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Franco E, Kreichman R, Metanes I, Segal M, Nae B, Bryzgalin L, Zouboulis C, Har-Shai Y. Intralesional Cryosurgery of a Bulky Postburned Auricular Keloid and EAR-Q Patient-reported Outcome Measure Assessment. J Burn Care Res 2024; 45:246-249. [PMID: 37795836 DOI: 10.1093/jbcr/irad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Indexed: 10/06/2023]
Abstract
Postburned auricular keloids are a challenging problem for the patient and physician. We describe a successful combined treatment of a bulky postburn auricular keloid employing intralesional cryosurgery followed by multiple W-plasty. An EAR-Q pre- and postoperative patient-reported outcome assessments have revealed a significant improvement in all ear parameters of appearance, adverse effects, and quality of life. This combined treatment might be added to the armamentarium of possible treatment modalities for this perplexing problem.
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Affiliation(s)
- Eyal Franco
- Department of Plastic Surgery, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Rita Kreichman
- Department of Plastic Surgery, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Issa Metanes
- Department of Plastic Surgery, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Miriam Segal
- Department of Plastic Surgery, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Bluma Nae
- Department of Plastic Surgery, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Leonid Bryzgalin
- Department of Plastic Surgery, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Christos Zouboulis
- Department of Dermatology, Venereology and Allergology/Immunological, Dessau Medical Center, Brandenburg Medical School, Dessau, Germany
| | - Yaron Har-Shai
- Department of Plastic Surgery, Carmel Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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2
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Qi W, Xiao X, Tong J, Guo N. Progress in the clinical treatment of keloids. Front Med (Lausanne) 2023; 10:1284109. [PMID: 38046417 PMCID: PMC10690427 DOI: 10.3389/fmed.2023.1284109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/03/2023] [Indexed: 12/05/2023] Open
Abstract
Keloid is a pathological scar that is higher than the skin surface following skin damage. Its lesion range often extends beyond the original damage boundary and does not naturally subside over time. Its pathogenesis is very complex, currently the main causes include fibroblast excessive proliferation, collagen and extracellular matrix (Extracellular matrix, ECM) excessive deposition, excessive angiogenesis, and so on. The traditional treatment method primarily involves surgical intervention, but it is associated with a high recurrence rate post-surgery. Consequently, many treatment methods are derived according to the different clinical characteristics of keloid. This paper will review the therapeutic progress in recent years from surgical treatment, physiotherapy, drug therapy, and biological therapy, with the goal of offering valuable insights for the clinical treatment of keloids.
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Affiliation(s)
| | | | - Jing Tong
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nengqiang Guo
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Quang TT, Yang J, Mikhail AS, Wood BJ, Ramanujam N, Mueller JL. Locoregional Thermal and Chemical Tumor Ablation: Review of Clinical Applications and Potential Opportunities for Use in Low- and Middle-Income Countries. JCO Glob Oncol 2023; 9:e2300155. [PMID: 37625104 PMCID: PMC10581629 DOI: 10.1200/go.23.00155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/31/2023] [Accepted: 07/01/2023] [Indexed: 08/27/2023] Open
Abstract
This review highlights opportunities to develop accessible ablative therapies to reduce the cancer burden in LMICs.
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Affiliation(s)
- Tri T. Quang
- Department of Bioengineering, University of Maryland, College Park, MD
| | - Jeffrey Yang
- Department of Bioengineering, University of Maryland, College Park, MD
- Center for Interventional Oncology, Radiology and Imaging Sciences, NIH Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Andrew S. Mikhail
- Center for Interventional Oncology, Radiology and Imaging Sciences, NIH Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Bradford J. Wood
- Center for Interventional Oncology, Radiology and Imaging Sciences, NIH Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Nimmi Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, NC
- Duke Global Health Institute, Duke University, Durham, NC
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC
| | - Jenna L. Mueller
- Department of Bioengineering, University of Maryland, College Park, MD
- Department of OB-GYN and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD
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4
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Keloid treatments: an evidence-based systematic review of recent advances. Syst Rev 2023; 12:42. [PMID: 36918908 PMCID: PMC10012475 DOI: 10.1186/s13643-023-02192-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 02/15/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Keloids are pathologic scars that pose a significant functional and cosmetic burden. They are challenging to treat, despite the multitude of treatment modalities currently available. OBJECTIVE The aim of this study was to conduct an evidence-based review of all prospective data regarding keloid treatments published between 2010 and 2020. METHODS A systematic literature search of PubMed (National Library of Medicine), Embase (Elsevier), and Cochrane Library (Wiley) was performed in November of 2020. Search strategies with the keywords "keloid" and "treatment" were performed by a medical librarian. The search was limited to prospective studies that were peer-reviewed, reported on clinical outcomes of keloid therapies, and were published in the English language between January 1, 2010, and November 24, 2020. RESULTS A total of 3462 unique citations were identified, of which 108 studies met inclusion criteria. Current literature supports silicone gel or sheeting with corticosteroid injections as first-line therapy for keloids. Adjuvant intralesional 5-fluorouracil (5-FU), bleomycin, or verapamil can be considered, although mixed results have been reported with each. Laser therapy can be used in combination with intralesional corticosteroids or topical steroids with occlusion to improve drug penetration. Excision of keloids with immediate post-excision radiation therapy is an effective option for recalcitrant lesions. Finally, silicone sheeting and pressure therapy have evidence for reducing keloid recurrence. CONCLUSIONS This review was limited by heterogeneity of subject characteristics and study outcome measures, small sample sizes, and inconsistent study designs. Larger and more robust controlled studies are necessary to further understand the variety of existing and emerging keloid treatments, including corticosteroids, cryotherapy, intralesional injections, lasers, photodynamic therapy, excision and radiation, pressure dressings, and others.
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5
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Frech FS, Hernandez L, Urbonas R, Zaken GA, Dreyfuss I, Nouri K. Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies. Am J Clin Dermatol 2023; 24:225-245. [PMID: 36662366 DOI: 10.1007/s40257-022-00744-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 01/21/2023]
Abstract
Hypertrophic scars and keloids can have significant detrimental effects on patients both psychosocially and functionally. A careful identification of patient risk factors and a comprehensive management plan are necessary to optimize outcomes. Patients with a history of dystrophic scarring should avoid unnecessary procedures and enhance the wound-healing process using various preventive strategies. As there is no single, fully efficacious treatment modality, prevention remains the best approach in reducing aberrant scar formation. When prevention therapies fail, keloids have been shown to be respond to a variety of therapies including topical and injectable corticosteroids, 5-fluorouracil, radiotherapy, lasers, and surgical excision, all with varying efficacies. As such, management should be tailored to the individual patient's risk factors with the use of combination therapies to reduce recurrence rates. Still, keloid and hypertrophic scar therapies are widely diverse with novel treatment modalities providing alternatives for recurring lesions. Laser-assisted drug delivery, skin priming, and novel topical therapies may provide alternative options for the management of hypertrophic scars and keloids.
