Epidemiological and clinical features of paediatric inpatients for scars: A retrospective study

OBJECTIVES

To describe the epidemiological and clinical features of paediatric scar inpatients and then to facilitate therapeutic schedule for children with scars.

METHODS

In this cross-sectional study, data of patients admitted for scar treatment in 1064 tertiary hospitals from 2013 to 2018 were extracted through the Hospital Quality Monitoring System (HQMS) database. Demographic and clinical features of children with scars were analysed statistically and highlighted compared with those of adults and the elderly scar cases.

RESULTS

In this study, 53,741 paediatric scar cases, accounting for 30.29% of all hospitalized for scar, were analysed. Compared to adults and the elderly, children with scars were mainly males (62.27% vs 50.98% vs 49.85%, P < 0.001) and were vulnerable to scalds (37.10%) and operative intervention (34.11%). Although the scalp/face/neck was the most common affected location, the proportion of scars involving upper limbs (27.88% vs 21.69% vs 7.28%, P < 0.001), lower limbs (15.14% vs 10.28% vs 6.56%, P < 0.001) and perineum (4.59% vs 3.13% vs 2.65%, P < 0.001) was higher in children than that in other two groups. Scar contracture was the most common complications in children (45.27%). Nearly 66% of paediatric scar cases received surgical treatment during hospitalization, among whom release of lesion was the most frequent operation (56.35%). The proportion of keloids was relatively lower in child cases than in other two groups (6.20% vs 14.48% vs 18.15%, P < 0.001). Additionally, the median LOS in child cases was 9 (5-15) days, slightly exceeding that in adult/elderly cases.

CONCLUSIONS

Scars were common inducing factors of hospitalization and contributed greatly to the disease burden of children. More attention should be paid to those who are males, burn survivors, or skin-injured at extremities and perineum to improve therapeutic strategies and prognoses for paediatric scar patients.

Comorbidities of Keloid and Hypertrophic Scars Among Participants in UK Biobank

Importance

Keloids and hypertrophic scars (excessive scarring) are relatively understudied disfiguring chronic skin conditions with high treatment resistance.

Objective

To evaluate established comorbidities of excessive scarring in European individuals, with comparisons across ethnic groups, and to identify novel comorbidities via a phenome-wide association study (PheWAS).

Design, Setting, and Participants

This multicenter cross-sectional population-based cohort study used UK Biobank (UKB) data and fitted logistic regression models for testing associations between excessive scarring and a variety of outcomes, including previously studied comorbidities and 1518 systematically defined disease categories. Additional modeling was performed within subgroups of participants defined by self-reported ethnicity (as defined in UK Biobank). Of 502 701 UKB participants, analyses were restricted to 230078 individuals with linked primary care records.

Exposures

Keloid or hypertrophic scar diagnoses.

Main Outcomes and Measures

Previously studied disease associations (hypertension, uterine leiomyoma, vitamin D deficiency, atopic eczema) and phenotypes defined in the PheWAS Catalog.

Results

Of the 972 people with excessive scarring, there was a higher proportion of female participants compared with the 229 106 controls (65% vs 55%) and a lower proportion of White ethnicity (86% vs 95%); mean (SD) age of the total cohort was 64 (8) years. Associations were identified with hypertension and atopic eczema in models accounting for age, sex, and ethnicity, and the association with atopic eczema (odds ratio [OR], 1.68; 95% CI, 1.36-2.07; P < .001) remained statistically significant after accounting for additional potential confounders. Fully adjusted analyses within ethnic groups revealed associations with hypertension in Black participants (OR, 2.05; 95% CI, 1.13-3.72; P = .02) and with vitamin D deficiency in Asian participants (OR, 2.24; 95% CI, 1.26-3.97; P = .006). The association with uterine leiomyoma was borderline significant in Black women (OR, 1.93; 95% CI, 1.00-3.71; P = .05), whereas the association with atopic eczema was significant in White participants (OR, 1.68; 95% CI, 1.34-2.12; P < .001) and showed a similar trend in Asian (OR, 2.17; 95% CI, 1.01-4.67; P = .048) and Black participants (OR, 1.89; 95% CI, 0.83-4.28; P = .13). The PheWAS identified 110 significant associations across disease systems; of the nondermatological, musculoskeletal disease and pain symptoms were prominent.

Conclusions and Relevance

This cross-sectional study validated comorbidities of excessive scarring in UKB with comprehensive coverage of health outcomes. It also documented additional phenome-wide associations that will serve as a reference for future studies to investigate common underlying pathophysiologic mechanisms.

Keloids in Darkly Pigmented Skin: Clinical Pattern and Presentation at a Tertiary Health Facility, Southwest Nigeria

BACKGROUND

Keloids are chronic dermal fibro-proliferative disorders resulting from excessive collagen deposition. Although it is commonly seen in the dark skin, it occurs in other races. It is a disfiguring dermatosis whose epidemiology and clinical pattern should be put into proper perspective in an area where it has not been extensively documented.

