Effect of skin surface temperature on skin pigmentation during contact and intralesional cryosurgery of keloids

Keloid Therapy: A Neoteric Comparative Study

BACKGROUND

Keloids are considered disorders of fibroproliferation characterized by accumulation of collagen fibers in hypodermis and dermis, caused by inflammation, surgery, and trauma.

OBJECTIVES

The main goal of the study was to approach a better modality for the treatment of keloids by comparing the effects and the side effects of intralesional cryotherapy and intralesional injection of bleomycin.

METHODS

This interventional, comparative clinical trial was conducted on 60 cases and were divided equally into the group (A) combined group where who were subjected to intralesional bleomycin followed by cryotherapy in the same session, group (B) who were subjected to intralesional injection of bleomycin, and group (C) intralesional cryotherapy. All cases were subjected to clinical examination, complete history taking, dermatological examination, examination, and evaluation of scar lesion using the Vancouver scar scale.

RESULTS

There was a statistically significant decrease in pliability among the combined group. Also, pliability decreased in the bleomycin group and cryotherapy, but this decrease wasn't statistically significant. Our results revealed that there was a statistically significant decrease in lesion height among all the studied groups, but the decrease was more among the combined group.

CONCLUSION

Intralesional cryotherapy was effective as Intralesional bleomycin. Combined therapy was a valid and more effective technique with few adverse effects than either alone for keloids as it achieved a decrease in volumes of scars or accompanied symptoms.

Effect of the combination of photobiomodulation therapy and the intralesional administration of corticoid in the preoperative and postoperative periods of keloid surgery: A randomized, controlled, double-blind trial protocol study

Keloid scars are characterized by the excessive proliferation of fibroblasts and an imbalance between the production and degradation of collagen, leading to its buildup in the dermis. There is no “gold standard” treatment for this condition, and the recurrence is frequent after surgical procedures removal. In vitro studies have demonstrated that photobiomodulation (PBM) using the blue wavelength reduces the proliferation speed and the number of fibroblasts as well as the expression of TGF-β. There are no protocols studied and established for the treatment of keloids with blue LED. Therefore, the purpose of this study is to determine the effects of the combination of PBM with blue light and the intralesional administration of the corticoid triamcinolone hexacetonide on the quality of the remaining scar by Vancouver Scar Scale in the postoperative period of keloid surgery. A randomized, controlled, double-blind, clinical trial will be conducted involving two groups: 1) Sham (n = 29): intralesional administration of corticoid (IAC) and sham PBM in the preoperative and postoperative periods of keloid removal surgery; and 2) active PBM combined with IAC (n = 29) in the preoperative and postoperative periods of keloid removal surgery. Transcutaneous PBM will be performed on the keloid region in the preoperative period and on the remaining scar in the postoperative period using blue LED (470 nm, 400 mW, 4J per point on 10 linear points). The patients will answer two questionnaires: one for the assessment of quality of life (Qualifibro-UNIFESP) and one for the assessment of satisfaction with the scar (PSAQ). The team of five plastic surgeons will answer the Vancouver Scar Scale (VSS). All questionnaires will be administered one, three, six, and twelve months postoperatively. The keloids will be molded in silicone prior to the onset of treatment and prior to excision to assess pre-treatment and post-treatment size. The same will be performed for the remaining scar at one, three, six, and twelve months postoperatively. The removed keloid will be submitted to histopathological analysis for the determination of the quantity of fibroblasts, the organization and distribution of collagen (picrosirius staining), and the genic expression of TGF-β (qPCR). All data will be submitted to statistical analysis.

Trial registration: This study is registered in ClinicalTrials.gov (ID: NCT04824612).