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Affiliation(s)
- Fabio Stefano Frech
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1150 Northwest 14th Street, Miami, FL, 33136, USA.
| | - Loren Hernandez
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1150 Northwest 14th Street, Miami, FL, 33136, USA
| | - Rebecca Urbonas
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Ghufran Abo Zaken
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1150 Northwest 14th Street, Miami, FL, 33136, USA
| | - Isabella Dreyfuss
- Nova Southeastern University, Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Keyvan Nouri
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1150 Northwest 14th Street, Miami, FL, 33136, USA
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Gong T, Yu P, Lu T, Chen J, Mi J, Fang R, Shan C. Cryotherapy Modifies Extracellular Matrix Expression of Vocal Fold in Rat Models. J Voice 2022:S0892-1997(22)00272-7. [PMID: 36182619 DOI: 10.1016/j.jvoice.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/30/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Vocal fold (VF) scarring is the major cause of voice disorders. Cryotherapy is an effective anti-scarring therapy for skin lesions. The aim of this study was to explore the anti-scarring potential of cryotherapy in vocal folds. METHODS The extracellular matrix (ECM) mRNA expression of cryotherapy on normal VF tissue and the histologic results of cryotherapy on vocal fold healing were studied. Fifteen rats were introduced cryotherapy on the normal VF bilaterally and were harvested for real-time polymerase chain reaction (RT-PCR) analysis for collagen I, collagen III, TGFβ1, decorin, fibronectin and HAS1 at 1 day, 3 days and 7 days. Ten rats were unilaterally injured by stripping lamina propria and immediately treated with or without cryotherapy and were harvested at 2 months for histological and immunohistochemical analysis. RESULTS Regenerative effect of cryotherapy was validated of ECM gene expression. Histological and immunohistochemical analysis showed significantly increased hyaluronan, decreased collagen, and increased decorin deposition in injury-cryotherapy cohort compared with injury control cohort and normal control cohort. CONCLUSIONS Cryotherapy may provide an optimal environment for vocal fold tissue regeneration. The results of the present investigation suggest that cryotherapy has therapeutic potential in prevention and treatment of vocal fold scarring.
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Affiliation(s)
- Ting Gong
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Pengcheng Yu
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | - Tao Lu
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiwei Chen
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jinxia Mi
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rui Fang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China.
| | - Chunlei Shan
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Center of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, China.
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7
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Chhabra A, Pandey S, Rathore Y, Kaur G, Lakhanpal T, Singh Tanwar K, Kumaran MS, De D, Shukla J. Nuclear medicine in the management of superficial skin abnormalities and institutional experience. Nucl Med Commun 2022; 43:625-630. [PMID: 35362693 DOI: 10.1097/mnm.0000000000001549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Keloid, hypertrophic scars and basal cell carcinoma (BCC) falls under the category of non-melanoma skin cancer. Intralesional steroids, external beam radiation therapy, 5-Fluorouracil, cryotherapy, laser, etc are the available treatment options. However, recurrence has been reported with each type of treatment mode. In the present article, various treatment modes have been discussed and institutional experience of Rhenium-188 skin patches for the treatment of keloids and BCC has been discussed.
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Affiliation(s)
| | | | | | | | | | | | - M Sendhil Kumaran
- Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dipankar De
- Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Har-Shai L, Ofek SE, Cohen S, Cohen KH, Yaacobi DS, Olshinka A, Dibbs RP, Ad-El DD. Israeli Innovations in the Field of Plastic Surgery. Semin Plast Surg 2022; 36:55-65. [DOI: 10.1055/s-0042-1748916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractNumerous innovations within the field of plastic surgery have been developed in Israel over the last few decades. Many of these therapeutic devices and techniques have been established globally with demonstrable efficacy and respectable safety profiles. This article offers an overview of recent Israeli cutting-edge medical therapeutic solutions contributing to the global practice of plastic surgery.
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Affiliation(s)
- Lior Har-Shai
- Department of Reconstructive Plastic Surgery & Burns, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sar-El Ofek
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stav Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren H. Cohen
- Department of Reconstructive Plastic Surgery & Burns, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dafna Shilo Yaacobi
- Department of Reconstructive Plastic Surgery & Burns, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Olshinka
- Department of Reconstructive Plastic Surgery & Burns, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rami P. Dibbs
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine. Houston, Texas
| | - Dean D. Ad-El
- Department of Reconstructive Plastic Surgery & Burns, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Ogawa R. The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago. Plast Reconstr Surg 2022; 149:79e-94e. [PMID: 34813576 PMCID: PMC8687618 DOI: 10.1097/prs.0000000000008667] [Citation(s) in RCA: 104] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review. METHODS All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available. RESULTS Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis. CONCLUSIONS Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.
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Affiliation(s)
- Rei Ogawa
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
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10
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Madura C, Nayak PB, Raj PR, Chandrashekar BS. Surgical approach in the management of ear keloids: our experience with 30 patients. Int J Dermatol 2021; 60:1553-1560. [PMID: 34302357 DOI: 10.1111/ijd.15761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 04/25/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ear keloids are benign, fibrous proliferations due to excessive collagen synthesis and deposition. It is a popular practice to pierce earlobes for decorative earrings and adornment; this might trigger the keloid process. Although there are varied treatment modalities, it is unsatisfactory and has always been a challenge. The aim is to evaluate the efficacy of surgical treatment with intralesional therapy in auricular keloids. METHODS We included 30 patients with 45 keloids over the ear. Patients were evaluated (including detailed history, complete physical and local examination), and photographs and written informed consent were taken. They were treated with: excision and closure, intralesional and/or surface cryotherapy, ablative laser, intralesional steroids, and 5-fluorouracil. Excision and closure, and intralesional cryotherapy were done under local anesthesia. Closure was done after intramarginal excision with or without raising auto flaps, followed by intraoperative intralesional steroids to margins. Recurrence was assessed at 3 weeks, 3 months, 6 months, and 1 year. RESULTS The age group of patients ranged from 14 to 57 years. A total of 32 out of 45 (71.1%) keloids were excised and were combined with intraoperative and postoperative intralesional steroid injection, with sessions depending on the patient's response. Eight (17.7%) and five (11.1%) keloids were treated using intralesional cryotherapy and only intralesional steroids, respectively. A total of 16.6% of patients had recurrence with one patient having recurrence of bilateral earlobes keloid. CONCLUSION Keloidectomy with intraoperative and postoperative intralesional steroid injections has been very effective in the treatment of ear keloids. Different treatment modalities act synergistically, but excision surgery gives good results as it aims at maintaining ear architecture.
