluminum-garnet lasers, may be used in the transdermal delivery of antifibrotic agents, such as interferon gamma, interferon alpha, vitamin D, triamcinolone and 5-fluorouracil, resulting in efficient target tissue penetration, limitation of systemic drug toxicity and decreased degradation. Although the combination of ablative fractional resurfacing and topical antifibrotic agents is a new treatment modality, there is a great potential for its efficient utility in the management of periocular scarring and cicatricial ectropion. The introduction of these innovative therapeutic modalities offers ophthalmologists a greater range of possible effective treatments to address periocular scar tissue and the resultant cicatricial ectropion.

Preliminary results of antiscarring therapy in the prevention of postendoscopic esophageal mucosectomy strictures

BACKGROUND

Esophageal endoscopic submucosal dissection (ESD) is an effective minimally invasive therapy for early esophageal cancer and high-grade Barrett dysplasia. However, esophageal stricture formation after circumferential or large ESD has limited its wide adoption. Mitomycin C (MMC), halofuginone (Hal), and transforming growth factor β3 (TGF-β3) exhibits antiscarring effects that may prevent post-ESD stricture formation.

METHODS

Using endoscopic mucosectomy (EEM) technique, an 8- to 10-cm-long circumferential esophageal mucosal segment was excised in a porcine model. The site was either untreated (control, n = 6) or received 40 evenly distributed injections of antiscarring agent immediately and at weeks 1 and 2. High and low doses were used: MMC 5 mg (n = 2), 0.5 mg (n = 2); Hal 5 mg (n = 2), 1.5 mg (n = 2), 0.5 mg (n = 2); TGF-β3 2 μg (n = 2), 0.5 μg (n = 2). The degree of stricture formation was determined by the percentage reduction of the esophageal lumen on weekly fluoroscopic examination. Animals were euthanized when strictures exceeded 80 % or the animals were unable to maintain weight.

RESULTS

The control group had a luminal diameter reduction of 78.2 ± 10.9 % by 2 weeks and were euthanized by week 3. Compared at 2 weeks, the Hal group showed a decrease in mean stricture formation (68.4 % low dose, 57.7 % high dose), while both TGF-β3 dosage groups showed no significant change (65.3 % low dose, 76.2 % high dose). MMC was most effective in stricture prevention (53.6 % low dose, 35 % high dose). Of concern, the esophageal wall treated with high-dose MMC appeared to be necrotic and eventually led to perforation. In contrast, low dose MMC, TGF-β3 and Hal treated areas appeared re-epithelialized and healthy.

CONCLUSIONS

Preliminary data on MMC and Hal demonstrated promise in reducing esophageal stricture formation after EEM. More animal data are needed to perform adequate statistical analysis in order to determine overall efficacy of antiscarring therapy.

Use of Mitomycin C for Refractory Esophageal Stricture following Tracheoesophageal Fistula Repair

Esophageal stricture is a well-described complication following tracheoesophageal fistula repair. Herein, we report two patients who had persistent esophageal strictures after several months of repeat balloon dilatations. Each patient was treated with a single application of topical mitomycin C in addition to esophageal dilatation, which resulted in complete resolution of the stricture.

Adjuvant chemotherapy reduces the incidence of abdominal hypertrophic scarring following immediate TRAM breast reconstruction

Among the many factors that affect the degree of completion and satisfaction of breast reconstruction, the scarring is one issue that a surgeon cannot completely control. We hypothesized that the administration of cytotoxic drugs following the immediate breast reconstruction using transverse rectus abdominis musculocutaneous (TRAM) flap might affect the process of scarring, thus resulting in reduced incidence of hypertrophic scarring at the donor site. Data have been collected from 1,000 consecutive patients between July 2001 and December 2009. The relationship between the adjuvant chemotherapy and the incidence of hypertrophic scarring was studied, and the influence of other presumed risk factors was analyzed. The incidence of hypertrophic scarring was 18.6 % (75 of 404) in the non-CTX group and 3.8 % (20 of 530) in the CTX group. Univariate analysis using logistic regression modeling confirmed the statistical significance of the reducing effect of chemotherapy on the incidence of hypertrophic scarring (p < 0.001; OR: 0.172). The incidence of donor-site hypertrophic scarring following immediate TRAM breast reconstruction was found in nearly 20 % of the patients without chemotherapy, showing a significant difference from the patients with chemotherapy. We believe that Asian patients who undergo immediate TRAM breast reconstruction without chemotherapy are a high-risk group that is prone to hypertrophic scarring, requiring active preventive measures.

