Introduction: Intralesional triamcinolone acetonide (TAC) is an accepted management option for paediatric keloid. TAC is a corticosteroid with five times the potency of hydrocortisone and acts by inhibiting fibroblast growth and thus keloid size. Dermatological adverse effects of TAC are common, but repeated high-dose intralesional TAC can cause the rare complication of Cushing syndrome and suppression of the hypothalamic–pituitary–adrenal (HPA) axis. Case: We report the case of an 11-year-old female referred for worsening lower limb striae and low serum cortisol. Prior to referral, intralesional TAC was administered by a general practitioner to a left lower limb keloid which had developed following an orthopedic intervention. A total of five injections were administered over 4 months: a cumulative dose of 150 mg (equivalent to 700 mg hydrocortisone). The last dose was administered 6 months prior to referral. The morning serum cortisol was low (<13.8 nmol/L) with a concomitantly low adrenocorticotropic hormone (ACTH 0.41 pmol/L) level, consistent with suppression of the HPA axis secondary to exogenous steroids. Renin (84.80 mU/L), aldosterone (280.40 pmol/L), testosterone (0.31 nmol/L), estradiol (85.9 pmol/L) and thyroid function were normal. Physiological oral hydrocortisone replacement was promptly commenced, with education on adrenal crisis and sick days while awaiting recovery of the HPA axis. Conclusion This case illustrates the serious complication of Cushing syndrome with secondary HPA axis suppression due to repeated intralesional TAC therapy for paediatric keloid scars. Factors such as appropriate paediatric doses, size of the keloid, site of injection (dermal, not subcutaneous), and frequency of injections should all be given due consideration before using TAC. Clinicians prescribing steroids to children should be aware that suppression of the HPA axis is a very real and life-threatening complication and that steroids should be prescribed judiciously.
Child ; Keloid ; Triamcinolone

INTRODUCTION

Epidermal inclusion cysts require surgical intervention to prevent recurrence and symptoms. Elliptical excision is definitive but results in longer scar, while minimal incision techniques offer better cosmetic outcomes despite higher recurrence rates probably due to incomplete excision. To date, there are currently no local studies published.

METHODOLOGY

A randomized controlled trial was conducted from October 2023 to May 2024 at a dermatology center in the Philippines. Patients were randomly assigned to minimal incision or elliptical excision techniques. Key metrics included operation time, scar length, post-operative complications, Hollander wound evaluation score (HWES), and histopathological completeness of excision.

RESULTS

Median operation duration was 31.86 minutes, with no significant difference between techniques (p = 0.5795). Post-operative scars were longer in the excision group (mean: 2.38 ± 0.66 cm) versus the minimal incision group (p < 0.001). Completeness of excision was higher in the excision group (83%) compared to the minimal incision group (27%) (p = 0.0123). Follow-up scar length was shorter in the minimal incision group (mean: 0.44 ± 0.21 cm) versus the excision group (mean: 2.1 ± 0.63 cm) (p < 0.001). HWES scores showed no significant difference in wound healing and aesthetic satisfaction.

CONCLUSION

Minimal incision technique results in shorter scars but lower completeness of excision compared to elliptical excision. Both techniques have similar long-term outcomes in wound healing and aesthetic satisfaction, with no recurrences or complications beyond two weeks. The choice should balance scar length and completeness of cyst removal, considering patient-specific factors.

Human ; Cicatrix ; Cysts ; Cosmetics

Scar formation is characterized by dynamic alterations in collagen secretion, which critically determine scar morphology and pathological progression. In fibroblasts, collagen secretion is initiated through the activation of cytokine- and integrin-mediated signaling pathways, which promote collagen gene transcription. The procollagen polypeptide α chains undergo extensive post-translational modifications, including hydroxylation and glycosylation, within the endoplasmic reticulum (ER), followed by folding and assembly into triple-helical procollagen. Subsequent intracellular trafficking involves the sequential transport of procollagen through the ER, Golgi apparatus, and plasma membrane, accompanied by further structural refinements prior to extracellular secretion. Once secreted, procollagen is enzymatically processed to form mature collagen fibrils, which drive scar tissue remodeling. Recent advances in elucidating regulation of collagen secretion have identified pivotal molecular targets, such as transforming growth factor-beta 1 (TGF-β1), prolyl 4-hydroxylase (P4H), heat shock protein 47 (HSP47), and transport and Golgi organization protein 1 (TANGO1), providing novel therapeutic strategies to mitigate pathological scar hyperplasia and improve regenerative outcomes. This review provides a comprehensive analysis of the molecular mechanisms governing collagen secretion during scar formation, with emphasis on signaling cascades, procollagen biosynthesis, intracellular transport dynamics, and post-translational modifications, thereby offering a framework for developing targeted anti-scar therapies.
Humans ; Collagen/metabolism* ; Cicatrix/pathology* ; Signal Transduction ; Transforming Growth Factor beta1/metabolism* ; Fibroblasts/metabolism* ; Animals