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Affiliation(s)
| | | | - Pavan R Raj
- Cutis Academy of Cutaneous Sciences, Bangalore, India
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Zawadiuk LRR, Van Slyke AC, Bone J, Redfern B, Carr NJ, Arneja JS. What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2021; 30:49-58. [PMID: 35096693 PMCID: PMC8793758 DOI: 10.1177/2292550321995746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids. Methods: We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality. Results: A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found. Conclusions: Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.
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Affiliation(s)
- Luke R. R. Zawadiuk
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aaron C. Van Slyke
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baillie Redfern
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas J. Carr
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jugpal S. Arneja
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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12
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Har-Shai Y, Har-Shai L, Zouboulis VA, Zouboulis CC. Different Types of Auricular Keloids and Treatment by Intralesional Cryosurgery: Best Practice for Obtaining Long-Lasting Clinical Results. Dermatology 2021; 238:170-179. [PMID: 33827090 DOI: 10.1159/000514954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Auricular keloids belong to the most perplexing medical conditions, which have significant psychosocial impact on the patient's body image and quality of life. SUMMARY The article is purposed to provide dermatologists and plastic surgeons with the best proven practice using intralesional cryosurgery for the treatment of the different auricular keloid types in order to obtain superior clinical results by minimizing the probability of recurrence. In the past 20 years, the authors have developed novel procedures in order to increase the effectiveness of intralesional cryosurgery on auricular keloids, including hydrodissection, warm gauze technique, and excision of dangling skin. Long-lasting clinical results with a low recurrence rate and a satisfactory aesthetic outcome are achieved with no deformation of the ear framework.
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Affiliation(s)
- Yaron Har-Shai
- The Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,The Bruce and Ruth Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Lior Har-Shai
- The Department of Plastic and Reconstructive Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Viktor A Zouboulis
- Faculty of Medicine, Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christos C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany
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13
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Zouboulis CC, Wild T, Zouboulis VA, Har-Shai Y. Intralesional cryosurgery of keloids: required treatment hold time. Br J Dermatol 2020; 184:173-175. [PMID: 33216367 DOI: 10.1111/bjd.19427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 12/01/2022]
Affiliation(s)
- C C Zouboulis
- Departments of, Department of, Dermatology, Venereology, Allergology, Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany
| | - T Wild
- Departments of, Department of, Dermatology, Venereology, Allergology, Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany.,Department of Plastic, Aesthetic and Hand Surgery, Interdisciplinary Center for Treatment of Chronic Wounds, Dessau Medical Center, Dessau, Germany.,Institut of Applied Bio-Sciences and Process Management, University of Applied Science Anhalt, Koethen, Germany
| | - V A Zouboulis
- Faculty of Medicine, Universitaetsklinikum Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Y Har-Shai
- The Unit of Plastic Surgery, Carmel Medical Center and the Bruce Rapapport Faculty of Medicine - Technion, Haifa, Israel
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14
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Zouboulis CC, Zouridaki E. Cryosurgery as a Single Agent and in Combination with Intralesional Corticosteroids Is Effective on Young, Small Keloids and Induces Characteristic Histological and Immunohistological Changes: A Prospective Randomized Trial. Dermatology 2020; 237:396-406. [PMID: 33279888 DOI: 10.1159/000511624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As the pathogenesis of keloids is poorly understood, there is no sound biological basis of keloid management. Few controlled therapeutic studies have been published, and recurrences are a major reason for treatment failure. OBJECTIVE To detect efficacy and safety of cryosurgery regimens on keloids and the occurring biological changes caused by the treatment. METHODS This prospective randomized study compared efficacy and tolerability as well as histological/immunohistochemical effects of liquid nitrogen contact cryosurgery as a single regimen (group A) and combined with intralesional corticosteroids (group B) on young (<2 years old), small (≤10 cm2) keloids in 40 patients (2-sided effect, α-error 1%, power 95%). RESULTS Marked flattening of the lesions was achieved by both regimens. Median lesional volumes decreased from 106 to 7 mm3 in group A (p = 0.001) and from 138 to 6 mm3 in group B (p < 0.0001; ns, between groups). Good to excellent responses were registered in 83.3 and 90% of patients in groups A and B, respectively, by evaluating the lesional volume, in 80 and 95% of patients by the physician's evaluation and in 95% of patients in either group by the patient's assessment. Follow-up of 6-36 months revealed no further significant changes. Cryosurgery was generally well tolerated, with minor pain during treatment not requiring (27.5%) or requiring local anaesthesia (5%) - but not analgesics -, and hypopigmentation (25%). Histological examination showed increased vessel number and lumen dilatation after treatment in group B and reduction of rete ridge length in both groups with more prominent changes in group A. Tenascin C staining demarcated keloids from normal skin before therapy, while after therapy the entire treated tissue was labelled. Interferon-γ expression was significantly decreased after therapy both regarding positively stained cells and intensity in both groups. CONCLUSION Cryosurgery without and with intralesional corticosteroids is effective and safe on young, small keloids not only as a destructive physical procedure, but also by inducing biochemical and immunological scar rejuvenation.