SUBJECTS AND METHOD

A cross-sectional design that included 120 consenting keloids patients was made at the dermatology and plastic surgery clinics of a tertiary hospital over one year. Keloid was diagnosed clinically, risk factors, locations and patterns of affectation were documented.

RESULTS

120 patients with 192 keloids were seen. The mean age of the patients was 36.3±16.0 years with a slight female preponderance (M: F, 1:1.9). The chest was the commonest site 37 (19.3%), then earlobe 27 (14.1%) and face 21(11.0%). The buttock/feet were the least affected areas. Trauma including ear piercing, shaving, lacerations/cuts were the commonest risk factors 108 (56.2%) for keloid. The commonest observed morphological patterns in descending order of occurrence include flat 61 (31.8%), nodular 54 (28.1%) and superficial spreading 51 (26.6%) type. Flat pattern was commonest in breast and chest areas 35 (71.4%), nodular pattern on earlobes 17 (63.0%), face 11 (52.3%), scalp 3 (50.0%), neck 5 (38.5%), and guttate pattern on the face 3 (14.0%) and back 2 (22.0%). The shoulder 5 (50.0%), arms 7 (58.3%) and back 4 (44.4%) had more of the superficial spreading pattern when the morphology/patterns of keloid in these areas were compared.

CONCLUSION

Keloids affects predominantly young adults with single anatomical site being the commonest presentation, with the chest mostly affected and the flat pattern commonly observed. The morphological distinction of keloids and location may influence the choice of treatment modality.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago

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.

Outcomes of 2-octyl cyanoacrylate skin adhesives following musculoskeletal oncology surgery: A STROBE-compliant observational study

ABSTRACT

2-octyl cyanoacrylate (2OCA) is a high-viscosity medical-grade tissue adhesive that is routinely used. However, no studies have evaluated its use in musculoskeletal surgery.We enrolled 99 patients who underwent musculoskeletal surgery. 2OCA was chosen for wound closure and was performed by a specific surgeon for all patients. The drying times for the adhesive were recorded, and photographs were obtained intra-operatively. Posttreatment follow-up consisted of queries regarding pain level and recording incisional dehiscence, wound infection, hematoma, and incisional bleeding. Data collection was performed postoperatively at 48 hours, 5 to 10 days, 14 days, and 30 days. Other adverse events were documented.2OCA was applied to 110 incisions in 99 patients, comprising 62 female and 37 male patients. The mean age of patients was 50.41 (±16.83) years; mean incision length was 10.24 (±5.7) cm, and the mean pain score using a visual analogue scale was 2.37 on a postoperative day 7. The mean drying time was 1.81 (±0.59) minutes; 91 (91%) patients reported excellent and superior satisfaction, and the remaining patients reported "good" (6%) and "fair" (2%) satisfaction. The percentages of dehiscence, hematoma and keloid formation were considerably low.In this study, 2OCA was safe for musculoskeletal oncology surgical incisions. The incidence of postoperative adverse events was low. However, some patients develop hematomas. Postoperative pain was low, and patient satisfaction was high. 2OCA can be a practical alternative to traditional suture closure for skin incisions after musculoskeletal surgery.

Keloid risk in patients with atopic dermatitis: a nationwide retrospective cohort study in Taiwan

OBJECTIVE

The pathogenesis of keloid is largely unknown. Because keloid and atopic dermatitis have overlapping pathophysiological mechanisms, we aimed to evaluate keloid risk in patients with atopic dermatitis.

STUDY DESIGN

Population-based retrospective cohort study.

SETTING

The Taiwan National Health Insurance Research Database was used to analyse data for people who had been diagnosed with atopic dermatitis.

PARTICIPANTS

We identified 8371 patients with newly diagnosed atopic dermatitis during 1996-2010. An additional 33 484 controls without atopic dermatitis were randomly identified and frequency matched at a one-to-four ratio.

PRIMARY AND SECONDARY OUTCOME MEASURE

The association between atopic dermatitis and keloid risk was estimated using Cox proportional hazard regression models.

RESULTS

After adjustment for covariates, the atopic dermatitis patients have a 3.19-fold greater risk of developing keloid compared with the non-atopic dermatitis group (3.19vs1.07 per 1000 person-years, respectively). During the study period, 163 patients with atopic dermatitis and 532 patients without atopic dermatitis developed keloid. Notably, keloid risk increased with severity of atopic dermatitis, particularly in patients with moderate to severe atopic dermatitis.

CONCLUSIONS

Our results indicate that patients with atopic dermatitis had a higher than normal risk of developing keloid and suggest that atopic dermatitis may be an independent risk factor for keloid.

