Effective keloid management using a combinatorial continuous-wave and repeat fractionated ablative CO2 laser regimen.

BACKGROUND: Keloids are benign proliferative scars that form as a result of dysregulated growth and collagen deposition in response to cutaneous injury. Laser therapies have emerged as promising options for the treatment of keloids, with performance varying by laser type and lesion characteristics. PURPOSE: To assess the combined continuous wave and repetitive fractionated CO2 laser treatment of keloids. METHODS: A retrospective chart review of 22 cases of keloid scars treated with combined CO2 laser modes. A single session of continuous wave followed by five sessions of fractional delivery. Efficacy was assessed using the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale. The Numeric Rating Scale was used to assess patient satisfaction and pain. RESULTS: Most patients were female (77.3%) with skin type IV (72.7%), age was 24.3 ± 9.3 years, most keloids were located on the earlobe (56.5%) or arm or hand (17.4%), size ranged from 5 to 10 cm, and time since injury ranged from 3 months to 35 years. No serious adverse events were reported. At 6 months, significant improvements from baseline occurred in all characteristics, scar color (4.8 ± 2.8 to 1.9 ± 1.1), rigidity (5.0 ± 2.8 vs. 5.4 ± 2.8), thickness (5.4 ± 2.8 vs. 2.0 ± 1.1), and irregularity (5.9 ± 2.4 vs. 1.9 ± 0.9). The Vancouver scores followed a similar trend. Patient-rated overall improvement from 37 ± 17.6 at baseline to 16.1 ± 8.5 at 6 months, and improvement in associated pain and pruritus. CONCLUSION: Combination of two ablative laser delivery modes within a single laser platform provided for effective and safe keloid management and left patients highly satisfied.

Inyección local de toxina botulínica para la prevención de cicatrices hipertróficas y queloides: un protocolo para una revisión panorámica

Introducción: Las cicatrices hipertróficas (CH) y queloides (QU) corresponden al resultado de una cicatrización patológica en la piel, que afectan la calidad de vida de quienes las presentan. Su tratamiento considera diversas intervenciones, muchas de las cuales son de alto costo y/o poco predecibles. Entre ellas, la toxina botulínica (TB) podría tener un efecto a nivel preventivo, aunque los resúmenes de evidencia presentan resultados disímiles. Por esto, proponemos sintetizar la evidencia proveniente de revisiones sistemáticas (RS) y metaanálisis (MA) de ensayos clínicos aleatorizados (ECA) sobre los efectos de la inyección local de TB en la prevención de CH y QU en pacientes que recibieron o recibirán un trauma quirúrgico en la piel. Métodos y análisis: Revisión panorámica siguiendo la declaración PRIOR. Ejecutaremos la búsqueda en la base de datos Epistemonikos. Realizaremos la selección de estudios, extracción de datos y evaluación de la calidad de las RS por duplicado. Compararemos las revisiones a través de matrices de evidencia, incluyendo las RS que aborden una pregunta similar y los ECA incluidos en estas. Estimaremos la superposición entre revisiones mediante el método de área cubierta y área cubierta corregida. Ética y difusión: No se requiere aprobación ética. Esta revisión se publicará después de un proceso de revisión por pares. Sus resultados podrían ser utilizados por personal de salud para informar decisiones individuales y por tomadores de decisión de servicios de salud para guiar la asignación de recursos.

Introduction: Hypertrophic scars (HS) and keloids (KE) result from an aberrant reparative process in the skin, impacting the quality of life of those who are affected by them. Their treatment consists of different interventions, many of which are costly and/or have unpredictable results. Among them, botulinum toxin (BT) might have a preventive effect, although current evidence summaries show varying results. Therefore, we aim to synthesize the evidence coming from systematic reviews (SRs) and meta-analyses (MA) of randomized controlled trials (RCTs) on the effects of local injection of TB in the prevention of HS and KE formation in patients after a surgical wound of the skin. Methods and analysis: This will be an overview of SRs following PRIOR statement. We will conduct the search in Epistemonikos Database. Two reviewers will independently conduct the screening of articles for inclusion, quality appraisal and data extraction. We will compare the SRs using an evidence matrix, including SRs that address this topic, and the RCTs included in them. We will estimate the overlap between them using the covered area method and corrected covered area index. Ethics and dissemination: Ethics approval is not required. This review will be published after a peer-review process. The results will inform areas of future research and could be used by health personnel to make individual decisions, and by healthcare managers, administrators, and policymakers to guide resource allocation.

