Chondroitin Sulfate Promotes the Proliferation of Keloid Fibroblasts Through Activation of the Integrin and Protein Kinase B Pathways.

Keloids are dermal fibroproliferative tumors that arise beyond the boundary of the original wound edges and invades adjacent tissue. Keloids are characterized by the extensive production of extracellular matrix (ECM) and abnormal fibroblast proliferation. Chondroitin sulfate (CS) is one of the major structural components of cartilage and ECM. Recently, we reported the over-accumulation of CS in keloid lesions. Keloid-derived fibroblasts (KFs) and normal dermal fibroblasts (NFs) were incubated with CS. The fibroblast proliferation rate was analyzed using a tetrazolium salt colorimetric assay. The activation of the intracellular signaling pathway was analyzed by Western blotting. Wortmannin, a PI3K inhibitor, and anti-integrin antibodies were tested to investigate the mechanism of the CS-induced cell proliferation. CS strongly stimulated the proliferation of KFs, but not NFs. The analysis of the intracellular signal transduction pathway revealed that the stimulation effect of CS on KF proliferation was due to the activation of the protein kinase B (AKT) pathway and that integrin α1 was responsible for this phenomenon. We revealed that CS probably activates the AKT pathway through integrin to induce KF proliferation. CS may be a novel clinical therapeutic target in keloids.

HtrA1 Is Specifically Up-Regulated in Active Keloid Lesions and Stimulates Keloid Development.

Keloids occur after failure of the wound healing process; inflammation persists, and various treatments are ineffective. Keloid pathogenesis is still unclear. We have previously analysed the gene expression profiles in keloid tissue and found that HtrA1 was markedly up-regulated in the keloid lesions. HtrA1 is a serine protease suggested to play a role in the pathogenesis of various diseases, including age-related macular degeneration and osteoarthritis, by modulating extracellular matrix or cell surface proteins. We analysed HtrA1 localization and its role in keloid pathogenesis. Thirty keloid patients and twelve unrelated patients were enrolled for in situ hybridization, immunohistochemical, western blot, and cell proliferation analyses. Fibroblast-like cells expressed more HtrA1 in active keloid lesions than in surrounding lesions. The proportion of HtrA1-positive cells in keloids was significantly higher than that in normal skin, and HtrA1 protein was up-regulated relative to normal skin. Silencing HtrA1 gene expression significantly suppressed cell proliferation. HtrA1 was highly expressed in keloid tissues, and the suppression of the HtrA1 gene inhibited the proliferation of keloid-derived fibroblasts. HtrA1 may promote keloid development by accelerating cell proliferation and remodelling keloid-specific extracellular matrix or cell surface molecules. HtrA1 is suggested to have an important role in keloid pathogenesis.

ß-Adrenergic Receptor Blockers Reduce the Occurrence of Keloids and Hypertrophic Scars after Cardiac Device Implantation: A Single-Institution Case-Control Study.

BACKGROUND: Keloids and hypertrophic scars are characterized by excessive proliferation of fibroblasts; abnormal accumulation of extracellular matrix; and clinical findings of raised, red, itchy, and painful lesions. There are few sufficient interventions for keloids, and the development of new therapeutic agents is urgently needed. Several studies suggest that a therapeutic possibility is ß-adrenergic receptor blocker treatment. METHODS: In this single-center case-control study, patients who had undergone cardiac device implantation 7 to 23 months earlier were identified. The implantation incision scars of the patients were deemed to be normal or abnormal depending on their redness. The cases (abnormal scars) and controls (normal scars) were compared in terms of their ß-blocker use rates. RESULTS: Of the 45 eligible patients, 12 and 33 patients were cases and controls, respectively. The cases tended to be less likely to have taken blockers than the controls (25 percent versus 45.5 percent). This difference became significant when the patients whose scars were diagnosed 7 or 8 months after implantation were excluded from the analysis: the age-adjusted odds ratios of the patients who were diagnosed 8 to 23 and 9 to 23 months after implantation were 0.10 (95 percent CI, 0.00 to 0.83; p = 0.0309) and 0.11 (95 percent CI, 0.00 to 0.98; p = 0.047), respectively. CONCLUSIONS: ß-Blockers may be an effective alternative modality for preventing and treating keloids and hypertrophic scars. Large-scale multicenter prospective studies that use histology to diagnose scars and diagnose the postoperative scars at the most suitable period are needed to confirm the effectiveness of blockers for abnormal scars. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Shear Wave Velocity on Elastography Correlates with the Clinical Symptoms and Histopathological Features of Keloids.