Adverse Effects and Surgical Complications in Pediatric Patients Undergoing Vagal Nerve Stimulation for Drug-Resistant Epilepsy

Vagal nerve stimulation (VNS) is an effective treatment for drug-resistant epilepsy that is not suitable for resective surgery, both in adults and in children. Few reports describe the adverse effects and complications of VNS. The aim of our study was to present a series of 33 pediatric patients who underwent VNS for drug-resistant epilepsy and to discuss the adverse effects and complications through a review of the literature.The adverse effects of VNS are usually transient and are dependent on stimulation of the vagus and its efferent fibers; surgical complications of the procedure may be challenging and patients sometimes require further surgery; generally these complications affect VNS efficacy; in addition, hardware complications also have to be taken into account.In our experience and according to the literature, adverse effects and surgical and hardware complications are uncommon and can usually be managed definitely. Careful selection of patients, particularly from a respiratory and cardiac point of view, has to be done before surgery to limit the incidence of some adverse effects.

Intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars

OBJECTIVE

To compare the use of intralesional triamcinolone acetonide and its combination with 5 flourouracil in the treatment of keloid and hypertrophic scars in terms of reduction in initial height of the scar.

METHODS

The randomised controlled trial was conducted at the Department of Plastic Surgery, King Edward Medical University, Lahore, from March 2011 to December 2012. It comprised patients of both genders having keloids or hypertrophic scars (1 cm to 5 cm in size) having no history of treatment for the scars in preceding 6 months. Those who were pregnant, planning pregnancy or lactating were excluded. The subjects were divided into two groups: Group A received intralesional triamcinolone acetonide alone; and Group B received triamcinolone acetonide + 5 flourouracil. Eight injections were given at weekly interval. Scars were assessed 4 weeks after the completion of treatment on a five-point scale. SPSS 16 was used for statistical analysis.

RESULTS

The 150 subjects in the study were divided into two equal groups of 75 (50%) each. Good to excellent results were seen in 51 (68%) cases in Group A compared to 63 (84%) in Group B. Frequency of complications was 18 (24%) and 6 (8%) in Group A and Group B respectively.

CONCLUSION

Combination of triamcinolone acetonide and 5 flourouracil is superior to triamcinolone acetonide therapy in the treatment of keloids and hypertrophic scars.

Keloids and non-diabetic kidney disease: similarities and the APOL1-MYH9 haplotype as a possible genetic link

Keloids and non-diabetic kidney disease are both fibrotic processes that disproportionately affect persons of African descent. Despite similarities in these conditions, the authors identified no studies to date investigating a shared genetic etiology. MYH9 and APOL1 are in linkage disequilibrium and have both been associated with non-diabetic kidney disease. MYH9 codes for a non-muscle myosin that is involved in cell adhesion and locomotion and is known to be overexpressed in keloids. Variations in APOL1 confer resistance to subspecies of Trypanosoma brucei, which may explain why otherwise deleterious genetic alterations in this haplotype could have gained prominence. We feel that the pathophysiological and epidemiological overlap between keloids and non-diabetic kidney disease support a common genetic origin and further investigation into keloids and the MYH9-APOL1 haplotype and keloids is warranted. Furthermore, we feel this haplotype might offer insight into thrombosis, stroke and other conditions that disproportionately affect persons of African descent.

Risk factors in pediatric dermatologic surgery

BACKGROUND

Specific risk factors for complications in pediatric dermatologic surgery have not been studied in previous reports.

OBJECTIVES

Analyze complications of a cohort of children for anesthetic and surgical complications and determine specific risk factors for surgical complications.

METHODS

Retrospective collection of data from 210 consecutive children having operations over 6 years. Bivariate and logistic regression statistical analysis of complications and risk factors was conducted for single step interventions.

RESULTS

General anesthesia complications were observed in 10.07 percent of the cases: Agitation and stridor were the most common anesthetic complications. Surgical complications were observed in 22.63 percent of the cases. Scar stretching followed by infection were the most prevalent complications. Complication rates, both anesthetic (9.09%) and surgical (13.63%) of multiple step interventions were similar to single step surgery. Intradermal absorbable suture in upper closure (p=0.028) and in limb (p=0.014) location were independently associated with complications.

CONCLUSION

General anesthesia is safe in pediatric dermatology in the hands of experienced pediatric anesthetists. The most frequent surgical complication was scar stretching. Limb location and use of absorbable continuous intradermal suture in the upper closures should be taken into account as possible risk factors when informing parents and performing these procedures.

A primary care perspective on keloids

Keloids are a common presenting complaint in the primary care clinic. This condition presents a formidable challenge, as recurrence is often difficult to prevent despite use of multiple therapeutic interventions. Part of the reason for the absence of a definitive treatment is the incomplete understanding of the pathogenesis of keloid formation, which creates a frustrating situation for both physician and patient. Here we review the most recent literature on the clinical features, pathogenesis, and management of keloids, with special emphasis on the unique challenges faced by primary care physicians.