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Affiliation(s)
- Christos C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane and Faculty of Health Sciences Brandenburg, Dessau, Germany,
| | - Eftychia Zouridaki
- Department of Dermatology, Andreas Sygros Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Zouboulis VA, Zouboulis CC. A novel experimental model for studying efficacy of cryosurgery in keloids. J Eur Acad Dermatol Venereol 2020; 34:1851-1854. [PMID: 32027410 DOI: 10.1111/jdv.16267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/27/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intralesional cryosurgery is effective in the treatment of keloids; however, clinical studies have presented diversified results. OBJECTIVE A novel, reproducible model for biophysical studies on intralesional cryosurgery of keloids is presented. METHODS Triplicate studies with a cryosurgical needle on 37°C-heated potatoes, which exhibit identical specific heat and similar heat conductivity with human skin, were performed. RESULTS No complete potato freezing resulted through a cryosurgical needle. The limited tissue damage achieved had a double concave form. The needle induced lower temperature and stronger tissue damage at the distal exit than the proximal entrance site. The concave form of tissue damage flattened with time at the area under the needle. Needle freezing with puncture distances of 0.5, 1.0 and 1.5 cm from the potato surface only revealed freezing temperatures within the 0.5 cm range. At any needle depth, tissue damage was detected at only an area to about 1 cm under the needle. CONCLUSION Clinical extrapolation of these experimental findings indicates a proper needle positioning towards the keloid basis, shows keloid volume freezing limitations by a single needle and corroborates the observations of minor epidermal and deep dermal damage induced by intralesional cryosurgery.
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Affiliation(s)
- V A Zouboulis
- Faculty of Medicine, Universitaetsklinikum Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - C C Zouboulis
- Departments of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany
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Abstract
Keloids are pathological scars that grow over time and extend beyond the initial site of injury after impaired wound healing. These scars frequently recur and rarely regress. They are aesthetically disfiguring, can cause pain, itching, discomfort as well as psychological stress, often affecting quality of life. Many treatment modalities, including surgical and non-surgical, have been explored and have been reported to be beneficial; however, none have been absolutely satisfactory or optimal for the treatment of all keloid subtypes to date. This poses a major challenge to clinicians. Often, a combinational therapeutic approach appears to offer the best results with higher patient satisfaction compared to monotherapy. The aetiopathogenesis of keloids is not fully elucidated; however, with recent advances in molecular biology and genetics, insight is being gained on the complex process of scar formation and hence new therapeutic and management options for keloids. In this paper, we explore the literature and summarise the general concepts surrounding keloid development and review both current (corticosteroids, surgical excision, silicone-based products, pressure therapy, radiotherapy, cryotherapy, laser therapy, imiquimod and 5-fluorouracil) and emerging (stem cell therapy, mitomycin C, verapamil, interferons, bleomycin, botulinum toxin type A and angiotensin-converting enzyme inhibitors) treatments. Increased knowledge and understanding in this area may potentially lead to the discovery and development of novel therapeutic options that are more efficacious for all keloid types. LAY SUMMARY Keloids are problematic scars that are difficult to treat and manage. The aetiopathogenesis of keloids is not clear; however, recent advances in molecular biology and genetics are beginning to shed light on the underlying mechanisms implicated in keloid scar formation which will hopefully lead to the development of treatment options for all keloid types. This review summarises current and emerging therapies.
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Affiliation(s)
- Nkemcho Ojeh
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Ambadasu Bharatha
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Uma Gaur
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Andrew LeRoy Forde
- Pine Medical Centre, 3rd Avenue Belleville, St. Michael, Barbados, West Indies
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Abstract
Autologous fat grafting is a technique with various applications in the craniofacial region ranging from the treatment of wounds, scars, keloids, and soft tissue deformities. In this review, alternative therapies to fat grafting are discussed. These are composed of established therapies like silicone gel or sheeting, corticosteroids, cryotherapy, and laser therapy. Novel applications of negative pressure wound therapy, botulinum toxin A injection, and biologic agents are also reviewed.
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Coentro JQ, Pugliese E, Hanley G, Raghunath M, Zeugolis DI. Current and upcoming therapies to modulate skin scarring and fibrosis. Adv Drug Deliv Rev 2019; 146:37-59. [PMID: 30172924 DOI: 10.1016/j.addr.2018.08.009] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 07/08/2018] [Accepted: 08/26/2018] [Indexed: 12/12/2022]
Abstract
Skin is the largest organ of the human body. Being the interface between the body and the outer environment, makes it susceptible to physical injury. To maintain life, nature has endowed skin with a fast healing response that invariably ends in the formation of scar at the wounded dermal area. In many cases, skin remodelling may be impaired, leading to local hypertrophic scars or keloids. One should also consider that the scarring process is part of the wound healing response, which always starts with inflammation. Thus, scarring can also be induced in the dermis, in the absence of an actual wound, during chronic inflammatory processes. Considering the significant portion of the population that is subject to abnormal scarring, this review critically discusses the state-of-the-art and upcoming therapies in skin scarring and fibrosis.
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Affiliation(s)
- João Q Coentro
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Eugenia Pugliese
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Geoffrey Hanley
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Michael Raghunath
- Center for Cell Biology and Tissue Engineering, Institute for Chemistry and Biotechnology (ICBT), Zurich University of Applied Sciences (ZHAW), Wädenswil, Switzerland
| | - Dimitrios I Zeugolis
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland.
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Gong T, Zhang C, Kang J, Lou Z, Scholp A, Jiang JJ. The effects of cryotherapy on vocal fold healing in a rabbit model. Laryngoscope 2018; 129:E151-E157. [PMID: 30468242 DOI: 10.1002/lary.27629] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVES/HYPOTHESIS Cryotherapy has been shown to be a scarless treatment modality for dermal lesions; however, there are limited data addressing the effect of cryotherapy on vocal fold tissue. The aim of this study was to clarify the effectiveness of cryotherapy for prevention of postsurgical vocal fold scarring. STUDY DESIGN Prospective animal study in rabbits. METHODS The lamina propria of 20 rabbit vocal folds was bilaterally stripped, followed by randomized unilateral cryotherapy. Five larynges were harvested for real-time polymerase chain reaction (RT-PCR) analysis at 1 day, 3 days, and 7 days postinjury. The remaining five were harvested for histologic analysis at 3 months. Images of the healing phase were recorded by laryngoscopy. Analyses of RT-PCR for cyclooxygenase (COX)-2, interleukin (IL)-6, collagen I, collagen III, matrix metallopeptidase 1 (MMP1), transforming growth factor β (TGFβ1), α smooth muscle actin (α-SMA), and hyaluronan synthase 1 (HAS1) were completed. Histological samples were completed for collagen and hyaluronic acid analysis. RESULTS RT-PCR results revealed that higher expressions of HAS1 and MMP1 and lower expressions of COX-2, IL-6, collagen I, collagen III, TGFβ1, and α-SMA were observed, and histological examination showed significantly increased hyaluronic acid, decreased deposition, and more organized configuration of collagen in injury with the cryotherapy cohort compared with the injury cohort. CONCLUSIONS Cryotherapy can inhibit the inflammatory reaction and simulate a fetal healing environment in extracellular matrix synthesis to regenerate vocal fold tissue with less fibrosis. Histological results showed that cryotherapy achieves a mature healing result with less scar, which tends to return to normal. In summary, the findings of this study suggest that administration of cryotherapy at the time of injury has the potential to minimize vocal fold scarring. LEVEL OF EVIDENCE NA Laryngoscope, 129:E151-E157, 2019.
