Hypertrophic scars and keloids: Overview of the evidence and practical guide for differentiating between these abnormal scars

Breaking the scar barrier: The anti-fibrotic and hemodynamic benefits of total salvianolic acid in hypertrophic scars

Hypertrophic scars (HS) affect up to 70 % of individuals following deep dermal injuries, burns, or surgical procedures, leading to significant functional impairments and psychological distress. Despite their high prevalence, effective therapeutic options remain limited, and the underlying pathophysiology is not fully elucidated. This study integrates network pharmacology, molecular docking, and in vivo experimentation to investigate the therapeutic potential of total salvianolic acid (TSA) from Salvia miltiorrhiza in HS treatment. A systematic pharmacology approach identified 186 target proteins, highlighting TGF-β1, Smad3, IL-2, and IL-4 as key modulators of fibrosis and inflammation. Molecular docking confirmed high-affinity interactions between TSA's active components and these targets. TSA significantly reduced scar elevation, fibrosis, and collagen deposition in a rabbit ear hypertrophic scar model, restoring tissue architecture and improving hemorheological parameters. Histological and immunohistochemical analyses confirmed TSA's ability to suppress TGF-β/Smad signaling, downregulate inflammatory cytokines and normalize collagen dynamics. These findings provide compelling evidence that TSA is a multi-targeted, pharmacologically active compound with promising anti-fibrotic and microcirculatory benefits, paving the way for novel therapeutic strategies in HS management. This study establishes a scientific foundation for TSA-based interventions, with potential clinical implications in regenerative medicine and scar therapy.

Integration of finite element simulations with 3D printing technology for personalized Chitin/PLA microneedle-based drug delivery systems in thoracic keloid treatment

The high prevalence of keloids in the thoracic (48.9 %) is closely associated with its unique anatomical morphology and mechanical environment. The irregular shape of keloids in this area significantly complicates treatment, particularly regarding drug delivery. Microneedle arrays (MNAs) have demonstrated remarkable advantages in the scar treatment due to their ability to deliver drugs evenly. However, existing MNAs often lack personalized design and present challenges during the treatment, such as unable to conform to the distinctive shapes of thoracic keloids, leading to uneven drug penetration. Consequently, we propose a preparation strategy for MNAs designed to meet the personalized treatment needs of thoracic keloids. In this study, personalized MNAs were constructed using 3D printing technology, incorporating chitin into polylactic acid (PLA) to enhance printing accuracy and drug-loading capacity. By integrating compressive properties of keloids with finite element analysis (FEA), we simulated the puncturing of keloids with a composite MNAs. The results indicated that the 0.2Chitin/PLA improves the accuracy and mechanical properties of the 3D-printed MNAs, and the drug-loading performance was improved by 6 times. Furthermore, FEA results revealed that Chitin/PLA MNAs can withstand the reaction forces encountered during the puncture process, thus achieving effective puncture depth. FEA combined with 3D printing and drug loading technology can effectively address the personalized needs and drug delivery in the treatment of thoracic keloids. This strategy not only improves the accuracy and effectiveness of the treatment, but also provides new research directions and technical support for the personalized treatment of keloids.

Keloids revisited: Current concepts in treatment and differential diagnosis

Keloid is a special type of scar considered prototypic of skin fibrosis. Unlike hypertrophic scars, keloids exceed the margins of the original wound, and exist over time without a quiescent or regressive phase. Although keloids do not metastasize, they exhibit tumor-like characteristics, and share many similarities. Large epidemiological study demonstrates that patients with keloids have a 1.49-fold higher risk for cancers. Keloids can lead to severe functional impairments and diminish quality of life which increases hidden costs for patients and medical systems. The main goals of treatments are to improve scar appearance, symptoms and patient's quality of life (QoL). However, the microenvironment, pathogenesis, formation and development of the keloid are complex, the efficacy of multiple treatments were limited. Therefore, this up-to-date review aimed to target the current concepts in keloid treatment and differential diagnosis. The goal is to provide a reference for doctors and researchers to improve the accuracy of diagnosis and facilitate the selection of personalized treatment methods for patients with keloids.

Clinical observation of super tension-relieving suture for wound repair following resection of benign skin tumors in pediatric patients

OBJECTIVE

To examine the clinical effectiveness of super tension-relieving sutures in surgical wound repair among pediatric patients after surgery.

METHODS

The study included 100 patients with skin tumors who underwent surgical resection in the Hunan Children's Hospital outpatient department between January 2021 and December 2022. The experimental group (n ​= ​55) received super tension-relieving sutures, while the control group (n ​= ​45) received traditional tension-relieving sutures. The wound healing status, decompression duration, scar status, and effectiveness rates between the two groups were compared after 6 months of treatment.

RESULTS

The experimental group exhibited higher wound eversion height, wound healing grade, the Vancouver Scar Scale scores, and wound satisfaction (p ​< ​0.05) compared to the control group, while no significant difference was observed in wound infection and subcutaneous hematoma between the two groups (p ​> ​0.05).

CONCLUSIONS

Using super tension-relieving sutures effectively reduces wound tension, minimizes scar formation, and improves postoperative aesthetics with patient satisfaction in pediatric dermatological surgery.

A First-In-Human Phase 1 Study to Evaluate the Safety and Tolerability of LEM-S401, a Novel siRNA-DegradaBALL Drug Targeting CTGF in Healthy Adults

This study evaluated the safety, tolerability, and pharmacokinetics of LEM-S401, a novel siRNA therapeutic with DegradaBALL, a mesoporous silica nanoparticle-based delivery system. LEM-S401 is designed to deliver siRNA targeting connective tissue growth factor (CTGF) to fibroblasts for treating hypertrophic scars and keloids, both of which result from abnormal collagen proliferation. LEM-S401, containing unmodified siRNA LEM-17234 encapsulated in DegradaBALL nanoparticles, was administered subcutaneously to healthy adults in a randomized, double-blind, placebo-controlled, single-ascending dose study. Safety and tolerability assessments included vital signs, adverse events (AEs), laboratory tests, and cytokine levels. Pharmacokinetic analysis of LEM-17234 and silicon (Si), the primary component of DegradaBALL, was performed using blood samples collected at specified time points. LEM-S401 demonstrated a favorable safety and tolerability profile with only mild, self-resolving injection site reactions including pain and erythema. No systemic AEs were observed, and cytokine levels showed no significant changes between the treatment and placebo groups. Pharmacokinetic analysis revealed that LEM-17234 was below the plasma detection limit, indicating no notable systemic exposure of siRNA, while Si showed no dose-dependent systemic exposure, suggesting minimal systemic circulation of the mesoporous silica nanoparticles. These findings suggest DegradaBALL effectively encapsulates and delivers siRNA locally without significant systemic exposure. The novel DegradaBALL delivery system enables the stable and targeted delivery of siRNA, which presumably overcomes challenges related to siRNA instability and off-target effects. LEM-S401 has the potential to advance the treatment of fibrotic skin diseases such as keloids and hypertrophic scars by delivering siRNA directly to fibroblasts, thereby inhibiting excessive collagen production. Trial Registration: ClinicalTrials.gov identifier: NCT04707131. https://clinicaltrials.gov/study/NCT04707131?cond=NCT04707131&rank=1.

Keloid management: a review of treatment modalities

Keloids are an aberrant fibroproliferative response to wound healing of the skin, leading to scar tissue that expands above and beyond the original cutaneous injury. Keloids can be difficult to treat because of their tendency to recur after treatments, including after excision. There is a myriad of treatment modalities used, which can be used as monotherapy or in combination with surgical excision or other treatment methods. This review covers many treatment approaches including surgical excision, compression, silicone sheets, steroid-impregnated tape, imiquimod, intralesional injections, cryotherapy, laser, radiation, pentoxifylline, and dupilumab.

Are symptoms in pathologic scars related to nerve function or density? A scoping review

BACKGROUND

Hypertrophic scars and keloids are forms of pathologic scarring that can give rise to pain and pruritus. The link between nerve function and nerve density and the symptoms in pathologic scars (PS) remains unclear.

OBJECTIVE

We aim to assess current knowledge on nerve function and nerve density in PS, and to explore a possible association between alterations in sensibility/nerve density and pathologic scar symptoms.

METHODS

A scoping review was conducted. After performing a systematic search using PubMed, Embase and Web-of-Science, relevant papers were selected and analyzed by 2 reviewers. Data was charted in tables in combination with a narrative summary of main findings.

