Nitric oxide produced by iNOS is associated with collagen synthesis in keloid scar formation

Nitric oxide (NO) has emerged as an important mediator of many physiological functions. Recent reports have shown that NO participates in the wound healing process, however, its role in keloid formation remains unclear. This study aimed to investigate the effect of NO on keloid fibroblasts (KF) and to determine the levels of inducible nitric oxide synthase (iNOS) expression in clinical specimens of keloid. Scar tissue from seven keloid patients with matched perilesion skin tissue controls was studied for inducible nitric oxide synthase expression and location. In addition, primary keloid and normal scar skin fibroblast cultures were set up to investigate the effects of NO in inducing collagen type I expression. Inducible nitric oxide synthase expression, and NO production were elevated in keloid scar tissues but not in matched perilesion skin tissues. Furthermore, exposure of KF to exogenous NO resulted in increased expression of collagen type I in a dose-dependent manner. NO exposure also induced time-course dependent collagen I expression that peaked at 24h in KF. Taken together, these results indicate that excess collagen formations in keloid lesion may be attributed to iNOS overexpression.     

瘢痕疙瘩及增生性瘢痕中MMP-2、MMP-9的表达

目的探讨基质金属蛋白酶-2、基质金属蛋白酶-9(MMP-2、MMP-9)在瘢痕疙瘩(keloid,Ke)及增生性瘢痕中(hypertrophic scar,HS)的表达。方法免疫组织化学SP法检测MMP-2、MMP-9在20例瘢痕疙瘩、15例增生性瘢痕及10例正常皮肤中的表达,采用图像分析技术对免疫组化结果进行定量分析。结果Ke中MMP-2表达高于正常皮肤(t=2.366,P<0.05),高于HS(t=2.223,P<0.05);MMP-9表达高于正常皮肤(t=3.198,P<0.01),高于HS(t=2.110,P<0.05)。HS中MMP-2表达与正常皮肤无差异(t=0.218,P>0.05),MMP-9表达与正常皮肤无差异(t=1.873,P>0.05)。正常人皮肤仅见MMP-2、MMP-9蛋白的弱阳性或阴性表达。结论MMP-2、MMP-9蛋白的表达与皮肤损伤后的过度增殖及肿瘤化倾向有关。     

Matrix metalloproteinase‐2 and ‐9 activities in human keloids,hypertrophic and atrophic scars: a pilot study

Proteolytic degradation of extracellular matrix is one of the principal features of cutaneous wound healing but little is known about the activities of gelatinases; matrix metalloproteinase‐2 (MMP‐2) and matrix metalloproteinase‐9 (MMP‐9) on abnormal scar formation. The aim of this study is to determine collagen levels and the gelatinase activities in tissue from hypertrophic scars, atrophic scars, keloids and donor skin in 36 patients and 14 donors. Gelatinase levels (proenzyme + active enzyme) were determined by ELISA and their activities by gelatin zymography. MMP‐9 activity was undetectable in gelatin zymography analysis. Pro‐MMP‐2 levels (median) were highest in normal skin group 53.58 (36.40–75.11) OD µg^?1 protein, while active MMP‐2 levels were highest in keloid group 52.53 (42.47–61.51) OD µg^?1 protein. The active/pro ratio was the highest in keloid group 0.97 followed by hypertrophic scar, normal skin and atrophic scar groups 0.69 > 0.54 > 0.48, respectively. According to results of our study, the two‐phase theory of the duration of hypertrophic scar and keloid formation can be supported by the data of tissue collagen and gelatinase analysis. This study is the first to relate scar formation relationship in regard to gelatinase activation ratio in a keloid, hypertrophic and atrophic scar patient group which is chosen appropriate in age and sex. Copyright © 2009 John Wiley & Sons, Ltd.     

