Post-burn Hypertrophic Scars Research Articles

Development and Validation of a Nomogram for Prediction of Risks of Hypertrophic Scar Outcomes According to Burn Location

Purpose: To develop and validate a nomogram for prediction of postburn hypertrophic scar according to burn location. Method: The prediction model was developed in a primary cohort that consisted of 125patients with 309 burn sites. and data were collected from June 2017 to December 2019. Lasso regression model was used for data feature selection and prediction model building. Signature risk factors were used to develop a nomogram to assess the individualized risk of postburn hypertrophic scar. The performance of the nomogram was assessed with respect to its calibration, discrimination and clinical usefulness and was developed decision curve analysis. Result: Predictors contained in the prediction nomogram included use of sex, age, burn causes, burn sites, burn depth, total body sur-face area, surgical treatment, and healing time. The model displayed good discrimination with a C-index of 0.852 (95% CI: 0.811-0.893) and good calibration. High C-index value of 0.814 could still be reached in the interval validation. Decision curve analysis showed that the nomogram was clinically useful when intervention was decided at the postburn hypertrophic scar possibility threshold between 0.3% and 87%. Conclusion: A simple-to-use nomogram could be conveniently used to facilitate individual hypertrophic scar risk prediction in postburn patients. Funding: This work was funded by the Guangxi medical High-level Leading Talents Training “139” Project (No: GWKJ [2018]22#) Declaration of Interest: None to declare. Ethical Approval: Research approval was obtained from the Youjiang Medical University for Nationalities’ Ethics Committee.

Influence of parental compliance on the treatment of hypertrophic scars in burn children

Objective: To explore the influence of parental compliance on the treatment of hypertrophic scars in burn children. Methods: A retrospective cohort study method was used. From June 2014 to June 2019, 49 children with post-burn hypertrophic scars who met the inclusion criteria and visited the outpatient department of the Department of Burns of the First Affiliated Hospital of Anhui Medical University were included in this study. In the follow-up of 9 months, according to the registration form and the results of the compliance questionnaire for parents, the children were divided into good compliance group (34 cases, 21 males and 13 females, aged 2.0 (2.0, 3.5) years) and poor compliance group (15 cases, 6 males and 9 females, aged 3.0 (2.0, 4.0) years). At the first attendance and in the follow-up of 3, 6, and 9 months, the scar scores of children in good compliance group were evaluated by Vancouver Scar Scale (VSS). At the first attendance and in the follow-up of 9 months, the scar scores of children in poor compliance group were evaluated by VSS. At the first attendance and in the follow-up of 9 months, the scar pruritus scores of children in the 2 groups were evaluated by Verbal Rating Score (VRS). Data was statistically analyzed with chi-square test, Wilcoxon rank sum test, Mann-Whitney U test, independent sample t test, and paired sample t test. Results: At the first attendance, the color, vascular distribution, softness, and thickness scores, and total score in VSS scoring of scars of children in the two groups were similar (Z=0.834, 0.026, 0.837, 0.076, 1.074, P>0.05). In the follow-up of 9 months, the softness and thickness scores, and total score in VSS scoring of scars of children in good compliance group were significantly lower than those in poor compliance group (Z=5.518, 4.732, 5.042, P<0.01). Compared with those in the first attendance, the color, vascular distribution, softness, and thickness scores, and total score in VSS scoring of scars of children in good compliance group were significantly decreased in the follow-up of 9 months (Z=5.241, 5.273, 5.214, 5.245, 3.451, P<0.01); the color and vascular distribution scores, and total score in VSS scoring of scars of children in poor compliance group were significantly decreased in the follow-up of 9 months (Z=3.606, 3.542, 3.448, P<0.01). At the first attendance, the VRS score of scar pruritus of children in good compliance group was 6.00 (5.00, 6.25) points, which was similar to (5.47±1.69) points in poor compliance group (Z=0.607, P>0.05). In the follow-up of 9 months, the VRS score of scar pruritus of children in good compliance group was 1.00 (1.00, 1.25) points, which was significantly lower than (3.27±1.71) points in poor compliance group (Z=2.606, P<0.01). Compared with those in the first attendance, the VRS score of scar pruritus of children in good compliance group was significantly decreased in the follow-up of 9 months (Z=4.002, P<0.01), while there was no obvious change in poor compliance group in the follow-up of 9 months (t=3.550, P>0.05). Conclusions: Under the same treatment plan, good parental compliance has a positive effect on the treatment of hypertrophic scars in burn children decreasing the degree of scar hyperplasia and pruritus.