Selective Cryolysis of Melanocytes: Critical Temperature and Exposure Time to Induce Selective Pigmentary Loss in Yucatan Pig Skin

BACKGROUND AND OBJECTIVES

Cryotherapy for melanocytic lesions is often accompanied by collateral damage to the surrounding skin, resulting in skin necrosis and scarring. Adipocytes, like melanocytes, are neural crest-derived cells. Adipocytes have been shown to be more sensitive to cold exposure than their neighboring cells of ectodermal origin, such as epidermal keratinocytes. Such differential sensitivity to cold exposure has led to the development of novel treatment modalities, like cryolipolysis, to selectively target a cell type while sparing neighboring cells.

STUDY DESIGN/MATERIALS AND METHODS

In this study, we investigated the roles of controlled skin freezing, tissue temperature, and exposure time in inducing selective loss of melanocytes and skin depigmentation in swines.

RESULTS

The results of our study demonstrated that contact cooling of the skin surface causes selective loss of epidermal melanocytes when the tissue temperature reaches -7.5°C or cooler with an exposure time of 10 minutes or longer, leading to partial skin depigmentation in swine skin. Longer exposures combined with colder temperature exposure led to more complete depigmentation in the treated skin surface.

CONCLUSION

Cold-sensitivity of melanocytes can be harnessed to selectively remove melanocytes while sparing surrounding keratinocytes. The results from this study demonstrated that improved clinical treatments specifically targeting melanocytic lesions is possible using skin cooling to achieve tissue temperatures capable of inducing selective loss of melanocytes without skin necrosis or scarring. Additional studies are needed to optimize the treatment conditions to prolong the selective removal of melanocytes. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Intralesional cryotherapy versus cryotherapy spray for the treatment of recalcitrant plantar warts: a prospective, randomized study

Background: Recalcitrant plantar warts are representing a therapeutic challenge. Intralesional cryotherapy (ILC) has emerged as a promising therapeutic option in recalcitrant plantar warts treatment.Objective: To compare the clinical efficacy, safety and tolerability of (ILC) versus Cryotherapy spray (Cryo-sp) for treatment of recalcitrant plantar warts.Methods: One hundred-thirty patients with recalcitrant plantar warts were assigned equally to two groups. Group A received ILC and group B treated with Cryo-SP. Both groups received one session at 2 weeks intervals until complete clearance or for a maximum of 5 sessions. The main outcome was complete clearance of warts guided by dermoscopy. Follow-up was carried out for 6 months after the treatment.Results: Complete clearance occurred in 80.3% in group A compared to 50.8% in group B with a highly significant difference between both groups (p < .001). The clearance rate was faster in group A (1.5 ± 0.40) than group B (4 ± 1.3) (p < .001). The adverse effects were mild in group A than group B (p < .001). The recurrence rate was 2% in group A versus 23.3% in group B (p < .007).patients satisfaction was higher in ILC (p < .001).Conclusion: Intralesional cryotherapy is more effective, requiring few sessions with a low recurrence rate than cryo-sp.

Chinese expert consensus on clinical prevention and treatment of scar. BURNS & TRAUMA 2018;6:27. [PMID: 30263894 PMCID: PMC6154406 DOI: 10.1186/s41038-018-0129-9]

Following injury, Asian skin has a tendency toward hyperpigmentation and scar formation than Caucasians. A standardized algorithm tailored to Asian patients, especially Chinese patients, is in great demand. Twelve independent, self-selected academic and military physicians from the department of burn/trauma, plastic surgery and dermatology with extensive experience in treating scars were assembled on January 17, 2015, establishing the consensus panel. This consensus was then appraised, drafted, reviewed, and finalized during the following 3 years, aiming to standardize and improve scar prevention and treatment in China. Hopefully, it may also provide some advices and references for the management of scarring in Asian patients.

Could -79 °C Spray-Type Cryotherapy Be an Effective Monotherapy for the Treatment of Keloid?