RESULTS

Nineteen studies were included. Overall, functional sensibility in PS seems disturbed, with a higher frequency of allodynia and altered thermosensory thresholds, suggesting involvement of small fiber neuropathy. Nerve fiber density varied with the investigated skin layer and the used staining techniques, which implied limitations to compare findings from different studies. However, evidence suggests involvement of neuropeptides in the pathologic scar formation and symptomatology.

CONCLUSIONS

Wide heterogeneity between studies exists. Therefore, no firm conclusions can be formulated. However, evidence suggests involvement of the cutaneous nervous system by neurogenic inflammation in the pathophysiology of pathologic scars and their symptoms.

Evaluation of the efficacy, safety, and satisfaction rate of topical latanoprost in patients with hypopigmented burn scars treated with fractional CO2 laser: a double-blind randomized controlled clinical trial

Burn scars present psychological and social challenges for patients, classified into atrophic and hypertrophic types. Treatments like corticosteroid injections, laser therapy, and platelet-rich plasma (PRP) injections are commonly recommended for hypertrophic scars, while regenerative medicine and fractional CO2 lasers are linked to some degree of improvement for atrophic scars. Hypopigmented and depigmented burn scars pose ongoing challenges for healthcare providers and patients, with therapies such as intense pulsed light and fractional CO2 laser showing variable effects in treating these conditions. This study evaluates the effectiveness of latanoprost, a prostaglandin analog, in combination with fractional CO2 laser for repigmentation of hypopigmented burn scar lesions. During the study, patients were treated with 0.005% latanoprost eye drop or normal saline twice a day for 6 months and underwent six monthly fractional CO2 laser sessions. Treatment instructions were provided by the physician, and patients were instructed to report any complications and avoid using other medications in the treatment area. Assessments included photography at the start of the study and in three follow-up sessions at three-month intervals. Improvement was assessed using the Subject Global Aesthetic Improvement Scale (SGAIS) by both the physician and patients. Patient satisfaction was evaluated using a Grade scale, and side effects were monitored in all follow-up sessions. In the third follow-up session, physicians assessing the Subject Global Aesthetic Improvement Scale (SGAIS) observed that a higher proportion (85.7%) of cases in the fractional CO2 laser with latanoprost group achieved a grade of 4 (50-74% improvement). In the placebo group, 0% of patients achieved grade 4, and 71.4% were classified as grade 2 (0-24% improvement), indicating a significant difference (P-value: 0.0001). Patient satisfaction, measured by the "Grade scale to evaluate patient satisfaction" index, revealed a notable contrast between the two groups, with average satisfaction scores of 8.50 ± 0.65 and 4.64 ± 1.00 for the fractional CO2 laser with latanoprost and placebo groups, respectively, indicating a statistically significant difference (P = 0.0001). Furthermore, throughout the study, no severe side effects were reported by any of the patients. Prostaglandin analogs, particularly latanoprost, have proven to be effective in promoting repigmentation of hypopigmented and depigmented burn scar lesions. When this topical medication is combined with fractional CO2 laser treatment, it enhances the laser's efficacy and overall effectiveness in treating the lesions. This combination is crucial for improving hypopigmented scar treatment by enhancing both the laser's effectiveness in scar improvement and the delivery of latanoprost through the laser. WHAT IS ALREADY KNOWN ABOUT THIS TOPIC? : Hypopigmented burn scars are one of the manifestations of burns that are resistant to treatment. These scars not only cause discomfort for patients but also present a treatment challenge for physicians. In previous studies, latanoprost and bimatoprost, analogs of prostaglandin PGF2a, showed effectiveness in repigmenting vitiligo lesions. However, no study has examined the role of these topical drugs in treating hypopigmented and depigmented burn scars. WHAT DOES THIS STUDY ADD? : The fractional CO2 laser caused significant repigmentation in hypopigmented lesions of burn scars. 64.3% of the patients who received this intervention showed grade 2 improvement (0-24% improvement), 7.1% showed grade 3 improvement (25-49% improvement), and 28.6% showed no improvement (grade 1) in the third follow-up session based on the SGAIS criteria as evaluated by the patients. The combination of CO2 fractional laser and latanoprost caused significant repigmentation in hypopigmented burn scar lesions. 85.7% of patients showed grade 4 improvement (50-74% improvement), and 14.3% showed grade 3 improvement (25-49% improvement) and 0% showed no improvement (grade 1) in the third follow-up session based on the SGAIS criteria as evaluated by the patients. The combination of CO2 fractional laser and latanoprost was significantly more effective than CO2 fractional laser alone based on the SGAIS criteria, as evaluated by physicians and patients in all three follow-up sessions. Additionally, the satisfaction of the patients in the combined treatment group was significantly higher than that of the CO2 fractional laser treatment group.

The Causal Role of Uterine Fibroid in Keloid and Hypertrophic Scar: A Bidirectional Mendelian Randomization Study on European Populations

BACKGROUND

The relationship between uterine fibroids and keloid/hypertrophic scars has been contradictory. Our research employs a bidirectional Mendelian Randomization (MR) approach to establish a clearer understanding of this potential causal link.

OBJECTIVE

This study aimed to determine the effect of uterine fibroids on keloid/hypertrophic scars and the effect of keloid/hypertrophic scars on uterine fibroids.

PURPOSE

We aimed to demonstrate the relationship between uterine fibroids and keloid/ hypertrophic scars.

METHODS

Our bidirectional MR study utilized summarized data from genome-wide association studies (GWAS) focused on European populations. Our primary tool for establishing causality was the Inverse-Variance Weighted (IVW) method. To reinforce the IVW findings, we also applied four alternative MR methods: MR-Egger, Maximum Likelihood, Weighted Mode, and Weighted Median.

RESULTS

The IVW method indicated a significant causal link, with uterine fibroids greatly raising the likelihood of developing keloids (Odds Ratio [OR] = 1.202, 95% Confidence Interval [CI]: 1.045-1.381; P=0.010) and hypertrophic scars (OR = 1.256, 95% CI: 1.039-1.519; P=0.018). Parallel results were observed with the MR-Egger, Maximum Likelihood, Weighted Mode, and Weighted Median methods. Sensitivity analyses indicated robustness in these findings, with no evidence of heterogeneity or horizontal pleiotropy. Conversely, the reverse MR analysis did not demonstrate an increased risk of uterine fibroids due to keloids or hypertrophic scars.

CONCLUSION

This study elucidates a significant causal effect of uterine fibroids on the development of keloid and hypertrophic scars, offering valuable insights into their pathogenesis and potential therapeutic targets.

Randomized, controlled, within-patient, single-blinded pilot study to evaluate the efficacy of 12-weeks of endermotherapy with adult burn survivors

BACKGROUND

Vacuum massage, or endermotherapy, is applied to scar tissue with the primary therapeutic goal of promoting structural or physiological changes. These changes are intended to enhance pliability, enabling the skin to possess the strength and elasticity required for normal mobility. The advantage of vacuum massage compared to therapist-generated manual massage is that it provides a standardized dosage using rollers and suction valves to mobilize the tissue. However, research documenting and supporting its impact on post-burn hypertrophic scar is lacking. Thus, this study was designed to objectively characterize the changes in scar elasticity, erythema, melanin, thickness, and transepidermal water loss immediately after a vacuum massage session and after a 12-week course of treatment compared to intra-individual matched control scars.

METHODS

We conducted a prospective, randomized, controlled, within-patient, single-blinded clinical trial, initially designed as a fully-powered study but limited to a pilot study due to COVID-19 restrictions. Nineteen burn survivors consented to participate and 16 completed the study. Two homogeneous, intra-individual scars were randomized to usual care control or vacuum massage therapy plus usual care. Vacuum massage interventions were provided by a certified massage therapist three times per week for 12 weeks. Scar characteristics were evaluated every four weeks immediately before and after mechanical massage treatment. The evaluations included measurements of elasticity (Cutometer), erythema and melanin (Mexameter), transepidermal water loss (TEWL) (Tewameter), and thickness (high-frequency ultrasound). Linear mixed-model analyses were performed to test for immediate and long-term treatment effects.

RESULTS

The ANOVA analyses revealed a non-significant time:treatment interaction for elasticity, erythema, melanin, thickness, or TEWL. There was a significant increase in elasticity and erythema and a decrease in TEWL in both the control and treatment sites over time with consistent standard care. However, there was no statistically significant immediate or long-term treatment effect for any of the skin characteristics. Nonetheless, the mean participant satisfaction was 4/5 (SD = 1.5) and the mean participant perception of effectiveness was 8/10 (SD = 1.9).