Altered KCa3.1 expression following burn injury and the therapeutic potential of TRAM-34 in post-burn hypertrophic scar formation

Hypertrophic scars are the most common post-burn complications characterized by fibroblast proliferation and excessive extracellular matrix deposition. The intermediate-conductance Ca2+-activated K+ channel (KCa3.1) mediates fibroblast activation, resulting in several fibrotic diseases; however, this channel's role in the formation of post-burn hypertrophic skin scars remains unknown. Herein, we investigated the role of KCa3.1 and the therapeutic potential of TRAM-34, a selective inhibitor of KCa3.1, in hypertrophic skin scar formation following burn injury. Cytosolic Ca2+ levels, the expression of KCa3.1 and hypertrophic markers, and the proliferation of skin fibroblasts obtained directly from patients with third-degree burns who consequently developed post-burn hypertrophic scars were assessed. The anti-fibrotic effect of KCa3.1 inhibition by TRAM-34 was evaluated in vitro (fibroblasts) and in vivo (mouse burn models). Fibroblasts from burn wounds exhibited remarkably higher levels of cytosolic Ca2+ than normal cells. KCa3.1 expression was markedly higher in the membrane fraction but lower in the cytosolic fraction of burn wound fibroblasts than in normal cells. Selective inhibition of KCa3.1 by TRAM-34 markedly reduced not only the proliferation of burn wound fibroblasts but also the expression of hypertrophic markers in these cells. Anti-scarring molecular, histological, and visual effects of TRAM-34 were confirmed in murine burn models. Altered subcellular expression of KCa3.1 is a novel mechanism underlying the cellular response to burn injury. Our results suggest that selective inhibition of KCa3.1 by TRAM-34 has therapeutic potential against post-burn hypertrophic scar formation.

34 Rete Ridges are Decreased in Dyschromic Burn Hypertrophic Scar: A Histological Study

Abstract Introduction Dyschromic hypertrophic scar (HTS) with areas of hyper- and hypo-pigmentation is a common sequelae of burn injury. The mechanism behind the development of dyschromia has not been elucidated. In this study, we provide a histological analysis of these scars with a focus on rete ridge presence. Rete ridges occur in epithelial tissues such as oral mucosa and skin and can be described as undulating “pegs” that are interdigitated with dermal papillae. Rete ridges enhance adhesion of the epidermis to the dermis. We hypothesize that rete ridge presence is important for normal skin physiology, and their absence or presence may hold mechanistic significance in post-burn HTS dyschromia. Methods Subjects with post-burn dyschromic HTS were consented and enrolled (n=27). Punch biopsies of hyper-, hypo-, and normally pigmented scar and skin were collected and stored in formalin. Biopsies were paraffin embedded, sectioned, stained with H&amp;E, and imaged. The number of rete ridges were investigated by calculating a rete ridge ratio from the length of the basement membrane and the length of the epidermis. Results The patient population was predominantly female (55.5%), black (70.4%), and had Fitzpatrick skin Type V (51.9%). The injuries were primarily as a result of flame (37%) and scald (33.3%) and resulted in a median TBSA burn of 7%. The median age of the scar at the time of sample acquisition was 12.2 months. The rete ridge ratio of normally pigmented, un-injured skin was above 1 (1.31 ± 0.04), indicating that normal skin’s basement membrane is longer than its epidermal length due to the presence of rete ridges. HTSs resulting from burn wounds that healed without split thickness autografts were first investigated. The number of rete ridges was higher in normal skin compared to HTS that was either hypo- or hyperpigmented (1.31 ± 0.04 vs. 1.13 ± 0.05 and 1.14 ± 0.04 vs, p&amp;lt; 0.05). This difference was similar despite pigmentation phenotype. When hyper-pigmented scars resulting from wounds that were treated with split thickness autografts (Hyper(+)) were investigated, rete ridge number was significantly higher than in Hyper(-) (1.89 ± 0.23, p&amp;lt; 0.01). Patient age showed a weak correlation (R=-0.33) with rete ridge ratio where older patients had lower rete ridge ratios in normal, un-injured skin. Hyper(+) showed a weak correlation between rete ridge ratio and age of scar (R=-0.38). Conclusions Post-burn HTS that is dyschromic has fewer rete ridges than normal skin. This finding may explain the decreased epidermal barrier function that is associated with HTS.