瘢痕疙瘩中TIEG1的高表达

转化生长因子-β1(TGF-β1/Smads)信号转导通路的持续激活是瘢痕疙瘩形成的重要机制.研究发现这条通路重要的负反馈调节信号分子Smad7表达明显下调,Smad2/3的磷酸化水平和蛋白质量并无明显改变.但是,Smad7下调的机制尚不清楚.采用生物信息学方法对Smad7的启动子进行分析;用RT-PCR和蛋白质印迹分别检测了正常皮肤、正常瘢痕及瘢痕疙瘩组织中的Sp1样转录因子TIEG1mRNA及蛋白质的表达水平;体外培养正常皮肤、正常瘢痕及瘢痕疙瘩成纤维细胞,检测TIEG1 mRNA及蛋白的表达水平.研究结果显示,Smad7启动子上有Sp1的位点,TIEG1 mRNA及蛋白质水平在瘢痕疙瘩组织及瘢痕疙瘩成纤维细胞中表达明显高于正常瘢痕和正常皮肤(P<0.05).说明瘢痕疙瘩中TIEG1可能是Smad7下调的重要原因,有必要进一步研究TIEG1对Smad7的调控作用机制.     

The use of antihistamine to retard the growth of fibroblasts derived from human skin, scar, and keloid

Sixty percent of the fibroblast strains derived from normal skin, scar, and keloid reached elevated growth plateaus when cultured in the presence of histamine. A pharmacologic level of the antihistamine diphenhydramine hydrochloride was able to suppress the stimulation in all the keloid strains that were histamine-sensitive.     

Surgical planing of the skin; dichlorotetrafluoro-ethane as a freezing agent

Surgical skin planing is, in the hands of an experienced operator, a safe and highly effective procedure for treating a number of cutaneous defects, most notably pitted acne scars. The operation is facilitated by the use of a new instrument (jet-spray handpiece) which allows the operator to freeze the skin and plane it almost simultaneously, and by a new freezing agent, dichlorotetrafluoro-ethane, which adds to the safety by eliminating the old hazards of inflammability, explosion, and the toxic inhalation of ethyl chloride. The ability to sharply differentiate between keloid and hypertrophic scar is fundamental to surgical skin planing. A hypertrophic scar results from the removal or destruction of the cutaneous appendages (hair follicles, oil and sweat glands and ducts); whereas a keloid is an idiosyncratic response without regard to damage of the appendages.Properly performed surgical planing does not entirely remove these appendages and therefore healing occurs without scarring.     

Growth kinetics and collagen synthesis of normal skin, normal scar and keloid fibroblasts in vitro.

Fibroblasts were isolated from keloid, normal skin, and normal scar and maintained in tissue culture for four passages. Growth kinetics were the same for all groups on days 2 through 12. However, the rate of collagen synthesis per fibroblast was greater in keloid derived cells than any controls at all growth phases. Keloid fibroblasts have an autonomous capacity to synthesize collagen at a significantly increased level in vitro, which may explain in part why these lesions are characterized by increased collagen deposition.     

Effects of platelet derived growth factor (PDGF) on fibronectin (FN) production by human skin and scar fibroblasts

The fibroblast-type cell found in hypertrophic scars and keloids demonstrates an elevated fibronectin (FN) production, compared to the same type of cell in normal dermis. We wished to determine if the effects of platelet derived growth factor (PDGF) on FN production in these cell types would be equivalent or different. Cell lines were established from the dermis (reticularis) of hypertrophic scars, keloids, uninvolved normal skin adjacent to the lesions, including an assumed normal skin adjacent to a keloid (AS), and normal skin from a different uninjured patient (DS). Each parent tissue from which the cell lines originated was diagnosed histologically. Each hypertrophic scar, keloid and normal adjacent skin, with one exception, showed typical histologic findings confirming the clinical diagnosis. DS was also normal. AS, although assumed to be normal, in fact, demonstrated portions of nodules from the adjacent keloid. All cell lines were grown under standard conditions with subconfluent cells metabolically labeled for radioimmunoassays measuring FN at passage 3 (8 to 9 weeks in culture) in the absence and presence of PDGF. Significant differences in production of FN/cell and FN/PR/cell between two hypertrophic scars and their matched normal skins and for one keloid and its matched normal skin were observed. However, no significant difference was observed between the other keloid and AS, nor between the other hypertrophic scar and DS. PDGF significantly stimulated FN production in 2 of 4 NS cell lines, and in the AS cell line. By FN/cell values, 2 of 5 cell lines from the lesions were inhibited and one was increased. In terms of FN/PR/cell, 1 of 5 cell lines from the lesions was stimulated and the others showed no differences. The mixed results may be attributable to the likelihood that the cell lines represent mixed populations. This study demonstrates the importance of: 1) histological characterization of all parent tissues from which cell lines are derived, and 2) matching cell lines from lesions with cell lines from uninvolved normal dermis, in the same individual.     