CONCLUSIONS

This pilot study did not find a treatment benefit of vacuum massage therapy for elasticity, erythema, melanin, thickness or TEWL, but it did find an improvement with time in elasticity, erythema and TEWL. Despite the lack of objective improvement of the treated scar site, participants were satisfied with the results and believed vacuum massage was very effective. Further high-quality research is required to better inform clinicians patient education and treatment decisions for this costly, burdensome treatment approach that has high participant satisfaction.

Macrophage Polarization: A Novel Target and Strategy for Pathological Scarring

BACKGROUND

Abnormal scarring imposes considerable challenges and burdens on the lives of patients and healthcare system. Macrophages at the wound site are found to be of great concern to overall wound healing. There have been many studies indicating an inextricably link between dysfunctional macrophages and fibrotic scars. Macrophages are not only related to pathogen destruction and phagocytosis of apoptotic cells, but also involved in angiogenesis, keratinization and collagen deposition. These abundant cell functions are attributed to specific heterogeneity and plasticity of macrophages, which also add an extra layer of complexity to correlational researches.

METHODS

This article summarizes current understanding of macrophage polarization in scar formation and several prevention and treatment strategies on pathological scarring related to regulation of macrophage behaviors by utilizing databases such as PubMed, Google Scholar and so on.

RESULTS

There are many studies proving that macrophages participate in the course of wound healing by converting their predominant phenotype. The potential of macrophages in managing hypertrophic scars and keloid lesions have been underscored.

CONCLUSION

Macrophage polarization offers new prevention strategies for pathological scarring. Learning about and targeting at macrophages may be helpful in achieving optimum wound healing.

[Effect of different degrees of wound eversion sutures on scar formation at donor site of anterolateral thigh flaps: A prospective randomized controlled study]

Objective

To investigate the effect of different degrees of wound eversion on scar formation at the donor site of anterolateral thigh flaps by a prospective clinical randomized controlled study.

Methods

According to the degree of wound eversion, the clinical trial was designed with groups of non-eversion (group A), eversion of 0.5 cm (group B), and eversion of 1.0 cm (group C). Patients who underwent anterolateral femoral flap transplantation between September 2021 and March 2023 were collected as study subjects, and a total of 36 patients were included according to the selection criteria. After resected the anterolateral thigh flaps during operation, the wound at donor site of each patient was divided into two equal incisions, and the random number table method was used to group them ( n=24) and perform corresponding treatments. Thirty of these patients completed follow-up and were included in the final study (group A n=18, group B n=23, and group C n=29). There were 26 males and 4 females with a median age of 53 years (range, 35-62 years). The body mass index was 17.88-29.18 kg/m 2 (mean, 23.09 kg/m 2). There was no significant difference in the age and body mass index between groups ( P>0.05). The incision healing and scar quality of three groups were compared, as well as the Patient and Observer Scar Assessment Scale (POSAS) score [including the observer component of the POSAS (OSAS) and the patient component of the POSAS (PSAS)], Vancouver Scar Scale (VSS) score, scar width, and patient satisfaction score [visual analogue scale (VAS) score].

Results

In group C, 1 case had poor healing of the incision after operation, which healed after debridement and dressing change; 1 case had incision necrosis at 3 months after operation, which healed by second intention after active dressing change and suturing again. The other incisions in all groups healed by first intention. At 6 months after operation, the PSAS, OSAS, and patient satisfaction scores were the lowest in group B, followed by group A, and the highest in group C. The differences between the groups were significant ( P<0.05). There was no significant difference between the groups in the VSS scores and scar widths ( P>0.05).

Conclusion

Moderate everted closure may reduce the formation of hypertrophic scars at the incision site of the anterior lateral thigh flap to a certain extent.

Efficacy and safety of sequential treatment with botulinum toxin type A, fractional CO2 laser, and topical growth factor for hypertrophic scar management: a retrospective analysis

Hypertrophic scars arise from aberrant wound healing and can lead to functional and aesthetic impairments. One of the common interventions for treating hypertrophic scars is fractional carbon dioxide (CO2) laser, which employs narrow laser beams to stimulate dermal collagen deposition. Recent studies and reports have suggested that combining laser therapy with other interventions such as botulinum toxin type A (BTX-A) and topical growth factors may enhance treatment outcomes. Here, we examine the efficacy and safety of a sequential combination of BTX-A, fractional CO2 laser, and topical growth factors, referred to as combined therapy, for treating hypertrophic scars compared with only using fractional CO2 laser and topical growth factors, referred to as monotherapy. Our retrospective study includes 128 patients with hypertrophic scars (56 underwent monotherapy and 72 underwent combined therapy), which were followed-up for up to 15 months after the initiation of treatment to collect demographic and clinical data. Our analysis showed that the combined therapy significantly outperformed monotherapy in improving Vancouver scar scale scores (P < 0.05) and in the reduction of scar thickness (P < 0.05), without increasing adverse complications. Repeated treatments further augmented the efficacy of the combined therapy. Subgroup analysis revealed that combined therapy was notably more effective in reducing Vancouver scar scale scores and scar thickness in early-stage scars compared to late-stage (P = 0.023 and P = 0.045, respectively). Our study suggests that including BTX-A treatment before fractional CO2 laser and topical growth factors offers superior efficacy in reducing hypertrophic scars. We encourage early intervention and repeated treatments for optimal treatment outcomes.

Characterization and Physiological Differences of Two Primary Cultures of Human Normal and Hypertrophic Scar Dermal Fibroblasts: A Pilot Study

Background/Objectives: Dermal fibroblasts (DFs) are key participants in skin hypertrophic scarring, and their properties are being studied to identify the molecular and cellular mechanisms underlying the pathogenesis of skin scarring. Methods: In the present work, we performed a comparative analysis of DFs isolated from normal skin (normal dermal fibroblasts, NDFs), and hypertrophic scar skin (hypertrophic scar fibroblasts, HTSFs). The fibroblasts were karyotyped and phenotyped, and experiments on growth rate, wound healing, and single-cell motility were conducted. Results: Comparative analysis revealed a minor karyotype difference between cells. However, HTSFs are characterized by higher proliferation level and motility compared to NDFs. These significant differences may be associated with quantitative and qualitative differences in the cell secretome. A proteomic comparison of NDF and HTSF found that differences were associated with metabolic proteins reflecting physiological differences between the two cells lines. Numerous unique proteins were found only in the vesicular phase of vHTSFs. Some proteins involved in cell proliferation (protein-glutamine gamma-glutamyltransferase K) and cell motility (catenin delta-1), which regulate gene transcription and the activity of Rho family GTPases and downstream cytoskeletal dynamics, were identified. A number of proteins which potentially play a role in fibrosis and inflammation (mucin-5B, CD97, adhesion G protein-coupled receptor E2, antileukoproteinase, protein S100-A8 and S100-A9, protein caspase recruitment domain-containing protein 14) were detected in vHTSFs. Conclusions: A comparative analysis of primary cell cultures revealed their various properties, especially in the cell secretome. These proteins may be considered promising target molecules for developing treatment or prevention strategies for pathological skin scarring.

Phosphodiesterase 4 is overexpressed in human keloids and its inhibition reduces fibroblast activation and skin fibrosis

There is a pressing medical need for improved treatments in skin fibrosis including keloids and hypertrophic scars (HTS). This study aimed to characterize the role of phosphodiesterase 4 (PDE4), specifically PDE4B in fibrotic skin remodeling in vitro and in vivo. In vitro, effects of PDE4A-D (Roflumilast) or PDE4B (siRNA) inhibition on TGFβ1-induced myofibroblast differentiation and dedifferentiation were studied in normal (NHDF) and keloid (KF) human dermal fibroblasts. In vivo, the role of PDE4 on HOCl-induced skin fibrosis in mice was addressed in preventive and therapeutic protocols. PDE4B (mRNA, protein) was increased in Keloid > HTS compared to healthy skin and in TGFβ-stimulated NHDF and KF. In Keloid > HTS, collagen Iα1, αSMA, TGFβ1 and NOX4 mRNA were all elevated compared to healthy skin confirming skin fibrosis. In vitro, inhibition of PDE4A-D and PDE4B similarly prevented TGFβ1-induced Smad3 and ERK1/2 phosphorylation and myofibroblast differentiation, elevated NOX4 protein and proliferation in NHDF. PDE4A-D inhibition enabled myofibroblast dedifferentiation and curbed TGFβ1-induced reactive oxygen species and fibroblast senescence. In KF PDE4A-D inhibition restrained TGFβ1-induced Smad3 and ERK1/2 phosphorylation, myofibroblast differentiation and senescence. Mechanistically, PDE4A-D inhibition rescued from TGFβ1-induced loss in PPM1A, a Smad3 phosphatase. In vivo, PDE4 inhibition mitigated HOCl-induced skin fibrosis in mice in preventive and therapeutic protocols. The current study provides novel evidence evolving rationale for PDE4 inhibitors in skin fibrosis (including keloids and HTS) and delivered evidence for a functional role of PDE4B in this fibrotic condition.