The relationship between alexithymia, sensory phenotype and neurophysiological parameters in patients with chronic upper limb neuropathy

In this study, we investigated the relationship between sensory abnormalities evaluated by quantitative sensory testing (QST) and alexithymia, depression and anxiety in patients with neuropathic pain involving the upper limbs. We enrolled 62 patients (34 with carpal tunnel syndrome, 7 with brachial plexopathy, 3 with cervical painful radiculopathy, 5 with ulnar entrapment neuropathy at elbow and 13 with post-burn hypertrophic scars) and 48 healthy controls. All underwent nerve conduction studies (NCS), evaluation of cold, heat pain and vibration detection threshold (VDT) by QST and evaluation of alexithymia by Toronto Alexithymia Scale (TAS-20), depression by Beck Depression Inventory II (BDI-II), anxiety by State-Trait Anxiety Inventory (STAI-Y), level of psychological distress by 12-item General Health Questionnaire (GHQ-12) and perceived social support by the Multidimensional Scale of Perceived Social Support (MSPSS). The general linear model analysis revealed a significant relationship between TAS-20 overall and TAS-20 sub-score for difficulty identifying feelings and VDT z-scores in the left index with no interaction by year of education and sensory NCS results. Our results demonstrated the association between impairment of vibratory sensation of the left hand, reflecting cutaneous mechanoceptor dysfunction, and alexithymia, particularly the difficulty to identify feelings. The importance of delivering to patients with neuropathic pain personalized care that takes into account not only the neurophysiological aspects but also the aspects of mental functioning is discussed.

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.

The Use of Collagen-Glycosaminoglycan Biodegradable Matrix (Integra®) in the Management of Neck Postburn Hypertrophic Scars and Contractures

Glycosaminoglycan (GAG) is a chain-like disaccharide that is linked to a polypeptide core to connect two collagen fibrils/fibers and provide the intermolecular force in a Collagen-GAG matrix which can be a valuable treatment of post-burn contractures and hypertrophic scars, which remain a challenge to reconstructive surgery. The face and neck contractures are the most difficult sites to treat. This article is meant to discuss our clinical experience in using collagen-glycosaminoglycan biodegradable matrix (Integra® Integra Lifesciences Corporation, Plainsboro, NJ, USA) to reconstruct defects created by excision of contracted areas from the neck and lower face areas. Between 2009 and 2011, we had 11 patients that underwent Integra reconstructive procedures. The mean follow-up period was 18 months. For all the patients, the intake of the Integra dermal regeneration template was 100%, even if one patient developed a minor infection treated with appropriate antibiotics. The patients are very satisfied with the result. A minor problem was a small difference in skin color, but this inconvenience was compensated by good skin elasticity.