Multicenter Study of Wound Healing in Neurofibromatosis and Neurofibroma

Based on clinical experience, the senior author has become convinced that wounds produced to correct the deformities of patients with neurofibromatosis (NF-1) have produced remarkably good scars, the interesting feature being that progression to keloid or hypertrophic scar is rare. The other point noted was that this situation did not change, no matter the patient's race or skin color. There have been few reports describing or discussing this hypothesis. The purpose of this study was to investigate whether wounds produced in the patients with NF-1 produce keloid or hypertrophic scars. The patients with solitary neurofibroma were also included in this study; these were compared with the NF-1 group. This was conducted as a multicenter study. Patients with neurofibromatosis/solitary neurofibroma, who were operated on from 1990 to 2000, were evaluated by reviewing their medical charts and photographs retrospectively. The patients were treated in centers from five different countries. The analysis was undertaken based on the following points: 1) age and sex at surgery; 2) race of the patients; 3) past and family histories of hypertrophic scar and keloid; 4) surgical site(s); 5) diagnosis, NF1 or solitary neurofibroma; 6) surgical complications; 7) number of reoperations to manage the complications; 8) adjuvant therapy for the tumor; 9) depth of the tumors; and 10) incidence of malignant degeneration. A total of 101 cases with neurofibromatosis or solitary neurofibroma was analyzed. The age at surgery ranged from 1 year 6 months to 74 years; sex ratio was 47 males and 54 females. The racial distribution of the patients was 13 white, 13 black, 3 Hispanic, and 58 Asian. There was no past or family history of hypertrophic scar or keloid. The surgical sites were head and neck in 70 cases, trunk in 20 cases, upper extremities in 22 cases, and lower extremities in 20 cases. The clinical diagnosis was NF-1 in 57 cases, solitary neurofibroma in 35 cases, plexiform neurofibroma in four cases, and no distinct clinical diagnosis in five cases. There were no other types of neurofibromatosis. Hematoma and white wide scar were the main postoperative complications found in six cases of NF-1. Infection was also noted in four cases. However, no patient developed hypertrophic scar or keloid in the neurofibromatosis group, whereas two cases showed hypertrophic scar in the solitary neurofibroma group. The outcome showed that the patients with NF-1 and plexiform neurofibroma, no matter the racial group, produce good scars without keloid or hypertrophic changes, whereas solitary neurofibroma has a potential to cause hypertrophic scar.

Genomic and proteomic profiling II: comparative assessment of gene expression profiles in leiomyomas, keloids, and surgically-induced scars

BACKGROUND

Leiomyoma have often been compared to keloids because of their fibrotic characteristic and higher rate of occurrence among African Americans as compared to other ethnic groups. To evaluate such a correlation at molecular level this study comparatively analyzed leiomyomas with keloids, surgical scars and peritoneal adhesions to identify genes that are either commonly and/or individually distinguish these fibrotic disorders despite differences in the nature of their development and growth.

METHODS

Microarray gene expression profiling and realtime PCR.

RESULTS

The analysis identified 3 to 12% of the genes on the arrays as differentially expressed among these tissues based on P ranking at greater than or equal to 0.005 followed by 2-fold cutoff change selection. Of these genes about 400 genes were identified as differentially expressed in leiomyomas as compared to keloids/incisional scars, and 85 genes as compared to peritoneal adhesions (greater than or equal to 0.01). Functional analysis indicated that the majority of these genes serve as regulators of cell growth (cell cycle/apoptosis), tissue turnover, transcription factors and signal transduction. Of these genes the expression of E2F1, RUNX3, EGR3, TBPIP, ECM-2, ESM1, THBS1, GAS1, ADAM17, CST6, FBLN5, and COL18A was confirmed in these tissues using quantitative realtime PCR based on low-density arrays.

CONCLUSION

the results indicated that the molecular feature of leiomyomas is comparable but may be under different tissue-specific regulatory control to those of keloids and differ at the levels rather than tissue-specific expression of selected number of genes functionally regulating cell growth and apoptosis, inflammation, angiogenesis and tissue turnover.

Prevalence of childhood acne, ephelides, warts, atopic dermatitis, psoriasis, alopecia areata and keloid in Kaohsiung County, Taiwan: a community-based clinical survey

BACKGROUND

Epidemiological study on childhood dermatoses performed by direct inspection of dermatologists is limited.

OBJECTIVE

To investigate the prevalence of selective childhood dermatoses in Taiwan.

METHODS

In a cross-sectional study carried out in June 2004, 4067 of 7851 children aged between 6 and 11 years living in the Kaohsiung County in south Taiwan were clinically surveyed and examined by two board-certified dermatologists (response rate 52%), regarding the point prevalence of acne, ephelides, warts, atopic dermatitis (AD), psoriasis, alopecia areata (AA) and keloid.

RESULTS

Acne vulgaris was found in girls and boys from the age of 6 and 7, respectively, with comedones being the earliest presentation. Ephelides were not infrequently observed in our children (prevalence rate 8.4%, 95% confidence interval, CI 7.9-9.3%). The prevalence of warts on hands was 2.4% (95% CI 1.9-2.9%). The prevalence of AD was 1.7% (95% CI 1.3-2.1%), without gender difference. There were only four cases of AA but no psoriasis was found. Keloid was identified in 13 boys and 10 girls, accounting for 0.6% (95% CI 0.598-0.602%) of the children.