Algoritmos para manejo de cicatrizes: a importância da sistematização de condutas / Algorithms for the management of scars: the importance of systematizing behaviors

■ RESUMO Introdução: As cicatrizes patológicas ocorrem a partir de hiperproliferaçãoo de fibroblastos, podendo ser classificadas em cicatrizes hipertróficas e queloides, basicamente as cicatrizes hipertróficas não crescem além dos limites da ferida original, enquanto os queloides crescem horizontalmente de forma nodular. Apesar da diversidade de instrumentos utilizados para orientar a prevenção, tratamento e seguimento de cicatrizes patológicas, existe a necessidade de instrumentos que contemplem realidades locais. O objetivo é realizar uma revisão narrativa de literatura sobre algoritmos para manejo de cicatrizes e criar um algoritmo atualizado. Métodos: Estudo descritivo de revisão narrativa de literatura, sendo realizado uma pesquisa nas bases de dados PubMed, SciELO, LILACS, MEDLINE e Cochrane, no período de novembro de 2010 até novembro de 2020, publicados nos idiomas inglês, português e espanhol. Os descritores utilizados foram: "cicatrix", "keloid", "algorithms" e "wound healing". A seleção da amostra consistiu da identificação dos artigos, leitura dos títulos e resumos e seleção de estudos relacionados ao tema e, posteriormente, foi realizada a leitura na íntegra dos estudos selecionados e classificação segundo os critérios de elegibilidade. Resultados: Foram encontrados 209 artigos sendo eliminados 116 devido duplicidade resultando em 45 artigos. Foram identificados um total de 8 artigos que preencheram os critérios de inclusão e após análise e reunião de consenso foram excluídos quatro artigos devido à ausência de algoritmos com rigor científico sendo este estudo composto de quatro artigos. Conclusão: Foram encontrados quatro algoritmos na revisão de literatura que resultaram na elaboração de um algoritmo atualizado para cicatrizes.

■ ABSTRACT Introduction: Pathological scars occur from the hyperproliferation of fibroblasts and can be classified into hypertrophic scars and keloids. Basically, hypertrophic scars do not grow beyond the limits of the original wound, while keloids grow horizontally in a nodular form. Despite the diversity of instruments used to guide the prevention, treatment and follow-up of pathological scars, there is a need for instruments that address local realities. The objective is to carry out a narrative review of the literature on scar management algorithms and create an updated algorithm. Methods: Descriptive study of narrative literature review, with a search in PubMed, SciELO, LILACS, MEDLINE and Cochrane databases, from November 2010 to November 2020, published in English, Portuguese and Spanish. The descriptors used were: "cicatrix," "keloid," "algorithms," and "wound healing." The sample selection consisted of identifying the articles, reading the titles and abstracts, and selecting studies related to the topic. Subsequently, the full reading of the selected studies and classification according to the eligibility criteria were carried out. Results: 209 articles were found, and 116 were eliminated due to duplicity, resulting in 45 articles. A total of 8 articles that met the inclusion criteria were identified. Four articles were excluded after analysis and consensus meeting due to the absence of algorithms with scientific rigor; this study is composed of four articles. Conclusion: Four algorithms were found in the literature review that resulted in the development of an updated algorithm for scars.

Methodological quality of clinical trials of keloid scars.

BACKGROUND: There is heterogeneity in the design of clinical trials (CT) for the treatment of keloid scars that compromises the validity of their results. OBJECTIVE: To assess the methodological quality of the CT published on keloid scars, mainly the outcomes used in them. METHOD: Articles of CT for keloid scars were analyzed, their methodological quality was evaluated following the CONSORT guidelines and the risk of bias based on the Cochrane tool. All the clinical outcomes measured in CT were identified. RESULTS: Fifty-two full-text articles were evaluated, of which, only 3.84% of the CT mentioned important changes in the methodology after starting patient recruitment. Fifty-nine percent of the CT were assessed as high risk of performance bias due to mistakes in blinding participants and personnel. The most frequent outcome was the height or thickness of the keloids. CONCLUSIONS: We recommend that participants with hypertrophic scars should be excluded from keloids' clinical trials, and that the main outcome must be the scar height and flattening. The pain and quality of life of patients should also be measured.

ANTECEDENTES: Existe heterogeneidad en el diseño de los ensayos clínicos (EC) para el tratamiento de cicatrices queloides que compromete la validez de sus resultados. OBJETIVO: Evaluar la calidad metodológica de los EC publicados sobre cicatrices queloides, principalmente las medidas de eficacia utilizadas. MÉTODO: Se analizaron los EC publicados sobre tratamientos para cicatrices queloides y se evaluó su calidad metodológica siguiendo los lineamientos CONSORT y el riesgo de sesgo según la herramienta de Cochrane. Se identificaron todas las medidas de eficacia utilizadas en los EC. RESULTADOS: Se incluyeron 52 artículos, de los cuales solo en el 3.84% se mencionan los cambios importantes en la metodología después de iniciar el reclutamiento de los pacientes. El 59.6% de los EC fueron evaluados con alto riesgo de sesgo de realización por errores en el cegamiento del equipo de investigación. La variable de respuesta más frecuente fue la altura o grosor de las cicatrices. CONCLUSIONES: Se recomienda que en los EC de cicatrices queloides se excluya a los participantes con cicatrices hipertróficas, y que la variable de resultado principal sea la altura de la cicatriz. También deben medirse el dolor y la calidad de vida de los pacientes.