114 Galectin-1 Is Overexpressed in Post-Burn Hypertrophic Scar

Abstract Introduction Upon healing, burn wounds often leave hypertrophic scars (HTS), a significant morbidity for patients that can have lasting psychosocial impacts. HTS is marked by excess collagen deposition, dermal and epidermal thickening, and an increased concentration of fibroblasts. The Galectins, a family of lectins with a conserved carbohydrate-recognition-domain, function intracellularly and extracellularly as mediators of a multitude of biological processes including inflammatory responses, cell migration and differentiation, and cell-ECM adhesion. Galectin-1 (Gal-1) has been associated with several fibrotic diseases and can induce keratinocyte and fibroblast proliferation and migration as well as differentiation into fibroproliferative myofibroblasts. Gal-1 transcription is driven by the PI3K/AKT pathway, and AKT activation is increased in HTS compared to normal skin (NS). In this study, Gal-1 expression was assessed in human and porcine HTS and NS tissues. Methods mRNA was isolated from biopsies of human or porcine HTS and NS tissue. Total transcriptome microarray analysis was performed in porcine HTS vs. NS. Transcription of the Galectin-1 gene (LGALS1) was assessed by qRT-PCR using primers specific to human or porcine LGALS1 and GAPDH genes. A Gal-1 antibody was used for immunofluorescent (IF) staining to corroborate gene expression data. Results LGALS1, 4, 8, and 12 were differentially regulated genes in pig HTS vs. NS by microarray analysis (fold change= 3.58, 6.11, 1.89, and 3.03, p&amp;lt; 0.01). Confirmatory qRT-PCR results showed significant upregulation of LGALS1 transcription in HTS compared to NS of both human and porcine tissues (Fold change= 6.11 and 7.70, n=15 and n=3 scars respectively, p&amp;lt; .001). In pig HTS, this upregulation was maintained throughout scar development and remodeling (days 49, 56, 77, 99, and 112 post-wounding). IF Gal-1 in human HTS showed significantly increased fluorescence (503±58 vs 346±23, p&amp;lt; .001, n=5 scars) compared to NS, and Gal-1 was visualized in both intracellular and extracellular areas of the dermis. Conclusions Galectin-1 is overexpressed in HTS at the mRNA and protein levels and may have a role in the development of scar phenotypes due to fibroblast over-proliferation, collagen secretion, and dermal thickening. The role of galectins shows promise for future study and may lead to development of new pharmacotherapies. Applicability of Research to Practice A better understanding of galectin signaling and its effects on the ECM and cell growth may lead to new treatments aimed at reducing scar formation. Changes in galectin expression could be induced as possible downstream effects of anti-scarring gene therapies aimed at AKT-inactivation.

CPEB1 or CPEB4 knockdown suppresses the TAK1 and Smad signalings in THP-1 macrophage-like cells and dermal fibroblasts

Post-burn hypertrophic scar (HTS) is a form of excessive dermal fibrosis characterized by cutaneous scarring, which is common in patients following burn injury. Moreover, at least 50% of HTS are accompanied by inflammation. Cytoplasmic polyadenylation element binding (CPEB) proteins are key mRNA-binding proteins that control the translation of several mRNAs. However, their potential roles in treating dermal fibrosis and scarring remain unknown. Therefore, in this study, we aimed to investigate the effects of small interfering RNA (siRNA)-mediated knockdown of CPEB1 or CPEB4 in human THP-1 macrophages and dermal fibroblasts treated with LPS and TGF-β1. We found significantly increased CPEB1 and CPEB4 mRNA and protein levels in LPS-treated THP-1 cells and TGF-β1–treated fibroblasts. CPEB1 and CPEB4 knockdowns suppressed LPS-activated TAK1 signaling cascades by reducing the levels of TNF-α and phosphorylated TAK1, p38, ERK, JNK, and NF-κB-p65 in THP-1 cells. CPEB1 and CPEB4 knockdowns also attenuated TGF-β1-activated Smad-dependent and -independent signaling cascades by reducing the levels of TAK1, p38, ERK, JNK, and phosphorylated Smad 2 and Smad 1/5/8 in fibroblasts. Furthermore, CPEB1 or CPEB4 knockdown markedly decreased the levels of fibrosis markers, including α-SMA, type I collagen, and fibronectin in fibroblasts. Our findings indicate that CPEB1 and CPEB4 are involved in the regulation of the TAK1 and Smad signalings in human macrophages and dermal fibroblasts. These activities may play a role in cutaneous scarring responses.