The Role of Extracorporeal Shock Wave Therapy in Keloids and Hypertrophic Scars: A Systematic Review

Keloids and hypertrophic scars are pathological scars that result from a prolonged and aberrant response to wound healing, resulting in raised and thickened skin lesions. Traditional treatments include occlusive dressings, compression therapy, intralesional steroids, and surgical excision with refashioning. Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment method that employs mechanotransduction to stimulate a biological cascade resulting in tissue regeneration. This review aims to explore the literature for published evidence on the role of ESWT in the treatment of keloids and hypertrophic scars. A literature search following the PRISMA guidelines was conducted on PUBMED, Google Scholar, and the Cochrane Database of Systematic Reviews, for studies demonstrating the use of ESWT in keloids and hypertrophic scars. From this, 79 articles were identified, 12 of which met the eligibility criteria and were thus analyzed and included in the study. As monotherapy for keloids, ESWT showed comparable improvements in functional and aesthetic outcomes compared to traditional intralesional steroid therapy. Keloids treated with combination therapy of ESWT with intralesional steroids had better outcomes than those treated with intralesional steroids alone. Improvements in hypertrophic scar cosmesis, discomfort, and function with the use of ESWT were reported. Histologic improvements such as decreased collagen content, reduction of fibrotic markers, and fibrogenic cytokines were also described. ESWT is a promising treatment modality for pathological scars, offering comparable outcomes to traditional therapies with added benefits such as non-invasiveness. Further research is warranted to establish optimal protocols and its role in pathological scar management.

The Efficacy of Botulinum Toxin Type A (BTA) in the Treatment of Hypertrophic Scars and Keloids: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Hypertrophic scars cause significant physical and emotional discomfort. Botulinum toxin type A (BTA) has shown promising outcomes in reducing scar formation. Research suggested its effectiveness in managing hypertrophic scars and keloids. This systematic review and meta-analysis were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including randomized controlled trials (RCTs). The included studies involved patients with hypertrophic scars treated with BTA. Five databases were searched from inception to August 2024. Studies were screened and selected by two independent reviewers. Data on study design, patient demographics, and interventions was extracted. The risk of bias (ROB) was assessed using the ROB revised tool developed by Cochrane (ROB2). Meta-analysis was performed using RevMan Web (The Cochrane Collaboration, London, UK) with a random-effects model due to high heterogeneity, calculating mean differences for the primary and secondary outcomes. Outcomes included Vancouver Scar Scale (VSS) scores, scar thickness, vascularity, pliability, and pigmentation. The systematic review identified 182 records from five databases. The screening process resulted in seven studies included in the final analysis after assessment for eligibility. The efficacy of BTA in treating hypertrophic scars and keloids was assessed. The meta-analysis showed that BTA significantly improved VSS scores, with a pooled mean difference of -1.69 (P = 0.01). However, BTA did not show a statistically significant effect on reducing scar height/thickness or improving vascularity. Scar pliability was significantly improved by BTA, with a pooled mean difference of -0.76 (P = 0.002), while there was no significant effect on pigmentation. High heterogeneity was observed across the studies. BTA could be used as an effective treatment for the components of hypertrophic scars and keloids, especially regarding their pliability and improving scar quality. However, for functions such as the change in scar height, vascularity, and pigmentation, more research is still required among larger RCTs. Future research should focus on refining the treatment regimens and the mode of action of BTA to the scar tissue.

Zinc-Alpha-2-Glycoprotein Peptide Downregulates Type I and III Collagen Expression via Suppression of TGF-β and p-Smad 2/3 Pathway in Keloid Fibroblasts and Rat Incisional Model

BACKGROUND

Keloids and hypertrophic scars result from abnormal collagen accumulation and the inhibition of its degradation. Although the pathogenesis remains unclear, excessive accumulation of the extracellular matrix (ECM) is believed to be associated with the TGF-β/SMAD pathway. Zinc-alpha-2-glycoprotein (ZAG) inhibits TGF-β-mediated epithelial-to-mesenchymal transdifferentiation and impacts skin barrier functions. In this study, we investigated the potential of a small ZAG-derived peptide against hypertrophic scars and keloids.

METHODS

The study examined cell proliferation and mRNA expression of collagen types I and III in human dermal fibroblast (HDF) cell lines and keloid-derived fibroblasts (KF) following ZAG peptide treatment. A rat incisional wound model was used to evaluate the effect of ZAG peptide in scar tissue.

RESULTS

Significantly lower mRNA levels of collagen types I and III were observed in ZAG-treated fibroblasts, whereas matrix metalloproteinase (MMP)-1 and MMP-3 mRNA levels were significantly increased in HDFs and KFs. Furthermore, ZAG peptide significantly reduced protein expression of collagen type I and III, TGF-β1, and p-Smad2/3 complex in KFs. Rat incisional scar models treated with ZAG peptide presented narrower scar areas and reduced immature collagen deposition, along with decreased expression of collagen type I, α-SMA, and p-Smad2/3.

CONCLUSION

ZAG peptide effectively suppresses the TGF-β and p-Smad2/3 pathway and inhibits excessive cell proliferation during scar formation, suggesting its potential therapeutic implications against keloids and hypertrophic scars.

The role of IL-17 and Th17 cells in keloid pathogenesis

Keloids are characterized histologically by excessive fibroblast proliferation and connective tissue deposition, and clinically by scar tissue extending beyond the original site of skin injury. These scars can cause pruritus, pain, physical disfigurement, anxiety, and depression. As a result, keloid patients often have a diminished quality of life with a disproportionate burden on ethnic minorities. Despite advances in understanding keloid pathology, there is no effective Food and Drug Administration (FDA)-approved pharmacotherapy. Recent studies have highlighted the possible pathologic role of T helper (Th)17 cells and interleukin (IL)-17 in keloid formation, as well as their implication in other inflammatory disorders. This systematic review characterizes the role of Th17 cells and IL-17 in keloid pathogenesis, highlighting this pathway as a potential therapeutic target. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search on PubMed, Embase, MEDLINE, and Web of Science databases on June 5, 2024. The search included terms related to Th17 cells, IL-17, and keloids. Thirteen studies met the inclusion criteria, comprising basic science and bioinformatic studies focusing on Th17 cells and IL-17. Key findings include increased Th17 cell infiltration and IL-17 expression in keloids, IL-17's role in amplifying the inflammatory and fibrotic response via the promotion of IL-6 expression, and IL-17's involvement in upregulating fibrotic markers via SDF-1 and HIF-1α pathways. IL-17 also activates the transforming growth factor beta (TGF-β)/Smad pathway in keloid fibroblasts. Th17 cells and IL-17 significantly contribute to the inflammatory and fibrotic processes in keloid pathogenesis. Therefore, targeting the IL-17 pathway offers a potential new therapeutic target to improve keloid patients' outcomes. Future research could further elucidate the role of Th17 cells and IL-17 in keloid pathogenesis and assess the safety and efficacy of targeting this pathway in human studies.

Recent Applications of Amphiphilic Copolymers in Drug Release Systems for Skin Treatment

Amphiphilic copolymers (ACs) are versatile systems with self-assembling and aggregating properties, enabling the formation of nanomaterials (NMs) such as micelles, vesicles, nanocapsules, and nanogels. These materials have been extensively explored for the delivery of various drugs and active compounds, enhancing the solubility and permeation of poorly water-soluble drugs into skin tissue. This improvement facilitates the treatment of skin diseases, including chronic conditions like cancer, as well as infections caused by bacteria, fungi, and viruses. This review summarizes recent applications of ACs in skin treatment, with a particular focus on their use in anti-cancer drug therapy. It covers the synthesis, classification, and characterization of ACs using various experimental techniques. Additionally, it discusses recent research on different drug delivery pathways using ACs, including encapsulation efficiency, release behavior, characteristics, applications, and responses to various chemical and physical stimuli (both in vivo and in vitro). Furthermore, this review provides a comprehensive analysis of the effects of ACs NMs on several skin diseases, highlighting their potential as alternative treatments.