OBJECTIVES: Keloids are fibrotic skin disorders characterized by excessive collagen deposition and a high recurrence rate, closely associated with inflammatory mediators. However, existing epidemiological studies are limited by confounding factors and reverse causality, making it difficult to establish causation. This study aims to investigate the causal relationship between circulating cytokines and keloids using Mendelian randomization analysis. METHODS: Significant single nucleotide polymorphisms (SNPs) associated with circulating cytokines (exposures) and keloids (outcomes) were extracted from genome-wide association study (GWAS) summary datasets. Eligible SNPs were selected as instrumental variables (IVs). Exposure data were derived from a cytokine GWAS including 8 293 Finnish participants, and outcome data from a keloid GWAS based on the UK Biobank. The inverse-variance weighted (IVW) method served as the primary analytical approach to estimate causal effects, supplemented by weighted median (WME), MR-Egger regression, and other sensitivity analyses. Horizontal pleiotropy was assessed using MR-Egger regression and the MR pleiotropy residual sum and outlier (MR-PRESSO) test, while Cochran's Q test evaluated heterogeneity. Leave-one-out analysis was used to verify robustness and consistency. A reverse MR analysis was also conducted, with keloid as the exposure and cytokines as outcomes, to rule out reverse causation. RESULTS: IVW analysis identified significant positive causal associations between two cytokines and keloids-macrophage migration inhibitory factor (MIF) [odds ratio (OR)=2.081, 95% confidence interval (CI) 1.219 to 3.552, P=0.007] and monocyte chemoattractant protein-1 (MCP-1) (OR=1.673, 95% CI 1.036 to 2.701, P=0.035). Conversely, stem cell factor (SCF) showed a negative causal relationship with keloids (OR=0.518, 95% CI 0.269 to 0.998, P=0.049). Results from the MR-Egger and weighted median analyses were consistent with IVW findings. No evidence of horizontal pleiotropy was observed (P>0.05). Except for interleukin-6 (P=0.014), no heterogeneity was detected in other cytokines. Leave-one-out analysis further confirmed the robustness of the causal associations. In reverse MR analysis, keloids were causally related only to β-nerve growth factor (beta-NGF) (OR=1.048, 95% CI 1.002 to 1.095, P=0.039), with no heterogeneity or pleiotropy detected in most cytokines (P>0.05). CONCLUSIONS MIF and MCP-1 exhibit positive causal associations with keloid formation, while SCF shows a negative causal relationship. These findings provide new evidence for the causal involvement of inflammatory cytokines in keloid pathogenesis and offer potential molecular targets for developing novel keloid therapies.
Humans ; Keloid/blood* ; Mendelian Randomization Analysis ; Cytokines/genetics* ; Polymorphism, Single Nucleotide ; Genome-Wide Association Study ; Chemokine CCL2/genetics* ; Interleukin-6/genetics* ; Macrophage Migration-Inhibitory Factors/genetics* ; Male ; Stem Cell Factor/blood* ; Female ; Intramolecular Oxidoreductases

A 40-year-old, gravida 3 para 2 (1-1-0-2), previous primary cesarean section for nonreassuring fetal status, presented at a tertiary hospital for confirmation of cesarean scar pregnancy (CSP). Transvaginal ultrasound confirmed a CSP at 8 2/7 weeks age of gestation with good embryonic cardiac activity, raising concern for early placenta accreta spectrum. A multidisciplinary team composed of an obstetrician, advanced pelvic surgeon, urologist, and anesthesiologist managed the patient. The patient underwent total abdominal hysterectomy with bilateral salpingectomy, as the patient has a completed family size. Before the procedure, she was given cefuroxime as prophylactic antibiotic. Intraoperatively, there were dense adhesions between the posterior bladder wall and the previous cesarean section scar. Inadvertent injury to the bladder wall was incurred during adhesiolysis. Cystorrhaphy was done by a urologist, while the rest of the surgery was unremarkable, with a 450 ml estimated blood loss. The postoperative course was unremarkable. Bladder rest was achieved by maintaining an indwelling Foley catheter, which remained in place upon discharge on postoperative day 3 and was continued for 7 days thereafter. At follow-up, a successful voiding trial was conducted, confirming the return of normal bladder function.

