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]

Keloids revisited: Current concepts in treatment and differential diagnosis

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

Piezo1-Mediated Calcium Flux Transfers Mechanosignal to Yes-Associated Protein to Stimulate Matrix Production in Keloid

Keloids are fibroproliferative diseases affecting millions of people worldwide, but curing keloids remains challenging. Mechanical force is a common initiator and driver of keloids, and blocking the proadhesive signaling pathways is expected to cure keloids. This study found higher levels of Piezo1 in human keloid fibroblasts than in normal skin fibroblasts. Single-cell transcriptome analysis revealed a correlation of Piezo1 with Yes-associated protein (YAP) in keloid fibroblasts. Knockdown of Piezo1/YAP in keloid fibroblasts versus fibroblasts decreased CCN2 and CCN1 expression and fibrosis-related cell behaviors, identifying Piezo1 and YAP as upstream signals of proadhesive signaling loop in keloids. Treatment of patient-derived keloid xenograft model with Piezo1 inhibitor GsMTx4 and YAP inhibitor verteporfin reduced keloid volume and decreased type I/III collagen ratio. Atomic force microscopy further confirmed the biomechanical improvements of keloids in elasticity, viscoelasticity, and roughness ex vivo. In addition, the calcium ion-sensitive fluorescent indicator Fluo-3/AM and double-labeling immunofluorescence stains showed that Piezo1 transferred mechanosignal to increase YAP nuclear translocation through calcium flux. Finally, transcriptomics revealed target genes of the Piezo1/YAP signaling pathway, such as TBX3, SESN2, SMAD7, FOSB, JARID2, and HAS2. Consequently, the Piezo1/calcium flux/YAP signaling axis contributes to the mechanically induced proadhesive signaling pathway, and thus, Piezo1 and YAP are promising targets for keloid treatment.

Combination therapy of pulsed dye laser and ablative fractional carbon dioxide laser for the treatment of pediatric postburn scar: a systematic review

This study aims to determine the effectiveness of combining pulsed dye laser (PDL) and ablative fractional carbon dioxide laser (AFCL) in the treatment of scars in pediatric patients, as well as to identify appropriate treatment parameters, initial treatment timing, and treatment intervals through a systematic literature review. A literature search was conducted between April 6, 2014 and April 6, 2024 in four databases to select studies on the effects of the combination of carbon dioxide fractional laser and pulsed dye laser therapy in children hypertrophic burn scars. This systematic literature review included 497 participants across 8 studies, with individual study sample sizes ranging from 17 to 125 participants. 7 studies reported the gender distribution of participants, with a higher proportion of males (60%, n = 264) than females (40%, n = 170). The average age of the patients was 7.18 years, and scald (62%, n = 235) were identified as the primary cause of scar. The combination therapy of 595 nm PDL and 10,600 nm AFCL significantly improved Vancouver Scar Scale (VSS) / Patient and Observer Scar Assessment Scale (POSAS) score. Study treatment intervals were approximately 1-2 months for simultaneous treatment and 1 month for PDL and 3 months for AFCL for sequential treatment. Two studies investigated the efficacy of early laser therapy (< 3 months), the AFCL laser energy parameters ranged from 30 mJ-50 mJ, significantly lower than the rest of the studies of laser energy parameters, which ranged from 50 mJ-120 mJ. The PDL energy density parameters showed little difference from study to study and were in the range of 5-12 J/cm2. Complications after treatment (4%, n = 22), with rash being the most common (50%, n = 11). Rational use of PDL combined with AFCL (lower laser energy, increase density parameters, shorten treatment intervals (< 1 month)) can safely and effectively treat hypertrophic scars in pediatric burn patients and is superior to single-type laser therapy in efficacy. Significant disorganization was observed among studies suggesting the need to explore high-level evidence-based clinical research that may improve treatment outcomes.

Fraxinellone-mediated targeting of cathepsin B leakage from lysosomes induces ferroptosis in fibroblasts to inhibit hypertrophic scar formation

BACKGROUND

Hypertrophic scar (HS) is a common fibrotic skin disorder characterized by the excessive deposition of extracellular matrix (ECM). Fibroblasts are the most important effector cells involved in HS formation. Currently no satisfactory treatment has been developed.

METHODS

The impact of fraxinellone (FRA) on the proliferation and migration capacity of human hypertrophic scar-derived fibroblasts (HSFs) was assessed by EdU proliferation, wound healing and transwell assays. Quantitative real-time PCR (qRT‒PCR), Western blot (WB), immunofluorescence staining and collagen gel contraction assays were performed to evaluate the collagen production and activation capacity of HSFs. Oxford Nanopore Technologies long-read RNA sequencing (ONT long-read RNA-seq) revealed the occurrence of ferroptosis in HSF and ferroptosis executioner-cathepsin B (CTSB). The mechanisms underlying FRA-induced HSF ferroptosis were examined through fluorescence staining, qRT‒PCR, WB and molecular docking study. The therapeutic efficacy of FRA was further validated in vivo using a rabbit ear scar model.

RESULTS

FRA treatment significantly suppressed the proliferation, migration, collagen production and activation capacity of HSFs. ONT long-read RNA-seq discovered that FRA modulated the expression of transcripts related to ferroptosis and lysosomes. Mechanistically, FRA treatment reduced the protein expression level of glutathione peroxidase 4 (GPX4) and induced the release of CTSB from lysosomes into the cytoplasm. CTSB further induced ferroptosis via spermidine/spermine-N1-acetyltransferase (SAT1)-mediated lipid peroxidation, mitochondrial damage and mitogen-activated protein kinase (MAPK) signalling pathway activation, eventually affecting the function of HSFs. Moreover, FRA treatment attenuated the formation of HS in rabbit ears via CTSB-mediated ferroptosis. The antifibrotic effects of FRA were abrogated by pretreatment with a CTSB inhibitor (CA-074-me).

CONCLUSIONS

This study reveals that FRA ameliorates HS by inducing CTSB leakage from lysosomes, causing SAT1-mediated lipid peroxidation, mitochondrial damage and MAPK signalling pathway activation, thus mediating HSF ferroptosis. Therefore, FRA could be a promising therapeutic agent for treating HS.

Knowledge, attitude, and practice of aesthetic medicine practitioners towards laser and/or light therapy for hypertrophic scars

This study investigated the knowledge, attitude, and practice (KAP) of aesthetic medicine practitioners concerning laser and/or light therapy for hypertrophic scars. Conducted at Hebei Medical University Third Hospital from December 25, 2023, to January 7, 2024, the cross-sectional study utilized a self-administered questionnaire to gather socio-demographic data and KAP scores. A total of 424 valid questionnaires were collected, with 220 (52.26%) female participants. The mean scores were 27.24 ± 4.28 for knowledge (range 8-40), 34.14 ± 3.49 for attitude (range 9-45), and 26.22 ± 3.46 for practice (range 6-30). Significant positive correlations were observed between knowledge and attitude (r = 0.471, P < 0.001), knowledge and practice (r = 0.593, P < 0.001), and attitude and practice (r = 0.640, P < 0.001). Multivariate logistic regression revealed that both knowledge (OR = 1.260, P < 0.001) and attitude scores (OR = 1.547, P < 0.001), along with the intermediate professional title (OR = 0.233, P = 0.042), were significantly associated with proactive practice. The findings indicate a need for targeted educational initiatives to enhance practitioners' knowledge in this area.