Cryotherapy has been regarded as an effective modality for the treatment of keloids, and the spray-type device is one of the novel cryotherapeutic units. However, the biological mechanisms and therapeutic effects of this technique are incompletely studied. We evaluated the clinical efficacy of our cryotherapy protocol with molecular and pathologic evidence for the treatment of keloids. We evenly split each of ten keloid lesions into a non-treated (C-) and treated (C+) area; the C+ area was subjected to two freeze-thaw cycles of spray-type cryotherapy using -79 °C spray-type CryoPen™. This treatment was repeated after an interval of two weeks. The proliferation and migration abilities of the fibroblasts isolated from the dermis under the cryotherapy-treated or untreated keloid tissues (at least 5 mm deep) were compared and pathologic findings of the full layer were evaluated. Molecular analysis revealed that the number of dermal fibroblasts was significantly higher in C+ group as compared with C- group. The dermal fibroblasts from C+ group showed more than two-fold increase in the migration ability as compared with the fibroblasts from C- group. The expression of matrix metallopeptidase 9 was increased by more than two-fold and a significant increase in transforming growth factor beta 1 expression and Smad2/3 phosphorylation level was observed in C+ group. C+ group showed more extensive lymphoplasmacytic infiltration with thicker fibrosis and occasional "proliferating core collagen" as compared with C- group. Thus, -79 °C spray-type cryotherapy is ineffective as a monotherapy and should be used in combination with intralesional corticosteroids or botulinum toxin A for favourable outcomes in the treatment of thick keloids.

Intralesional cryotherapy for hypertrophic scars and keloids: a review

Introduction

Hypertrophic and keloid scarring remain notoriously troublesome for patients to tolerate and frustratingly difficult for clinicians to treat. Many different treatment modalities exist, signifying the failure of any method to achieve consistently excellent results. Intralesional cryotherapy is a relatively recent development that uses a double lumen needle, placed through the core of a keloid or hypertrophic scar, to deliver nitrogen vapour, which freezes the scar from its core, outwards.

Methods

This article provides a comprehensive review of the literature on intralesional cryotherapy for hypertrophic scars and keloids. A systematic review or meta-analysis was not possible, since the existing articles did not permit this.

Results

A search of English language, peer-reviewed literature was carried out. The evidence base was found to be low (level 4). In addition, much of the published evidence comes from a very few groups. Despite this, consistent findings from case series suggest that the technique is safe and achieves good scar reduction with very few treatments. Adverse effects include depigmentation, recurrence and pain. Pain and recurrence appear to be uncommon and depigmentation may be temporary.

Discussion

Well-constructed, prospectively recruited comparative trials are absent from the literature. These are strongly encouraged, in order to strengthen general confidence in this technique and in the repeatability of outcomes reported thus far.

Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for patient and physician alike. Laser treatment plays an important role in scar management with additional support from ancillary modalities. Subsequent to part 1: Burns scars, part 2 focuses on our strategies and literature review of treatment of keloid, hypertrophic, pigmented and acne scars where lasers are used in conjunction with other measures, and illustrated with case studies.

Successful treatment of cutaneous squamous cell carcinoma with intralesional cryosurgery: Case report

BACKGROUND

Wide excision or Mohs surgery is the standard treatment of skin squamous cell carcinoma (SCC). Superficial SCC or tumor smaller than 1 cm has been treated successfully with open spray cryosurgery. Larger tumor may not be as effective because tissue destruction is usually superficial. Intralesional cryosurgery (IC) may provide a deeper and better cell killing effect in larger tumors. We investigated the safety and efficacy of treating nodular SCC in 4 patients with IC.

METHODS

Four patients with nodular SCC/keratoacanthoma (tumor size, 1-2.5 cm, average 1.48 cm) on the face and extremity were treated with IC. An 18-ga needle was connected to a cryogun and inserted into the center of the tumor after local anesthesia. The tumors were treated with 2 freeze-thaw cycles with a 5- to 10-mm free margin. Additional IC or open spray cryosurgery was applied if residual tumor was noted during monthly follow-up.

RESULTS

No patient required analgesics or experienced wound infection after the procedures. After IC, all tumors reduced 40% to 75% in size within 1 week. Two patients received 1 additional spray cryosurgery. Complete remission was noted in all tumors (100%) in 2 months. No recurrence was noted during follow-up (average 5.1 years). All patients were satisfied with the results.