BACKGROUND: Keloids present as red, painful lesions causing serious functional and cosmetic problems; however, there is no consensus regarding tools for objectively evaluating keloids. To demonstrate the utility of shear wave elastography in keloids, we investigated the correlations between clinical symptoms, ultrasound shear wave velocity, and histopathological findings. METHODS: Three patients with keloids containing both red hypertrophic and mature areas were evaluated using the shear wave velocity and histopathological findings. RESULTS: The results indicate that the shear wave velocity is high in active hypertrophic areas and low in mature areas. The areas with high elastography values exhibited numerous fibrillar collagenous matrices forming a whorled pattern with hyalinized tissue on hematoxylin-eosin staining corresponding with metachromasia on toluidine blue staining. In the mature area, the collagen fibers were oriented parallel to each other without metachromasia. CONCLUSIONS: Shear wave elastography provides quantitative estimates of tissue stiffness that correlate with the clinical symptoms and histopathological findings of the keloid lesions and can be used to assess the activity of keloids.

A toe keloid after syndactyly release treated with surgical excision and intralesional steroid injection.

SUMMARY: A keloid is a benign fibroproliferative disease of unknown etiology. Although it is common among Asians, the development of keloid on the foot is rare. We experienced a case of a keloid which arose on the foot of a 4-year-old boy after the surgical release of syndactyly. He had congenital cutaneous syndactyly of the third and fourth toes. After the reconstructive operation was performed when the patient was 2 years old, the wound became hypertrophic and grew to 37 × 37 × 8 mm. After the diagnosis of keloid based on a pathological examination, the keloid was resected completely. The web was reconstructed with a planter rectangular flap, and the skin defects were covered with a full-thickness skin graft. After the operation, we administered 5 intralesional steroid injections. Finally, the keloid was diminished 2 years after the operation.

Treatment for infection of artificial dura mater using free fascia lata.

Synthetic artificial dura mater materials, such as expanded polytetrafluoroethylene sheets, are widely used in dura mater reconstruction in cases involving brain tumors or trauma surgery. In patients with postoperative infection related to the use of artificial dura mater, surgical debridement of the infected wound and removal of the artificial dura mater materials are necessary to control infection. In cases involving cerebrospinal fluid leakage, dura mater reconstruction must be performed immediately. Many useful techniques for performing dura mater reconstruction to treat postoperative infection have been reported; however, some have drawbacks with respect to the need for microvascular anastomosis or difficulties in obtaining watertight closure. We successfully treated 6 patients with postoperative artificial dura mater infection using free thigh fascia lata. Some surgeons believe that the use of free fascia in infected wounds is dangerous because free fascia is a non-vascularized tissue. However, performing complete debridement and covering such free fascia with well-vascularized tissue allow the fascia to become vascularized and tolerant of infection. Therefore, if the blood flow in the scalp is acceptable after a sufficient debridement, free fascia lata can be used for reconstruction in patients with postoperative infection of artificial dura mater. Furthermore, skull reconstruction can be performed safely and easily with solid-type artificial bone, sometimes combined with tissue expansion, thus resulting in good aesthetic outcomes.

Severe Acute Radiodermatitis in a Keloid Patient with Takayasu's Arteritis.

SUMMARY: Although combination therapy for keloid including postoperative radiation therapy (RT) is common, the radiation toxicity of RT in a patient with a history of collagen vascular disease has not been fully recognized. We experienced a case of an acute radiodermatitis in a patient with keloid. This patient had a chest keloid because of the bypass surgery for Takayasu's arteritis. After we performed an excision and postoperative RT, severe radiodermatitis occurred. We speculate that the higher single dose and the use of electron beams may be related to the onset of severe acute radiodermatitis in this case. It should be kept in mind that there is a risk of exacerbation of radiation toxicity in patients with collagen vascular disease.

Keloids can be forced into remission with surgical excision and radiation, followed by adjuvant therapy.

We have treated keloids using a combination of surgical excision and postoperative irradiation. The objective of this study was to evaluate the results of our treatment over 12 years. From 1995 until 2006, we treated keloids using the aforementioned treatment. If we identified a sign of recurrence during the follow-up period, we started an intralesional injection of triamcinolone acetonide immediately. We selected 91 keloids for which we had more than 2 years of follow-up data for this study and assessed the results according to our original scale (Kyoto scar scale) based on objective and subjective symptoms. In all, 51 keloids (56.0%) were cured completely by a combination of surgical excision and postoperative irradiation without additional treatment, and finally 81 keloids (89.0%) showed good results with additional treatment. Keloids are a controllable condition when treated with combination therapy, involving surgical excision with postoperative irradiation and early conservative treatment after the detection of recurrence.