Dichloro-tetrafluoro-ethane as a Freezing Agent

Surgical skin planing is, in the hands of an experienced operator, a safe and highly effective procedure for treating a number of cutaneous defects, most notably pitted acne scars.The operation is facilitated by the use of a new instrument (jet-spray handpiece) which allows the operator to freeze the skin and plane it almost simultaneously, and by a new freezing agent, dichlorotetrafluoro-ethane, which adds to the safety by eliminating the old hazards of inflammability, explosion, and the toxic inhalation of ethyl chloride.The ability to sharply differentiate between keloid and hypertrophic scar is fundamental to surgical skin planing. A hypertrophic scar results from the removal or destruction of the cutaneous appendages (hair follicles, oil and sweat glands and ducts); whereas a keloid is an idiosyncratic response without regard to damage of the appendages.Properly performed surgical planing does not entirely remove these appendages and therefore healing occurs without scarring.     

Genetic susceptibility to keloid disease and hypertrophic scarring: transforming growth factor beta1 common polymorphisms and plasma levels

Keloid disease and hypertrophic scars are dermal tumors that are often familial and typically occur in certain races. Their exact etiology is still unknown. Transforming growth factor beta1 (TGF-beta1) plays a central role in wound healing and fibrosis and has been implicated in the pathogenesis of keloid disease and hypertrophic scar. The aims of this study were to measure the plasma level of TGF-beta1 in patients compared with controls, and to investigate the association of five common single nucleotide polymorphisms in TGF-beta1 with the risk of keloid disease and hypertrophic scar formation. Platelet-poor plasma levels of TGF-beta1 in 60 patients (15 with hypertrophic scar and 45 with keloid disease) and 18 controls were measured using an enzyme-linked immunoabsorbent assay technique. A polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping TGF-beta1 polymorphisms. DNA samples from 133 patients (101 with keloid disease and 32 with hypertrophic scar) and 200 controls were examined. All patients and controls were Caucasians of Northern European extraction. There was no statistically significant difference in TGF-beta1 plasma levels between patients with keloid disease and hypertrophic scar and controls. There was also no statistically significant difference in genotype or allele frequency distributions between patients and controls for codons 10, 25, and 263 and for -509 and -800 single nucleotide polymorphisms of the TGF-beta1 gene. These results suggest that TGF-beta1 plasma levels and common polymorphisms are not associated with a risk of keloid disease and hypertrophic scar formation. This lack of association may be significant in view of the importance attached to the role of TGF-beta1 in dermal scarring. To the authors' knowledge, this is the first report of a case-control association study in keloid disease and hypertrophic scars using any single nucleotide polymorphisms.     

Increased vascular endothelial growth factor may account for elevated level of plasminogen activator inhibitor-1 via activating ERK1/2 in keloid fibroblasts

Keloids are characterized as an "overexuberant" healing response in which disequilibrium between production and catabolism of extracellular matrix (ECM) occurs. Previous studies from our laboratory and others demonstrate an intrinsically higher level of plasminogen activator inhibitor-1 (PAI-1) expression in keloid tissues and cultured fibroblasts compared with normal bordering skin. These findings support the concept that an altered balance of activator and inhibitor activities in the plasminogen system, in particular, an overexpression of PAI-1, may partly contribute to keloid formation and tissue fibrosis. Vascular endothelial growth factor (VEGF) has been implicated as a critical factor in regulating angiogenesis and inflammation under both physiological and pathological conditions. This study was designed to assess whether VEGF plays a role in keloid fibrosis. We report that VEGF was expressed at higher levels in keloid tissues and their derived fibroblasts compared with their associated normal skin. We have further demonstrated that VEGF stimulated the expression of PAI-1, but not urokinase plasminogen activator (uPA), in keloid fibroblasts at both mRNA and protein levels, in a dose- and time-dependent manner. However, treatment of normal skin fibroblasts with VEGF exerted little effects on PAI-1 gene expression. Additionally, we have characterized for the first time that the extracellular signal-regulated kinase (ERK)1/2 signaling pathway is mainly involved in VEGF-induced PAI-1 expression and have demonstrated its potential as a target molecule for modulation of scar fibrosis. These findings suggest that VEGF may play an important role in keloid formation by altering ECM homeostasis toward a state of impaired degradation and excessive accumulation. urokinase plasminogen activator; extracellular matrix; fibrosis     

Immunoglobulin, complement, and histocompatibility antigen studies in keloid patients.