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Affiliation(s)
- Ting Gong
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | - Chi Zhang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | - Jing Kang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | - Zhewei Lou
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | - Austin Scholp
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Jack J Jiang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
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Han B, Fan J, Liu L, Tian J, Gan C, Yang Z, Jiao H, Zhang T, Liu Z, Zhang H. Adipose-derived mesenchymal stem cells treatments for fibroblasts of fibrotic scar via downregulating TGF-β1 and Notch-1 expression enhanced by photobiomodulation therapy. Lasers Med Sci 2018; 34:1-10. [DOI: 10.1007/s10103-018-2567-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 06/14/2018] [Indexed: 12/23/2022]
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Gong T, Zhang C, Kang J, Lamb JJ, Jiang JJ. Cryotherapy has antifibrotic and regenerative effects on human vocal fold fibroblasts. Laryngoscope 2018; 129:E143-E150. [PMID: 30315572 DOI: 10.1002/lary.27499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/22/2018] [Accepted: 07/13/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVES/HYPOTHESIS Vocal fold scarring remains a major treatment challenge, and scar prevention without residual lesions remains a dilemma. Cryotherapy has shown cosmetic outcomes on skin lesions with minimal scarring. The aim of this study was to clarify the beneficial effects of cryotherapy for the prevention and the treatment of vocal fold scarring. STUDY DESIGN In vitro. METHODS Primary cultures of human vocal fold fibroblasts (VFFs) were used in this study. Myofibroblast differentiation was stimulated by transforming growth factor β1 (TGF-β1). We mimicked the cryotherapy effect on vocal fold healing in vivo by freezing VFFs ± TGF-β1 in vitro. The influence of freezing on cell viability, proliferation, migration, and contractile properties were analyzed. The expression of collagen I, collagen III, fibronectin, TGF-β1, matrix metallopeptidase 1 (MMP1), hyaluronan synthase 1 (HAS1) were investigated by real-time polymerase chain reaction (RT-PCR), and the expression of alpha smooth muscle actin (α-SMA) and decorin were investigated by RT-PCR and Western blot. RESULTS Freezing was found to modify extracellular matrix (ECM) synthesis and differentiation of VFFs. Expression of collagen I, collagen III, fibronectin, α-SMA, and TGF-β1 was downregulated, and MMP1 was upregulated in VFFs + TGF-β1 (myofibroblast) by freezing. HAS1 and decorin were upregulated in both VFFs ± TGF-β1 by freezing. Freezing VFFs + TGF-β1 (myofibroblast) with fast thawing had a lower expression of α-SMA when compared with slow thawing. Freezing reduced the migration and collagen contraction of VFFs + TGF-β1 (myofibroblast). CONCLUSION Cryotherapy induces antifibrotic and regenerative ECM alterations in VFFs. These data provide insight into the prevention and the treatment of vocal fold scarring with cryotherapy in phonomicrosurgery. LEVEL OF EVIDENCE NA Laryngoscope, 129:E143-E150, 2019.
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Affiliation(s)
- Ting Gong
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | - Chi Zhang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | - Jing Kang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China
| | | | - Jack J Jiang
- Department of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China.,Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, U.S.A
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Azzam EZ, Omar SS. Treatment of auricular keloids by triple combination therapy: Surgical excision, platelet-rich plasma, and cryosurgery. J Cosmet Dermatol 2018; 17:502-510. [DOI: 10.1111/jocd.12552] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Ehab Zaki Azzam
- Department of Plastic and Reconstructive surgery; Faculty of Medicine; Alexandria University; Alexandria Egypt
| | - Salma Samir Omar
- Department of Dermatology, Venereology & Andrology; Faculty of Medicine; Alexandria University; Alexandria Egypt
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Intralesional excision combined with intralesional cryosurgery for the treatment of oversized and therapy-resistant keloids of the neck and ears. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018. [DOI: 10.1007/s00238-017-1360-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Intralesional cryotherapy versus excision with corticosteroid injections or brachytherapy for keloid treatment: Randomised controlled trials. J Plast Reconstr Aesthet Surg 2018; 71:847-856. [PMID: 29426811 DOI: 10.1016/j.bjps.2018.01.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/25/2017] [Accepted: 01/21/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Keloids are a burden for patients due to physical, aesthetic and social consequences. Treatment remains a challenge due to therapy resistance and high recurrence rates. The main goals of treatment are to improve scar appearance and symptoms and patients' quality of life (QoL). METHODS Two multicentre, randomised controlled open trials that compared 1) intralesional cryotherapy with excision and corticosteroid injections for primary keloids, and 2) intralesional cryotherapy with excision and brachytherapy for therapy resistant keloids. Primary outcome was scar appearance assessed with the Patient and Observer Scar Assessment Scale. Secondary outcomes were patient reported QoL (Skindex-29, SF-36, EQ-5D-5L), recurrence rates and scar volume reduction. For analysis, a linear mixed model was used. Power analysis indicated 33 patients in each group were needed. RESULTS The trial was prematurely terminated after inclusion of 26 patients due to unexpectedly inferior outcomes after intralesional cryotherapy. For primary keloids no convincing difference between treatments was found, but surgery improved scar appearance while cryotherapy did not. For resistant keloids, excision followed by brachytherapy improved scar appearance (POSAS) and scar symptoms (itch and pain) significantly (p < 0.001, p < 0.001 and p = 0.006 respectively) while cryotherapy did not. Neither of the treatments caused indisputable improvements in QoL. CONCLUSIONS Intralesional cryotherapy is inferior to keloid excision followed by brachytherapy for resistant keloids. In primary keloids, intralesional cryotherapy reduced keloid volume and, therefore, may be used in these patients and specific cases. Primary keloid group size was too small to draw valid conclusions, further research on the efficacy of intralesional cryotherapy for primary keloids is warranted.
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Abstract
This article provides a review of the surgical and nonsurgical options available to manage a variety of auricular scars. The basics of wound healing are discussed in addition to the etiology of keloids and the cauliflower ear. Many auricular scars can be revised with scar excision techniques, but separate discussions for the treatment of keloids and the cauliflower ear are provided. The management plan for auricular scarring requires appropriate patient counseling regarding the risk of recurrence in keloids, regrowth of scar tissue in cauliflower ears, scar hypertrophy at the line of closure, widening of the scar, and persisting ear contour deformities.
