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Background
Since the management of keloid and hypertrophic scars still remains a difficult clinical problem, there is need for adequate, effective therapy. In this study, we explored for the first time the efficacy and the potential synergetic effect of combined triamcinolone and verapamil for the treatment of hypertrophic and keloid scars. The obj...
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Motivation
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Citations
... Mohammadi et al. found that 1% enalapril significantly improved (72). Verapamil is a calcium channel antagonist that induces collagen degradation by inhibiting the inflammatory response and reducing ECM and collagen production (73). Verapamil was first given by Lawrence's team for 7-14 days postoperatively and 52% of these patients recovered (74). ...
Keloid is a pathological scar that is higher than the skin surface following skin damage. Its lesion range often extends beyond the original damage boundary and does not naturally subside over time. Its pathogenesis is very complex, currently the main causes include fibroblast excessive proliferation, collagen and extracellular matrix (Extracellular matrix, ECM) excessive deposition, excessive angiogenesis, and so on. The traditional treatment method primarily involves surgical intervention, but it is associated with a high recurrence rate post-surgery. Consequently, many treatment methods are derived according to the different clinical characteristics of keloid. This paper will review the therapeutic progress in recent years from surgical treatment, physiotherapy, drug therapy, and biological therapy, with the goal of offering valuable insights for the clinical treatment of keloids.
... Their effectiveness and limitations have been extensively studied. 5 Triamcinolone functions by reducing inflammation and collagen synthesis and acting as a potent vasoconstrictor, collectively leading to an improvement in scar appearance. 6 While triamcinolone has been a standard treatment for keloids, its effectiveness varies considerably when used alone. ...
... The reduction in VSS scores observed in both groups aligns with findings from previous studies. 3,5,14 This effect can be attributed to the unique mechanism of action of triamcinolone, which involves decreasing collagen synthesis and inhibiting fibroblast degradation. 3 The intralesional injection of triamcinolone reduces keloid regression by suppressing inflammation triggered by the immune system, reducing blood flow to the keloids through vasoconstriction, and slowing down collagen synthesis by inhibiting keratinocytes and fibroblasts. ...
... Their experiment revealed that the combination of verapamil and triamcinolone restored decorin expression and decreased scar fibroblast proliferation. Kant et al. 5 employed a mixture of triamcinolone and verapamil on keloids and hypertrophic scars to retrospectively evaluate the effects of combination therapy on chronic wounds, using the Patient and Observer Scar Assessment Scale (POSAS). Their results demonstrated notable scar improvement at the early stages, approximately 3 to 4 months after the first injection. ...
Introduction:
In this clinical trial, we investigated the efficacy of two treatment methods for keloids resulting from surgical incisions: intralesional triamcinolone injections alone versus in combination with verapamil.
Material and methods:
Patients were divided into two groups: one received triamcinolone alone (Group T) and the other received a triamcinolone-verapamil blend (Group VT). Regular treatments were conducted until the keloids were nearly flat or for a maximum of eight sessions.
Results:
Both groups showed significant improvements, but Group VT saw quicker resolution of skin redness and needed fewer sessions. Though the Vancouver Scar Scale (VSS) scores were generally similar across both groups, Group VT exhibited greater improvements, leading to lower final scores. The VT group also attained normal scar flexibility faster than the T group.
Conclusion:
These findings suggest that the combination of verapamil and triamcinolone provides a more effective treatment for keloids, thereby highlighting the potential of verapamil in scar reduction.
... Moreover, keloids neither subside spontaneously nor are limited by original scar boundaries, differentiating them from hypertrophic scars. Currently, many treatments are available to inhibit the keloid formation, such as physical compression therapy (e.g., silicone gel bandaging or compression) [2], intralesional injection (e.g., corticosteroids, verapamil, or 5-Fluorouracil) [3][4][5], cryotherapy [6], radiation therapy [7], laser (e.g., carbon dioxide [CO 2 ] laser or pulsed dye laser) [8,9], and surgical excisions [10]. However, few results have shown satisfaction in the treatment of multiple keloids induced by wound, severe burn, ethnic background or cultural behaviors, or unexplained skin healing. ...
Background:
The keloid treatment is still a thorny and complicated clinical problem, especially in multiple keloids induced by wound, severe burn, ethnic background or cultural behaviors, or unexplained skin healing. Mainstream treatments have limited efficacy in treating multiple keloids. As no oral treatment with painlessness and convenience is available, oral treatment strategies should be formulated.
Objectives:
This study aimed to investigate the efficacy and therapeutic mechanism of oral tofacitinib in keloid patients.