The Effectiveness of Early Treatment With Intense Pulsed Light Combined With Fractional Erbium Laser in Preventing Post-traumatic Hypertrophic Scar Formation

BACKGROUND

Once scars form and begin to proliferate, treatment becomes challenging. Traditional methods of scar treatment often provide suboptimal results. Therefore, early intervention has become widely accepted, with a focus on prevention during the wound-healing phase rather than later treatment. Here, the authors evaluate the effectiveness of early treatment with intense pulsed light (IPL) combined with fractional erbium laser in preventing the formation of post-traumatic hypertrophic scars.

METHODS

A total of 120 patients who underwent emergency cosmetic suture surgery for facial trauma between January 2019 and December 2021 were selected for the study. The control group received conventional antiscar therapy (pressure therapy or antiscar medication), while the observation group received IPL combined with fractional erbium laser in addition to the conventional treatment. The specific treatment doses were adjusted based on the patient's age, scar color, texture, and thickness. A treatment course consisted of 3 to 5 sessions, with 4-week intervals between treatments. Follow-up was conducted within 1 year after treatment to assess the improvement in scar appearance before and after therapy.

RESULTS

After IPL combined with fractional erbium laser treatment, patients in the observation group showed significantly lower scores in color, thickness, vascular distribution, softness, and total scores on the Vancouver Scar Scale (VSS) compared with the control group. During the follow-up, 3 complications were observed: 2 cases of skin blisters and 1 case of pigmentation. No immediate skin lesions, depigmentation, infections, ulcers, or other adverse reactions were reported.

CONCLUSIONS

For patients with early-stage superficial scars following trauma surgery, early treatment with IPL combined with fractional erbium laser not only leads to significant improvements in appearance and effectively prevents hypertrophic scar formation but also promotes rapid recovery with few complications. This approach has clinical value.

A novel model of post-burn hypertrophic scarring in rat tail with a high success rate and simple methodology

BACKGROUND

Hypertrophic scars present a serious concern after surgeries and trauma, particularly with the highest risk following burn injury. The current modeling methods usually involve relatively complicated surgical operations and special equipment, and have unstable reproducibility and reliability. This study aimed to establish a simple and reliable model of post-burn hypertrophic scarring in the rat tail.

METHODS

Wet gauze saturated with hot water (94-98 °C) was applied to the dorsal side of the rat tail for varying durations to induce burn injury. Wounds were left exposed until completely healed, and the optimal duration for scalding treatment was determined based on gross examination. Thereafter, the optimal scalding duration was used again to evaluate scar formation over time, which was tracked through hematoxylin-eosin (HE) and Masson staining, immunohistochemistry of scar-related proteins and number/distribution of vascular endothelial cells, and picrosirius red staining to measure the quantities and proportion of type I and III collagen.

RESULTS

The scalding duration which led to optimal post-burn scarring was 15 s, with an overall success rate of 87.5 %. Complete healing of the wound occurred after roughly 30 days, leading to the formation of scars grossly red in appearance, tough to the touch and raised compared to the surrounding skin. Microscopically, the epidermis and dermis of the scar were significantly thicker than normal rat tail skin, and the dermis of scar contained a large number of disorganized bundles of fine filamentous collagen. We also observed a significant increase in the number of TGF-β1-positive cells and capillaries in the dermis (p < 0.05). Picrosirius red staining showed that compared to type III collagen, the expression of type I collagen was more dominant in scar tissue, and was more finely distributed than in normal rat tail skin.

CONCLUSION

We successfully established a model for post-burn hypertrophic scarring, utilizing reliable and simple techniques and materials, which could simulate the biological characteristics of post-burn scarring. Our innovative model has the potential to facilitate the study of post-burn wound healing and scar formation.

Efficacy and Safety of Corticosteroid in Combination with 5-Fluorouracil in the Treatment of Keloids and Hypertrophic Scars: A Systematic Review and Meta-analysis

BACKGROUND

Addressing hypertrophic scars and keloids poses a significant challenge in the realm of preventive and curative medicine. Combination corticosteroid with 5-fluorouracil (5-FU) is presumed to enhance the treatment of hypertrophic scars and keloids, although supportive evidence is lacking. This study is aimed at comparing the efficacy and safety profile of a combined corticosteroid and 5-FU regimen in treating hypertrophic scars and keloids.

METHODS

A comprehensive search was conducted for pertinent studies across various databases, including Web of Science, PubMed, Google Scholar, Cochrane Library, and Medline. The calculation of weighted mean difference (WMD), risk ratios (RR), odds ratios (OR), and 95% confidence intervals (CIs) was executed. Additionally, the Cochrane Collaboration's Risk of Bias Tool was utilized to evaluate potential bias risks.

RESULTS

A total of 15 studies were involved. The effectiveness based on patient self-assessment and the effectiveness based on observer assessment were significantly higher in the corticosteroid+5-FU group compared to those treated with control. A meta-analysis of scar height showed that the corticosteroid+5-FU group performed better than the control group (WMD = -0.38, 95% CI -0.58 to -0.18). There was no significant difference between the corticosteroid+5-FU group and the control group in improving scar vascularity, pliability and pigmentation. The result revealed that the corticosteroid+5-FU group of patients had less adverse effect of hypopigmentation, skin atrophy and telangiectasia than the control group.

CONCLUSION

The combined use of corticosteroids and 5-FU appears to be a more effective strategy for the treatment and prevention of hypertrophic scars and keloids, as evidenced by greater improvements in scar height and overall effectiveness, coupled with a reduced incidence of side effects.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Natural products for the treatment of hypertrophic scars: Preclinical and clinical studies

Hypertrophic scarring (HS) is a complication of wound healing that causes physiological and psychological distress in patients. However, the possible mechanism underlying HS is not fully understood, and there is no gold standard for its treatment. Natural products are more effective, economical, convenient, and safe than existing drugs, and they have a wide application prospect. However, there is a lack of literature on this topic, so we reviewed in vivo, in vitro, and clinical studies and screened natural products showing beneficial effects on HS that can become potential therapeutic agents for HS to fill in the gaps in the field. In addition, we discussed the drug delivery systems related to these natural products and their mechanisms in the treatment of HS. Generally speaking, natural products inhibit inflammation, myofibroblast activation, angiogenesis, and collagen accumulation by targeting interleukins, tumor necrosis factor-α, vascular endothelial growth factors, platelet-derived growth factors, and matrix metalloproteinases, so as to play an anti-HS effects of natural products are attributed to their anti-inflammatory, anti-proliferative, anti-angiogenesis, and pro-apoptotic (enhancing apoptosis and autophagy) roles, thus treating HS. We also screened the potential therapeutic targets of these natural compounds for HS through network pharmacology and constructed a protein-protein interaction (PPI) network, which may provide clues for the pharmacological mechanism of natural products in treating this disease and the development and application of drugs.

Immediate SVF-Gel Injection Reduced Incision Scar Formation: A Prospective, Double-Blind, Randomized, Self-control Trial

BACKGROUND

Skin incision scars are cosmetically displeasing; the effects of current treatments are limited, and new methods to reduce scar formation need to be found.