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Affiliation(s)
- Deborah Watson
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, 3350 La Jolla Village Drive, 112-C, San Diego, CA 92161, USA
| | - Bharat Panuganti
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, 3350 La Jolla Village Drive, 112-C, San Diego, CA 92161, USA.
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O'Boyle CP, Shayan-Arani H, Hamada MW. Intralesional cryotherapy for hypertrophic scars and keloids: a review. Scars Burn Heal 2017; 3:2059513117702162. [PMID: 29799581 PMCID: PMC5965337 DOI: 10.1177/2059513117702162] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Ciaran P O'Boyle
- Department of Burns & Plastic Surgery, Nottingham University Hospitals NHS Trust, School of Medicine, The University of Nottingham, UK
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Awad SM, Ismail SA, Sayed DS, Refaiy AE, Makboul R. Suppression of transforming growth factor-beta1 expression in keloids after cryosurgery. Cryobiology 2017; 75:151-153. [DOI: 10.1016/j.cryobiol.2017.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 03/02/2017] [Accepted: 03/09/2017] [Indexed: 11/29/2022]
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McGoldrick RB, Theodorakopoulou E, Azzopardi EA, Murison M. Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars. Scars Burn Heal 2017; 3:2059513116689805. [PMID: 29799579 PMCID: PMC5965340 DOI: 10.1177/2059513116689805] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Rory Boyd McGoldrick
- Welsh Regional Burns, Plastic, Reconstructive Surgery and Laser Unit, Morriston Hospital, Swansea, Wales, UK
| | - Evgenia Theodorakopoulou
- Welsh Regional Burns, Plastic, Reconstructive Surgery and Laser Unit, Morriston Hospital, Swansea, Wales, UK
| | | | - Maxwell Murison
- Welsh Regional Burns, Plastic, Reconstructive Surgery and Laser Unit, Morriston Hospital, Swansea, Wales, UK
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Abstract
BACKGROUND Keloid and hypertrophic scars represent an aberrant response to the wound healing process. These scars are characterized by dysregulated growth with excessive collagen formation, and can be cosmetically and functionally disruptive to patients. OBJECTIVE Objectives are to describe the pathophysiology of keloid and hypertrophic scar, and to compare differences with the normal wound healing process. The classification of keloids and hypertrophic scars are then discussed. Finally, various treatment options including prevention, conventional therapies, surgical therapies, and adjuvant therapies are described in detail. MATERIALS AND METHODS Literature review was performed identifying relevant publications pertaining to the pathophysiology, classification, and treatment of keloid and hypertrophic scars. RESULTS Though the pathophysiology of keloid and hypertrophic scars is not completely known, various cytokines have been implicated, including interleukin (IL)-6, IL-8, and IL-10, as well as various growth factors including transforming growth factor-beta and platelet-derived growth factor. Numerous treatments have been studied for keloid and hypertrophic scars,which include conventional therapies such as occlusive dressings, compression therapy, and steroids; surgical therapies such as excision and cryosurgery; and adjuvant and emerging therapies including radiation therapy, interferon, 5-fluorouracil, imiquimod, tacrolimus, sirolimus, bleomycin, doxorubicin, transforming growth factor-beta, epidermal growth factor, verapamil, retinoic acid, tamoxifen, botulinum toxin A, onion extract, silicone-based camouflage, hydrogel scaffold, and skin tension offloading device. CONCLUSION Keloid and hypertrophic scars remain a challenging condition, with potential cosmetic and functional consequences to patients. Several therapies exist which function through different mechanisms. Better understanding into the pathogenesis will allow for development of newer and more targeted therapies in the future.
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Intralesional cryosurgery for the treatment of keloid scars following cochlear implant surgery and removal of cholesteatoma. EUROPEAN JOURNAL OF PLASTIC SURGERY 2016. [DOI: 10.1007/s00238-016-1183-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Har-Shai Y, Sommer A, Gil T, Krausz J, Gal-Or N, Mettanes I, Lavi I, Eyal N, Brizgalin L, Taran A, Har-Shai L, Elmalach I. Intralesional cryosurgery for the treatment of basal cell carcinoma of the lower extremities in elderly subjects: a feasibility study. Int J Dermatol 2016; 55:342-50. [PMID: 26749491 DOI: 10.1111/ijd.13168] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/10/2015] [Accepted: 08/01/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Yaron Har-Shai
- Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Adir Sommer
- Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Tamir Gil
- Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Judit Krausz
- Department of Pathology, Ha-Emek Medical Center, Afula, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Nir Gal-Or
- Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Issa Mettanes
- Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Idit Lavi
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Nir Eyal
- Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Leonid Brizgalin
- Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Amir Taran
- Unit of Plastic Surgery, Carmel Medical Center, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Lior Har-Shai
- Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
| | - Irit Elmalach
- Department of Pathology, Ha-Emek Medical Center, Afula, Israel.,Bruce Rappaport Faculty of Medicine, Israel Institute of Technology (Technion), Haifa, Israel
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Abstract
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.
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Intralesional Cryotherapy for the Treatment of Keloid Scars: Evaluating Effectiveness. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e437. [PMID: 26180738 PMCID: PMC4494507 DOI: 10.1097/gox.0000000000000348] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/04/2015] [Indexed: 12/11/2022]
Abstract
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.