Methods:
We recruited the 7 patients with keloid scars and prescribed 5 mg of tofacitinib twice a day orally with a maximum follow-up of 12 weeks. The Patient and Observer Scar Assessment Scale (POSAS), the Vancouver scar scale (VSS), ANTERA 3D camera, and the DUB Skin Scanner 75 were used to assess the characteristics of the lesion. Immunohistochemistry was performed to evaluate collagen synthesis, proliferation, and relative molecular pathways. Moreover, the effects of tofacitinib were assessed on keloid fibroblast in vitro.
Results:
After 12 weeks of oral tofacitinib, significant improvement in POSAS, VSS, and Dermatology Life Quality Index (DLQI) scores was observed (p < 0.05). The volume, lesion height, and dermis thickness of the keloid decreased (p < 0.05). Moreover, significant decreases in the expression of collagen I, Ki67, p-STAT 3, and p-SMAD2 were observed after 12 weeks of administration. In vitro experiments suggested that tofacitinib treatment inhibits fibroblast proliferation and collagen I synthesis via suppression of STAT3 and SMAD2 pathway.
Conclusion:
Tofacitinib, a new candidate oral drug for keloid, could reduce keloid lesion volume by inhibiting collagen synthesis and inhibiting fibroblast proliferation, and alleviate itch and pain to obtain a better life quality.
... There are numerous more or less invasive treatments aimed at improving residual aesthetic stigmatizations and facial dysfunctions (Table 1, [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]), but an optimal treatment has not yet been identified [44,45]. In fact, although many interventions appear promising, sometimes the results reported in the literature are conflicting [32][33][34][35], or interventions suitable for some types of scars are not effective for others [29,[43][44][45]. ...
... There are numerous more or less invasive treatments aimed at improving residual aesthetic stigmatizations and facial dysfunctions (Table 1, [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]), but an optimal treatment has not yet been identified [44,45]. In fact, although many interventions appear promising, sometimes the results reported in the literature are conflicting [32][33][34][35], or interventions suitable for some types of scars are not effective for others [29,[43][44][45]. This may depend on the extreme variability of individual situations, for each of which a personalized medicalsurgical-rehabilitation path should be identified. ...
... Non-invasive Silicone sheet coating [25] Topical treatment [26,27] Application of mesenchymal stem cells in tissue scaffolds [28] Minimally invasive Corticosteroid injection [29] (principally injectable therapies) Botox injection [30] Mesenchymal stem cells injection (principally obtained from fat grafting) [31][32][33] Hyaluronic acid filler [34,35] Invasive Cryotherapy (generally applied after surgical excision) [36] Others (more/less invasive) ...
Acid attacks are on the rise, and they cause extensive and deep burns, especially on the face. The treatments used to improve the aesthetic, functional and social impact of non-acid scars do not always prove useful for acid scars. This article reports the case of a woman with an extended, mature, acid facial scar, caused by sulfuric acid assault, treated with a recent new procedure that combines the application of vacuum and electromagnetic fields. Before and after the treatment, the aesthetic appearance, and motor function of the face and neck were evaluated, as well as the level of hydration, the amount of sebum, the elasticity, and the pH of the skin. The improvements highlighted after the treatment of the aesthetic and functional characteristics of the face and neck, and of the physical parameters of the skin seemed to indicate that this particular treatment induces tissue regeneration, even in the nerve component. However, it is evident that the rehabilitation pathways of facial wounds and scars must be personalized, and must include continuous psychological support for the patient.
... IntraLesional Injection of Triamcinolone Acetonide (that we called ILITA treatment), alone or in combination with other therapy, is one of the first-line treatment modalities. 7,9,[13][14][15][16][17][18][19][20] The efficacy of triamcinolone acetonide in keloids treatment has been demonstrated in various clinical trials since 1960, with efficacy rate from 50 to 100%, and recurrence rate of 50% in five years. [18][19][20][21] Corticosteroids reduce collagen synthesis, inhibit rapid growth of fibroblasts (antimitotic effect), promote vasoconstriction (reducing the delivery of oxygen and nutrients to the wound bed) and control local inflammation (inhibiting leukocyte and monocyte migration and phagocytosis). ...
... 7,18,19,21 ILITA therapy may induce adverse effects such as telangiectasias, atrophy, hypo/hyperpigmentation, ulcers, necrosis, and Cushing's syndrome. [13][14][15][16][17][18][19][20] The efficacy of treatment may be evaluated with subjective scales. In literature we identified 10 different scales: Vancouver Scar Scale (VSS), Dermatology Life Quality Index (DLQI), Manchester Scar Scale (MSS), Patient and Observer Scar Assessment Scale (PSAS/OSAS), Bock Quality of Life questionnaire (Bock QoL), Stony Brook Scar Evaluation Scale (SBSES), Patient-Reported Impact of Scars Measure (PRISM), Patient Scar Assessment Questionnaire (PSAQ), University of North Carolina "4P" Scar Scale (UNC4P) ( Table 1). ...