OBJECTIVE

We sought to determine whether immediate postoperative injection of stromal vascular fraction gel (SVF-gel) could reduce scar formation at skin incision sites.

METHODS

A prospective, randomized, double-blind, self-controlled trial was conducted in patients who underwent breast reduction. SVF-gel was intradermally injected into the surgical incision on one randomly selected side, with the other side receiving saline as a control. At the 6-month follow-up, the incision scars were evaluated using the Vancouver scar scale (VSS) and visual analog scale (VAS). Antera 3D camera was used for objective evaluation.

RESULTS

The VSS score and VAS score were significantly different between the SVF-gel-treated side (3.80 ± 1.37, 3.37±1.25) and the control side (5.25 ± 1.18, 4.94 ± 1.28). Moreover, the SVF-gel-treated side showed statistically significant improvements in scar appearance, based on evidences from Antera 3D camera.

LIMITATIONS

This was a single-center, single-race, and single-gender study. Furthermore, the results were available only for the 6-month interim follow-up period.

CONCLUSION

Postoperative immediate SVF-gel injection in surgical incisions can reduce scar formation, and exert a preventive effect on scars.

LEVEL OF EVIDENCE I

Evidence obtained from at least one properly designed randomized controlled trial. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Isorhamnetin inhibits hypertrophic scar formation through TGF-β1/Smad and TGF-β1/CREB3L1 signaling pathways

Background

Hypertrophic scar (HS) is a common fibrotic skin disease that occurs secondary to burns or injuries. The activation of the TGF-β signaling pathway contributes immensely to HS formation. Isorhamnetin (ISO) is a type of flavonoid compound that exerts an antifibrotic effect via TGF-β signaling suppression. However, whether ISO can inhibit HS formation via TGF-β signaling is yet to be elucidated. This study aimed to examine the influence of ISO on HS pathogenesis and TGF-β signaling, especially the downstream molecules and networks of TGF-β signaling that facilitate HS formation.

Methods

Hypertrophic scar fibroblasts (HSFBs) were isolated from human HS tissues. The in vitro proliferation, migration, contractile ability, cell cycle, and apoptosis of HSFBs after ISO treatment were determined using cell viability assay, EdU staining, wound healing assay, collagen gel contraction assay, and flow cytometry. The expressions of genes and proteins involved in TGF-β signaling and its downstream molecules in ISO-treated HSFBs were determined using quantitative PCR (qPCR), immunofluorescence, and western blotting. In vivo, a rabbit HS model was established, and the effects of ISO on rabbit HS formation were investigated using histological analysis, immunohistochemical staining, and qPCR.

Results

In vitro studies indicated that ISO treatment suppressed the proliferation, migration, and contractile ability of HSFBs; attenuated the expressions of COL Ⅰ, COL Ⅲ, and α-SMA; and inhibited TGF-β1 signaling-induced activation of HSFBs by decreasing the levels of phosphorylated Smad2/3 and cleaved CREB3L1 in a dose-dependent manner. Furthermore, ISO augmented apoptosis and G2 phase cell cycle arrest of HSFBs by upregulating the expressions of the proapoptotic proteins Bax and cleaved caspase-3 and downregulating the expression of the antiapoptotic protein Bcl-2. In vivo studies revealed that ISO ameliorated HS formation in the rabbit ear by lowering the scar elevation index, attenuating the collagen density, facilitating the regular arrangement of collagen fibers, and downregulating the expressions of TGF-β1, CREB3L1, COL Ⅰ, COL Ⅲ, and α-SMA.

Conclusions

ISO suppressed HS pathogenesis by dampening TGF-β1/Smad and TGF-β1/CREB3L1 signaling pathways, which suggests that it may serve as a candidate inhibitor of TGF-β1 signaling and a promising anti-HS drug with a high therapeutic potential.

A Comprehensive Review of Non-Surgical Treatments for Hypertrophic and Keloid Scars in Skin of Color

Hypertrophic and keloid scars are fibroproliferative growths resulting from aberrant wound healing. Individuals with Fitzpatrick skin types (FSTs) IV-VI are particularly predisposed to hypertrophic and keloid scarring, yet specific guidelines for these populations are still lacking within the literature. Therefore, this comprehensive review provides a list of various treatments and considerations for hypertrophic and keloid scarring in patients with skin of color. We constructed a comprehensive PubMed search term and performed quadruple-blinded screening on all resulting studies to achieve this objective. Our findings demonstrate 1) the lack of efficacious treatments for raised scars within this population and 2) the need to empirically investigate individualized and multimodal therapeutic options for those with skin of color.

Facial Rejuvenation: A Global Trend of Dermatological Procedures in the Last Decade

Background

We aimed to track the global trend of cosmetic treatment outcomes for facial rejuvenation and the differences in modalities used in East Asian and Western populations.

Methods

Articles reporting on facial rejuvenation procedures (invasive/noninvasive) were identified in PubMed from 2013 to March 2023 and bibliometrically analyzed for type of published document, citation frequency, authors with most articles, author's affiliation, and frequency distribution of keywords.

Results

From 553 articles, most were published in 2021 (n = 86, 15.6%). Western countries (n = 323, 58.4%) contributed more than East Asian (n = 230, 41.6%), with more invasive interventions (n = 355, 64.2%) than noninvasive techniques (n = 198, 35.8%). Numbers of invasive techniques in West versus East Asian countries were 225 (40.7%) versus 135 (24.4%). Main indications were the reduction of facial wrinkles and antiageing treatments. Hyaluronic acid, fillers, and botulinum toxin were the main hotspots for invasive treatments, whereas laser, platelet-rich plasma, and radiofrequency were for noninvasive treatments. Nasolabial folds (13.4%) and glabellar lines (12.4%) were the top research hotspots in the East Asian and Western regions. Common adverse events were pain, erythema, swelling, and bruising. Approximately, 89.3% of publications were from single countries, whereas 10.7% of publications were from international collaborations. Most articles (n = 387; 69.95%) presented their findings using level II evidence. Dermatological surgery (IF = 2.914) had the greatest number of publications (n = 109; 19.71%).

Conclusions

The main hotspots were antiaging and youthfulness. This study provides a trend and a new perspective on the future research directions in the field of facial rejuvenation.

Postoperative Scar Management Protocol for Asian Patients

BACKGROUND

Postoperative scar formation remains a morbidity for patients even with the advent of minimally invasive techniques. Furthermore, the significant difference between the Asian and Caucasian skin results in poorer postoperative scar outcomes in Asians, supporting the need for an evidence-based scar management protocol.

METHODS

Following a literature review of the PubMed and the Cochrane databases over the past 10 years, we constructed a novel postoperative scar management protocol for the Asian skin, utilized in a Singaporean tertiary healthcare institution.

RESULTS

We describe a timeline-based scar protocol from the point of skin closure to a minimum of 1 year of follow-up. We support the use of intraoperative botulinum toxin for selected high-risk individuals upon skin closure with a follow-up regimen in the postoperative setting. For recalcitrant keloids, we have described a multimodal therapy comprising elements of intralesional steroids, botulinum toxin, lasers, surgery, and radiotherapy.