Update on Keloid Management: Clinical and Basic Science Advances

BACKGROUND

Keloids are benign, fibroproliferative lesions that represent abnormal healing resulting in excessive fibrosis. They are composed of mainly type III (early) or type I (late) collagen. Some of the symptoms include pruritus, tenderness, and pain. Often, they are very difficult to treat and prevent from recurrence. In contrast to hypertrophic scars, keloids extend beyond the margin of the wound.

THE PROBLEM

There is very limited evidence on the best wound management for minimizing scarring. Multiple available therapeutic modalities have been used for the treatment of keloids; however, high-recurrence rates continue to be reported. Unsuccessful treatment of keloids leads to psychological impact on the patients and increased economic burden.

BASIC/CLINICAL SCIENCE ADVANCES

Currently, there are biological and antineoplastic agents that can potentially treat and prevent excessive scar formation. Some of them have been used as "off label" therapies, and others are still in the experimental phase such as interferon alpha (IFN-α), imiquimod, and transforming growth factor beta1 (TGF-β1). The use of IFN-α2b showed 18% recurrence rate when applied to postsurgical excised keloids. Imiquimod 5% can lower recurrence rate on postshaved keloids to 37.5% at 6-month and to 0% at a 12-month follow-up period. TGF-β1 oligonucleotides have shown effective and long-lasting inhibition of TGF-β-mediated scarring in vitro as well as in animal models. Daily injections of neutralizing antibodies against TGF-β1 and -β2 have shown successful reductions in scarring.

CONCLUSION

Latest discoveries in the use of novel agents suggest therapeutic alternatives for the prevention of recurrences of hypertrophic scars and postexcision keloid lesions.

Can single use negative pressure wound therapy be an alternative method to manage keloid scarring? A preliminary report of a clinical and ultrasound/colour-power-doppler study

Keloid scarring represents a pathological healing where primary healing phenomenon is deviated from normal. Pico is a single use negative pressure wound therapy system originally introduced to manage open or just closed wounds. Pico dressing is made of silicone, and distributes an 80 mmHg negative pressure across wound bed. Combination of silicon layer and continuous compression could be a valid method to manage keloid scarring. Since November 2011, three patients were enrolled and evaluated before negative pressure treatment, at end of treatment (1 month) and 2 months later, through Vancouver Scar Scale (VSS), Visual Analog Scale (VAS) and a scoring system for itching. Ultrasound (US) and colour-power-doppler (CPD) examination was performed to evaluate thickness and vascularisation of the scar. One patient was discharged from study after 1 week. In last two patients, VSS, VAS and itching significantly improved after 1 month therapy and the results were stable after 2 months without any therapy. At end of therapy, the 'appearance of palisade vessels' disappeared in both cases at CPD exam; US showed a thickness reduction (average 43·8%). We propose a well-tolerated, non invasive treatment to manage keloid scarring. Prospective studies are necessary to investigate whether these preliminary observations are confirmed.

Keloids: prevention and management

Keloids result from an abnormal wound-healing process in which the normal regulatory pathways during tissue regeneration and scar remodeling are disrupted. While the pathogenesis of keloids continues to be investigated, numerous treatment options exist. Although prevention of keloid formation is the best management, early recognition of keloid formation is integral in treatment and prevention of recurrence. Surgical resection with adjuvant silicone gel sheeting or triamcinolone injection is common, but can still result in recurrence. New treatments include chemotherapeutics such as 5-fluorouracil, bleomycin, and mitomycin C. Although further clinical investigation is required for newer treatments, initial results are promising.

In vitro study of ethosome penetration in human skin and hypertrophic scar tissue

The purpose of this study is to characterize a novel transdermal delivery carrier, ethosomes containing 5-fluorouracil. The delivery of drugs from ethosomes in human hypertrophic scar (HS) and the mechanisms of action of ethosomes in human HS were investigated. Percutaneous ethosome permeation was evaluated in vitro in human HS and skin using a Franz's cell. The amount of 5-fluorouracil that permeated HS and skin after 24 hours was most abundant in ethosomes via HS (E-Scar), followed by hydroethanolic solution via HS (H-Scar), ethosomes via skin (E-Skin), and hydroethanolic solution via skin (H-Skin). The penetration of ethosomes in HS and skin was analyzed by ethosomes fluorescently labeled with rhodamine 6GO using confocal laser scanning microscopy. The fluorescence intensity after application for 24 hours was highest in E-Scar, followed by E-Skin, H-Scar, and H-Skin, which indicates the penetration of ethosomes in HS was greatest. In conclusion, we consider that ethosomes are a highly efficient carrier in HS.