CONCLUSION

Our observation suggests that IC can be simple and effective alternative treatment for SCC patients whose condition is not suitable for or who refused operation.

The Aldo-Keto Reductase AKR1B10 Is Up-Regulated in Keloid Epidermis, Implicating Retinoic Acid Pathway Dysregulation in the Pathogenesis of Keloid Disease

Keloid disease is a recurrent fibroproliferative cutaneous tumor of unknown pathogenesis for which clinical management remains unsatisfactory. To obtain new insights into hitherto underappreciated aspects of keloid pathobiology, we took a laser capture microdissection-based, whole-genome microarray analysis approach to identify distinct keloid disease-associated gene expression patterns within defined keloid regions. Identification of the aldo-keto reductase enzyme AKR1B10 as highly up-regulated in keloid epidermis suggested that an imbalance of retinoic acid metabolism is likely associated with keloid disease. Here, we show that AKR1B10 transfection into normal human keratinocytes reproduced the abnormal retinoic acid pathway expression pattern we had identified in keloid epidermis. Cotransfection of AKR1B10 with a luciferase reporter plasmid showed reduced retinoic acid response element activity, supporting the hypothesis of retinoic acid synthesis deficiency in keloid epidermis. Paracrine signals released by AKR1B10-overexpressing keratinocytes into conditioned medium resulted in up-regulation of transforming growth factor-β1, transforming growth factor-β2, and collagens I and III in both keloid and normal skin fibroblasts, mimicking the typical profibrotic keloid profile. Our study results suggest that insufficient retinoic acid synthesis by keloid epidermal keratinocytes may contribute to the pathogenesis of keloid disease. We refocus attention on the role of injured epithelium in keloid disease and identify AKR1B10 as a potential new target in future management of keloid disease.

Intralesional cryosurgery for the treatment of basal cell carcinoma of the lower extremities in elderly subjects: a feasibility study

BACKGROUND

Incidences of basal cell carcinoma (BCC) on the lower extremities in elderly patients are rising. Surgical approaches to the treatment of BCC are subject to possible difficulties in healing, failure of skin grafts, and wound infection. This study assessed the efficacy of intralesional cryosurgery in the treatment of BCC of the lower limbs in elderly patients.

METHODS

This study included eight patients aged >60 years in whom a total of 10 nodular or superficial BCCs of the lower limbs were confirmed by biopsy. The patients' medical histories revealed comorbidities including hypertension, diabetes, hypercholesterolemia, venous insufficiency, and deep vein thrombosis of the legs, congestive heart failure, chronic renal failure, and ischemic heart disease. Using liquid nitrogen, an intralesional cryosurgery needle (CryoShape) was inserted into the tumor to facilitate its complete freezing. Treatment success was confirmed by biopsy taken approximately 3 months after complete healing of the cryo-wound.

RESULTS

The average size of the lesions treated was 2.49 cm(2) (16.4 × 15.2 mm). Mean recovery time was 79.9 days. Biopsies were obtained at a mean of 85.3 days after the wound had healed. All 10 biopsies verified the complete destruction of the tumor. There was no evidence of wound infection or tumor recurrence over a follow-up period of 28 months.

CONCLUSIONS

This study demonstrates that a single intralesional cryosurgery session can completely eradicate BCC on the lower extremities in elderly patients. This technique is associated with relatively minor complications, is well tolerated, and represents a safe and effective therapeutic modality for BCC of the lower limbs.