P53(Cp44), an Endogenous Human p53 Fragment Generated via M-Calpain-Mediated Cleavage Beyond Degradation

Endogenous fragments of p53 identified recently in human cytomegalovirus (HCMV)-infected human lung fibroblasts, specifically a ~44-kDa N- terminal fragment referred to as p53(Cp44), have been shown to be generated via m-calpain cleavage. p53(Cp44) appeared to be tightly associated with a chromatin-rich fraction, and was stabilized by the proteasome inhibitor MG132, particularly in mock-infected cells. The N- terminal p53 fragments were also present in three human dermal fibroblast cell lines tested, including fibroblasts isolated from post-burn hypertrophic scar. Understanding the biological functions of these fragments in the regulation of physiological and pathological processes, and the mechanisms regulating their generation and degradation, may shed light on currently unrecognized aspects of p53 regulation and function, and may provide a pathway for drug discovery.

Focused versus radial extracorporeal shock wave therapy in post burn hypertrophic scar: A single blinded randomized controlled trial

Purpose. Hypertrophic scar (HTS) is one of the common post-burn complications that lead to functional and cosmetic impairments, so we pursued to examine efficacy of extracorporeal shock wave therapy (ESWT) on HTS in expression of improving scar thickness and appearance. Materials and Methods. 60 patients with post burn HTS were recruited in this trial and divided randomly into 3 equal groups. Group A: received focus ESWT (100 shock waves per cm2, 0.037 mJ/mm2, 4 Hz, 2 times/week for six weeks) plus traditional topical medication (MEBO Scaro cream). Group B: received radial ESWT (500 shock waves per cm2, 0.13 mJ/mm2, 6 Hz, 2 times/week for six weeks) plus MEBO Scaro cream. Group: received only MEBO Scaro cream. Ultrasonography was utilized for scar thickness measurement and scar characteristics assessment was done by Modified Vancouver Scar Scale (MVSS). All measures were gathered before the start of the study, and after termination of the trial (after 6 weeks). Results. Both focus and radial ESWT showed significant advance in scar thickness and MVSS post treatment (p &gt; 0.001), without statistical differences between them (p &gt; 0.05), while group C showed only a significant diminution in MVSS post treatment (p &gt; 0.001), without any change in scar thickness. Conclusion. Higher statistical results were achieved with both focus and radial ESWT without any side effects, confirming the safety and efficiency of ESWT in HTS management.

Efficacy of Low Level Laser Therapy versus Therapeutic Ultrasound on Pediatric Post Burn Hypertrophic Scars: A Scar Split Study

Background. The treatment of scars caused by burn is a difficult challenge in developing countries that includes enormous treatment cost. Burn scars tend to get worse with hypertrophy and contracture, leading to limitations of function. This study aimed to compare the efficacy of low-level laser therapy (LLLT) to therapeutic ultrasound (US) on hypertrophic scar in pediatric burns. Methods. 45 children participated in the study, their age ranges from 12 to 15 years of age, suffering from hypertrophic scars. Each scar divided to 2 identical halves. One half received (LLLT) with deep friction massage and the other received therapeutic ultrasound with deep friction massage. Participants were assessed pre &amp; post two months of study by Ultrasonography and Vancouver Scar Scale. Results. Significant improvement was reported in both halves of scar but laser was more effective in decreasing scar height, and lowering Vancouver scale score (p &lt; 0.0001). Conclusion. LLLT and US are proficient and secure modalities for post-burn hypertrophic scars treatment in children.

Persistent Pixel Stamping Marks: a novel complication of fractional CO2 laser in scar treatment.

Fractional CO2 laser rejuvenation of scars offers a high safety profile. Laser marks usually disappear clinically within 1week. The authors observed occasional persistence of the laser marks on the scar surface. The purpose of this study is to report the incidence and to describe the clinical, dermoscopic, and histological features of a novel observed complication of fractional CO2 laser scar rejuvenation "Persistent Pixel Stamping Marks (PPSM)".One hundred seventy-one cases were consecutively recruited from patients assigned for fractional CO2 laser scar rejuvenation. Patients who developed the phenomenon 1month post laser session were recorded and subjected to clinical photography, dermoscopy, and optical coherence tomography (OCT) as well as a 4-mm punch biopsy from pixelated scars. The evolution of PPSM was followed up for 6months. PPSM developed in 16 patients (9.4%), 15 of which were post burn hypertrophic scars. PPSM was significantly related to darker skin type, darker scar color, and longer scar duration. Histopathological findings included characteristic holes in stratum corneum and superficial dermis, thick collagen bundles perpendicular to the skin surface with loss of elastic tissue, focal interface changes, and triangular focus of fibroblastic proliferation. The marks disappeared in 5 and lasted in 11 patients. Their longevity was significantly related to longer dwell times and lower densities. PPSM represent miniature scarring at the sites of the microscopic thermal zones or a sign of their delayed healing. They tend to follow fractional CO2 laser resurfacing of hyperpigmented, long-standing burn scars. Longer dwell times and lower densities make them last longer.