CONCLUSION

Acne vulgaris is as common in Taiwan as in Western countries. Ephelides are not uncommon in our population with the main skin types III-IV. A clustered distribution of the wart infection was noted. The low prevalence of AD in Taiwan seems unaltered over the past decade. AA and psoriasis are rare in our series. Most keloids in our children are caused by BCG vaccination.

Lobomycosis in Venezuela

Lobomycosis is a chronic dermal infection that presents a wide spectrum of clinical- dermatological manifestations, mainly characterized by the development of keloid lesions as well as nodular, verrucoid and sometimes ulcerous forms. The etiological agent at an international level, according to the consensus nomenclature, has been called Loboa loboi, even though recently it has been accommodated as Lacazia loboi. The present review extensively covers the clinical-epidemiological aspects as well as the most outstanding historical aspects, including the Venezuelan experience and the presentation of two new cases, which substantiate the Amazon basin as an endemic area for the disease.

[p53 gene codon 72 polymorphism and susceptibility to keloid]

OBJECTIVE

To investigate the relationship between p53 codon 72 polymorphism and susceptibility to keloid in a southern Chinese population.

METHODS

The p53 genotypes were determined by polymerase chain reaction-reverse dot blot (PCR-RDB) and DNA direct sequencing in 45 patients with keloid and 60 unrelated healthy controls.

RESULTS

The frequency of the p53 Pro allele among keloid patients was significantly higher than that among healthy controls (chi2 = 4.485, P = 0.034). The Pro/Arg and Arg/Arg genotype distribution among keloid patients was not significantly different from that among healthy controls (chi2 = 0.949, 1.346; P = 0.330, 0.246, respectively). However, the Pro/Pro genotype frequency among keloid patients was significantly higher than that among healthy controls (chi2 = 4.375, P = 0.036). The p53 Pro/Pro genotype significantly increased the risk for developing keloid, compared to the combination of Pro/Arg and Arg/Arg genotypes,with the odds ratio (OR) of 2.400 (95%CI: 1.048-5.498).

CONCLUSIONS

Determination of the p53 codon 72 genotype may be used as a stratification marker to predicate high-risk individuals for keloid.

Retrospective analysis of treatment of unresectable keloids with primary radiation over 25 years

AIMS

The purpose of the study was to review retrospectively the role of primary radiotherapy for unresectable keloids.

MATERIALS AND METHODS

Kilovoltage X-rays and mega-voltage electron beams were used to irradiate large bulky unresectable keloids. A total of 3750 cGy was given in five once-weekly fractions, over a period of 5 weeks. Eighty-six keloids in 64 patients were treated between 1977 and 2002.

RESULTS

Ninety-seven per cent of this cohort had significant regression, and 3% had partial regression 18 months after completing radiotherapy. Both acute and long-term reactions were acceptable, and so far none of the patients have been reported as having cancer of any sort. Sixty-three per cent of the patients surveyed were very happy with the outcome of their treatment.

CONCLUSION

Unresectable bulky symptomatic keloids can be satisfactorily treated with hypo-fractionated radiotherapy primarily using either kilovoltage X-rays or electron beams without significant short- or long-term side-effects.

Hypertrophic scars and keloids: etiology and management

Keloid and hypertrophic scars have affected patients and frustrated physicians for centuries. Keloid and hypertrophic scars result from excessive collagen deposition, the cause of which remains elusive. Clinically, these scars can be disfiguring functionally, aesthetically, or both. A thorough understanding of the pathophysiology and clinical nature of the scar can help define the most appropriate treatment strategy. Although many articles have been published on the management of hypertrophic and keloid scars, there is no universally accepted treatment protocol. Prevention of keloid and hypertrophic scars remains the best strategy; therefore, those patients with a predisposition to develop excessive scar formation should avoid nonessential surgery. Once a scar is present, there are many treatments from which to choose. Hypertrophic scars and keloids have been shown to respond to radiation, pressure therapy, cryotherapy, intralesional injections of corticosteroid, interferon and fluorouracil, topical silicone or other dressings, and pulsed-dye laser treatment. Simple surgical excision is usually followed by recurrence unless adjunct therapies are employed. Biologic agents that are directed towards the aberrant collagen proliferation that characterizes keloid and hypertrophic scars might be an important addition to the current armamentarium of modalities in the near future.

Control of an outbreak of BCG complications in Gaza

OBJECTIVE

We aim to describe Bacille Calmette Guerin (BCG) complications in Gaza using two studies: one during an outbreak and the other after control of the possible contributing factors to this outbreak.

METHODOLOGY

The first study was conducted on 6145 newborn infants vaccinated in 21 primary care centres in Gaza with BCG vaccine, Pasteur Paris, batch number 5122 from July to October 2001. The study was repeated after changing the BCG vaccine and training 63 nurses from November to December 2001. The training program included theoretical lectures on BCG and tuberculosis and practical training in strict intradermal injection. The second study included 6877 newborn infants vaccinated with BCG vaccine, batch number 101023, Denmark, from January to April 2002.

