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.

Keloids, hypertrophic scars, and uterine fibroid development: a prospective ultrasound study of Black and African American women.

OBJECTIVE: To examine the association between keloids, hypertrophic scars, and uterine fibroid incidence as well as growth. Both keloids and fibroids are fibroproliferative conditions that have been reported to be more prevalent among Blacks than Whites, and they share similar fibrotic tissue structures, including extracellular matrix composition, gene expression, and protein profiles. We hypothesized that women with a history of keloids would have greater uterine fibroid development. DESIGN: A prospective community cohort study (enrollment 2010-2012) with 4 study visits over 5 years to conduct standardized ultrasounds to detect and measure fibroids ≥0.5 cm in diameter, assess the history of keloid and hypertrophic scars, and update covariates. SETTING: Detroit, Michigan area. PATIENTS: A total of 1,610 self-identified Black and/or African American women aged 23-35 years at enrollment without a previous clinical diagnosis of fibroids. EXPOSURE(S): Keloids (raised scars that grow beyond the margins of the original injury) and hypertrophic scars (raised scars that stay within the bounds of the original injury). Because of the difficulties in distinguishing keloids and hypertrophic scars, we separately examined the history of keloids and the history of either keloids or hypertrophic scars (any abnormal scarring) and their associations with fibroid incidence and growth. MAIN OUTCOME MEASURE(S): Fibroid incidence (new fibroid after a fibroid-free ultrasound at enrollment) was assessed using Cox proportional-hazards regression. Fibroid growth was assessed using linear mixed models. The estimates for the change in log volume per 18 months were converted to the estimated percentage difference in volume for scarring vs. no-scarring. Both incidence and growth models were adjusted for time-varying demographic, reproductive, and anthropometric factors. RESULT(S): Of the 1,230 fibroid-free participants, 199 (16%) reported ever having keloids, 578 (47%) reported keloids or hypertrophic scars, and 293 (24%) developed incident fibroids. Neither keloids (adjusted hazard ratio = 1.04; 95% confidence interval: 0.77, 1.40) nor any abnormal scarring (adjusted hazard ratio = 1.10; 95% confidence interval: 0.88, 1.38) were associated with fibroid incidence. Fibroid growth differed little by scarring status. CONCLUSION(S): Despite molecular similarities, self-reported keloid and hypertrophic scars did not show an association with fibroid development. Future research may benefit from the examination of dermatologist-confirmed keloids or hypertrophic scars; however, our data suggest little shared susceptibility for these 2 types of fibrotic conditions.

Initial experience with brachytherapy treatment adjuvant to surgical resection of keloid scars in the pediatric population. / Experiencia inicial del tratamiento braquiterápico en coadyuvancia a la resección quirúrgica de cicatrices queloideas en población pediátrica.

OBJECTIVES: The treatment of keloid scars is based on multiple lines of therapy, with varying levels of efficacy(1), and there is currently no single treatment that guarantees cure and prevents recurrence. In the pediatric population, the treatments used are not standardized, and there is insufficient evidence to support efficacy and complications. The objective of this study was to analyze the patients who required brachytherapy as an adjuvant to surgical resection in recurrent keloid scars. MATERIALS AND METHODS: A retrospective analysis of patients diagnosed with keloids and undergoing adjuvant brachytherapy in our institution was carried out, while assessing efficacy and implementation in our treatment protocol for keloid scarring. RESULTS: After various therapeutic lines, 4 patients aged 9-17 years old with recurrent keloid scars around the ear and eligible for adjuvant brachytherapy - administered after surgical resection, in two sessions - were studied and followed up for up to 18-21 months. CONCLUSIONS: Despite our limited experience in the use of adjuvant brachytherapy, the results obtained to date support its efficacy, as reported in the literature. We therefore consider its inclusion in the treatment of keloid scars that have recurred after other treatments to be appropriate.