CONCLUSIONS

A consolidated postoperative scar management protocol provides the necessary guidance for improved scar outcomes in the Asian skin. There is inherent potential in expanding the protocol to include post-traumatic and burn wounds or support other skin types including the Caucasian skin.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Experimental Study on the Effect of Caffeine Hydrogel on the Expression of TGF -β1, α-SMA and Collagen in Hypertrophic Scar of Rabbit Ears

This study evaluated the effects of topical use of caffeine hydrogel on hypertrophic scar in a rabbit ear wound model. Nine rabbits were randomly divided into three groups: control group, caffeine hydrogel group, and matrix group. Punched defects were established on each rabbit's ear which resulted in a hypertrophic scar. When the wound epithelialization and scar hyperplasia could be seen, control group did not do any treatment, while caffeine hydrogel group and matrix group were treated with caffeine hydrogel and hydrogel matrix, respectively. After 3 weeks of administration, the general morphological changes of scar were observed, and the scar tissue of rabbit ears was stained with HE and Masson. The relative expressions of TGF β-1, α-SMA, type I collagen, and type III collagen in scar tissue were detected by Western blot. In all three groups, findings showed that caffeine hydrogel can inhibit scar growth by reducing the expression of TGF β-1, reducing the proliferation of fibroblasts, improving collagen arrangement and reducing collagen deposition. The overall study shows efficacy and mechanism of caffeine. It concluded that caffeine could be an effective therapeutic agent for hypertrophicscars.

Centella triterpenes cream as a potential drug for the treatment of hypertrophic scar through inhibiting the phosphorylation of STAT3: A network pharmacology analysis and in vitro experiments

BACKGROUND

Hypertrophic scars (HS) often affect the normal function and appearance of the skin and bring adverse effects to the body and mind of patients, being a challenge in the fields of burns and plastic surgery as well as rehabilitation. Despite significant efficacy of centella triterpenes cream for treating HS clinically, its pharmacodynamics and molecular targets are still unclear. Therefore, the network pharmacology analysis combined with in vitro cell molecular biology experiments was used to explore the mechanism and targets of centella triterpenes cream treating HS in this study.

METHODS

First, target genes of asiaticoside (AC) were obtained from the databases including the Comparative Toxicogenomics Database, similarity ensemble approach, SwissTargetPrediction and TargetNet, and HS targets were acquired from the databases like Disgenet, GeneCards, and Online Mendelian Inheritance in Man. The common targets of AC-HS were obtained through plotting a Venn diagram. Subsequently, STRING 11.0 was employed for analyzing the protein-protein interaction (PPI) network of the common targets, and cytoscape 3.9.0 for analyzing the connectivity of PPI and plotting the network diagram of "drug-component-target". Additionally, a modified tissue culture method was applied to separate primary normal fibroblasts (NFs) in human skin and hypertrophic scar fibroblasts (HSFs). HSFs after 24-h AC treatment were subjected to MTT assay to detect cell viability, scratch assay to assess cell migration ability, and western blot to test the protein expression levels of STAT3, p-STAT3, transforming growth factor-β1 (TGF-β1), collagen I (COL 1), fibronectin 1 (FN1), and alpha-smooth muscle actin (α-SMA).

RESULTS

In network pharmacology analysis, 134 pharmacodynamic targets of AC and 2333 HS targets were obtained after retrieving the database, 50 AC-HS common targets were obtained by a Venn diagram, and a total of 178 edges and 13 core genes such as JUN and STAT3 were acquired by PPI analysis. In vitro experiments showed that the phosphorylation level of STAT3 (p-STAT3) was increased in HSFs. In addition to reducing p-STAT3 in HSFs, AC significantly inhibited the cell viability and migration of HSFs and downregulated the protein levels of TGF-β1, COL 1, FN 1, and α-SMA.

CONCLUSION

STAT3 can be activated in HS. AC may exert its pharmacological effects of inhibiting TGF-β1 signal transduction and regulating extracellular matrix remodeling in HS by inhibiting STAT3 phosphorylation. However, the specific molecular mechanism of AC remains to be verified through further experiments.

Clinical Effects of Pulsed Dye Laser Dynamically Combined with Triamcinolone Acetonide in the Treatment of Postoperative Recurrence Keloids

Purpose

This study aimed to explore the clinical effects of pulsed dye laser (PDL) dynamically combined with triamcinolone acetonide (TAC) in the treatment of post-operative keloids recurrence.

Materials and Methods

This study retrospectively analysed the clinical data of 29 keloid patients (with 39 keloids) from April 2014 to February 2020. The patients were divided into TAC group (14 patients with 19 keloids) and dynamic treatment group (15 patients with 20 keloids) according to the post-operative treatment that they received. The keloids were assessed by Vancouver scar scale (VSS), patient and observer scar assessment scale (POSAS) and the effect of keloids on the quality of life of patients was evaluated with dermatology life quality index (DLQI) scale before the surgical treatment, at any time of relapse, and 24 months after the surgical treatment. The recurrence-free interval, relative cure time, and the cumulative times of TAC injection when the relative cure could be assessed as achieved, and the incidence of adverse reactions were calculated.

Results

Patients experiencing a recurrence within 2 years after surgery included 19 keloids (25.33%) that developed a recurrent event within 6 months, 34 keloids (45.33%) that within 12 months, and 39 keloids (52.00%) that within 24 months after surgery. Anterior chest keloid had the highest recurrence rate and ear keloid had the lowest recurrence rate. The total pigmentation and vascularity (VSS and POSAS) scores of patients' keloids in TAC group and dynamic treatment group 24 months after treatment were significantly lower than those before treatment and at relapse (P < 0.05), the total VSS and POSAS scores were significantly lower at 24 months than before treatment and at relapse (P < 0.05), and the DLQI scale score was significantly lower at 24 months than before treatment (P < 0.05). The VSS and POSAS scores of patients' keloids at 24 months after treatment were significantly lower in the dynamic treatment group than in the TAC group. The relative cure time of patients' keloids in the dynamic treatment group was 6.47 ± 2.72 months, which was significantly shorter than 8.65 ± 3.67 months in the TAC group (P < 0.05). The cumulative number of TAC injections that were given to achieve a relative cure of patients' keloids in dynamic treatment group was 3.60 ± 1.76, which was significantly less than 5.24 ± 2.25 in TAC group. The total incidence of adverse reactions was lower in the dynamic group than in TAC group, but this difference did not reach statistical significance (P > 0.05).

Conclusions

Compared with TAC injection alone, PDL dynamically combined with TAC in the treatment of keloid with post-operative recurrence can shorten the relative cure time, reduce the number of TAC injections and improve the clinical efficacy.

The Role of Physical Therapies in Wound Healing and Assisted Scarring

Wound healing (WH) is a complex multistep process in which a failure could lead to a chronic wound (CW). CW is a major health problem and includes leg venous ulcers, diabetic foot ulcers, and pressure ulcers. CW is difficult to treat and affects vulnerable and pluripathological patients. On the other hand, excessive scarring leads to keloids and hypertrophic scars causing disfiguration and sometimes itchiness and pain. Treatment of WH includes the cleaning and careful handling of injured tissue, early treatment and prevention of infection, and promotion of healing. Treatment of underlying conditions and the use of special dressings promote healing. The patient at risk and risk areas should avoid injury as much as possible. This review aims to summarize the role of physical therapies as complementary treatments in WH and scarring. The article proposes a translational view, opening the opportunity to develop these therapies in an optimal way in clinical management, as many of them are emerging. The role of laser, photobiomodulation, photodynamic therapy, electrical stimulation, ultrasound therapy, and others are highlighted in a practical and comprehensive approach.