RESULTS

During the outbreak, BCG complications occurred in 225 infants with a complication rate of 36.61 per 1000 vaccinations. The mean age at presentation was 4 months. The commonest complications were regional lymphadenitis in 138 (61.33%) infants, local abscess in 48 (21.33%) infants, local ulcer in 26 (11.56%) infants, keloid scar in 12 (5.33%) infants and one (0.44%) infant who died from disseminated disease had severe combined immunodeficiency. In the follow-up study, BCG complications occurred in 43 infants with a complication rate of 6.25 per 1000 vaccinations, which is significantly lower (P < 0.001) than that during the initial outbreak.

CONCLUSION

The study supports the use of a less virulent vaccine and proper vaccination techniques to minimize the incidence of BCG complications. The training of nurses in strict intradermal injection should be maintained and the proper selection of those receiving the vaccines should be considered to avoid the vaccination of any infant with immunodeficiency.

Keloid in Iraqi patients: a clinicohistopathologic study

BACKGROUND

Keloid is a benign, well-demarcated area of fibrous tissue overgrowth that extends beyond the original defect. It is not an uncommon problem and is encountered frequently in daily practice.

OBJECTIVE

To evaluate the different clinical and histopathologic aspects of this disease in Iraqi people.

METHODS

Eighty-eight patients with keloid were clinically assessed. Histopathologic examination was performed in 16 patients. Giemsa stain was used in eight patients to assess the presence of mast cells.

RESULTS

There were 47 females and 41 males. The disease started in the second and third decades of life in 62 patients (70.5%). Itching was present in 46 patients (52.2%) and was more predominant in those with early lesions. Darier sign was elicited in 22 patients (25%); all of them had itching. The duration of the disease ranged from 0.33 to 20 years, with a mean of 5.4 years. Spontaneous keloid was found in 30 patients (34%). The lesions were mainly single (63.4%). All of these patients had lesions on the face and upper trunk in addition to involvement of extremities in five of them (16.7%). BCG keloid was observed in females only, and it showed downward gravitational extension in three of seven patients (43%). The histopathologic examination of keloid in 16 patients showed many interesting findings, such as the presence of hyperplastic epidermis in six specimens (37.5%), Grenz zone in 11 patients (68.75%), telangiectasia in 12 patients (75%), and pseudopodia extension of the growth to the adjacent tissues in half of the patients. Giemsa stain of eight specimens demonstrated the presence of mast cells in four patients (50%), more in biopsies that were taken from early lesions.

A controlled cohort study examining the onset of hypertension in black patients with keloids

We compared the incidence of hypertension in 281 black patients with keloids and 148 black patients with tinea versicolor (control). No difference in the overall incidence of hypertension was detected, however, we detected an increased incidence of hypertension in patients with keloids under thirty (7.9%) as compared to the control (0%).

Health disparities in arthritis and musculoskeletal and skin diseases-the dermatology session: National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, December 15-16, 2000

The National Institute of Arthritis and Musculoskeletal and Skin Diseases hosted a diverse group of physicians and scientists to discuss health disparities in arthritis, musculoskeletal, and skin diseases. This article discusses the cutaneous disease portion of the conference. Speakers described a history of scarce information on cutaneous diseases in skin of color, problems with the data that do exist, and inappropriate use of dermatologic data. Basic descriptive data on the structure and function of skin in people of color is needed. For specific cutaneous diseases, information must be collected on their epidemiology, clinical presentation, natural history, complications, and therapeutics. Researchers are standardizing methods for studying keloidal scars, and are developing and validating measurement tools for cutaneous diseases in skin of color, such as atypical nevi, psoriasis, and hand dermatitis, but more is needed.

Clinical genetics of familial keloids

BACKGROUND

Keloids are proliferative fibrous growths that result from an excessive tissue response to skin trauma. Most keloids occur sporadically, but some cases are familial. However, the genetics of keloid formation have only rarely been documented, and the mode of inheritance is not known.

OBJECTIVE

To elucidate the clinical genetic characteristics of keloid wound-healing disorder.

OBSERVATIONS

We studied the clinical and genetic characteristics of 14 pedigrees with familial keloids. The ethnicity of these families is mostly African American (n = 10), but also white (n = 1), Japanese (n = 2), and African Caribbean (n = 1). The pedigrees account for 341 family members, of whom 96 displayed keloids. Of the affected family members, 36 are male and 60 are female. The age of onset varies from early childhood to late adulthood. There is variable expression of keloids within the same families: some affected members have only minor earlobe keloids, whereas others have very severe keloids affecting large areas of the body. In the described pedigrees, 7 individuals are obligate unaffected carriers, revealing nonpenetrance in about 6.8% of keloid gene carriers. Syndromes associated with keloids, namely Rubinstein-Taybi and Goeminne syndrome, were not found in these families. Additionally, linkage to the gene loci of these syndromes and X-chromosomal linkage were excluded.