Human ; Female ; Adult: 25-44 Yrs Old ; Cesarean Section ; Salpingectomy ; Hysterectomy ; Fetal Distress ; Placenta Accreta ; Cefuroxime ; Catheters ; Cicatrix

OBJECTIVES: To propose a hypothesis that aloe-emodin may inhibit scar tissue fibrosis through thrombospondin-1(THBS1)-PI3K-Akt pathway. METHODS: By cultivating fibroblasts derived from scar tissue after cleft palate surgery in humans, aloe emodin of different concentrations (10, 20, 30, 40 and 50 μmol/L) was added to the cells which activity was detected. At the same time, transcriptome sequencing was performed on scar tissue and cells, and bioinformatics methods were used to explore potential targets and signaling pathways of scar tissue fibrosis. RESULTS: Aloe-emodin had a concentration dependent inhibitory effect on fibroblast proliferation,with the 40 μmol/L concentration group showing the most significant effect. The results of tissue and cell sequencing indicated that differentially expressed genes were significantly enriched in extracellular matrix-receptor interaction pathway, and shared a common differential gene which was THBS1. The ORA analysis results indicated that differentially expressed genes, including THBS1, were significantly enriched in the PI3K-Akt signaling pathway. CONCLUSIONS Aloe emodin may inhibit the PI3K-Akt pathway by downregulating THBS1, thereby reducing the proliferation activity of fibroblasts derived from postoperative palatal scar tissue.
Thrombospondin 1/genetics* ; Humans ; Signal Transduction/drug effects* ; Fibroblasts/cytology* ; Proto-Oncogene Proteins c-akt/metabolism* ; Fibrosis ; Phosphatidylinositol 3-Kinases/metabolism* ; Cicatrix/metabolism* ; Cell Proliferation/drug effects* ; Anthraquinones/pharmacology* ; Cells, Cultured

BACKGROUND

Keloids and hypertrophic scars are overgrowth of fibrous tissue after damage to the skin. There have been various published treatment modalities for these lesions. Currently, there are still no published studies on the use of laser-assisted drug delivery for hypertrophic scars and keloids in the Philippine setting.

OBJECTIVE

To determine the efficacy and safety of laser-assisted drug delivery versus intralesional steroid injection alone for the treatment of keloid and hypertrophic scar.

METHODS

This was a single center, randomized single-blind controlled study. Participants were randomly assigned into a control group (intralesional steroid injection) or a treatment group (laser-assisted drug delivery). The procedure was done monthly for four sessions. Assessment of lesions using the Vancouver Scar Scale was done at baseline and monthly post-sessions.

RESULTS

A total of 42 participants completed the study, which was divided into two groups of 21 samples each. Results showed that the mean difference in overall skin score from baseline to fourth treatment session was significantly lower in the laser-assisted drug delivery group than the intralesional group (–0.48±0.75 vs. –0.24±0.54, t=2.31, p=0.026). No adverse events were noted throughout the study period.

CONCLUSION

It is a promising option to use non-ablative fractional CO2 laser-assisted drug delivery as the treatment outcome was comparable to using intralesional steroid injection as monotherapy for keloids and hypertrophic scars.

Human ; Keloid ; Scars, Hypertrophic ; Cicatrix, Hypertrophic

OBJECTIVE: To explore the effectiveness of free paraumbilical perforator flaps in repairing skin and soft tissue defects in children. METHODS: Between February 2018 and March 2024, 12 children with skin and soft tissue defects were treated with the free paraumbilical perforator flaps. There were 7 boys and 5 girls with an average age of 6.3 years (range, 2-12 years). The defects located on the upper limbs in 6 cases, lower limbs in 5 cases, and neck in 1 case. The causes of wounds included 7 cases of electrical burns, 1 case of thermal burn, 2 cases of scar release and excision due to scar contraction after burns, 1 case of scar ulcer at the amputation stump after severe burns, and 1 case of skin necrosis after a traffic accident injury. The size of defects after debridement ranged from 7.0 cm×4.0 cm to 18.0 cm×10.0 cm. According to the defect size, 11 cases were repaired with unilateral paraumbilical perforator flaps centered on the umbilicus, among which 3 cases with larger defects were designed as "L"-shaped flaps along the lateral and lower ends of the perforator; the donor sites were directly closed. One case with extensive defect after scar excision and release was repaired with bilateral expanded paraumbilical perforator flaps; the donor sites were repaired with autologous split-thickness skin grafts. The size of flaps ranged from 9.0 cm×4.0 cm to 20.0 cm×11.0 cm. Postoperatively, analgesia and sedation were provided, and the blood supply of the flaps was observed. RESULTS: All operations were successfully completed. The operation time was 4-7 hours, with an average of 5.0 hours. After postoperative analgesia and sedation, the visual analogue scale (VAS) score for pain in all children was less than or equal to 3, and there was no non-cooperation due to pain. All flaps and skin grafts survived completely, and the wounds healed by first intention. Ten children underwent 1-4 times of flap de-fatting, finger separation, and trimming. All children were followed up 6-48 months (mean, 26.6 months). No obvious swelling of the flaps occurred, and the texture was soft. At last follow-up, among the 6 children with upper limb defects, 2 had upper limb function grade Ⅳ and 4 had upper limb function grade Ⅴ according to the Carroll upper limb function assessment method. The 4 children with lower limb defects had no limitation of joint movement. The neck flexion and rotation in the 1 child with neck defect significantly improved when compared with that before operation. The 1 child with residual ulcer at the amputation stump could wear a prosthesis and move without limitation, and no new ulcer occurred. Linear scars were left at the donor sites, and no abdominal wall hernia was formed. CONCLUSION The free paraumbilical perforator flap has abundant blood supply and can be harvested in large size. It can be used to repair skin and soft tissue defects in children and has the advantages of short operation time, minimal injury, high safety, and minimal impact on the growth and development of children.
Humans ; Perforator Flap/transplantation* ; Child ; Male ; Female ; Soft Tissue Injuries/surgery* ; Child, Preschool ; Plastic Surgery Procedures/methods* ; Burns/surgery* ; Umbilicus/surgery* ; Skin Transplantation/methods* ; Skin/injuries* ; Cicatrix/surgery* ; Treatment Outcome