Interleukin-31, Interleukin-31RA, and OSMR Expression Levels in Post-burn Hypertrophic Scars.

BackgroundAlthough several studies have shown the role of interleukin-31 (IL-31) and its receptors in inducing pruritus in certain skin disorders, knowledge of its role in post-burn hypertrophic scars is insufficient. Therefore, the histopathological expression levels of IL-31, IL-31 receptor alpha (IL-31RA), and oncostatin M receptor (OSMR) in post-burn hypertrophic scar tissues were investigated and compared with normal tissue expression levels.MethodsSamples of hypertrophic scar tissue were obtained from 20 burn patients through punch biopsy. Normal samples were obtained from areas adjacent to the burn injury site of the same patients. Samples were placed in 10% neutral buffered formalin, embedded in paraplast, and processed into serial 5-μm sections. Immunohistochemistry results were semi-quantitatively evaluated for IL-31, IL-31RA, and OSMR. By hematoxylin and eosin staining, epidermal and dermal thickness were assessed with a microscope and digital camera. Intensities were rated on a scale of 1 to 4.ResultsPercentages for IL-31, IL-31RA, and OSMR in the epidermal basal layer cell cytoplasm were significantly greater in the burn scar tissue compared to normal skin, as well as the dermal and epidermal thickness (p < .05). There was a significant difference in IL-31 epidermal basal layer intensity in burn scar tissue compared to normal skin (p < .05). Besides the OSMR basal layer intensity, IL-31 and IL-31RA intensities between the burn scar and normal tissues were not significant. However, correlations were significant, indicating that the greater the infiltration percentage, the higher the intensity (p < .05).ConclusionsIL-31, IL-31RA, and OSMR expression levels are increased in hypertrophic scars compared with normal tissue.

Fractional Carbon Dioxide Laser Resurfacing in Combination With Potent Topical Corticosteroids for Hypertrophic Burn Scars in the Pediatric Age Group: An Open Label Study.

Lasers and potent topical corticosteroids are used as therapeutic options in hypertrophic burn scars. To assess the therapeutic effect of fractional CO2 laser resurfacing in combination with potent topical corticosteroids on hypertrophic burn scars in pediatric age group. Ten children (5-12 years) with postburn hypertrophic scars were treated with 3 to 5 sessions of fractional CO2 laser resurfacing at 1-month intervals, and triamcinolone suspension was applied immediately after each laser session. Patients were also instructed to apply clobetasol propionate gel for 1 week after each laser session. Response to treatment was assessed using Vancouver Scar Scale (VSS) and Physician Global Assessment (PGA). Tolerability for the procedure and adverse effects were also assessed. Laser sessions were well tolerated under the effect of topical or local anesthesia. At the time of final assessment, there was mean reduction of 4.2 (range: 2.8-7) in VSS. Reduction of VSS by ≥4 points was observed in 8 of 10 cases, whereas PGA revealed excellent response in 6 of 10 cases. No significant adverse effects were reported by any patient. Fractional CO2 laser resurfacing in combination with potent topical steroids leads to significant therapeutic benefits in children with postburn hypertrophic scars.

Evaluation of scars in children after treatment with low-level laser.