OBJETIVOS: El tratamiento de las cicatrices queloideas se basa en múltiples líneas terapéuticas, con diferentes niveles de eficacia(1), sin existir actualmente un tratamiento que garantice su curación y prevenga su recurrencia. En la población pediátrica los tratamientos empleados no están estandarizados y no hay evidencia suficiente que avale su eficacia y sus complicaciones. Este trabajo tiene como objetivo analizar los pacientes que han precisado braquiterapia coadyuvante a la resección quirúrgica en cicatrices queloideas recidivantes. MATERIAL Y METODOS: Análisis retrospectivo de los pacientes diagnosticados en nuestro centro de cicatriz queloidea, en los que se realizó braquiterapia coadyuvante, valorando su eficacia y su implementación en nuestro protocolo de tratamiento de la cicatriz queloidea. RESULTADOS: Se estudiaron 4 pacientes entre 9-17 años con cicatrices queloideas a nivel auricular, recidivantes a varias líneas terapéuticas, que fueron candidatos para el uso de braquiterapia coadyuvante, administrada posterior a la resección quirúrgica, en dos sesiones, se realizó seguimiento hasta 18-21 meses. CONCLUSIONES: A pesar de nuestra limitada experiencia en el uso de la braquiterapia coadyuvante, los resultados obtenidos hasta la fecha avalan su eficacia, de acuerdo con lo publicado en la literatura. Consideramos adecuada su inclusión en el tratamiento de cicatrices queloideas recidivantes a otros tratamientos.

No difference in wound complications with or without a post-operative pressure dressing: Our experience in 135 children undergoing mastoidectomy.

OBJECTIVES: To assess the efficacy of avoiding mastoid pressure dressing (MPD) on children as a means of preventing discomfort and post-operative pain. DESIGN: A retrospective controlled study. SETTING: All operations were carried out by experienced surgeons using standard techniques, whose custom, not the gravity of any individual case, dictated the use of MPD. PARTICIPANTS: Children who underwent mastoidectomy for inflammatory middle ear diseases at a tertiary centre from 2010 to 2021. MAIN OUTCOME MEASURES: Wound-related complications and Visual Analogue Scale (VAS) pain scores at discharge were compared between children who had an MPD applied following surgery and those who did not. RESULTS: One hundred thirty-five cases were included. The demographic characteristics of the patients and surgical techniques employed were similar for both groups. There were 91 patients in the MPD group and 44 in the non-mastoid dressing (NMPD) group. In the MPD group, five patients developed minor wound dehiscence, eight experienced surgical site infections (SSI), and one patient developed a keloid. In the NMPD group, one patient had an SSI, one patient suffered from a keloid scar, wound dehiscence was observed in one patient, and another one had a local hematoma. Therefore, there were no differences between the groups in relation to post-operative complications (p = .32). Despite these similitudes, the NMPD patients suffered less post-operative pain, as measured by the VAS (p = .02). CONCLUSION: This study shows that no significant benefit is derived from using an MPD after mastoidectomy in children. Surgeons should adhere to principles of appropriate haemostasis and wound closure to prevent post-operative wound complications. Our study supports the abandonment of routine MPD in children following mastoidectomy.

Exon skip-inducing variants in FLNA in an attenuated form of frontometaphyseal dysplasia.

Pathogenic variation in the X-linked gene FLNA causes a wide range of human developmental phenotypes. Loss-of-function is usually male embryonic-lethal, and most commonly results in a neuronal migration disorder in affected females. Gain-of-function variants cause a spectrum of skeletal dysplasias that present with variable additional, often distinctive, soft-tissue anomalies in males and females. Here we present two, unrelated, male individuals with novel, intronic variants in FLNA that are predicted to be pathogenic. Their phenotypes are reminiscent of the gain-of-function spectrum without the skeletal manifestations. Most strikingly, they manifest urethral anomalies, cardiac malformations, and keloid scarring, all commonly encountered features of frontometaphyseal dysplasia. Both variants prevent inclusion of exon 40 into the FLNA transcript, predicting the in-frame deletion of 42 amino acids, however the abundance of FLNA protein was equivalent to that observed in healthy individuals. Loss of these 42 amino acids removes sites that mediate key FLNA functions, including binding of some ligands and phosphorylation. This phenotype further expands the spectrum of the FLNA filaminopathies.

Risk of cancer development in patients with keloids.