Skin Aging and the Upcoming Role of Ferroptosis in Geroscience

The skin is considered the most important organ system in mammals, and as the population ages, it is important to consider skin aging and anti-aging therapeutic strategies. Exposure of the skin to various insults induces significant changes throughout our lives, differentiating the skin of a young adult from that of an older adult. These changes are caused by a combination of intrinsic and extrinsic aging. We report the interactions between skin aging and its metabolism, showing that the network is due to several factors. For example, iron is an important nutrient for humans, but its level increases with aging, inducing deleterious effects on cellular functions. Recently, it was discovered that ferroptosis, or iron-dependent cell death, is linked to aging and skin diseases. The pursuit of new molecular targets for ferroptosis has recently attracted attention. Prevention of ferroptosis is an effective therapeutic strategy for the treatment of diseases, especially in old age. However, the pathological and biological mechanisms underlying ferroptosis are still not fully understood, especially in skin diseases such as melanoma and autoimmune diseases. Only a few basic studies on regulated cell death exist, and the challenge is to turn the studies into clinical applications.

Evidence of a causal relationship between blood pressure and pathological scars: a bidirectional Mendelian randomization study

Background

Recent advancements in basic medicine and epidemiology suggest a potential influence of blood pressure on scar formation, yet the specifics of this relationship are not fully understood. This study aims to clarify the causal link between blood pressure and the development of pathological scars using Mendelian randomization (MR).

Methods

This study employed genetic variants closely linked to blood pressure as instrumental variables to explore the relationship between blood pressure and pathological scars. The inverse variance weighted (IVW) method was used for analysis.

Results

Our analysis identified a notable association where higher blood pressure was correlated with a lower risk of pathological scars. Specifically, an increase in diastolic blood pressure (odds ratio [OR] per standard deviation increase: 0.67 [95% Confidence Interval [CI], 0.49-0.99]), systolic blood pressure (OR per standard deviation increase: 0.66 [95% CI, 0.46-0.93]), and hypertension (pooled OR: 0.39 [95% CI, 0.18-0.85]) were significantly associated with a reduced risk of keloids. Similarly, a genetic predisposition to hypertension (pooled OR: 0.31 [95% CI, 0.11-0.89]) was significantly associated with a reduced risk of hypertrophic scars. Neither reverse MR analysis nor Steiger's test indicated a significant reverse causal relationship between hypertension and either keloids or hypertrophic scars.

Conclusion

The findings suggest a protective role of higher blood pressure against the development of pathological scars, including keloids and hypertrophic scars. However, the inconsistency observed across different MR methods warrants cautious interpretation and underscores the need for further investigation to confirm these findings.

Human amniotic membrane modulates collagen production and deposition in vitro

Pathological fibrosis is a significant complication of surgical procedures resulting from the accumulation of excess collagen at the site of repair which can compromise the tissue architecture and severely impede the function of the affected tissue. Few prophylactic treatments exist to counteract this process; however, the use of amniotic membrane allografts has demonstrated promising clinical outcomes. This study aimed to identify the underlying mechanism of action by utilizing relevant models that accurately represent the pathophysiology of the disease state. This study employed a pro-fibrotic in vitro system using TGFβ1 stimulation and macromolecular crowding techniques to evaluate the mechanism by which amniotic membrane allografts regulate collagen biosynthesis and deposition. Following treatment with dehydrated human amnion chorion membrane (DHACM), subsequent RNA sequencing and functional enrichment with Reactome pathway analysis indicated that amniotic membranes are indeed capable of regulating genes associated with the composition and function of the extracellular matrix. Furthermore, macromolecular crowding was used in vitro to expand the evaluation to include both the effects of DHACM and a lyophilized human amnion/chorion membrane (LHACM). DHACM and LHACM regulate the TGFβ pathway and myofibroblast differentiation. Additionally, both DHACM and LHACM modulate the production, secretion, and deposition of collagen type I, a primary target for pathological fibrosis. These observations support the hypothesis that amniotic membranes may interrupt pathological fibrosis by regulating collagen biosynthesis and associated pathways.

Effect of a topical silicone gel and a polyurethane dressing on the evolution of scars

OBJECTIVE

To assess the effectiveness and safety of a topical silicone gel (BE + Gel reductor y reparador de cicatrices) and a polyurethane dressing (BE + Apósito reductor y reparador de cicatrices) on the evolution of scars of patients who were previously recruited in the emergency care unit while seeking wound care.

METHOD

A single center, stratified observational, open label study was performed in the emergency care unit of Donostia Universitary Hospital (recruitment) and in the Biodonostia Health Research Institute (intervention). Scars located in unexposed body areas with the dressing, and scars located in exposed areas with either the gel or the dressing. Investigators assessed interventions at day 1 and on weeks 4, 8 and 12. Vancouver Scar Scale (VSS) and a photographical assessment were used to determine the scars evolution, and the subjective perception of the scar was evaluated by means of a questionnaire administered to the patients.

RESULTS

Patients whose scars were treated with the silicone gel had an average initial VSS score of 5.4 ± 2.08. This value was reduced to 0.86 ± 1.17 after 90 days of treatment. Patients treated with the polyurethane dressing had an average initial VSS score of 5.8 ± 2.29. After 90 days of treatment, this average score was reduced to 0.33 ± 0.66. Positive evolution of scars was also supported by photographs and by a patient questionnaire.

CONCLUSIONS

Both treatments appear to be safe and effective, objectively, and subjectively, in the context of scar evolution.

Laser-mediated Solutions: Breaking Barriers in Transdermal Drug Delivery

Skin diseases pose challenges in treatment due to the skin's complex structure and protective functions. Topical drug delivery has emerged as a preferred method for treating these conditions, offering localized therapy with minimal systemic side effects. However, the skin's barrier properties frequently limit topical treatments' efficacy by preventing drug penetration into deeper skin layers. In recent years, laser-assisted drug delivery (LADD) has gained attention as a promising strategy to overcome these limitations. LADD involves using lasers to create microchannels in the skin, facilitating the deposition of drugs and enhancing their penetration into the target tissue. Several lasers, such as fractional CO2, have been tested to see how well they work at delivering drugs. Despite the promising outcomes demonstrated in preclinical and clinical studies, several challenges persist in implementing LADD, including limited penetration depth, potential tissue damage, and the cost of LADD systems. Furthermore, selecting appropriate laser parameters and drug formulations is crucial to ensuring optimal therapeutic outcomes. Nevertheless, LADD holds significant potential for improving treatment efficacy for various skin conditions, including skin cancers, scars, and dermatological disorders. Future research efforts should focus on optimizing LADD techniques, addressing safety concerns, and exploring novel drug formulations to maximize the therapeutic benefits of this innovative approach. With continued advancements in laser technology and pharmaceutical science, LADD has the potential to revolutionize the field of dermatology and enhance patient care.

Stem cell-based therapy for fibrotic diseases: mechanisms and pathways

Fibrosis is a pathological process, that could result in permanent scarring and impairment of the physiological function of the affected organ; this condition which is categorized under the term organ failure could affect various organs in different situations. The involvement of the major organs, such as the lungs, liver, kidney, heart, and skin, is associated with a high rate of morbidity and mortality across the world. Fibrotic disorders encompass a broad range of complications and could be traced to various illnesses and impairments; these could range from simple skin scars with beauty issues to severe rheumatologic or inflammatory disorders such as systemic sclerosis as well as idiopathic pulmonary fibrosis. Besides, the overactivation of immune responses during any inflammatory condition causing tissue damage could contribute to the pathogenic fibrotic events accompanying the healing response; for instance, the inflammation resulting from tissue engraftment could cause the formation of fibrotic scars in the grafted tissue, even in cases where the immune system deals with hard to clear infections, fibrotic scars could follow and cause severe adverse effects. A good example of such a complication is post-Covid19 lung fibrosis which could impair the life of the affected individuals with extensive lung involvement. However, effective therapies that halt or slow down the progression of fibrosis are missing in the current clinical settings. Considering the immunomodulatory and regenerative potential of distinct stem cell types, their application as an anti-fibrotic agent, capable of attenuating tissue fibrosis has been investigated by many researchers. Although the majority of the studies addressing the anti-fibrotic effects of stem cells indicated their potent capabilities, the underlying mechanisms, and pathways by which these cells could impact fibrotic processes remain poorly understood. Here, we first, review the properties of various stem cell types utilized so far as anti-fibrotic treatments and discuss the challenges and limitations associated with their applications in clinical settings; then, we will summarize the general and organ-specific mechanisms and pathways contributing to tissue fibrosis; finally, we will describe the mechanisms and pathways considered to be employed by distinct stem cell types for exerting anti-fibrotic events.