[Cryosurgery in dermatology]

This article provides information on the clinical development of skin reactions after cryosurgery/cryotherapy and the indications, complications and contraindications of skin cryosurgery. Successful skin cryosurgery requires rapid freezing and slow thawing, minimum tissue temperature of -25 to -60℃ and, in malignant lesions, repetition of the freeze-thaw cycle. Frozen tissue reacts with peripheral erythema immediately after thawing, followed by edema, bulla formation, exudation and mumification. Lesions usually heal with a fine atrophic scar after approximately 4 weeks. Nowadays, cryosurgery is considered the treatment of choice in hypertrophic scars and keloids, granuloma annulare, small capillary infantile hemangioma and isolated actinic keratoses. It is also a valuable alternative therapy for various other skin diseases, including common warts, solar lentigo, superficial basal cell carcinoma and Kaposi's sarcoma. Cryosurgery is a safe regimen with relatively few adverse effects and contraindications. Pain during and/or shortly after treatment, bulla formation and local edema are the major temporary adverse effects; lesional hypopigmentation and/or peripheral hyperpigmentation is the most common long-term complication.

Intralesional Cryotherapy for the Treatment of Keloid Scars: Evaluating Effectiveness

Background:

Intralesional (IL) cryotherapy is a novel treatment technique for keloid scars, in which the scar is frozen from inside. Over the past decade, several studies have been published with varying outcomes. A critical analysis of the current literature is, therefore, warranted to determine whether IL cryotherapy is an alternative to established keloid scar treatments.

Methods:

A comprehensive review was performed, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. PubMed and EMBASE were searched from inception. Studies and level of recommendation were graded according to the American Society of Plastic Surgeons criteria.

Results:

Eight studies meeting the inclusion criteria were selected. The average scar volume decrease ranged from 51% to 63%, but no complete scar eradication was achieved on average. Scar recurrence ranged from 0% to 24%. Hypopigmentation posttreatment was seen mostly in Fitzpatrick 4–6 skin type patients. Finally, complaints of pain and pruritus decreased significantly in most studies.

Conclusions:

IL cryotherapy for the treatment of keloid scars shows favorable results in terms of volume reduction and alleviated complaints of pain and pruritus. However, no complete scar eradication is established, and recurrences are seen. Also, persistent hypopigmentation proved a problem in Fitzpatrick 4–6 skin type patients. Summarized, the evidence proved limited and inconsistent resulting in an American Society of Plastic Surgeons grade C recommendation for this type of treatment of keloid scars.

Comparison of two devices for the treatment of keloid scars with the use of intralesional cryotherapy: An experimental study

BACKGROUND

Intralesional (IL) cryotherapy is a new technique for the treatment of keloid scars, in which the scar is frozen from inside. Two cryodevices are available, which were recently evaluated. Both devices showed promising results, but differed in clinical outcome. To explain these differences, more understanding of the working mechanism of both devices is required.

OBJECTIVE

This experimental study was designed to investigate and compare the thermal behavior of an argon gas- and a liquid nitrogen-based device. Thermal behavior constitutes: (1) minimum tissue temperature (°C), (2) the freezing rate (°C/min). The thermal behavior was measured inside and on the outer surface of the scar. Both devices were tested ex vivo and in vivo.

RESULTS

Ex vivo, when determining the maximum freezing capacity, the argon gas device showed a higher end temperature compared to the liquid nitrogen device (argon gas: -120°C, liquid nitrogen: -140°C) and a faster freezing rate (argon gas: -1300°C/min, liquid nitrogen: -145°C/min). In vivo, measured inside the keloid, the argon gas device showed a lower end temperature than the liquid nitrogen device (argon gas: -36.4°C, liquid nitrogen: -8.1°C) and a faster freezing rate (argon gas: -14.7°C/min, liquid nitrogen: -5°C/min). The outer surface of the scar reached temperatures below -20°C with both devices as measured with the thermal camera.

CONCLUSION

In conclusion, the argon gas device displayed a lower end temperature and a faster freezing rate in vivo compared to the liquid nitrogen device. Although this resulted in lower recurrence rates for the argon gas device, more hypopigmentation was seen compared to the liquid nitrogen device following treatment. Finally, the low outer surface temperatures measured with both devices, suggest that some hypopigmentation following treatment is inevitable.