Hydrocolloid dressings can be used to treat hypertrophic scars: An outpatient dermatology service devoted to treat keloids and challenging scars.

Since we first described the rationale for the use of hydrocolloid dressings to treat keloids and hypertrophic scars, this technique has been used as an occlusive therapy alternative to the use of silicone sheets in our outpatient clinic. In this paper, we describe the use of these dressings on two patients with challenging scars: a large postburn hypertrophic scar on a young patient's hand and arm, with a growing keloid on the wrist, and a progressive scar on the lower eyelid, developing after a complication of a cosmetic blepharoplasty procedure, leading to ectropium. The methods on the proper use of these dressings are reviewed here in detail. Larger clinical trials are needed to further evaluate this technique in the treatment of hypertrophic scars and keloids.

Silicone sheets and new gels to treat hypertrophic scars and keloids: A short review.

Silicone dressings have been used to treat hypertrophic scars and keloids since 1983. This treatment modality is considered to be safe and efficacious, leading to a progressive improvement in scar color, size, erythema, pliability, pain, and itching. Its mechanism of action is due to the hydration of the skin corneal layer; and modulating the cell signaling between fibroblasts and keratinocytes, mediated by cytokines. Silicone dressings are considered first line treatments for hypertrophic scars and keloids. Silicone gels were developed later, in order to help treating those scars in areas such as the scalp or joints, where fixing the silicone sheets would be a more difficult task, or on the face, where a silicone dressing would be cosmetically undesirable to most. Similar to silicone sheets, silicone gels have also proved to help treating and preventing hypertrophic scars and keloids. A new silicone gel combined with hypochlorous acid has recently been developed to help in treating scars. Hypochlorous acid acts as a biocide and anti-inflammatory agent, therefore, it has also been used in post procedure, on recent traumatic scars or on nonepithelized skin. This manuscript reviews the use of silicone dressings, silicone gels, and combined gels to treat scars.

Efecto de la dehidroepiandroesterona y el acetónido de triamcinolona sobre la línea celular 3T3-L1 / Effect of dehydroepiandroesterone and triamcinolone acetonide on 3T3-L1 cell line

RESUMEN: La piel es el órgano más extenso en el ser humano, su integridad representa protección contra diferentes agentes químicos, biológicos y mecánicos. Las lesiones ocasionadas en este tejido se resuelven mediante la formación de una cicatriz, sin embargo, diferentes alteraciones moleculares pueden sobre estimular este proceso, lo que conlleva a la formación de cicatrices aberrantes (hipertrófica o queloide). El tratamiento más recomendado para este tipo de lesiones es la aplicación intralesional del acetónido de triamcinolona (AT) y por otro lado, la dehidroepiandrosterona (DHEA) es una pro-hormona que posee una gran variedad de efectos biológicos como: regulación de la síntesis de fibras de colágeno, protección celular, propiedades antitumorales, antiinflamatorias y antioxidante. En este trabajo, se estudió la combinación de AT-DHEA sobre la proliferación y muerte celular en la línea celular de fibroblastos 3T3-L1. Los resultados mostraron que la AT a 100 M y la DHEA a 1000 M inhiben la proliferación en un 50 y 40% respectivamente. La combinación de AT-DHEA (10000-10 M) inhibe la proliferación celular e inducen muerte celular programada, entonces esta combinación pudiera utilizarse en cicatrices hipertróficas o queloides para su eliminación.

ABSTRACT: The skin in the human is the largest organ, his integrity represents protection against various chemical, biological and mechanical agents. The injuries in this tissue are solved by forming a scar, however, different molecular alterations may overstimulate this process, leading to the formation of aberrant scars (hypertrophic or keloid). The most recommended treatment for such injuries is the intralesional application of triamcinolone acetonide (TA) and on the other hand, dehydroepiandrosterone (DHEA) is a pro-hormone that has a wide variety of biological effects such as regulation of the synthesis of collagen fibers, cell protection, anti-tumor properties, anti-inflammatory and antioxidant. In this paper, the combination of AT-DHEA on proliferation and cell death in fibroblast cell line 3T3-L1 was studied. The results showed that the AT 100 and 1000 M DHEA to inhibit proliferation by 50 and 40% respectively. The combination of AT-DHEA (10000-10 M) inhibits cell proliferation and induce programmed cell death, so this combination could be used in hypertrophic or keloid scars for disposal.

Febrile ulceronecrotic mucha habermann disease: case report of a dark-skinned patient.