The increased collagen synthesis and deposition, which is characteristic of keloids, may be related to an immune response initiated by wounding. Therefore, we examined various systemic and localized immune parameters in keloid patients to establish if such factors are related to keloid pathogenesis. To determine if there is a systemic immune response, we compared the serum levels of IgG and IgM in keloid patients to those in a closely matched population. In addition, we measured complement levels (Clq, C3, and C4) and receptors for sheep (E), mouse erythrocytes (MRBC), and complement (EAC) on blood lymphocytes. All of these were in the normal range in the keloid patients. However, the extractable IgG from keloid tissue was significantly increased (compared to normal skin and normal scar controls), suggesting a localized immune response. To determine whether keloid formation is associated with a specific histocompatibility locus, human lymphocyte antigen (HLA) profiles of 45 keloid patients were analyzed; no significant differences in the incidence of HLA-A and B antigens were found (compared to 200 controls). These studies suggest that there is a localized immune response involved in keloid pathogenesis, one which is not related to either the HLA-A or B histocompatibility loci.     

Endoscopic correction of pectus excavatum

Endoscopic surgery is minimally invasive and can be used to achieve superior cosmetic results. Conventional correction of pectus excavatum results in a long scar. Correction by use of endoscopic surgery involves a smaller skin incision. In this study, endoscopic correction of pectus excavatum was performed in 20 cases. A small transverse skin incision was made above the xyphoid process. A wide area beneath the pectoralis major muscle was dissected under endoscopic visualization. Subperichondrial resection was performed under direct visualization when possible. Subperichondrial resection of the third or fourth rib was performed under endoscopic visualization. Ravitch's chondrotomy of the second or third rib was performed under endoscopic visualization. Endoscopy was also useful for sternal elevation, with minimal risk of pleural perforation. Kirschner wire was inserted percutaneously under the sternum to prevent postoperative paradoxical respiration. In all cases, the postoperative course was uneventful. The advantages of endoscopic pectus excavatum correction are a short scar, control of bleeding, safe dissection of the pleura from the sternum without the risk of pleural perforation, and ease of sternal elevation without injury to the intramammary vessels. However, the endoscopic operation is long and is not useful in adults because subperichondrial resection in adults is difficult to perform.     

The effects of a single dose of 5-fluorouracil on keloid scars: a clinical trial of timed wound irrigation after extralesional excision

The possibility of altering the pathophysiology of keloid scars was investigated in 11 patients, using a single application of 5-fluorouracil solution for 5 minutes after extralesional excision was performed. Similar excisional wounds treated with phosphate-buffered saline for 5 minutes served as synchronous controls. An objective scoring system and subjective assessment were made to assay the change in the quality of the wound-healing and scar tissue produced by this treatment. A keloid scar score was used at regular time intervals after treatment to assess the quality of scar produced, thereby enabling the treated and control scars to be clinically compared.Biopsies were taken of the control and treated scars 1 month after treatment; the biopsy specimens were then subjected to immunohistochemical analysis as well as a functional assessment of cultured keloid fibroblasts. The immunohistochemical antigens assayed were Ki-67 (also called MIB-1; a marker of cell proliferation); vascular cell adhesion molecule-1 (a marker of inflammation); transforming growth factor beta-1 (a factor involved in scarring) and CD-68 (a macrophage-specific marker). Fibroblast-populated collagen lattices provided a functional assessment of fibroblast contraction.All treated and control wounds healed without any dehiscence or infection. The keloid scar score revealed that there was a perceived improvement in condition for those treated with 5-fluorouracil, compared with the control specimens, during the 6-month follow-up period in the five patients who attended all their clinic appointments; data on later recurrence are not complete as yet. The wounds treated with 5-fluorouracil produced scars that had a significant (p < 0.01) reduction in all the markers assayed, apart from CD-68. Functionally, the keloid fibroblasts from three of five of the treated patients showed reduced contractile capacity.This pilot study demonstrates that a "single-touch" technique with 5-fluorouracil can produce a change in the characteristics of the healing keloid wound after extralesional excision. Long-term studies are required to elucidate the correct dosage and time of exposure to improve the efficacy of this potential treatment.     