Expanded forehead flap in Asian nasal reconstruction

This article reviewed our experience of Chinese nasal reconstruction over 12 years and evaluated the effect of expanded forehead flap both aesthetically and functionally. The special skin type and other anatomic features of Chinese patients was understood thoroughly during the treatment. This article thus catered for the need of multiracial nasal reconstruction. We analyzed existing clinical data and demonstrated a typical case in detail. The postoperative result supported our strategy which advocated the extensive application of expanded forehead flap, together with flip scar flap as the internal lining. The features of Chinese patients also prompted the use of costal and auricular cartilage. Emerging technology like 3D-printing would benefit nasal reconstruction from more aspects.

Efficiency of hypericum perforatum, povidone iodine, tincture benzoin and tretinoin on wound healing

Different topical agents have been used to accelerate wound healing. The purpose of this study is to compare the safety and efficacy of topical application of the extract of Hypericum perforatum (HPE), povidone iodine (PI), tincture benzoin (TB) and tretinoin (T) on surgical wound healing. Ten adult female, Wistar albino rats were included in the study. HPE, PI, TB and T solutions were applied on the wounds. After seven days, tissue samples were collected and inflammatory cells, re-epithelialization, granulation tissue, angiogenesis, collagen accumulation, hemorrhage and lysis of cells were investigated histopathologically. No dermal toxicity was noted. HPE, TB, PI have all showed good epithelialization and granulation, but HPE showed the most advanced stage of healing within a short period of time. HPE had significantly higher values of re-epithelialization and collagen accumulation, but lower inflammatory cell count and granulation tissue. TB had the second best in re-epithelialization, collagen accumulation and the highest granulation tissue. PI induced better reepithelialization and granulation than the control group with remarkable cell lysis. As a result, HPE can be a safe, effective, and cheap agent that can be used for surgical wounds.

MSC-derived sEV-loaded hyaluronan hydrogel promotes scarless skin healing by immunomodulation in a large skin wound model

Designing hydrogel-based constructs capable of adjusting immune cell functions holds promise for skin tissue regeneration. Mesenchymal stem cell (MSC)-derived small extracellular vesicles (sEVs) have attracted increasing attention owing to their anti-inflammatory and proangiogenic effects. Herein, we constructed a biofunctional hydrogel in which MSC-derived sEVs were incorporated into the injectable hyaluronic acid (HA) hydrogel, thus endowing the hydrogel with immunomodulatory effects. When implanted onto the wound site in a mouse large skin injury model, this functional hydrogel facilitates wound healing and inhibits scar tissue formation by driving macrophages towards an anti-inflammatory and anti-fibrotic (M2c) phenotype. Further investigation showed that the M2c-like phenotype induced by MSC-derived sEVs markedly inhibited the activation of fibroblasts, which could result in scarless skin wound healing. Taken together, these results suggest that modulation of the immune response is a promising and efficient approach to prevent fibrotic scar formation.

Skin Wound Tension Reduction Device Combined with Ablative Fractional Carbon Dioxide Laser to Reduce Scar Formation After Excision of Pediatric Facial Skin Lesions: A Prospective Cohort Study

Purpose

To investigate the efficacy of skin wound tension reduction device (SWTRD) combined with ablative fractional carbon dioxide laser (CO2-AFL) for the prevention of scar formation following the excision of facial cutaneous lesions in children.

Methods

Patients undergoing surgical excision of facial cutaneous lesions in our hospital between May 2019 and April 2021 were enrolled. After the excision of facial cutaneous lesions and based on the personal intents and conditions, patients were assigned to undergo SWTRD combined with CO2-AFL. Outcome evaluations were as follows: defect size, incision width, scar width, the Vancouver Scar Scale (VSS) and University of North Carolina 4P Scar Scale (UNC4P).

Results

A total of 25 pediatric patients (mean age, 9.88 years) were enrolled in the study. Following the treatment of SWTRD+CO2-AFL, scar widths were relatively narrow and the appearance of the incision scars was significantly improved. A significant reduction in the patient-reported UNC4P scores at 6 months (3, 1–4) was observed when compared with that at 2 months (0, 0–1) after surgery (p<0.001). A similar reduction in the VSS scar scale was also evident (6 months: 1, 0.75–2.5 vs 2 months: 6.5–8.5; p<0.001).

Conclusion

Combined SWTRD and CO2-AFL treatment effectively modulates the scar formation after the incision is healed and resulting in preventing scar widening, leading to the improvement of scar appearance, reduction in wound pain and pruritus and its overall prognosis.

Clinical status of hospitalized keloid cases from 2013 to 2018

OBJECTS

Keloids are intractable scar diseases and sometimes undergo hospitalization. This study aims to represent current status of keloid management in a national sample of hospitalized scar cases.

METHODS

Data of scar-diagnosed cases admitted in 1064 China's tertiary hospitals between 2013 and 2018, were obtained from the Hospital Quality Monitoring System (HQMS) database. Variables analyzed include sex, age, nationality, occupation, hospital department, accompanied symptoms at admission, surgical treatment, length of stay (LOS), and hospitalization cost. The potential risk factors of keloid diagnosis among scar cases were preliminarily identified through the Cochran-Mantel-Haenszel tests and univariate regression analyses.

RESULTS

This study identified 177,586 scar cases including 21,777 keloid cases and 155,809 non-keloid scar cases. The prevalence of scars in the HQMS database was gradually decreased from 0.123% in 2013 to 0.075% in 2018. We found a preponderances of males (54.32%), adults (61.52%), Han nationality (93.38%), and students (17.35%) in scar cases, among whom keloid cases accounted for growing proportions increasing from 9.2% in 2013 to 15.1% in 2018. Comparing non-keloid scar cases, keloid cases consisted of more women (59.1% VS 43.8%), office staffs (13.08% VS 6.75%) and retirees (5.16% VS 2.65%), and less Zhuang (0.79% VS 1.40%) and Hui nationalities (0.76% VS 1.00%), and showed lower incidence of accompanied symptoms (4.51% VS 47.96%) and higher rate of receiving operations (57.96% VS 50.28%, P < 0.001). Both the LOS and cost per hospitalization were lower in keloid cases. Furthermore, the adult and older women, Han and Uyghur nationalities, office staffs and retirees, and admitted in otolaryngology and dermatology departments, were potential predictors of keloid diagnosis among hospitalized scar cases.

CONCLUSION

When viewed at the national level, keloid occupies an important part in scar management in Chinese tertiary hospitals. Demographic and clinical differences between keloids and other scars facilitate understanding and promoting of individualized anti-scar therapeutic strategies.