ARMET is a soluble ER protein induced by the unfolded protein response via ERSE-II element.

Arginine rich, mutated in early stage of tumors (ARMET) was first identified as a human gene highly mutated in a variety of cancers. However, little is known about the characteristics of the ARMET protein and its expression. We identified ARMET as a gene upregulated by endoplasmic reticulum (ER) stress. Here, we show that the mouse homologue of ARMET is an 18-kDa soluble ER protein that is mature after cleavage of a signal sequence and has four intramolecular disulfide bonds, including two in CXXC sequences. ER stress stimulated ARMET expression, and the expression patterns of ARMET mRNA and protein in mouse tissues were similar to those of Grp78, an Hsp70-family protein required for quality control of proteins in the ER. A reporter gene assay using a mouse ARMET promoter revealed that the unfolded protein response of the ARMET gene is regulated by an ERSE-II element whose sequence is identical to that of the HERP gene. ARMET is the second fully characterized ERSE-II-dependent gene and likely contributes to quality control of proteins in the ER.

Identification of cartilage progenitor cells in the adult ear perichondrium: utilization for cartilage reconstruction.

For cartilage reconstruction, it is still difficult to obtain a sufficient volume of cartilage and to maintain its functional phenotype for a long period. Utilizing tissue stem cells is one approach to overcome such difficulties. We show here the presence of cartilage progenitor cells in the ear perichondrium of adult rabbits by 5-bromo-2'-deoxyuridine labeling, clonogenicity, and differentiation analyses. Long-term label-retaining cells were demonstrated in the perichondrium. Cells from the perichondrium, that is, perichondrocytes were mechanically isolated using a raspatory and maintained in D-MEM/F-12 medium with 10% FCS. They proliferated more vigorously than chondrocytes from the cartilage. Perichondrocytes could differentiate into adipocytes as well as osteocytes in differentiation induction medium. For cartilage reconstruction in vivo, perichondrocytes were seeded on collagen sponge scaffolds and implanted in nude mice. After 4 weeks, the composites with perichondrocytes generated the same weight of cartilaginous tissue as those with chondrocytes. They produced glycosaminoglycan and type II collagen as shown by RT-PCR and immunohistochemical examination. On the contrary, rabbit bone marrow mesenchymal stem cells used as control could regenerate significantly smaller cartilage than perichondrocytes in the implant study. Based on these findings, we propose that the perichondrium containing tissue progenitor cells is one of the potential candidates for use in reconstructing cartilage and new therapeutic modalities.

Gene expression in human keloids is altered from dermal to chondrocytic and osteogenic lineage.

Keloids are a dermal fibrotic disease whose etiology remains totally unknown and for which there is no successful treatment. Here, we employed cDNA microarray analysis to examine gene expression in keloid lesions and control skin. We found that 32 genes among the 9000 tested were strongly up-regulated in keloid lesions, of which 21 were confirmed by Northern blotting. These included at least seven chondrocyte/osteoblast marker genes, and RT-PCR analysis revealed that transcription factors specific for these genes, SOX9 and CBFA1, were induced. Immunostaining and in situ hybridization further supported that these markers are expressed in keloid lesions. Intriguingly, scleraxis, a transcription factor known as a marker of tendons and ligaments, was also induced in keloid fibroblasts. We propose that reprogramming of gene expression or disordered differentiation from a dermal pattern to that of a chondrocytic/osteogenic lineage, probably closer to that of tendon/ligament lineage, may be involved in the etiology of keloids.

Correction of atrophic nasal ala by sandwiching an auricular cartilage graft between para-alar and nasal floor retrogressive flaps.

To correct atrophy of the nasal ala, combined flaps of the para-ala and the nasal floor were used. The flaps were pedicled on the alar base then slid in a retrograde fashion. Auricular cartilage harvested from the concha was placed in the original ala and between the para-alar and the nasal floor flaps to support the reconstructed nasal ala. The resulting skin defects in the nasal floor were covered with the skin grafts taken from postauricular regions. Postoperative scars were not conspicuous because suture lines were placed on the alar groove and the postauricular groove.