Fibronectin (FN) in hypertrophic scars and keloids

Summary Fibronectin (FN) distribution was compared among samples of normal human dermis, hypertrophic scar, keloid, and granulation tissues from deep injuries. Localization was established by use of fibronectin antibodies and the indirect immunofluorescence method. Fresh-frozen tissue was sectioned on a cryostat and examined by epifluorescence. Hypertrophic scar and keloid demonstrated heavy deposition of FN, which conformed to the nodular characteristics of the lesions. Intense localization occurred in granulation tissue over fibroblasts which were stellate and vesiculated, and over small blood vessels. FN-staining was weak in areas over fibroblasts which were more rounded and nonvesiculated. Staining for FN was also minimal over the collagen in normal dermis and the deeper, larger collagen fascicles in the lesions. Fibroblasts cultured from normal dermis, hypertrophic scar, and keloid for 5–6 weeks were intensely stained for FN. Extracellular matrix was heavily positive in cultures from the lesions compared with those from normal dermis.Supported in part by NIH Research Grant 1 R01GM 25159     

Keloids in rural black South Africans. Part 1: general overview and essential fatty acid hypotheses for keloid formation and prevention

In the first part of this study a general overview on the hypertrophic scar and keloid phenomena regarding history, epidemiology, histopathology and aetiology, in general, together with an essential fatty acid approach as basis for hypotheses of keloid formation and prevention are given. Upon reviewing the literature in planning a strategy for prevention and treatment of keloids, one encounters an overwhelming amount of hypotheses on this topic. Based on a preliminary study on total fatty acid compositions in keloids, compared with normal skin of keloid prone and non-keloid prone patients, there can be argued as follows: an essential fatty acid deficiency of precursors and inflammatory competitors for arachidonic acid may be a factor in the multifactorial aetiology of keloid formations, and apart from a local essential fatty acid deficiency in the wound area, nutrition may also be a contributing factor in rural black South Africans. To confirm or refute the stated hypotheses of the role of essential fatty acids in keloid formation and prevention (outlined in this part of the study), dietary questionnaires and blood (plasma and red blood cell) phospholipid analyses for general information and true fatty acid intake and metabolism, respectively, in the diets of these patients (outlined in part II of this study), as well as a lipid model for keloid formations regarding phospholipids, triglycerides, cholesterol esters and free fatty acids (outlined in part III of this study), are given. The purpose of this comprehensive fatty acid study was an attempt to assess the enigma surrounding keloids and to end the nightmare of the plastic and reconstructive surgeon, since these dermal tumours are notoriously recurrent.     

The role of the activin system in keloid pathogenesis

Keloid scars represent a pathological response to cutaneous injury under the regulation of many growth factors. Activin-A, a dimeric protein and a member of the transforming growth factor- superfamily, has been shown to regulate various aspects of cell growth and differentiation in the repair of the skin mesenchyme and the epidermis. Thus our aim was to study the role of activin and its antagonist, follistatin, in keloid pathogenesis. Increased mRNA expression for activin was observed in keloid scar tissue by performing RNase protection assay. Immunohistochemistry showed increased localization of both activin-A and follistatin in the basal layer of epidermis of keloid tissue compared with normal tissue. ELISA demonstrated a 29-fold increase in concentration of activin-A and an 5-fold increase in follistatin in conditioned media in keloid fibroblasts compared with normal fibroblasts. Although keloid keratinocytes produced 25% more follistatin than normal keratinocytes, the amounts of activin-A, in contrast, was 77% lower. Proliferation of fibroblasts was stimulated when treated with exogenous activin-A (46% increase in keloids fibroblasts) or following co-culture with hAHaCaT cells (66% increase). Activin-A upregulated key extracellular matrix components, namely collagen, fibronectin, and -smooth muscle actin, in normal and keloid fibroblasts. Co-treatment of follistatin with activin-A blocked the stimulatory effects of activin on extracellular matrix components. These findings emphasize the importance of the activin system in keloid biology and pathogenesis and suggest a possible therapeutic potential of follistatin in the prevention and treatment of keloids. collagen; fibroblasts; follistatin; keloid scar; keratinocytes; -smooth muscle actin; transforming growth factor-     