Ferrostatin-1 inhibits fibroblast fibrosis in keloid by inhibiting ferroptosis

Background

Keloid is a chronic proliferative fibrotic disease caused by abnormal fibroblasts proliferation and excessive extracellular matrix (ECM) production. Numerous fibrotic disorders are significantly influenced by ferroptosis, and targeting ferroptosis can effectively mitigate fibrosis development. This study aimed to investigate the role and mechanism of ferroptosis in keloid development.

Methods

Keloid tissues from keloid patients and normal skin tissues from healthy controls were collected. Iron content, lipid peroxidation (LPO) level, and the mRNA and protein expression of ferroptosis-related genes including solute carrier family 7 member 11 (SLC7A11), glutathione peroxidase 4 (GPX4), transferrin receptor (TFRC), and nuclear factor erythroid 2-related factor 2 (Nrf2) were determined. Mitochondrial morphology was observed using transmission electron microscopy (TEM). Keloid fibroblasts (KFs) were isolated from keloid tissues, and treated with ferroptosis inhibitor ferrostatin-1 (fer-1) or ferroptosis activator erastin. Iron content, ferroptosis-related marker levels, LPO level, mitochondrial membrane potential, ATP content, and mitochondrial morphology in KFs were detected. Furthermore, the protein levels of α-smooth muscle actin (α-SMA), collagen I, and collagen III were measured to investigate whether ferroptosis affect fibrosis in KFs.

Results

We found that iron content and LPO level were substantially elevated in keloid tissues and KFs. SLC7A11, GPX4, and Nrf2 were downregulated and TFRC was upregulated in keloid tissues and KFs. Mitochondria in keloid tissues and KFs exhibited ferroptosis-related pathology. Fer-1 treatment reduced iron content, restrained ferroptosis and mitochondrial dysfunction in KFs, Moreover, ferrostatin-1 restrained the protein expression of α-SMA, collagen I, and collagen III in KFs. Whereas erastin treatment showed the opposite results.

Conclusion

Ferroptosis exists in keloid. Ferrostatin-1 restrained ECM deposition and fibrosis in keloid through inhibiting ferroptosis, and erastin induced ECM deposition and fibrosis through intensifying ferroptosis.

Patients with hypertrophic scars following severe burn injury express different long noncoding RNAs

OBJECTIVE

Research indicates that long noncoding RNAs (lncRNAs) contribute significantly to fibrotic diseases. Although lncRNAs may play a role in hypertrophic scars after burns, its mechanisms remain poorly understood.

METHODS

Using chip technology, we compared the lncRNA expression profiles of burn patients and healthy controls (HCs). Microarray results were examined by quantitative reverse-transcription polymerase chain reaction (RT-PCR) to verify their reliability. The biological functions of differentially expressed mRNAs and the relationships between genes and signaling pathways were investigated by Gene Ontology (GO) and pathway analyses, respectively.

RESULTS

In contrast with HCs, it was found that 2738 lncRNAs (1628 upregulated) and 2166 mRNAs (1395 upregulated) were differentially expressed in hypertrophic scars after burn. Results from RT-PCR were consistent with those from microarray. GO and pathway analyses revealed that the differentially expressed mRNAs are mainly associated with processes related to cytokine secretion in the immune system, notch signaling, and MAPK signaling.

CONCLUSION

The lncRNA expression profiles of hypertrophic scars after burn changed significantly compared with HCs. It was believed that the transcripts could be used as potential targets for inhibiting abnormal scar formation in burn patients.

Utilizing stem cell-secreted molecules as a versatile toolbox for skin regenerative medicine

Stem cells are recognized as an important target and tool in regenerative engineering. In this study, we explored the feasibility of engineering amniotic fluid-derived mesenchymal stem cell-secreted molecules (afMSC-SMs) as a versatile bioactive material for skin regenerative medicine applications in a time- and cost-efficient and straightforward manner. afMSC-SMs, obtained in powder form through ethanol precipitation, effectively contributed to preserving the self-renewal capacity and differentiation potential of primary human keratinocytes (pKCs) in a xeno-free environment, offering a potential alternative to traditional culture methods for their long-term in vitro expansion, and allowed them to reconstitute a fully stratified epithelium sheet on human dermal fibroblasts. Furthermore, we demonstrated the flexibility of afMSC-SMs in wound healing and hair regrowth through injectable hydrogel and nanogel-mediated transdermal delivery systems, respectively, expanding the pool of regenerative applications. This cell-free approach may offer several potential advantages, including streamlined manufacturing processes, scalability, controlled formulation, longer shelf lives, and mitigation of risks associated with living cell transplantation. Accordingly, afMSC-SMs could serve as a promising therapeutic toolbox for advancing cell-free regenerative medicine, simplifying their broad applicability in various clinical settings.

Neutrophil extracellular traps (NETs) and fibrotic diseases

Fibrosis, a common cause and serious outcome of organ failure that can affect any organ, is responsible for up to 45% of all deaths in various clinical settings. Both preclinical models and clinical trials investigating various organ systems have shown that fibrosis is a highly dynamic process. Although many studies have sought to gain understanding of the mechanism of fibrosis progression, their findings have been mixed. In recent years, increasing evidence indicates that neutrophil extracellular traps (NETs) are involved in many inflammatory and autoimmune disorders and participate in the regulation of fibrotic processes in various organs and systems. In this review, we summarize the current understanding of the role of NETs in fibrosis development and progression and their possibility as therapeutic targets.

Pharmacotherapy for Keloids and Hypertrophic Scars

Keloids (KD) and hypertrophic scars (HTS), which are quite raised and pigmented and have increased vascularization and cellularity, are formed due to the impaired healing process of cutaneous injuries in some individuals having family history and genetic factors. These scars decrease the quality of life (QOL) of patients greatly, due to the pain, itching, contracture, cosmetic problems, and so on, depending on the location of the scars. Treatment/prevention that will satisfy patients' QOL is still under development. In this article, we review pharmacotherapy for treating KD and HTS, including the prevention of postsurgical recurrence (especially KD). Pharmacotherapy involves monotherapy using a single drug and combination pharmacotherapy using multiple drugs, where drugs are administered orally, topically and/or through intralesional injection. In addition, pharmacotherapy for KD/HTS is sometimes combined with surgical excision and/or with physical therapy such as cryotherapy, laser therapy, radiotherapy including brachytherapy, and silicone gel/sheeting. The results regarding the clinical effectiveness of each mono-pharmacotherapy for KD/HTS are not always consistent but rather scattered among researchers. Multimodal combination pharmacotherapy that targets multiple sites simultaneously is more effective than mono-pharmacotherapy. The literature was searched using PubMed, Google Scholar, and Online search engines.

Wound healing, scarring and management

Understanding wound healing is imperative for the dermatological physician to optimize surgical outcomes. Poor healing may result in negative functional, cosmetic and psychological sequelae. This review briefly outlines the physiology of wound healing, with a view to improving the management of wounds and scars, and minimizing the long-term scarring complications.

Benzbromarone Induces Targeted Degradation of HSP47 Protein and Improves Hypertrophic Scar Formation

Fibrotic diseases are characterized by the abnormal accumulation of collagen in the extracellular matrix, leading to the functional impairment of various organs. In the skin, excessive collagen deposition manifests as hypertrophic scars and keloids, placing a substantial burden on patients and the healthcare system worldwide. HSP47 is essential for proper collagen assembly and contributes to fibrosis. However, identifying clinically applicable HSP47 inhibitors has been a major pharmaceutical challenge. In this study, we identified benzbromarone (BBR) as an HSP47 inhibitor for hypertrophic scarring treatment. BBR inhibited collagen production and secretion in fibroblasts from patients with keloid by binding to HSP47 and inhibiting the interaction between HSP47 and collagen. Interestingly, BBR not only inhibits HSP47 but also acts as a molecular glue degrader that promotes its proteasome-dependent degradation. Through these molecular mechanisms, BBR effectively reduced hypertrophic scarring in mini pigs and rats with burns and/or excisional skin damage. Thus, these findings suggest that BBR can be used to clinically treat hypertrophic scars and, more generally, fibrotic diseases.