Keloid is a skin disease characterized by exaggerated scar formation, excessive fibroblast proliferation, and excessive collagen deposition. Cancers commonly arise from a fibrotic microenvironment; e.g., hepatoma arises from liver cirrhosis, and oral cancers arise from submucosal fibrosis. As keloids are a prototypic fibroproliferative disease, this study investigated whether patients with keloids have an increased cancer risk. In a matched, population-based study, first 17,401 patients treated for keloids during 1998-2010 with 69,604 controls without keloids at a ratio of 1:4 were evaluated. The association between keloids and risk of cancer was estimated by logistic regression or Cox proportional hazard regression models after adjustment of covariates. In total, 893 first-time cases of cancer were identified in the 17,401 patients with keloids. The overall cancer risk was 1.49-fold higher in the keloids group compared to controls. Regarding specific cancers, the keloids group, had a significantly higher risk of skin cancer compared to controls (Relative risk = 1.73). The relative risk for skin cancer was even higher for males with keloids (Relative risk = 2.16). Further stratified analyses also revealed a significantly higher risk of developing pancreatic cancer in female patients with keloids compared to controls (Relative risk = 2.19) after adjustment for known pancreatic cancer risk factors. This study indicates that patients with keloids have a higher than normal risk for several cancer types, especially skin cancers (both genders) and pancreatic cancer (females). Therefore, patients with keloids should undergo regular skin examinations, and females with keloids should regularly undergo abdominal ultrasonography.

Calcium Electroporation for Keloids: A First-in-Man Phase I Study.

BACKGROUND: Keloid scarring is a pathologic proliferation of scar tissue that often causes pruritus, pain, and disfigurement. Keloids can be difficult to treat and have a high risk of recurrence. Recent studies have shown promising results in the treatment of cutaneous metastases with intralesional calcium combined with electroporation (calcium electroporation). As calcium electroporation has shown limited side effects it has advantages when treating benign keloid lesions, and on this indication we performed a phase I study. METHODS: Patients with keloids were treated with at least 1 session of calcium electroporation and followed up for 2 years. Calcium was administered intralesionally (220 mM) followed by the application of eight 100-µs pulses (400 V) using linear-array electrodes and Cliniporator (IGEA, Italy). Treatment efficacy was evaluated clinically (size, shape, erythema), by patient self-assessment (pruritus, pain, other) and assessed histologically. RESULTS: Six patients were included in this small proof of concept study. Treatment was well tolerated, with all patients requesting further treatment. Two out of 6 patients experienced a decrease in keloid thickness over 30%. A mean reduction of 11% was observed in volume size, and a mean flattening of 22% was observed (not statistically significant). Five out of 6 patients reported decreased pain and pruritus. No serious adverse effects or recurrences were observed over a mean follow-up period of 338 days. CONCLUSION: In this first phase I clinical study on calcium electroporation for keloids, treatment was found to be safe with minor side effects. Overall, patients experienced symptom relief, and in some patients keloid thickness was reduced.

Low-Grade Myofibroblastic Sarcoma Arising From Keloid Scar on the Chest Wall After Thoracic Surgery.

Keloids are considered as benign fibroproliferative skin tumors, and rare cases of malignancies have been reported. We present a case of low-grade myofibroblastic sarcoma arising from a recurrent painful keloid scar on the right chest wall after video-assisted thoracic surgery for pneumothorax in a 77-year-old man. Wide composite excision of the keloid, surrounding ribs, and partial diaphragm were performed. The chest wall pleural defect was reconstructed with Teflon (Chemours, Wilmington, DE), and soft tissue was reconstructed with a transverse rectus abdominis myocutaneous flap. This case highlights that refractory keloids may be considered a harbinger of malignancy.

Disease Severity and Quality of Life Outcome Measurements in Patients With Keloids: A Systematic Review.