Early Intervention with Autologous Fat Grafting to Reduce Hypertrophic Scar Formation: A Prelimilary Study

BACKGROUND

Once an early-stage immature scar develops into a hypertrophic scar, it is difficult to achieve satisfactory improvement with existing treatments. Therefore, the prevention of hypertrophic scar formation should be given priority. Fat grafting was previously proven to be an effective treatment for mature scars, but it has not been used in the early-stages of (less than three months) scar formation.

OBJECTIVES

We present our experience with the use of combined grafting of macro fat and emulsified fat for prevention of hypertrophic scar formation in patients.

METHODS

Thirty-five patients who received fat grafting for facial scar repair were included as a treatment group and another 35 patients without particular interventions were classified as the control group. Patients in both groups were followed up every three months during one year, and the Vancouver Scar Scale (VSS) was used for evaluation of the clinical outcomes at baseline (within one to three months after trauma, burn or surgery) and after 12 months of follow-up.

RESULTS

All patients in the treatment group achieved a marked improvement after their first fat grafting procedure. Thirteen patients (37.1%) underwent the second procedure and seven (20%) underwent the third procedure. Statistical analysis of average VSS score also showed significant differences between the treatment and control groups.

CONCLUSION

The results of this retrospective study suggest that treatment of immature scars with combined grafting of macro fat and emulsified fat can successfully prevent the formation of hypertrophic scars.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Application of ADSCs and their Exosomes in Scar Prevention

Scar is a common way of healing after tissue injury. The poor scar healing will not only cause dysfunction of tissues and organs but also affect the appearance of the patients’ body surface, which causes the pressure of life and spirit to the patients. However, the formation of scar tissue is an extremely complex process and its mechanism is not fully understood. At present, there is no treatment method to eliminate scars completely. Fibroblasts are the most abundant cells in the dermis, which have the ability to synthesize and remodel extracellular matrix (ECM). Myofibroblasts actively participate in the wound healing process and influence the outcome. Therefore, both of them play important roles in wound healing and scar formation. Adipose tissue-derived stem cells (ADSCs) are pluripotent stem cells that can act on target cells by paracrine. Adipose tissue stem cell-derived exosomes (ADSC-Exos) are important secretory substances of ADSCs. They are nanomembrane vesicles that can transport a variety of cellular components and fuse with target cells. In this review, we will discuss the effects of ADSCs and ADSC-Exos on the behavior of fibroblasts and myofibroblasts during wound healing and scarring stage in combination with recent studies.

Ablative fractional CO2 laser surgery improving sleep quality, pain and pruritus in adult hypertrophic scar patients: a prospective cohort study

Background

Poor sleep quality is associated with a decrease in quality of life in patients with major burn scars, combined with pruritus and pain. Few interventions have been reported to improve the sleep quality of patients with scars. In the current prospective cohort study, we investigated the efficacy of CO₂-ablative fractional laser (AFL) surgery vs conventional surgery in post-burn patients with hypertrophic scars with sleep quality as the primary study outcome.

Methods

In total 68 consecutive patients undergoing scar surgical treatment were recruited, including a CO₂-AFL surgery cohort (n = 35) and a conventional surgery cohort (n = 33). A subgroup from the AFL cohort was selected. Sleep quality, pain and pruritus were evaluated. Multiple linear regression analyses were performed to reveal the effect of CO₂-AFL surgery.

Results

The CO₂-AFL surgery cohort had significantly lower Pittsburgh sleep quality index (PSQI) global scores than the conventional surgery cohort after the last surgical treatment. In the subgroup of patients receiving hardware sleep monitoring, CO₂-AFL markedly increased deep sleep time, deep sleep efficiency and reduced initial sleep latency. Compared to the conventional surgery cohort, the CO₂-AFL cohort presented significantly lower pain and pruritus scores. Correlation analysis showed pain and pruritus were significantly associated with PSQI scores, and there were also significant correlations between pain and pruritus scores. Multiple linear regression analysis showed that surgery method was negatively linearly correlated with visual analog scale (VAS) pain score, brief pain inventory (BPI) total, VAS pruritus score, 5-D itch scale total, four-item itch questionnaire (FIIQ) total and PSQI total.

Conclusions

CO₂-AFL surgery significantly improved sleep quality and reduced pain and pruritus of hypertrophic scar patients. The alleviation of sleep disorder was associated with improvement of deep sleep quality including deep sleep time and deep sleep deficiency.

Trial registration

The Chinese Clinical Trial Registry (ChiCTR200035268) approved retrospectively registration on 5 Aug 2020.

Prevalence and predictors of scar contracture-associated re-hospitalisation among burn inpatients in China

Scar contracture, a common destructive complication causing increased re-hospitalisation rate of burn survivors and aggravated burden on the medical system, may be more seriously in Chinese population because of their higher susceptibility to scar formation. This study aims to evaluate the prevalence and predictors of scar contracture-associated re-hospitalisation among Chinese burn inpatients. This cross-sectional study screened burn inpatients hospitalised during 2013 to 2018 through the Hospital Quality Monitoring System database, among whom re-hospitalised for scar contracture were identified. Variables including sex, age, occupations, burn area, burn site and surgical treatment were analysed. Potential predictors of scar contracture-associated re-hospitalisation among burn inpatients were determined by univariate regression analyses. Of the 220,642 burn inpatients, 2146 (0.97%) were re-hospitalised for scar contracture. The re-hospitalised inpatients were predominantly men and blue-collar workers, showing younger median age at the time of burns, larger burn sizes, and higher percentage of surgical treatment compared other burn inpatients. Significant univariate predictors of scar contracture-associated re-hospitalisation included male sex, age < 50 years, blue-collar work, ≥ 40% total body superficial area burned, inhalation injured, and surgical treatment. Scar contracture is an intractable complication and a significant factor to increase re-hospitalisation rate among Chinese burn inpatients.

Treatment of keloids and hypertrophic scars. Position statement of the Brazilian expert group GREMCIQ

Keloids (K) and hypertrophic scars (HS) are abnormal responses to wound healing that occur as the result of dermal inflammation. Despite the advances on their treatment, many patients still suffer from the negative effects of excessive scarring; its approach is impaired by the lack of objective data on different treatments and the large genetic variability among patients and the difficulties in producing multicentre studies. Their incidence among the Brazilian population is high, as the result of an admixture of Amerindians, Europeans and Africans ancestral roots. With the aim of producing multicentre studies on K and HS, a panel of senior Brazilian dermatologists focused on their treatment was invited to contribute with the K and HS Treatment Brazilian Guidelines. In the first part of this study, different treatment modalities for keloids and HS are fully reviewed by the panel. The second part of the study presents a consensus recommendation of treatment for different types of lesions. More than a literature review, this article aims to show the pitfalls and pearls of each therapeutic option, as well as a therapeutic approach by the Panel of Experts on keloids and Scars on a highly mixed population, providing simple guidelines.