Background:
Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. These lesions do not spontaneously regress and can cause cosmetic disfigurements and functional disabilities. IntraLesional Injection of Triamcinolone Acetonide (ILITA), alone or in combination with other therapy, is one of the first-line treatment modalities. In this study the authors evaluated the objective efficacy of ILITA treatment in keloids management using this new imaging system.
Materials and methods:
37 patients with 45 keloid scars were treated with intralesional injection of triamcinolone acetonide (TAC) 20 mg/ml at an interval of three weeks. Antera3D® camera took the images and dates of the treated area in each patient, before the treatment (T0) and at three weeks after the last injection (T1). The system processed the levels of color, elevations, melanin and hemoglobin expression. All the scars were also evaluated, at the same times, by validated Vancouver Scar Scale (VSS). Comparison of the variables was performed using a Wilcoxon signed-rank test with a p < 0.05.
Results:
At T0, mean VSS score was 8.67 ± 1.35 which reduced to 3.62 ± 1.72 at final follow up. Antera3D® scores were statistically significant differences in color (8.14 ± 2.41 vs 9.54 ± 1.81), protrusion (381.3 ± 15.6 vs 198.6 ± 21.3), melanin (0.53 ± 0.02 vs 0.62 ± 0.2) and hemoglobin (1.26 ± 0.41 vs 2.21 ± 0.41) expression levels after the treatment.
Conclusions:
In our clinical trial, the data results demonstrated that ILITA seems to be effective in reducing keloid dimensions and symptoms such as itching and pain, even if the treatment has local minimal adverse effects such as pain, telangiectasias and atrophy.
Lay summary:
Keloids are pathological scars characterized by nodular fibrous tissue that extends beyond the border of initial damage. Large keloids can cause cosmetic disfigurements and functional disabilities that affect quality of life. In literature, several treatment approaches have been described but, to date, no single method is considered superior. The International Advisory Panel on Scar Management recommended the use of intralesional steroid injections for keloids treatment. The efficacy of treatment may be evaluated with subjective scale; as no one can guarantee an objective evaluation. To eliminate the observer and/or patient factors, and to obtain a reliable, consistent, feasible, valid and objective evaluation a skin analysis camera system called Antera3D® (Miravex, Dublin, Ireland) can be used.In this study the authors evaluated the objective efficacy of triamcinolone acetonide treatment in keloids management using this imaging system. In this series, for Antera3D® scores there were statistically significant differences in color, protrusion, melanin and hemoglobin expression levels before and after treatment. The device directly shows the treatment changes, measured objectively and accurately, without bias of traditional evaluation scoring scale.Antera3D® system guarantees an objective evaluation of effectiveness of scar treatment enabling clinicians to modulate the therapy according to the scores registered.
... Hypertrophic scarring is a popular condition that manifests on a wound that rises by deep injury, burns, or poor recovery from surgical proceedings. [1] Clinical manifestations of the budding HTs appear that tissue is elevated than the surrounding skin stays within the boundaries of the main wound, it is dark red or purple in most cases, and it is firmer than normal skin in many lesions and sometimes attached by localburning soreness and pruritus. These symptoms may continue for many months or even years before imperceptible declination. ...
Background and objectives: Keloids and HTs appear to have an abundant healing response that sets a challenge for physicians. Patients and methods: Patients with keloids and HTs were handled by a long-pulsed 1064 nm Nd: YAG laser every 4 weeks for five sessions. The number of patients was twenty. The scars were rated by VSS, consisting of 4 ingredients: vascularity, pigmentation, pliability, and height. Moreover, histopathological assessment by hematoxylin and eosin stain and Masson trichrome stain. After 6 months of finishing the treatment, the lesion was estimated to evaluate the recurrence rate. Results: According to VSS, there was a considerable improvement in vascularity, pigmentation, pliability, and height after the treatment than before the treatment. The score of the scar assessment dropped off from 9.40 to 3.75 after treatment. Hematoxylin and eosin staining and Elastica Masson-Goldner staining appeared to change the structure of the tissue collagen. Collagen bundles lost their whirl structure, and the thickness of the collagen layer decreased. The Wall of blood vessels was thinner, and the number of blood vessels was decreased. Conclusion: The treatment of keloids and HTs showed great results with a long-pulsed Nd-YAG laser.