BACKGROUND: Keloids have been assessed by numerous methods and severity indices resulting in a lack of standardization across published research. OBJECTIVE: This study aims to evaluate published keloid randomized controlled trials (RCTs) and identify the need for a gold standard of assessment. METHODS AND MATERIALS: PubMed, MEDLINE, and Embase were searched for human RCTs on keloid treatment during a 10-year period. Eligible studies were English language RCTs reporting disease severity outcome measures after keloid treatments. RESULTS: A total of 40 disease outcome measures were used in 41 included RCTs. Twenty-four (59%) of the included studies used more than one disease severity scale. The most frequently used outcome measures were the Vancouver Scar Scale (34%) (n = 14), followed by serial photography (24%) (n = 10). These were followed by adverse events and complications (20%) (n = 8), Visual Analogue Scale (12%) (n = 5), keloid dimensions (12%) (n = 5), and Patient and Observer Scar Assessment Scale (10%) (n = 4). Only one study reported quality of life outcomes. CONCLUSION: There is wide variation in keloid outcome measures in the published literature. A standardized method of assessment should be implemented to reduce the disparities between studies and to better be able to compare the numerous treatment modalities.

Management of epidermal cysts arising from scar tissues: A retrospective clinical study.

Few reports have described epidermal cysts (ECs) arising from scar tissues, and the standard course of treatment has not been established. We aimed to report the findings of a Korean patient series with ECs arising from scar tissues, to describe patient management in the context of previous publications, and to present a simple algorithm for managing ECs arising from scar tissues.We managed 6 patients with ECs arising from scar tissues, and retrospectively reviewed their demographic and clinical data.The scars were located on the anterior chest wall (n = 3), shoulder (n = 1), forehead (n = 1), and ear lobule (n = 1). Two patients with anterior chest wall scars, 1 with a shoulder scar, and 1 with an ear lobule scar had keloid scars, whereas the other patients had hypertrophic scars. The scar sizes ranged from 2 × 1 cm to 9 × 7 cm. The EC sizes ranged from 0.2 × 0.2 cm to 2 × 1.5 cm. Three patients underwent total scar revisions with complete EC excisions, 2 underwent partial scar tissue excisions with complete EC excisions, and 1 had laser therapy for the scar and EC. No complications occurred, and all patients' final outcomes were satisfactory during the mean follow-up period of 14.8 months.We successfully managed the patients with ECs arising from scar tissues. We recommend that surgeons and patients first decide whether the ECs and scar tissue should be completely removed. Moreover, consideration should be given to the options chosen for the management of ECs. Finally, postoperative scar care is necessary to prevent hypertrophic and keloid scar recurrences.

Intralesional cryotherapy versus excision with corticosteroid injections or brachytherapy for keloid treatment: Randomised controlled trials.

BACKGROUND: Keloids are a burden for patients due to physical, aesthetic and social consequences. Treatment remains a challenge due to therapy resistance and high recurrence rates. The main goals of treatment are to improve scar appearance and symptoms and patients' quality of life (QoL). METHODS: Two multicentre, randomised controlled open trials that compared 1) intralesional cryotherapy with excision and corticosteroid injections for primary keloids, and 2) intralesional cryotherapy with excision and brachytherapy for therapy resistant keloids. Primary outcome was scar appearance assessed with the Patient and Observer Scar Assessment Scale. Secondary outcomes were patient reported QoL (Skindex-29, SF-36, EQ-5D-5L), recurrence rates and scar volume reduction. For analysis, a linear mixed model was used. Power analysis indicated 33 patients in each group were needed. RESULTS: The trial was prematurely terminated after inclusion of 26 patients due to unexpectedly inferior outcomes after intralesional cryotherapy. For primary keloids no convincing difference between treatments was found, but surgery improved scar appearance while cryotherapy did not. For resistant keloids, excision followed by brachytherapy improved scar appearance (POSAS) and scar symptoms (itch and pain) significantly (p < 0.001, p < 0.001 and p = 0.006 respectively) while cryotherapy did not. Neither of the treatments caused indisputable improvements in QoL. CONCLUSIONS: Intralesional cryotherapy is inferior to keloid excision followed by brachytherapy for resistant keloids. In primary keloids, intralesional cryotherapy reduced keloid volume and, therefore, may be used in these patients and specific cases. Primary keloid group size was too small to draw valid conclusions, further research on the efficacy of intralesional cryotherapy for primary keloids is warranted.

Intratracheal Keloid.

BACKGROUND: Keloidal scarring can complicate surgical procedures. CASE REPORT: This 21-month-old African-American child developed a keloid around his tracheostomy that extended into the trachea. CONCLUSION: Keloidal formation from a tracheostomy site can extend into the trachea.