Exosomale microRNA-21 Promotes Keloid Fibroblast Proliferation and Collagen Production by inhibiting Smad7

In keloid fibroblasts, microRNA-21 (miR-21) enhances activation of the TGF-β-Smad-signaling pathway by downregulating Smad7 expression, thereby promoting keloid fibroblast proliferation and collagen production. However, it is unclear whether miR-21 performs the above-mentioned functions through exosomal transport. Here, we extracted exosomes from the culture supernatants of keloid and normal skin fibroblasts, and observed that exosomes from both cell types secreted exosomes; however, keloid fibroblasts secreted significantly more exosomal miR-21 than normal skin fibroblasts (P < 0.001). Interestingly, we also observed that exosomal miR-21 could enter target keloid fibroblasts. In addition, inhibiting exosomal miR-21 upregulated Smad7 protein expression and reduced Smad2 and Smad3 protein levels in target keloid fibroblasts. Furthermore, inhibiting exosomal miR-21 downregulated collagen I and collagen III expression in target keloid fibroblasts, increased the proportion of apoptotic cells, and reduced cell proliferation. Taken together, these results show that exosomal miR-21 promoted proliferation and collagen production in keloid fibroblasts by inhibiting Smad7. Thus, we identified regulatory roles for miR-21 in promoting keloid fibroblast proliferation and participating in keloid formation and development. These findings imply that miR-21 may serve as a novel target for controlling the development of keloids.

Strontium-90 brachytherapy following intralesional triamcinolone and 5-fluorouracil injections for keloid treatment: A randomized controlled trial

Background

Keloid disease is hard to fully eradicate. Recurrence and other unsatisfactory results were found in many patients. No current therapeutic modality has been determined to be most effective for treating keloid scars. Intralesional corticosteroid injections is most commonly recommended for primary management of small and young keloids as well as hypertrophic scars. However, it’s difficult for patients to adhere to long-term triamcinolone acetonide injection therapy because of the pain, inconvenience or complications including hormonal imbalance or irregular menstruation.

Objective

We aimed to determine whether and how Strontium-90 brachytherapy as an adjuvant radiation could affect keloid recurrence after intralesional triamcinolone and 5-fluorouracil injections.

Methods

We included keloid patients from March 2019 to September 2019 and randomly allocated them to two groups after 3 intralesional triamcinolone and 5-fluorouracil injections at 3 weeks interval. The experimental group received Strontium-90 brachytherapy at a total dose of 15-20Gy, while the control group didn’t receive any adjuvant treatment. We performed both Vancouver Scar Scale scoring and Color Doppler ultrasound examination to monitor and evaluate lesions regularly. A one-year follow-up was completed for each patient.

Results

31 patients who had 42 keloids in total were recruited. We found intralesional triamcinolone and 5-fluorouracil injections could effectively reduce the thickness and modify the hardness of small and young keloids. Strontium-90 brachytherapy reduced the one-year recurrence rate from 85.7 percent to 44.4 percent after 3 intralesional triamcinolone and 5-fluorouracil injections. The lesions’ thickness or elasticity was not affected by Strontium-90 brachytherapy.

Conclusion

Strontium-90 brachytherapy as an adjuvant radiation could effectively reduce small sized keloids recurrence after intralesional triamcinolone and 5-fluorouracil injections. It worked by enhancing the lesions’ stability post-injection.

Trial registration

The clinical trial registration number: ChiCTR2000030141.

Name of trial registry: Chinese Clinical Trial Registry (http://www.chictr.org.cn/)

Management of keloid scars: noninvasive and invasive treatments

Scars vary from mature linear scars to abnormal excessive scars such as hypertrophic scars and keloid scars. Keloid scars are fibro-proliferative disease entities that reflect an abnormal process of wound healing. They can cause pain, itching, stiffness, and psychological distress, all of which can affect quality of life. Various treatment options have been advocated as ways to prevent and treat keloid scars. These include noninvasive treatments such as use of silicone gel sheeting and compression therapy, and invasive treatments such as intralesional corticosteroid injections, surgery, and radiotherapy. Novel treatments include chemotherapy, immunotherapy, and anti-inflammatory therapies. Unfortunately, keloids continue to pose a significant challenge due to the lack of efficacious treatments. Therefore, clinicians should be familiar with various therapeutic options and apply the most suitable treatment plan for patients. In this review, we introduce the current therapeutic options for the management of keloid scars.

ABT-263 Reduces Hypertrophic Scars by Targeting Apoptosis of Myofibroblasts

Background: Inhibiting proliferation and inducing apoptosis of myofibroblasts is becoming one of the promising and effective ways to treat hypertrophic scar. ABT-263, as an orally bioavailable BCL-2 family inhibitor, has showed great antitumor characteristics by targeting tumor cell apoptosis. The objective of this study was to explore whether ABT-263 could target apoptosis of overactivated myofibroblasts in hypertrophic scar. Methods: In vivo, we used ABT-263 to treat scars in a rabbit ear scar model. Photographs and ultrasound examination were taken weekly, and scars were harvested on day 42 for further Masson trichrome staining. In vitro, the expression levels of BCL-2 family members, including prosurvival proteins, activators, and effectors, were detected systematically in hypertrophic scar tissues and adjacent normal skin tissues, as well as in human hypertrophic scar fibroblasts (HSFs) and human normal dermal fibroblasts (HFBs). The roles of ABT-263 in apoptosis and proliferation of HSFs and HFBs were determined by annexin V/PI assay, CCK-8 kit, and cell cycle analysis. Mitochondrial membrane potential was evaluated by JC-1 staining and the expression of type I/III collagen and α-SMA was measured by PCR, western blotting, and immunofluorescence staining. Furthermore, immunoprecipitation was performed to explore the potential mechanism. Results: In vivo, ABT-263 could significantly improve the scar appearance and collagen arrangement, decrease scar elevation index (SEI), and induce cell apoptosis. In vitro, the expression levels of BCL-2, BCL-XL, and BIM were significantly higher in scar tissues and HSFs than those in normal skin tissues and HFBs. ABT-263 selectively induced HSFs apoptosis by releasing BIM from binding with prosurvival proteins. Moreover, ABT-263 inhibited HSFs proliferation and reduced the expression of α-SMA and type I/III collagen in a concentration- and time- dependent manner. Conclusion: HSFs showed increased mitochondrial priming with higher level of proapoptotic activator BIM and were primed to death. ABT-263 showed great therapeutic ability in the treatment of hypertrophic scar by targeting HSFs.

Targeting FSTL1 for Multiple Fibrotic and Systemic Autoimmune Diseases

Follistatin-like 1 (FSTL1) is a matricellular protein that is upregulated during development and disease, including idiopathic pulmonary fibrosis (IPF), keloid, and arthritis. The profibrotic and pro-inflammatory roles of FSTL1 have been intensively studied during the last several years, as well as in this report. We screened and identified epitope-specific monoclonal neutralizing antibodies (nAbs) to functionally block FSTL1. FSTL1 nAbs attenuated bleomycin-induced pulmonary and dermal fibrosis in vivo and transforming growth factor (TGF)-β1-induced dermal fibrosis ex vivo in human skin. In addition, FSTL1 nAbs significantly reduced existing lung fibrosis and skin fibrosis in experimental models. FSTL1 nAbs exerted their potent antifibrotic effects via reduced TGF-β1 responsiveness and subsequent myofibroblast activation and extracellular matrix production. We also observed that FSTL1 nAbs attenuated the severity of collagen-induced arthritis in mice, which was accompanied by reduced inflammatory responses in vitro. Our findings suggest that FSTL1 nAbs are a promising new therapeutic strategy for the treatment of multiple organ fibrosis and systemic autoimmune diseases.