Burn scars are known for their tendency to worsen with hypertrophy and contracture, causing esthetic and functional problems. The objective is to analyze the effectiveness of low-level laser therapy on post-burn hypertrophic scar tissue in children. A randomized controlled study included 15 children, ranging from 2 to 10years of age, presented with post-burn hypertrophic scars. They received He-Ne laser and topical treatment. Each scar was divided into two halves. One half was treated with laser therapy and topical treatment (study area), and the other half was treated with topical treatment only (control area). The children were evaluated before, and after 3months of the study by Vancouver Scar Scale (VSS), ultrasonography, and laser Doppler perfusion imaging. Significant improvement was reported in the studied area, compared to the control area for patients with P values (P= 0.003) and (P= 0.005), for VSS and U/S scores, respectively. No differences were detected for blood perfusion of the scar between both areas (P = 0.73). In addition, no adverse effects were reported. Photobiomodulation (PBM) is an efficient and safe therapeutic modality for post-burn hypertrophic scars in children, with no side effects, and should be considered a part of combination therapy for better results.

The recovery of post-burn hypertrophic scar in a monitored pressure therapy intervention programme and the timing of intervention

IntroductionPressure therapy used to be considered as the mainstay non-invasive treatment of hypertrophic scar. However, the maturation process of hypertrophic scar during pressure therapy process has seldom be reported. Moreover, although early application of pressure therapy after burn injuries is reco6mmended, minimal evidence exists to support it. This study aimed to examine the maturation trajectory of post-burn hypertrophic scars in a 6-month monitored pressure therapy intervention programme and investigate the difference in the trajectory between patients receiving early intervention and patients receiving late intervention. MethodsThirty-four patients with sixty-five post-burn hypertrophic scar samples were recruited for the study. All the subjects were treated with a 6-month pressure therapy programme with the pressure dosage regulated using a newly developed pressure therapy system, the Smart Pressure Monitored Suits. The selected scars were assessed with MiniScan XE Spectrocolorimeter on scar pigmentation, and Terason t3000 portable ultrasound imaging equipment on scar thickness. The Vancouver Scar Scale (VSS) was used to evaluate pigmentation, pliability, vascularity and height of the scars. Subjects’ report of pain and itch was documented. Assessments were conducted before treatment began and then monthly during the 6 month-intervention process. Patients were further divided into two groups according to the time of intervention post-burn injuries to review differences in the maturation trajectory between those who received early versus late treatment (early intervention group, prescribed within 60days after injuries; late intervention group, prescribed after 61 days). The changes of scar features were recorded to formulate the recovery trajectory of scar, and the outcomes of intervention between the early and the late groups were compared. ResultsPre- and post-treatment comparison demonstrated significant improvement in scar pigmentation, thickness, VSS scores and scores of pain and itch (p<0.01) for the early intervention group. For the later intervention, only scar lightness, yellowness, VSS scores and scores of pain and itch was found with significant improvement (p<0.01). The improvement in these scar characteristics was sustained over time during the treatment process. The early group demonstrated superior effect in improving scar lightness, yellowness (p<0.01), thickness (p<0.01), pigmentation score (p<0.05) and pain score (p<0.01) than the late group in comparison between the two groups at similar post-burn timing. ConclusionsHypertrophic scars appeared to undergo continuous improvement in the appearance, pain and itch over time during the process of a monitored pressure intervention programme. Early application of pressure therapy after burn injury may contribute to better outcomes as shown by their faster recovery than those with late intervention. In order to achieve the best outcomes, regular evaluation and adjustment for optimal interface pressure is necessary.

Risk factors for hypertrophic burn scar pain, pruritus, and paresthesia development.