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van Leeuwen MCE, Bulstra AEJ, van der Veen AJ, Bloem WB, van Leeuwen PAM, Niessen FB. Comparison of two devices for the treatment of keloid scars with the use of intralesional cryotherapy: An experimental study. Cryobiology 2015; 71:146-50. [PMID: 25920961 DOI: 10.1016/j.cryobiol.2015.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/14/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Michiel C E van Leeuwen
- Department of Plastic and Reconstructive Surgery, VU University Medical Center, Amsterdam, The Netherlands.
| | - Anne Eva J Bulstra
- Department of Plastic and Reconstructive Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - A J van der Veen
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - W B Bloem
- Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands
| | - P A M van Leeuwen
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - F B Niessen
- Department of Plastic and Reconstructive Surgery, VU University Medical Center, Amsterdam, The Netherlands
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Ahuja RB, Chatterjee P, Deraje V. A critical appraisal of nonsurgical modalities for managing hypertrophic scars and keloids. FORMOSAN JOURNAL OF SURGERY 2015. [DOI: 10.1016/j.fjs.2015.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abdel-Meguid AM, Weshahy AH, Sayed DS, Refaiy AE, Awad SM. Intralesional vs. contact cryosurgery in treatment of keloids: a clinical and immunohistochemical study. Int J Dermatol 2014; 54:468-75. [DOI: 10.1111/ijd.12667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Ahmed Hany Weshahy
- Department of Dermatology and Venereology; Cairo University; Cairo Egypt
| | - Doaa S. Sayed
- Department of Dermatology and Venereology; Assiut University; Assiut Egypt
| | | | - Sara M.I. Awad
- Department of Dermatology and Venereology; Assiut University; Assiut Egypt
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Chopinaud M, Pham AD, Labbé D, Verneuil L, Gourio C, Bénateau H, Dompmartin A. Intralesional cryosurgery to treat keloid scars: results from a retrospective study. Dermatology 2014; 229:263-70. [PMID: 25248067 DOI: 10.1159/000365392] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 06/16/2014] [Indexed: 11/19/2022] Open
Abstract
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.
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Abstract
BACKGROUND Following injury, Asian skin has a tendency towards hyper-pigmentation and scar formation, and therefore the prevention of scarring is particularly important in Asian patients. Since publication of an International Clinical Recommendation on Scar Management in 2002, there have been numerous publications in the field of scar management. Advances in understanding scar formation have also led to the introduction of new treatments as well as a better understanding of established therapeutic options. METHODS A literature search for abstracts, clinical trials and meta-analyses evaluating scar prevention and treatment was performed using PubMed and the Cochrane Database of Systematic Reviews. Based on this data a panel of experts formulated treatment recommendations for Asian patients. RESULTS Following surgery, scar prevention should be initiated in all Asian patients due to the high risk of poor scars. There is strong evidence for the efficacy of silicone based products, and due to their ease of use, they can be considered first-line therapy. Silicone gel (versus silicone gel sheets) products have demonstrated efficacy. For patients who fail to respond to first-line therapy, intralesional steroid injections, radiation therapy, and intralesional 5-flourouracil injections have achieved widespread acceptance. Laser treatments have been increasingly used, although the evidence remains largely anecdotal without a clear consensus on optimal wavelength, or amount of energy. Surgical approaches have increased in sophistication with recognition of the impact that tension has on scar formation. CONCLUSION Updated scar management recommendations will benefit practitioners making decisions regarding optimal, evidence-based treatment strategies for their patients.
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Bijlard E, Timman R, Verduijn GM, Niessen FB, van Neck JW, Busschbach JJV, Mureau MAM. Intralesional cryotherapy versus excision and corticosteroids or brachytherapy for keloid treatment: study protocol for a randomised controlled trial. Trials 2013; 14:439. [PMID: 24354714 PMCID: PMC3878407 DOI: 10.1186/1745-6215-14-439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 12/09/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Keloids are a burden for patients due to physical, aesthetic and social complaints and treatment remains a challenge because of therapy resistance and high recurrence rates. The main goal of treatment is to improve the quality of life (QoL); this implies that, apart from surgical outcomes, patient-reported outcome measures (PROMs) need to be taken into account. Decision making in keloid treatment is difficult due to heterogeneity of the condition and the lack of comparative studies. METHODS/DESIGN This is a multicentre, randomised controlled open trial that compares 1) intralesional cryotherapy versus excision and corticosteroids for primary keloids, and 2) intralesional cryotherapy versus excision and brachytherapy for therapy-resistant keloids. The primary outcome is the Patient and Observer Scar Assessment Scale (POSAS), a 12-item scale (with score 12 indicating the best and 120 indicating the worst scar imaginable). A difference of six points on the total score is considered to be of clinical importance. Secondary outcomes are recurrence rates, volume reduction, Skindex-29 scores, SF-36 scores and complication rates. Primary and secondary outcome measurements are taken at baseline, and at 2, 12, 26 and 52 weeks postoperatively. For analysis, a linear mixed model is used. A total of 176 patients will be included over a period of 2.5 years. The protocol is approved by the Medical Ethics Committee of the Erasmus University Medical Centre Rotterdam and follows good clinical practice guidelines. DISCUSSION The outcomes of this study will improve evidence-based decision making for the treatment of keloids, as well as patient education. TRIAL REGISTRATION Dutch Trial Register NTR4151.
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Affiliation(s)
- Eveline Bijlard
- Department of Plastic Reconstructive and Hand Surgery ErasmusMC, Erasmus University Medical Centre Rotterdam Room EE1591 Dr, Molewaterplein, 50 3015 GE, Rotterdam, Netherlands.
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Litrowski N, Boullie M, Dehesdin D, De Barros A, Joly P. Treatment of earlobe keloids by surgical excision and cryosurgery. J Eur Acad Dermatol Venereol 2013; 28:1324-31. [DOI: 10.1111/jdv.12282] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 12/01/2022]
Affiliation(s)
- N. Litrowski
- Dermatology Department; Inserm U905; Institute for Research and Innovation in Biomedicine; Rouen University Hospital; University of Normandy; Rouen France
| | - M.C. Boullie
- Dermatology Department; Inserm U905; Institute for Research and Innovation in Biomedicine; Rouen University Hospital; University of Normandy; Rouen France
| | - D. Dehesdin
- Otorhinolaryngology-Head and Neck Surgery Department; Rouen University Hospital; Rouen France
| | - A. De Barros
- Otorhinolaryngology-Head and Neck Surgery Department; Rouen University Hospital; Rouen France
| | - P. Joly
- Dermatology Department; Inserm U905; Institute for Research and Innovation in Biomedicine; Rouen University Hospital; University of Normandy; Rouen France
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Al Aradi IK, Alawadhi SA, Alkhawaja FA. Earlobe Keloids: A Pilot Study of the Efficacy of Keloidectomy with Core Fillet Flap and Adjuvant Intralesional Corticosteroids. Dermatol Surg 2013; 39:1514-9. [DOI: 10.1111/dsu.12262] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Osman OS, Selway JL, Harikumar PE, Stocker CJ, Wargent ET, Cawthorne MA, Jassim S, Langlands K. A novel method to assess collagen architecture in skin. BMC Bioinformatics 2013; 14:260. [PMID: 23971965 PMCID: PMC3765639 DOI: 10.1186/1471-2105-14-260] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 08/21/2013] [Indexed: 12/01/2022] Open
Abstract
Background Texture within biological specimens may reveal critical insights, while being very difficult to quantify. This is a particular problem in histological analysis. For example, cross-polar images of picrosirius stained skin reveal exquisite structure, allowing changes in the basketweave conformation of healthy collagen to be assessed. Existing techniques measure gross pathological changes, such as fibrosis, but are not sufficiently sensitive to detect more subtle and progressive pathological changes in the dermis, such as those seen in ageing. Moreover, screening methods for cutaneous therapeutics require accurate, unsupervised and high-throughput image analysis techniques. Results By analyzing spectra of images post Gabor filtering and Fast Fourier Transform, we were able to measure subtle changes in collagen fibre orientation intractable to existing techniques. We detected the progressive loss of collagen basketweave structure in a series of chronologically aged skin samples, as well as in skin derived from a model of type 2 diabetes mellitus. Conclusions We describe a novel bioimaging approach with implications for the evaluation of pathology in a broader range of biological situations.