The efficacy, satisfaction, and safety of carbon dioxide (CO2) fractional laser in combination with pulsed dye laser (PDL) versus each one alone in the treatment of hypertrophic burn scars: a single-blinded randomized controlled trial

The tendency to use less-invasive laser-based methods with far more obvious effectiveness has been taken into consideration today for improvement of burning scars. The present study thus aimed to assess the efficacy of two laser-based techniques including pulsed dye laser (PDL) and ablative fractional CO2 laser (AFCL) and its combination on improving different aspects of burning scars regardless of the types of scar as hypertrophic or keloid scars. This randomized single-blinded clinical trial was performed on patients suffering hypertrophic or keloid burning scars. The patients were randomly assigned into three groups scheduling for treatment with PDL alone, AFCL alone, or its combination. All patients were visited before and 40 days after the last treatment session, and their scars were assessed. In all groups, significant improvement was revealed in the Vancouver scar scale (VSS) score, the color of scar, vascular bed in the scar, the and height of scar and its pliability; however, the improvement in each item was more highlighted in the group receiving a combination therapy with PDL and AFCL techniques. In this regard, the highest improvement was found in vascular bed and pliability in the combination therapy group as compared to other groups. Although the superiority of the combined group was not statistically significant, due to the high percentage of improvement in total VSS and most of its indicators, it can be clinically significant. The efficacy of the treatment protocols was different considering subgroups of mature and immature scars (less than 1 year), so that more improvement in pliability of scar, vascularity, and color of scar was found in the group scheduling for PDL + AFCL as compared to those who were treated with PDL alone in immature scar group but not in mature scar group. Combined treatment can be much more effective in improving the appearance and pathological characteristics of scars than each individual treatment. This effectiveness can be seen mainly in immature scars.

Identification of inflammation-related biomarkers in keloids

Background

The relationship between inflammation-related genes (IRGs) and keloid disease (KD) is currently unclear. The aim of this study was to identify a new set of inflammation-related biomarkers in KD.

Methods

GSE145725 and GSE7890 datasets were used in this study. A list of 3026 IRGs was obtained from the Molecular Signatures Database. Differentially expressed inflammation-related genes (DEGs) were obtained by taking the intersection of DEGs between KD and control samples and the list of IRGs. Candidate genes were selected using least absolute shrinkage and selection operator (LASSO) regression analysis. Candidate genes with consistent expression differences between KD and control in both GSE145725 and GSE7890 datasets were screened as biomarkers. An alignment diagram was constructed and validated, and in silico immune infiltration analysis and drug prediction were performed. Finally, RT-qPCR was performed on KD samples to analyze the expression of the identified biomarkers.

Results

A total of 889 DEGs were identified from the GSE145725 dataset, 169 of which were IRGs. Three candidate genes (TRIM32, LPAR1 and FOXF1) were identified by the LASSO regression analysis, and expression validation analysis suggested that FOXF1 and LPAR1 were down-regulated in KD samples and TRIM32 was up-regulated. All three candidate genes had consistent changes in expression in both the GSE145725 and GSE7890 datasets. An alignment diagram was constructed to predict KD. Effector memory CD4 T cells, T follicular helper cell, Myeloid derived suppressor cell, activated dendritic cell, Immature dendritic cell and Monocyte were differentially expressed between the KD and control group. Sixty-seven compounds that may act on FOXF1, 108 compounds that may act on LPAR1 and 56 compounds that may act on TRIM32 were predicted. Finally, RT-qPCR showed that the expression of LPAR1 was significantly lower in KD samples compared to normal samples whereas TRIM32 was significantly higher, while there was no difference in the expression of FOXF1.

Conclusion

This study provides a new perspective to study the relationship between IRGs and KD.

TEM1/endosialin/CD248 promotes pathologic scarring and TGF-β activity through its receptor stability in dermal fibroblasts

BACKGROUND

Pathologic scars, including keloids and hypertrophic scars, represent a common form of exaggerated cutaneous scarring that is difficult to prevent or treat effectively. Additionally, the pathobiology of pathologic scars remains poorly understood. We aim at investigating the impact of TEM1 (also known as endosialin or CD248), which is a glycosylated type I transmembrane protein, on development of pathologic scars.

METHODS

To investigate the expression of TEM1, we utilized immunofluorescence staining, Western blotting, and single-cell RNA-sequencing (scRNA-seq) techniques. We conducted in vitro cell culture experiments and an in vivo stretch-induced scar mouse model to study the involvement of TEM1 in TGF-β-mediated responses in pathologic scars.

RESULTS

The levels of the protein TEM1 are elevated in both hypertrophic scars and keloids in comparison to normal skin. A re-analysis of scRNA-seq datasets reveals that a major profibrotic subpopulation of keloid and hypertrophic scar fibroblasts greatly expresses TEM1, with expression increasing during fibroblast activation. TEM1 promotes activation, proliferation, and ECM production in human dermal fibroblasts by enhancing TGF-β1 signaling through binding with and stabilizing TGF-β receptors. Global deletion of Tem1 markedly reduces the amount of ECM synthesis and inflammation in a scar in a mouse model of stretch-induced pathologic scarring. The intralesional administration of ontuxizumab, a humanized IgG monoclonal antibody targeting TEM1, significantly decreased both the size and collagen density of keloids.

CONCLUSIONS

Our data indicate that TEM1 plays a role in pathologic scarring, with its synergistic effect on the TGF-β signaling contributing to dermal fibroblast activation. Targeting TEM1 may represent a novel therapeutic approach in reducing the morbidity of pathologic scars.

Application of fractional carbon dioxide laser monotherapy in keloids: A meta-analysis

BACKGROUND

There is no evidence-based guidance on the use of fractional CO2 laser in the excision of scars.

AIM

To explore the effectiveness and safety of fractional CO2 laser in the treatment of keloids.

METHODS

In this meta-analysis, we searched the PubMed, Embase, and Cochrane databases from inception to April 2023. We only included studies reporting fractional CO2 laser treatment of keloids. We excluded duplicate published studies, incomplete studies, those with incomplete data, animal experiments, literature reviews, and systematic studies.

RESULTS

The pooled results showed that the Vancouver Scar Scale (VSS) parameters of height weighted mean difference (WMD) = -1.10, 95% confidence interval (CI): -1.46 to -0.74), pigmentation (WMD = -0.61, 95% CI: -1.00 to -0.21), and pliability (WMD = -0.90, 95% CI: -1.17 to -0.63) were significantly improved after fractional CO2 laser treatment of keloids. However, vascularity did not significantly change. Additionally, the total VSS was significantly improved after treatment (WMD = -4.01, 95% CI: -6.22 to -1.79). The Patient Scars Assessment Scale was significantly improved after treatment (WMD = -15.31, 95% CI: -18.31 to -12.31). Regarding safety, the incidences of hyperpigmentation, hypopigmentation, pain, telangiectasia, and atrophy were 5%, 0%, 11%, 2% (95% CI: 0%-6%), and 0% (95% CI: 0%-4%), respectively.

CONCLUSIONS

Fractional CO2 laser is effective in the treatment of keloids and can effectively improve the height, pigmentation, and pliability of scars, and patients are satisfied with this treatment. Further studies should explore the role of combination therapy.