Hypertrophic scar pain, pruritus, and paresthesia symptoms are major and particular concerns for burn patients. However, because no effective and satisfactory methods exist for their alleviation, the clinical treatment for these symptoms is generally considered unsatisfactory. Therefore, their risk factors should be identified and prevented during management. We reviewed the medical records of 129 postburn hypertrophy scar patients and divided them into two groups for each of three different symptoms based on the University of North Carolina "4P" Scar Scale: patients with scar pain requiring occasional or continuous pharmacological intervention (HSc pain, n = 75) vs. patients without such scar pain (No HSc pain, n = 54); patients with scar pruritus requiring occasional or continuous pharmacological intervention (HSc pruritus, n = 63) vs. patients without such scar pruritus (No HSc pruritus, n = 66); patients with scar paresthesia that influenced the patients' daily activities (HSc paresthesia, n = 31) vs. patients without such scar paresthesia (No HSc paresthesia, n = 98). Three multivariable logistic regression models were built, respectively, to identify the risk factors for hypertrophic burn scar pain, pruritus, and paresthesia development. Multivariable analysis showed that hypertrophic burn scar pain development requiring pharmacological intervention was associated with old age (odds ratio [OR] = 1.046; 95% confidence interval [CI], 1.011-1.082, p = 0.009), high body mass index (OR = 1.242; 95%CI, 1.068-1.445, p = 0.005), 2-5-mm-thick postburn hypertrophic scars (OR = 3.997; 95%CI, 1.523-10.487, p = 0.005), and 6-12-month postburn hypertrophic scars (OR = 4.686; 95%CI, 1.318-16.653, p = 0.017). Hypertrophic burn scar pruritus development requiring pharmacological intervention was associated with smoking (OR = 3.239; 95%CI, 1.380-7.603; p = 0.007), having undergone surgical operation (OR = 2.236; 95%CI, 1.001-4.998; p = 0.049), and firm scars (OR = 3.317; 95%CI, 1.237-8.894; p = 0.017). Finally, hypertrophic burn scar paresthesia development which affected the patients' daily activities was associated with age (OR = 1.038; 95%CI, 1.002-1.075; p = 0.040), fire burns (OR = 0.041; 95%CI, 0.005-0.366; p = 0.004, other burns vs. flame burns), and banding and contracture scars (OR = 4.705; 95%CI, 1.281-17.288, p = 0.020).

Extracorporeal Shock Wave Therapy Alters the Expression of Fibrosis-Related Molecules in Fibroblast Derived from Human Hypertrophic Scar

Extracorporeal shock wave therapy (ESWT) considerably improves the appearance and symptoms of post-burn hypertrophic scars (HTS). However, the mechanism underlying the observed beneficial effects is not well understood. The objective of this study was to elucidate the mechanism underlying changes in cellular and molecular biology that is induced by ESWT of fibroblasts derived from scar tissue (HTSFs). We cultured primary dermal fibroblasts derived from human HTS and exposed these cells to 1000 impulses of 0.03, 0.1, and 0.3 mJ/mm2. At 24 h and 72 h after treatment, real-time PCR and western blotting were used to detect mRNA and protein expression, respectively, and cell viability and mobility were assessed. While HTSF viability was not affected, migration was decreased by ESWT. Transforming growth factor beta 1 (TGF-β1) expression was reduced and alpha smooth muscle actin (α-SMA), collagen-I, fibronectin, and twist-1 were reduced significantly after ESWT. Expression of E-cadherin was increased, while that of N-cadherin was reduced. Expression of inhibitor of DNA binding 1 and 2 was increased. In conclusion, suppressed epithelial-mesenchymal transition might be responsible for the anti-scarring effect of ESWT, and has potential as a therapeutic target in the management of post-burn scars.

Photobiomodulation effect on children's scars.

The management of burn scars has become one of the major clinical challenges in the developing countries which involve enormous treatment cost; this needs new methods for better cost benefit relationship. The objective of the study is to analyze the effectiveness of low-level laser therapy on post-burn scar tissue in children. A randomized controlled study included 15 children, ranging from 2 to 10years of age, presenting with burn scars. They received diode laser and topical treatment. Each scar was divided into two halves. One half was treated with laser therapy and topical treatment (study area), and the other half was treated with topical treatment only (control area). The children were evaluated before and after 3months of the study by Vancouver Scar Scale (VSS), ultrasonography (U/S), and laser Doppler perfusion imaging. Significant improvement was reported in the studied area compared to the control area for patients with P values (P = 0.005) and (P = 0.0001) for VSS and U/S scores, respectively. No difference was detected for blood perfusion to the scar between both areas (P = 0.18). In addition, no adverse effect was reported. Photobiomodulation is an efficient and safe therapeutic modality for post-burn hypertrophic scars in children and should be considered a part of combination therapy for better results.