Laser treatment of specific scar characteristics in hypertrophic scars and keloid: A systematic review

BACKGROUND

Hypertrophic scarring and keloid can cause significant emotional and physical discomfort. Cosmetic appearance, functional limitations, pain and pruritus form a degree of impairment. While the etiology is not fully known, there is a wide array of treatment options, which include excision, radiation, cryotherapy, silicone gel sheeting, and intralesional injections. A relatively new modality is laser therapy. While results are promising, the number of different laser systems is substantial. This review evaluates the available evidence regarding outcomes on specific objective characteristics (i.e., erythema, pigmentation, height, and pliability) of the different laser systems.

METHODS

A systematic literature review was performed using MEDLINE, Cochrane Library, and EMBASE. Data on scar characteristics were extracted from scar scales Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS), and from objective measurement tools.

RESULTS

Heterogeneity was seen in a lot of aspects: maturity of scar, origin of scar, follow-up, and number of treatments. The fractional ablative lasers CO₂ 10,600 nm and Er:YAG 2940 nm were found to produce the best results regarding erythema, height, and pliability, while the flash lamp-pumped pulsed dye laser (PDL) 585 nm scored slightly below that.

CONCLUSIONS

Laser systems, and specifically the fractional ablative lasers CO₂ and Er:YAG, improved various characteristics of excessive scarring. An overview of preferred laser modality per scar characteristic is presented. Accounting for the methodological quality and the level of evidence of the data, future research in the form of randomized trials with comparable standardized scar scales is needed to confirm these results.

Improved Scar Outcomes with Increased Daily Duration of Pressure Garment Therapy

Objective: Despite the development of a number of treatment modalities, scarring remains common postburn injury. To reduce burn scarring, pressure garment therapy has been widely utilized but is complicated by low patient adherence. To improve adherence, reduced hours of daily garment wear has been proposed. Approach: To examine the efficacy of pressure garment therapy at reduced durations of daily wear, a porcine burn-excise-autograft model was utilized. Grafted burns were treated with pressure garments (20 mmHg) for 8, 16, or 24 h of daily wear with untreated burns serving as controls. Scar area, thickness, biomechanical properties, and tissue structure were assessed over time. Results: All treatment groups reduced scar thickness and contraction versus controls and improved scar pliability and elasticity. Pressure garments worn 24 h per day significantly reduced contraction versus the 8- and 16-h groups and prevented alignment of collagen within the dermis. Innovation: Though pressure garment therapy is prescribed for use 23 h per day, the need for almost continuous use has not been previously examined. Adjustable, low-fatigue pressure garments were developed for this porcine study to examine the role of daily duration of wear without confounding factors such as garment fatigue and patient adherence. Conclusion: For maximum efficacy, pressure garments should be worn 23 to 24 h per day; however, garments worn as little as 8 h per day significantly improve scar outcomes versus no treatment.

Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations

BACKGROUND AND OBJECTIVES

There is currently intense multidisciplinary interest and a maturing body of literature regarding laser treatments for traumatic scars, but international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the tremendous potential of laser techniques, offer recommendations for safe and efficacious treatment, and promote wider patient access guided by future high-quality research.

STUDY DESIGN/MATERIALS AND METHODS

An international panel of 26 dermatologists and plastic and reconstructive surgeons from 13 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the laser treatment of traumatic scars. A three-step modified Delphi method took place between March 2018 and March 2019 consisting of two rounds of emailed questionnaires and supplementary face-to-face meetings. The panel members approved the final manuscript via email correspondence, and the threshold for consensus was at least 80% concurrence among the panel members.

RESULTS

The manuscript includes extensive detailed discussion regarding a variety of laser platforms commonly used for traumatic scar management such as vascular lasers and ablative and non-ablative fractional lasers, special considerations such as coding and laser treatments in skin of color, and 25 summary consensus recommendations.

CONCLUSIONS

Lasers are a first-line therapy in the management of traumatic scars and contractures, and patients without access to these treatments may not be receiving the best available care after injury. Updated international treatment guidelines and reimbursement schemes, additional high-quality research, and patient access should reflect this status. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Investigating the potential of LSKL peptide as a novel hypertrophic scar treatment

Hypertrophic scar (HTS) is a common pathologic dermal fibroproliferative disease after skin injury. Transforming growth factor β (TGF-β) plays a central role in HTS formation and development. Thrombospondin-1 (TSP-1) activates latent TGF-β by binding to latency-associated peptide-β on TGF-β structure. So far, LSKL peptide was shown to selectively antagonize TSP-1. In this study, TSP-1 was first confirmed to be highly expressed in HTS. LSKL peptide was proven to inhibit the overexpression of extracellular matrix and contractile ability of HTS fibroblasts. In vivo, LSKL could attenuate the thickness of HTS, distortion of collagen alignment and fibrogenesis. Results also demonstrated that LSKL peptide not only remarkably attenuated cell proliferation and migration, but also induced cell apoptosis of HTS fibroblasts. Western blot analysis further revealed that LSKL peptide significantly suppressed the phosphorylation of PI3K, AKT, and mTOR, while not affecting the phosphorylation of Smad2/3 and MEK/ERK. These findings suggested that LSKL might be a promising anti-fibrosis agent to HTS through PI3K/AKT/mTOR signaling pathway.

Joint contractures in severe burn patients with early rehabilitation intervention in one of the largest burn intensive care unit in China: a descriptive analysis

Background

Joint contracture is the major clinical complication in burn patients, especially, the severe burn patients. This study aimed to investigate the number and severity of joint contractures in patients with burns affecting greater than or equal to 50% of the total body surface area (TBSA) undergoing early rehabilitation in a burn intensive care unit (BICU).

Methods

We analyzed burn patients with burns affecting greater than or equal to 50% of the TBSA admitted to a BICU who received early rehabilitation within 7 days post-injury from January 2011 to December 2015. Demographic and medical information was collected. The range of motion (ROM) of different joints was measured 1 month post-admission. Spearman’s correlation coefficient and logistic regression analysis was used to determine predictors of the presence and severity of contractures.

Result

The average affected TBSA of the included burn patients was 67.4%, and the average length of stay in the BICU was 46.2 ± 28.8 days. One hundred and one of 108 burn patients (93.5%) developed at least one joint contracture. The ROM in 67.9% of the affected joints was mildly limited. The majority of contractures in severe burn patients were mild (37.7%) or moderate (33.2%). The wrist was the most commonly affected joint (18.2%), followed by the shoulder, ankle, hip, knee, and elbow. A predictor of the presence of contractures was the length of hospital stay (p = 0.049). The severe contracture was related to the area of full-thickness burns, the strict bed rest time, and the duration of rehabilitation in BICU. The length of rehabilitation stay (days) in patients with moderate contracture is 54.5% longer than that in severe contracture (p = 0.024)

Conclusion

During the long stay in BICU, the length of rehabilitation stay in a BICU could decrease the severity of contractures from severe to moderate in the patients with equal to 50% of the TBSA. Hence, this research reveals the important role of early rehabilitation interventions in severe burn patients.

Electronic supplementary material

The online version of this article (10.1186/s41038-019-0151-6) contains supplementary material, which is available to authorized users.