Insights into How Plant-Derived Extracts and Compounds Can Help in the Prevention and Treatment of Keloid Disease: Established and Emerging Therapeutic Targets

Keloid is a disease in which fibroblasts abnormally proliferate and synthesize excessive amounts of extracellular matrix, including collagen and fibronectin, during the healing process of skin wounds, causing larger scars that exceed the boundaries of the original wound. Currently, surgical excision, cryotherapy, radiation, laser treatment, photodynamic therapy, pressure therapy, silicone gel sheeting, and pharmacotherapy are used alone or in combinations to treat this disease, but the outcomes are usually unsatisfactory. The purpose of this review is to examine whether natural products can help treat keloid disease. I introduce well-established therapeutic targets for this disease and various other emerging therapeutic targets that have been proposed based on the phenotypic difference between keloid-derived fibroblasts (KFs) and normal epidermal fibroblasts (NFs). We then present recent studies on the biological effects of various plant-derived extracts and compounds on KFs and NFs. Associated ex vivo, in vivo, and clinical studies are also presented. Finally, we discuss the mechanisms of action of the plant-derived extracts and compounds, the pros and cons, and the future tasks for natural product-based therapy for keloid disease, as compared with existing other therapies. Extracts of Astragalus membranaceus, Salvia miltiorrhiza, Aneilema keisak, Galla Chinensis, Lycium chinense, Physalis angulate, Allium sepa, and Camellia sinensis appear to modulate cell proliferation, migration, and/or extracellular matrix (ECM) production in KFs, supporting their therapeutic potential. Various phenolic compounds, terpenoids, alkaloids, and other plant-derived compounds could modulate different cell signaling pathways associated with the pathogenesis of keloids. For now, many studies are limited to in vitro experiments; additional research and development are needed to proceed to clinical trials. Many emerging therapeutic targets could accelerate the discovery of plant-derived substances for the prevention and treatment of keloid disease. I hope that this review will bridge past, present, and future research on this subject and provide insight into new therapeutic targets and pharmaceuticals, aiming for effective keloid treatment.

RNA-seq unravels distinct expression profiles of keloids and Dupuytren's disease

Keloid scars and Dupuytren's disease are two common, chronic, and incurable fibroproliferative disorders that, among other shared clinical features, may induce joint contractures. We employed bulk RNA sequencing to discern potential shared gene expression patterns and underlying pathological pathways between these two conditions. Our aim was to uncover potential molecular targets that could pave the way for novel therapeutic strategies. Differentially expressed genes (DEGs) were functionally annotated using Gene Ontology (GO) terms and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways with the Database for Annotation, Visualization, and Integrated Discovery (DAVID). The protein-protein-interaction (PPI) networks were constructed by using the Search Tool for the Retrieval of Interacting Genes (STRING) and Cytoscape. The Molecular Complex Detection (MCODE) plugin was used for downstream analysis of the PPI networks. A total of 1922 DEGs were identified within Dupuytren's and keloid samples, yet no overlapping gene expression profiles were detected. Significantly enriched GO terms were related to skin development and tendon formation in keloid scars and Dupuytren's disease, respectively. The PPI network analysis revealed 10 genes and the module analysis provided six protein networks, which might play an integral part in disease development. These genes, including CDH1, ERBB2, CASP3 and RPS27A, may serve as new targets for future research to develop biomarkers and/or therapeutic agents.

Combining scar-modulating agents for the treatment of hypertrophic scars and keloids: A systematic review

Injury to the skin can cause abnormal wound healing and continuous inflammation that leads to the formation of hypertrophic scars and keloids. These lesions often cause significant negative impact on a patient's life due to aesthetic, physical, social, and psychological consequences. Numerous treatment modalities exist for these hypertrophic scars and keloids, which include silicone sheeting, pressure garments, intralesional injection/topical application of scar-modulating agents, laser therapy, and surgical excision. Due to increased efficacy, an evolving treatment paradigm encourages the use of multiple treatment modalities instead of one treatment modality. However, no gold standard treatment exists for these lesions, leaving many people with unsatisfactory results. Adding scar-modulating agents such as 5-Fluorouracil, bleomycin, or Botulinum Toxin A to triamcinolone monotherapy has emerged as a potential drug combination for treating hypertrophic scars and keloids. We sought to critically analyze the evidence that exists for the use of more than one scar-modulating agent. This was done by conducting a systematic review to determine the efficacy of these combined drug regimens. We found that many of these combinations show evidence of increased efficacy and fewer/similar adverse events to triamcinolone monotherapy. Triamcinolone and 5-Fluorouracil showed the strongest and most consistent evidence out of all combinations. With this review, we intend to encourage more research into unique drug combinations that may improve outcomes for patients with symptomatic hypertrophic scars or keloids.

Identification of novel biomarkers of ferroptosis involved in keloid based on bioinformatics analysis

Keloid is a fibroproliferative disease of unknown aetiology, which has a significant impact the quality of life of patients. Ferroptosis plays an important role in the occurrence and development of fibrosis, but there is still a lack of research related to keloids. The objective of this work was to identify the hub genes related to ferroptosis in keloid to better understand the keloid process. The microarray data (GSE7890 GSE145725, and GSE44270) (23 keloid and 22 normal fibroblast) were analysed via the gene expression comprehensive database (GEO). Only GSE7890 met the FerrDB database. Cell cycle and pathway analysis were performed with gene ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis was performed to differentially expressed genes (DEG). The differential genes were confirmed in other GEO datasets (GSE145725 and GSE44270), and multi-fibrosis-gene correlation analysed. To validate these hub genes, quantitative real-time PCR (qRT-PCR) was conducted. A total of 581 DEGs were screened, with 417 genes down-regulated and 164 genes up-regulated, with 11 ferroptosis genes significantly up-regulated in both keloid and normal tissue, and 6 genes are consistent with our findings and are associated with multiple fibrosis genes. The qRT-PCR results and tissues of normal skin and keloid agreed with our predictions. Our findings provide new evidence for the ferroptosis-related molecular pathways and biomarker of keloid.

From Histopathology to High-Resolution Ultrasound Imaging of Skin Scars

Nowadays, modern ultrasound machines and high-frequency transducers allow us to accurately assess the superficial soft tissues of the human body. In this sense, sonographic evaluation of the skin and related pathologies is progressively growing in the pertinent literature. To the best of our knowledge, a standardized sonographic protocol focused on the assessment of pathological skin scars is still lacking. As such, the main purpose of the present study was to propose a technical guide to sonographically assess skin scars in the daily practice of clinicians-starting from knowledge on their histopathological features. In order to standardize the ultrasound examination, a superficial-to-deep, layer-by-layer approach has been proposed to optimize its reproducibility and to promote a common language among the different healthcare providers.

Fibrosis in burns: an overview of mechanisms and therapies

Scar development remains a common occurrence and a major healthcare challenge affecting the lives of millions of patients annually. Severe injuries to the skin, such as burns can lead to pathological wound healing patterns, often characterized by dermal fibrosis or excessive scarring, and chronic inflammation. The two most common forms of fibrotic diseases following burn trauma are hypertrophic scars (HSCs) and keloids, which severely impact the patient's quality of life. Although the cellular and molecular mechanisms are similar, HSC and keloids have several distinct differences. In this review, we discuss the different forms of fibrosis that occur postburn injury, emphasizing how the extent of burn influences scar development. Moreover, we highlight how a systemic response induced by a burn injury drives wound fibrosis, including both the role of the inflammatory response, as well as the fate of fibroblast during skin healing. Finally, we list potential therapeutics aimed at alleviating pathological scar formation. An understanding of the mechanisms of postburn fibrosis will allow us to effectively move studies from bench to bedside.

Scars

Wound healing occurs as a response to disruption of the epidermis and dermis. It is an intricate and well-orchestrated response with the goal to restore skin integrity and function. However, in hundreds of millions of patients, skin wound healing results in abnormal scarring, including keloid lesions or hypertrophic scarring. Although the underlying mechanisms of hypertrophic scars and keloid lesions are not well defined, evidence suggests that the changes in the extracellular matrix are perpetuated by ongoing inflammation in susceptible individuals, resulting in a fibrotic phenotype. The lesions then become established, with ongoing deposition of excess disordered collagen. Not only can abnormal scarring be debilitating and painful, it can also cause functional impairment and profound changes in appearance, thereby substantially affecting patients' lives. Despite the vast demand on patient health and the medical society, very little progress has been made in the care of patients with abnormal scarring. To improve the outcome of pathological scarring, standardized and innovative approaches are required.

Microneedle-mediated drug delivery for scar prevention and treatment

Scars are an inevitable natural outcome of most wound healing processes and affect skin functions, leading to cosmetic, psychological and social problems. Several strategies, including surgery, radiation, cryotherapy, laser therapy, pressure therapy and corticosteroids, can be used to either prevent or treat scars. However, these strategies are ineffective, have side effects and are typically expensive. Microneedle (MN) technology is a powerful, minimally invasive platform for transdermal drug delivery. This review discusses the most recent progress in MN-mediated drug delivery to prevent and treat pathological scars (hypertrophic and keloids). A comprehensive overview of existing challenges and future perspectives is also provided.