Low-dose enalapril in the treatment of surgical cutaneous hypertrophic scar and keloid--two case reports and literature review

Hypertrophic scars and keloids are 2 forms of excessive cutaneous scarring that occur in predisposed individuals. The healing process varies greatly among patients, and the risk of a bad scar evolution is unpredictable. Keloids create disfiguring scars with associated erythema and pain or pruritus or restricted range of motion, and are a major cause of morbidity. A fortuitous observation was made by the first author of this study who, at age 54, developed an erythematous and painful postsurgical abdominal keloid scar after undergoing left colectomy for colon adenocarcinoma. Four months later, after treatment with low-dose enalapril (10 mg, once a day) for mild arterial hypertension, her keloid scar rapidly improved and she eventually made a complete recovery. second case involved a 70-year-old female with diabetes who was affected by a long-standing postsurgical abdominal keloid scar of 2 years' duration. She was intentionally treated with the same low dose of enalapril, and, after 6 months of therapy, the bad scar showed marked improvement. We conducted an exhaustive search of the literature pertaining to the wound healing process, specifically to determine whether angiotensin-converting enzyme (ACE) inhibitors have a healing effect on wounds. ACE inhibitors are known to induce reduction of left ventricular collagen content and to attenuate remodeling during the postinfarctual period (thus improving ventricular function), and they have been shown to exert a pulmonary antifibrotic effect. After conducting this literature search, it became apparent that no data on cutaneous scars and ACE inhibitors are available. During the posttraumatic or postoperative stage, it is useful to achieve the best possible aesthetic results and to decrease the risk of a disfiguring keloid scar, thereby avoiding revision surgery; to this purpose, an early treatment with a low dose of enalapril is a possible solution, even if further confirmatory observations are needed.     

Reconstruction of burn scar of the upper extremities with artificial skin

The management of upper-extremity burn contractures is a major challenge for plastic surgeons. After approval by the Food and Drug Administration, artificial skin (Integra) has been available in Taiwan since 1997. From January of 1997 to July of 1999, the authors applied artificial skin to 13 severely burned patients for the reconstruction of their upper extremities, resulting in an increased range of motion in the upper-extremity joints and improved skin quality. An additional benefit was the rapid reepithelialization of the donor sites. There were no complications of infection throughout the therapeutic course, and the overall results were satisfactory. During the 2-year study, scar condition was monitored between 8 and 24 months, and a good appearance and pliable skin were obtained according to the Vancouver Scar Scale. According to this evaluation of Oriental skin turgor, normal pigmentation was restored about 6 months after the resurfacing procedure. For patients with severe burns in whom there is insufficient available skin for a full-thickness skin graft or another appropriate flap for scar revision, Integra is an alternative. The two major concerns in dealing with artificial skin are (1) a 10- to 14-day waiting period for maturation of the neo-dermis, necessitating a two-stage operation, and (2) prevention of infection with antibiotics and meticulous wound care.     

Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies

Excessive scars form as a result of aberrations of physiologic wound healing and may arise following any insult to the deep dermis. By causing pain, pruritus and contractures, excessive scarring significantly affects the patient's quality of life, both physically and psychologically. Multiple studies on hypertrophic scar and keloid formation have been conducted for decades and have led to a plethora of therapeutic strategies to prevent or attenuate excessive scar formation. However, most therapeutic approaches remain clinically unsatisfactory, most likely owing to poor understanding of the complex mechanisms underlying the processes of scarring and wound contraction. In this review we summarize the current understanding of the pathophysiology underlying keloid and hypertrophic scar formation and discuss established treatments and novel therapeutic strategies.