CONCLUSIONS

The pattern of inheritance observed in these families is consistent with an autosomal dominant mode with incomplete clinical penetrance and variable expression. This is the most comprehensive collection of keloid families described to date, and it allows for the first time the elucidation of the clinical genetic characteristics of the familial form of this wound-healing disorder.

[The long-term anterior chest median wound keloid after the cardiac surgery]

We discussed on the long-term anterior chest median wound keloid after the cardiac surgery by using a questionnaire. The risk of the anterior chest median wound keloid was high significantly in the cases using the bilateral internal thoracic artery compared with the cases using no internal thoracic artery. Participation of the decreased blood supply was highly suggested as the cause of this keloid formation.

[Short- and long-term results of parotidectomy, apropos of 24 cases at the Ougadougou University Hospital Center]

We reported the short and medium results of the 24 parodectomies performed at the ORL Department of the NHC of Ouagadougou between 1985 and 1993 in order to assess the frequency of the complications and to search for their causes. It is a retrospective study on 15 women and 9 men aging between 14 to 56 years. The research for the VII has been always done at the trunk. In the absence of an extemporan histological test, 3 exofacial parotidectomies have been performed for slight injuries of the superficial ear-lobe, 2 total parotidectomies in the other cases. All our sick persons have a 3-years recession. We registered: 1 case of post surgery haemorrhagia (4%) 2 cases of additional infection (8%) 3 cases of facial paralysis that are recessive or not (12.5%) 6 cases with Frei syndrome (25%). Multiple factors can explain the profile that follows surgery of our sick-persons. We insist on the fact that there is minimum specialist that are used to this kind of surgery and to the smallest of the technical board. Complications and after effects after-parotidectomy were in our view almost frequent in our conditions of work. It is true that it is a delicate surgery, but the after effects can be better improved by additional specialist in ORL and with an adequate equipment.

Prevalence of acne keloidalis nuchae in football players

BACKGROUND

Acne mechanica (AM) is common in football players. Severe cases of nuchal AM may precede acne keloidalis nuchae (AKN). Factors that may be associated with the progression of nuchal AM to AKN are unknown. The prevalence of AKN in football players has not been reported.

OBJECTIVE

We investigated the frequency of nuchal AM and AKN within a susceptible population and attempted to identify factors that may be associated with AKN.

METHODS

Four hundred fifty-three high school, collegiate, and professional football players were examined for the presence of nuchal AM or AKN. Those with positive findings completed a questionnaire regarding their disease.

RESULTS

Nuchal AM was more prevalent in high school players (15.5%) than older players (1.2%). AKN was more frequent in players beyond the high school level and was found exclusively in blacks. AKN was not associated with a positive family history of AKN nor a positive personal or family history of keloid formation.

CONCLUSION

AKN occurs almost exclusively in blacks. The level of football play may be associated with the development of AKN. Positive family history of AKN and positive family or personal history of keloids is not associated with AKN development.

Does keloid pathogenesis hold the key to understanding black/white differences in hypertension severity?

Repeated national surveys have shown that in the United States hypertension is more common and more severe in the black than in the white population. This discussion presents the hypothesis that the racial difference in hypertension severity is because of differences in growth factors (cytokines) affecting vascular smooth muscle cell growth. This hypothesis is derived from studies of keloids, which occur almost exclusively in blacks. Keloid fibroblasts in culture have growth characteristics that differ substantially from those of normal skin. Furthermore, there is evidence that peripheral blood mononuclear cells from patients with keloids produce different amounts of cytokines than do similar preparations from the blood of individuals without keloids. A growing body of evidence indicates that growth factors play a pivotal role in the pathogenesis of atherosclerosis, in experimental forms of hypertension, and in various renal diseases; it may be that they function in clinical hypertension as well.

Hypertrophic and keloid scars

A comparison of the histological, epidemiological and aetiological characteristics of hypertrophic scars and keloids

Keloids treated with excision followed by radiation therapy

BACKGROUND

In the treatment of keloids surgical excision followed by radiation therapy provides the highest reported control rates of 72% to 92%.

OBJECTIVE

We evaluated the effectiveness of excision followed by radiation therapy in the treatment of keloids and compared the efficacy of orthovoltage and electron beam radiation.

METHODS

One hundred twenty-six keloids were treated with radiation therapy after surgical excision. Median follow-up period was 12 years. Recurrence rate, side effects, and effectiveness of therapy were assessed. Data were analyzed with multivariate analysis for significant objective and subjective factors.

RESULTS

Higher posttreatment recurrence rates were noted with keloids forming at infected sites and in patients with a family history. No increased likelihood of recurrence was noted with respect to patient age, sex, or ethnicity; keloid size or location; individual keloid history; or prior therapy or radiation type used.

CONCLUSION

Excision followed by radiation therapy is a useful and effective method of keloid eradication, particularly in cases in which lesions are disfiguring or refractory. Electron beam radiation offers no advantage over orthovoltage as a treatment.