A male dark-skinned patient, 33 years old, complaining of a 1-month history of skin lesions in the abdominal region and high fever was admitted to the clinical ward. There were ulcerated and coalescent skin lesions all over the body but sparing the palmar region. The culture of material obtained from the penile lesions was positive for Staphylococcus aureus. He was treated with oxacillin and prednisone. The patient persisted with high fever and skin lesions. After histopathological diagnosis of Mucha Habermann's disease, treatment was started with tetracycline with rapid improvement of the lesions. He was reexamined by the dermatologic service with no recurrences during the 12 months of follow-up. At this time, there was a great number of keloid scars from the skin lesions.

Queloides na adolescência: a busca pelo melhor tratamento / Keloids in adolescence: searching for the best treatment

Queloides são lesões benignas que resultam de uma proliferação fibroblástica excessiva da derme após o trauma de pele. As lesões são espessas, ultrapassam os limites da lesão inicial e invadem a pele normal. Existem diversas teorias que procuram explicar os mecanismos de formação desse tipo de lesão, mas a real patogênese ainda não foi elucidada, o que explica a multiplicidade de tratamentos disponíveis, não havendo consenso na literatura sobre a melhor abordagem terapêutica. No presente artigo, descrevemos o caso de uma adolescente que desenvolveu queloide em abdome após lesão por arma de fogo e abordamos os diversos aspectos do tratamento. Nessa faixa etária, deve-se atentar para a seguran- ça dos métodos terapêuticos empregados. Entre as opções existentes, a combinação de excisão cirúrgica com aplicação de triancinolona representa uma opção segura e eficaz (AU)

Keloids are benign lesions resulting from excessive fibroblastic proliferation of the dermis after skin injury. The lesions are thick, surpass the edges of the initial injury and invade the normal skin. There is a number of theories explaining the mechanisms of formation of this type of lesion, but the real pathogenesis is not yet elucidated, with no consensus on the best therapeutic approach, which accounts for the many available treatments. In this article, we report the case of a teenager who developed an abdominal keloid after fire gun injury and discuss several aspects of treatment. In this age group, the safety of the therapeutic methods used must be heeded. Among the existing options, the combination of surgical resection and triamcinolone administration stands as an effective, safe choice (AU)

Avaliação da ação da associação de cepalin®, alantoína e heparina sódica* na evolução do processo de cicatrização de incisões cirúrgicas / Evaluation of the Cepalin®, allantoin and sodic heparin association in the process of surgical incisions healing

Objetivo: Avaliar a eficácia da associação de cepalin, alantoína e heparina sódica (Contractubex®), aplicada topicamente sob forma de massagem, na qualidade das cicatrizes pós-cirúrgicas de pacientes submetidos a mamoplastias redutoras e abdominoplastias.Tipo de estudo: Prospectivo, observacional, duplo-cego, randomizado, placebo controlado.Local do estudo: Serviço de Cirurgia Plástica e Queimaduras do Hospital do Servidor Público Estadual na cidade de São Paulo - Brasil.Sujeitos do estudo: Foram 60 pacientes do sexo feminino submetidas a mamoplastia redutora ou abdominoplastia, randomizadas para receber aplicação do produto teste ou placebo sobre as cicatrizes cirúrgicas a partir do 21º dia de pós-operatório, durante seis meses.Principal resultado observado: O sucesso do tratamento, considerado quando a qualidade das cicatrizes fossem consideradas boas ou excelentes ao seu final.Resultados: Entre as 60 pacientes randomizadas, 58 permaneceram até o final do estudo, sendo que 30 receberam tratamento com o produto teste e 28 placebo. Na análise dos resultados se comparou os eventos sucesso e insucesso com a utilização de placebo ou produto teste isoladamente de insucessos entre o placebo ou produto teste e, finalmente, de sucessos entre o placebo ou produto teste. Posteriormente, realizaram-se duas análises complementares: a primeira analisando-se as freqüências de sucessos entre os vários observadores, comprovando-se que todos obedeceram aos mesmos critérios na avaliação a segunda, comparou-se por aderência, o total de sucessos com o de insucessos para comprovar que, caso o produto teste fosse superior, não importasse quais parcelas tivessem sido agregadas, desde que atribuídas ao simples acaso, a superioridade fosse mantida. Foram aplicados testes de Quiquadrado para a análise das variáveis sucesso e insucesso relativas à utilização do produto testado (Contractubex®) ou placebo, admitindo-se a = 5% (p£0,05 ). As reações adversas observadas foram consideradas leves e previsíveis, não havendo por isso necessidade de exclusão do presente estudo.Conclusões: A associação de cepalin, alantoína e heparina sódica (Contractubex®) aplicada topicamente em cicatrizes pós-operatórias por período de seis meses melhora significativamente a qualidade da cicatrizes quando comparada ao mesmo procedimento utilizando-se placebo.