Intralesional cryosurgery combined with topical silicone gel sheeting for the treatment of refractory keloids

BACKGROUND

A variety of therapeutic procedures for treating keloids have been previously reported, with varying success and recurrence rates. As a monotherapy, intralesional cryosurgery has yielded convincing clinical results.

OBJECTIVE

We combined intralesional cryosurgery with the application of topical silicone gel sheeting.

MATERIALS AND METHODS

In this retrospective study, which was conducted between 2008 and 2012, 21 patients with 32 keloids were enrolled. Twenty-five lesions were treated with intralesional cryotherapy combined with postoperative silicone gel sheeting (the cryotherapy + silicone group), and 7 keloids were treated with intralesional cryotherapy alone (the cryotherapy group). The scar volume reduction was assessed, and the patients' subjective and objective parameters were evaluated. Additionally, patient satisfaction was estimated using a modified Gorney Gram scale (0-3).

RESULTS

In all cases (n = 32 for both groups), a significant keloid volume reduction was observed. The patients' subjective complaints were significantly improved, whereas the combined therapy showed slightly better results in hardness (p < .0012), pain (p < .0233), and discomfort (p < .0029), whereas monotherapy achieved higher satisfaction scores in redness (p < .0220) and pruritus (p < .0206), although these differences were not significant between the treatment modalities.

CONCLUSION

The results of this study support the use of combined intralesional cryosurgery followed by the application of silicone gel sheeting to treat refractory keloids.

Intralesional cryosurgery to treat keloid scars: results from a retrospective study

BACKGROUND

A variety of treatment modalities have been proposed to treat keloid scars, but outcomes are often disappointing. Intralesional cryosurgery may significantly reduce these scars.

OBJECTIVE

To evaluate the clinical safety and efficacy of intralesional cryosurgery to treat keloid scars. Feedback from patients on pain, pruritus and aesthetic discomfort was recorded before and after treatment.

METHODS

A total of 10 patients with 14 keloid scars resistant to conventional treatments were enrolled in a retrospective study between October 2007 and October 2013. The efficacy of this treatment was evaluated by measuring the reduction in scar surface.

RESULTS

Scar surface was reduced by an average of 58.5% after intralesional cryosurgery treatment for all scars (average pre-operative keloid scar surface: 874.6 ± 954.1 mm2; average post-operative keloid scar surface: 505.8 ± 1,024.7 mm2; p = 0.002). Pain and aesthetic discomfort were significantly decreased after treatment in all patients (p = 0.008 and p = 0.012, respectively).

CONCLUSION

Our data suggest that intralesional cryosurgery is an effective treatment for keloids.

[Keloid scars of the head and neck]

A keloid scar is a benign proliferative lesion of dermic collagen. It is predominant in black skin patients. It is most commonly located on the head and neck. Skin trauma and a genetic predisposition may be responsible for the keloid scar. Nevertheless, the pathogenesis of keloid scar is still unclear, and no currently available treatment is 100% effective. The authors had for aim to review the current data on keloid scar pathogenesis and treatment for an optimal management of this condition.

Intralesional cryosurgery for the treatment of hypertrophic scars and keloids following aesthetic surgery: the results of a prospective observational study

Hypertrophic scars and keloids following aesthetic surgery, which ignite patient dissatisfaction, are difficult to handle. Intralesional cryosurgery for the treatment of such scars has been introduced. This study was designed to evaluate the efficacy of this technology in the treatment of such scars and to assess the reduction of dissatisfaction. Eleven scars (on 11 patients) were treated by intralesional cryosurgery, following breast surgery, otoplasty, face-lifting, and brachioplasty. Each patient scored the concern from the scar and the scar deformity (scale from 1 to 5) prior and following treatment (higher score represents least satisfaction and a severe deformity). The follow-up period was between 3 months and 8 years. The results demonstrated a significant reduction in concern and deformity scores compared with before the cryotreatment (P = .001). The intralesional cryosurgery technique provides the plastic surgeon with an effective instrument to treat hypertrophic scars and keloids following aesthetic surgery, thus reducing the dissatisfaction of patients.