A short course postoperative radiotherapy regime for keloid scars in Nigeria

The unsatisfactory high rate of recurrence following the traditional approach for the radiotherapy of keloid scars in Nigeria, led to the design of this study which employed a short course post operative radiotherapy regime. Two hundred and forty four patients with four hundred and fifty four (454) keloidal scars treated with superficial X-ray therapy within 72 hours following surgical excision at the Lagos University Teaching Hospital Lagos, Nigeria, between January, 1984 and December, 1988 were analyzed. The commonest site treated was the ear lobe (36.8%). Radiation dose ranged between 5-6Gy in single sessions and 12-15Gy in 3 fractions over 5 days. A complete response rate of 93% at 24 months was achieved. The treatment was well tolerated with no serious complications reported to date.

The treatment of 783 keloid scars by iridium 192 interstitial irradiation after surgical excision

PURPOSE

the aim of this study is to confirm the effectiveness of irradiation associated with surgery in the treatment of keloids, to precise the factors favoring the recurrence of these keloids, and to evaluate the risk of recurrence, according to their initial distinctive features.

METHODS AND MATERIALS

between 1977 and 1988, 544 patients, with a total of 855 keloids, were treated by interstitial radiotherapy immediately following total excision.

RESULTS

recurrence rate is 21%, as against 50 to 80% for surgery alone, according to most authors. This recurrence rate is about the same as for external radiotherapy, but we prefer our method for practical reasons (cost, equipment, radiobiology, technique). Ninety percent of recurrences occurred in the year following therapy, which proves that a follow-up time of at least 12 months is needed for a study of keloids. In our experience, the keloids that are the most likely to recur are the largest and those giving rise to most symptoms. Bruising and loosened stitches, but in particular infection during therapy, largely favor a recurrence. In our series, the symptoms disappeared or were much improved in 80% of cases, and the cosmetic result was judged good by 75% of the patients.

CONCLUSION

the results of this study proves the effectiveness of the method linking surgical excision and Iridium 192 interstitial irradiation and shows the importance of the sterile conditions of the treatment.

Considerations for cosmetic surgery in the black population

The availability of cosmetic surgical procedures to the general public, especially blacks, has become increasingly widespread. Aesthetic surgeons should not be deterred from performing these procedures in blacks. The myth that all black patients develop keloids or dyspigmentation after surgery should be dispelled; however, in those patients with a history of keloid formation or hypertrophic scarring, elective cosmetic procedures should be either withheld or performed with extreme caution. In general, the cosmetic surgeon can proceed with surgery in blacks and attain good aesthetic results if the procedures are slightly modified when indicated to minimize pigmentary changes and scarring and to maintain ethnic congruency.

The role of kilovoltage irradiation in the treatment of keloids

This is a retrospective analysis of the results of kilovoltage irradiation given to prevent the regrowth of 203 keloids excised at the University of Iowa Hospitals and Clinics, Iowa City, Iowa, Lutheran Hospital in Moline, Illinois, and Mercy Hospital in Cedar Rapids, Iowa. We found that a minimum follow-up of 1 year is needed to evaluate the results of post-excisional kilovoltage x-ray therapy. A dose versus response effect was also observed. Although it is desirable to use the lowest possible dose of radiation that is likely to be effective, the likelihood of failure is too great to justify the routine use of doses of less than 900 cGy regardless of how they are fractionated or when they are given. It appears that the total dose of irradiation that is given to prevent the regrowth of an excised keloid is more important than when irradiation is started, the size of the largest fraction given, whether the irradiation is completed in 1 week or 3, or where the keloid has grown. When a small number of keloids were irradiated less than 1 year after they first appeared greater than or equal to 1500 cGy were sufficient to control 90% of them without re-excision.

Keloids

Keloids are benign fibrous growths that result from an abnormal connective tissue response in certain predisposed individuals. Blacks form keloids more often than whites; however, the reason for this racial difference is not known. Trauma, foreign-body reactions, infections, and endocrine dysfunction have all been proposed as precipitating factors. Keloids are found most commonly on the ear lobes, shoulders, upper back, and midchest. They extend past the area of trauma and once present tend to remain stable. Although sometimes pruritic, painful, or tender, they are usually asymptomatic. Histologically, keloids are characterized by thick collagen bundles, abundant mucinous ground substance, few fibroblasts, and few if any foreign-body reactions. Although there have been many therapeutic modalities, most have had limited success. The most commonly used therapeutic approach is a combination of cryotherapy, intralesional steroid injections, surgical excision, and pressure devices.

[Between Yucatan, Florida and French Guiana does lobomycosis exist in the Antilles?]

Lobomycosis, or Blastomicose queloidiforme de Jorge Lobo, has been described in men around the North of South America, Central America, and the case reported in Yucatan, Mexico, is the northest. The same disease has been seen in Dolphins in Florida, where the humans cases are unknown. Epidemiology, pathogenic curiosities, and diagnosis are presented for all practicians in the geographic area.