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Affiliation(s)
- Osman S Osman
- The Clore Laboratory, The University of Buckingham, Hunter Street, Buckingham MK18 1EG, UK.
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Weshahy AH, Abdel Hay R. Intralesional cryosurgery and intralesional steroid injection: a good combination therapy for treatment of keloids and hypertrophic scars. Dermatol Ther 2013; 25:273-6. [PMID: 22913446 DOI: 10.1111/j.1529-8019.2012.01456.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Hypertrophic scars and keloids exhibit high recurrence rates following surgical excision. Intralesional cryosurgery (ILC) can achieve a higher degree of effectiveness than the surface cryotherapy. The aim of this study is to assess the clinical efficacy of ILC using Weshahy cryoneedles followed by IL steroid in a trial of getting rid of the fibrous mass by destruction, not by surgery to avoid being under tension of the new scar. This study included 22 patients. Evaluation of the volume reduction of the lesions was done after a single ILC session followed by IL steroid injections. There was a significant decrease in the volume of the lesions after 4 months (P < 0.01), with a volume reduction of 93.5%. By using ILC at the base of keloids or hypertrophic scars, we can change the old fibrous tissue into a recent scar or granulation tissue which will respond more successfully to IL steroid injection.
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Affiliation(s)
- Ahmed Hany Weshahy
- Dermatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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Ogawa R, Okai K, Tokumura F, Mori K, Ohmori Y, Huang C, Hyakusoku H, Akaishi S. The relationship between skin stretching/contraction and pathologic scarring: The important role of mechanical forces in keloid generation. Wound Repair Regen 2012; 20:149-57. [DOI: 10.1111/j.1524-475x.2012.00766.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 12/26/2011] [Indexed: 12/16/2022]
Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery; Nippon Medical School; Tokyo; Japan
| | - Kazuhisa Okai
- Research and Development Department; Nichiban Co., Ltd; Tokyo; Japan
| | - Fumio Tokumura
- Medicinal Safety Information Group; Nichiban Co., Ltd; Hidaka; Japan
| | - Kazuyuki Mori
- Research and Development Department; Nichiban Co., Ltd; Tokyo; Japan
| | - Yasutaka Ohmori
- Department of Plastic, Reconstructive and Aesthetic Surgery; Nippon Medical School; Tokyo; Japan
| | - Chenyu Huang
- Department of Plastic, Reconstructive and Aesthetic Surgery; Nippon Medical School; Tokyo; Japan
| | - Hiko Hyakusoku
- Department of Plastic, Reconstructive and Aesthetic Surgery; Nippon Medical School; Tokyo; Japan
| | - Satoshi Akaishi
- Department of Plastic, Reconstructive and Aesthetic Surgery; Nippon Medical School; Tokyo; Japan
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Intralesional cryosurgery for the treatment of basal cell carcinoma in an elderly patient. EUROPEAN JOURNAL OF PLASTIC SURGERY 2012. [DOI: 10.1007/s00238-012-0692-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cutaneous scarring: Pathophysiology, molecular mechanisms, and scar reduction therapeutics. J Am Acad Dermatol 2012; 66:13-24; quiz 25-6. [DOI: 10.1016/j.jaad.2011.08.035] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 08/13/2011] [Accepted: 08/17/2011] [Indexed: 02/08/2023]
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Verhaegen PDHM, Marle JV, Kuehne A, Schouten HJ, Gaffney EA, Maini PK, Middelkoop E, Zuijlen PPMV. Collagen bundle morphometry in skin and scar tissue: a novel distance mapping method provides superior measurements compared to Fourier analysis. J Microsc 2011; 245:82-9. [PMID: 21919907 DOI: 10.1111/j.1365-2818.2011.03547.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Histopathological evaluations of fibrotic processes require the characterization of collagen morphology in terms of geometrical features such as bundle orientation thickness and spacing. However, there are currently no reliable and valid techniques of measuring bundle thickness and spacing. Hence, two objective methods quantifying the collagen bundle thickness and spacing were tested for their reliability and validity: Fourier first-order maximum analysis and Distance Mapping, with the latter constituting a newly developed morphometric technique. Histological slides were constructed and imaged from 50 scar and 50 healthy human skin biopsies and subsequently analyzed by two observers to determine the interobserver reliability via the intraclass correlation coefficient. An intraclass correlation coefficient larger than 0.7 is considered as representing good reliability. The interobserver reliability for the Fourier first-order maximum and for the Distance Mapping algorithms, respectively, showed an intraclass correlation coefficient above 0.72 and 0.89. Additionally, we performed an assessment of validity in the form of responsiveness, in particular, demonstrating medium to excellent results via a calculation of the effect size, highlighting that both methods are sensitive enough to measure a treatment effect in clinical practice. In summary, two reliable and valid measurement methods were demonstrated for collagen bundle morphometry for the first time. Due to its superior reliability and more useful measures (bundle thickness and bundle spacing), Distance Mapping emerges as the preferred and more practical method. Nevertheless, in the future, both methods can be used for reliable and valid collagen morphometry of skin and scars, whereas further applications evaluating the quantitative microscopy of other fibrotic processes are anticipated.
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Mirmovich O, Gil T, Goldin I, Lavi I, Mettanes I, Har-Shai Y. Pain evaluation and control during and following the treatment of hypertrophic scars and keloids by contact and intralesional cryosurgery - a preliminary study. J Eur Acad Dermatol Venereol 2011; 26:440-7. [DOI: 10.1111/j.1468-3083.2011.04092.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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