OBJECTIVE: To review recent advances in the application of hair transplantation in wound healing and scar repair in special areas. METHODS: An extensive review of the literature on the application of hair transplantation in wound healing and scar repair in special areas was conducted, focusing on cellular functions, molecular mechanisms, and clinical applications. RESULTS: Hair transplantation has been shown to effectively promote wound healing and scar repair in special areas. The underlying mechanisms are complex, but current understanding emphasizes a strong association with hair follicle-associated stem cells (including epidermal stem cells, dermal papilla cells, dermal sheath cells, etc). CONCLUSION The application of hair transplantation in wound healing and scar repair in special areas remains in its early stages. Further investigation into its mechanisms of action is essential, and randomized controlled trials are needed to establish its efficacy.
Humans ; Wound Healing/physiology* ; Cicatrix/therapy* ; Hair/transplantation* ; Hair Follicle/transplantation*

OBJECTIVE: To investigate the clinical outcome of sensory reconstruction about the functional perforator flap for repairing the complex defects on the limbs. METHODS: A retrospective analysis was conducted on 21 patients with limb complex defects admitted between March 2018 and January 2023. There were 12 males and 9 females, with a median age of 36 years (range, 19-62 years). The wounds were on the upper limbs (hands) in 13 cases and the lower limbs (feet) in 8 cases. Five patients with tumor/scar, and the left defects after en-bloc resection of the tumor lesion and scar were repaired immediately. The remaining 16 cases were acute/chronic wounds, undergoing the emergent debridement and vacuum sealing drainage placement, and the left defects were repaired with flaps during second-stage operation. The size of the defects ranged from 5.5 cm×4.5 cm to 17.0 cm×12.0 cm. The donor sites were located on the thoracic and back in 4 cases, the anterior lateral thigh in 6 cases, and the feet in 11 cases. All flaps were functional perforator flaps with sensory nerve. The donor sites were closed directly or repaired with skin grafting. At last follow-up, the sensation of flap and the muscle strength of recipient site were evaluated according to the British Medical Research Council (BMRC) sensory grading (S₀-S₄) and muscle strength grading (M₀-M₅) criteria. RESULTS: Twenty flaps survived completely without significant complication, and partial edge necrosis was observed in 1 flap, which healed after the debridement and skin grafting. The donor and recipient sites healed by first intention. All patients were followed up 10-18 months (mean, 12 months). At last follow-up, the flaps with satisfactory shape and soft texture were observed, and no abnormal hair growth or pigmentation occurred. The sensation of flap was evaluated as S₁ in 2 cases, S₂ in 7, S₃ in 9, and S₄ in 3. The muscle strength of recipient site was evaluated as M₂ in 4 cases, M₃ in 9, M₄ in 5, and M₅ in 3. Only linear scars were left at the donor site. CONCLUSION The functional perforator flap with sensory nerve is beneficial for early sensation reconstruction for repairing the complex defects on the limbs, and could reconstruct the functional subunit structure defect in one stage. The short-term functional follow-up results are satisfactory.
Humans ; Male ; Adult ; Female ; Perforator Flap/transplantation* ; Middle Aged ; Plastic Surgery Procedures/methods* ; Retrospective Studies ; Young Adult ; Treatment Outcome ; Extremities/injuries* ; Cicatrix/surgery* ; Skin Transplantation/methods*