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Keloids and their management
Abnormal scars are common, painful, itchy in darker skin types. Several treatments are available, but clearance can be challenging (1,400 words, 7 minutes)
People with skin of colour are at higher risk of developing keloids, Dr. Gary Sibbald reported in his presentation at the 8th annual Skin Spectrum Summit on Sept. 17, 2022. He discussed several treatment approaches for the condition.
“Keloids don't usually regress spontaneously,” said Dr. Sibbald. “They can be associated with intense pain and pruritis.” He is a professor of public health and medicine at the University of Toronto and the director of Project ECHO Ontario Skin and Wound Care.
People with skin of colour are at higher risk of developing keloids, especially on the chest, upper back and shoulders, and earlobes, said Dr. Sibbald. A keloid is a hyperproliferation of tissue that extends beyond a scar's border, unlike a hypertrophic scar.
He said that intralesional steroids are the first line of treatment for keloids and hypertrophic scars.
Silicone dressings are also valuable first-line treatments, and are something patients can use themselves, said Dr. Sibbald. Compression can also be of benefit.
Thick silicone sheets have been available for some time, but thinner tapes are now also marketed, he said. “Because the tape has a silicone adhesive, it doesn't cause trauma, but it still gives the patient the same negative [tension] feedback of the thick sheets we've had before. Patients can buy silicone sheets on the web for less than $25, and the blue tape is even cheaper.”
The second line of treatment includes cryosurgery and radiation, said Dr. Sibbald.
He said that liquid nitrogen is not an ideal choice for cryosurgery as the cold does not penetrate deeply into the abnormal scar. Cryosurgery devices that use a probe are more effective.
Third-line treatments include laser therapy, topical retinoic acid, and surgery. “Usually, with surgery, there will be an injection of steroid into the edges of the surgical site.”
Bottom Line: People of colour are at higher risk of developing keloids that can strongly impact their quality of life. Different treatment approaches are available, but managing the condition is challenging.
From the literature on keloids and keloid management
Exosomes released by melanocytes modulate fibroblasts to promote keloid formation: A pilot study
In this small in-vitro study, researchers observed that melanocytes in keloids are more active than those in normal scars. In particular, they observed more melanocytes and melanosomes in keloid tissue.
The authors found that exosomes containing the micro-RNA (miR)-7704, derived from melanocytes, promote keloid formation by inhibiting the protein Smurf1 in fibroblasts and activating the TGF-β/Smads pathway.
They write that their findings highlight a novel mode of communication between melanocytes and fibroblasts and tie the function of exosomes to the regulation of keloid formation. The study also contributes to understanding the biological nature of keloids prevalent in dark-skinned people from the microenvironmental perspective.
Greater understanding of genetic factors in keloid development
This study, conducted in China, investigated genetic factors, particularly the function of ‘susceptibility locus’ (parts of chromosomes associated with susceptibility to specific diseases), involved in developing keloids. People with keloids and those without keloids took part in the study.
They found that rs1348270 (a susceptibility locus of keloid) played a role in keloid development. This locus is associated with reducing the expression of a non-coding RNA known as DEIK. This downregulation promoted keloid formation by upregulating the protein BMP2. This, in turn, increased the expression of the proteins POSTN and COMP, as well as collagens.
The authors conclude their findings improve the understanding of the role of genetic factors in the development of keloids. This knowledge could lead to new treatment strategies or methods for screening individuals for keloid risk.
Comorbidities of keloid and hypertrophic scars among participants in U.K. Biobank
This cross-sectional, population-based cohort study evaluated established comorbidities of excessive scarring in European individuals. The researchers compared data across ethnic groups and identified novel comorbidities.
Of 972 people with excessive scarring included in the study, there was a higher proportion of female participants compared to 229,106 controls (65% vs 55%) and a lower ratio of White ethnicity (86% vs 95%). The mean (standard deviation, S.D.) age of the total cohort was 64 (8) years.
The authors identified associations between excessive scarring and hypertension, and atopic eczema after accounting for age, sex, and ethnicity. The association with atopic eczema (odds ratio [OR], 1.68; 95% CI, 1.36-2.07; p<0.001) remained statistically significant after accounting for additional potential confounders.
Fully adjusted analyses within ethnic groups revealed associations with hypertension in Black participants (OR, 2.05; 95% CI, 1.13-3.72; p=0.02) and with vitamin D deficiency in Asian participants (OR, 2.24; 95% CI, 1.26-3.97; p=0.006). There was a borderline significant association with uterine leiomyoma in Black women (OR, 1.93; 95% CI, 1.00-3.71; p=0.05), and a significant association with atopic eczema in White participants (OR, 1.68; 95% CI, 1.34-2.12; p<0.001). There was a similar trend for atopic eczema association in Asian (OR, 2.17; 95% CI, 1.01-4.67; p=0.048) and Black participants (OR, 1.89; 95% CI, 0.83-4.28; p=0.13). Phenome-wide association analysis identified 110 significant associations across disease systems. Apart from skin conditions, there were prominent associations with musculoskeletal disease and pain.
Intralesional corticosteroid administration in the treatment of keloids: A scoping review on injection methods
This study reviews the details of intralesional corticosteroid administration (ICA) in keloids described in randomized controlled trials (RCTs).
Researchers searched PubMed, Ovid MEDLINE, Ovid EMBASE and CENTRAL databases for RCTs that included patients with keloids treated with intralesional corticosteroids. Thirty-eight RCTs were included.
Triamcinolone acetonide was used in 37 (97.4%) studies. Dosing per cm2 could only be compared among ten (26%) studies and varied from 1 to 20 mg. The maximum dose per session ranged from 20 to 80 mg. Anesthetics were administered locally and orally in seven and one RCT(s). Treatment intervals varied from weekly to monthly, with four weeks most frequently (50%) used. Needle size was reported in 11 (29%) studies and ranged from 26 to 30 gauge. The syringe size was specified in four (11%) studies (1 mL). The injection level was described in 11 (29%) studies. Blanching as an endpoint was reported in 10 (26%) studies.
In the included studies, the authors found that outcome measures varied widely, from height, surface area or volume to Vancouver Scar Scale, Patient and Observer Scar Assessment Scale, pain and itch scores, patient satisfaction and efficacy rates.
Only six studies had a follow-up of six months or longer. Recurrence was identified in two studies with 18 weeks and one year of follow-up. Adverse events were reported in 25 (66%) studies.
VIDEO: Doctor V - How to treat scars: Skin of colour, brown or black skin
At the intersection of skin and society
A recent report from Statistics Canada shows that there has been a significant increase in the number of First Nations youth hospitalized for mental health issues.
First Nations youth were twice as likely to be hospitalized for mental health issues in 2011 as in 2006, according to the report published on Jan. 18, 2023.
This study is the first to investigate changes in hospitalization patterns among Indigenous children and youth over time to “more comprehensively report the healthcare use of Indigenous populations.”
The increases involved youth both on and off reserve.
Mental health-related hospitalizations were higher for the 2011 cohort than the 2006 cohort for Métis youth (+53%), First Nations youth living on reserve (+51%) and First Nations youth living off-reserve (+49%).
The report’s authors note that hospitalizations for non-mental-health-related reasons decreased for Indigenous youth in the same period.
“With childbirth excluded, all-cause hospitalizations were significantly lower in 2011 than in 2006 for First Nations children and youth living on reserve, Métis children, and non-Indigenous children, among others,” the authors write. “Hospitalizations for diseases of the respiratory system as well as for injuries significantly decreased from 2006 to 2011 among First Nations children and First Nations youth living on reserve.”
Among non-Indigenous youth, mental health-related hospitalizations increased by 73% from 2006 to 2011. However, in 2011, mental health-related hospitalization rates were higher for every Indigenous youth group compared to non-Indigenous youth.
The full report can be read here.
February is National Black History Month in the U.S.
Feb. 4 is World Cancer Day
Feb. 4 is International Day of Human Fraternity
Something to think about in the week ahead…
Goodness is the only investment that never fails.
Henry David Thoreau
A recently published study detailed how racialized beauty norms motivate the use of chemical hair straighteners and skin lighteners linked to poor health outcomes.
The study was conducted by researchers at Columbia University Mailman School of Public Health in partnership with the environmental justice group WE ACT for Environmental Justice.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper in print providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Dr. Kim Papp (Waterloo, Ont.) discusses recent research on the TYK2 inhibitor deucravacitinib as a treatment for psoriasis
A review of 2022’s new dermatology treatments, featuring interviews with Dr. Ben Barankin (Toronto), Dr. Kerri Purdy (Halifax), and Dr. Marlene Dytoc (Edmonton)
Plus regular features, including the popular column “Vender on Psoriasis” by Hamilton dermatologist Dr. Ron Vender
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
Season two of the Shear Listening Pleasure podcast with Dr. Neil Shear has launched. Listen to the fourth episode here, where Dr. Shear speaks with Dr. Trevor Champagne about switching from computer science to medicine, how the experience of treating patients varies between provinces and the benefits of using A.I. and big data in dermatology.
And if you’re looking for a web destination for all things derm, please visit derm.city, “Where Dermatology Lives.” Please like it, rate it, and share it with your colleagues.