... Triamcinolone acetonide (TA) is the most popular conservative treatment for keloids and hypertrophic scars due to its anti-inflammatory function [7]. Ehab Eltahawy and Sarah Neu both reported single injection of TA after surgical interventions of holmium laser and cold knife incisions resulted in 83% success rates in treating BNC [8,9]. ...
Bladder neck contracture (BNC), one of the most challenging complications after transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP), lacks effective treatment. In the present study, our experience in treating BNC using GreenLight laser vaporization with triamcinolone acetonide (TA) injections was shared. This is a retrospective cohort study that included 46 patients with BNC after TURP and PVP in our center. GreenLight laser surgeries (180 W) were carried out and TA was administrated simultaneously. TA injections were repeated every week for three times after surgeries. The perioperative and postoperative parameters were reviewed and compared. Bladder neck tissues were examined by immunohistochemical staining to explore the expressions of collagen I, matrix metalloproteinase-3 (MMP-3), and transforming growth factor-β (TGF-β) after treatments. The chief complaint symptoms of all patients were significantly relieved after our treatments. None of them showed BNC recurrence during the follow-up. Complications were rare and mild. Postoperative assessments including maximal urinary flow rate (P < 0.01), International Prostate Symptom Score (P < 0.01), quality of life index (P < 0.01), and post-void residual volume (P < 0.001) were significantly better than baseline values, respectively. Immunohistochemical staining showed significantly lower expressions of collagen I (P < 0.001), MMP-3 (P < 0.001), and TGF-β (P < 0.001) after treatments. In conclusion, 180-W GreenLight laser with repeated TA injections demonstrated the safety and long-term efficacy in treating BNC, by inhibiting the expressions of fibrotic factors. Our procedure was a promising treatment for BNC after PVP and TURP.
... Kant et al studied this innovative treatment on 58 patients with either keloid or hypertrophic scars. 10 The etiology of the included scars had a different distribution than what was seen in our meta-analysis. The most common etiology in their study was surgery followed by trauma. ...
... They found a statistically significant decrease from the keloid Patient and Observer Scar Assessment Scale baseline scores at follow-up from 3 to 6 months. 10 This included decreases in every component of the score with significant decreases in pain, pruritus, scar relief, pliability, and surface area. They report that all patients who underwent the full treatment regimen had fast improvement of their scars. ...
... Furthermore, those patients who followed up for more than 12 months still retained a decrease in baseline Patient and Observer Scar Assessment Scale score showing the ability of combination triamcinolone and verapamil to be effective in the long term. 10 With the combination treatment of triamcinolone and verapamil injections, very few side effects were noted. Only one patient had hardening of the scar, one had indentation, and there were some reports of pruritis for a short duration. ...
Keloids are skin lesions of abnormal and excessive scar proliferation that have no agreed upon gold standard of therapy. Extensive research in this area has shown that both intralesional triamcinolone and verapamil are effective in their treatment.
Methods:
A review of these two treatment modalities was conducted via an extensive search of existing literature published in PubMed, Scopus Libraries, and Science Direct databases using keywords "keloid," "verapamil," "triamcinolone," "intralesional," "treatment," and "corticosteroid" published between 1996 and 2021. From these included studies, clinical trials that directly compared the effects of intralesional triamcinolone and verapamil from 2008 to 2021 were included in a meta-analysis. Lastly, the minimal current research pertaining to a potential future direction of their combination was described.
Results:
Over 30 publications were included in this literature review to describe the current state of keloid treatment and outline the advantages and disadvantages of intralesional triamcinolone and verapamil. Eight of these studies were included in the meta-analysis which had varying results. In all studies, greater improvement was seen in the triamcinolone acetonide group compared with the verapamil group. However, these improved results were associated with a higher rate of adverse effects.
Conclusions:
When comparing the modalities of triamcinolone acetonide and verapamil for keloid treatment, triamcinolone acetonide shows more significant and rapid improvement compared with verapamil; however, there are also increased adverse effects. Minimal combination studies of these treatments have shown that perhaps using them together can augment their mechanisms without the unwanted side effects.
... Kant et al revealed a fast and abiding improvement of both keloid and hypertrophic scars after treatment with the combination therapy in their study conducted at the department of plastic surgery at the Maastricht University hospital among 58 patients. 16 In another study, Saki et al conducted a randomized, singleblind, single-group comparison with 15 patients (30 scars) to compare the effects of intralesional triamcinolone with verapamil injections. 17 In both study groups there was a reduction in height and pliability at the end of the study. ...
Background: Keloids and hypertrophic scars are still a therapeutic problem. Despite numerous proposed therapies reported in the literature, the management of keloid and hypertrophic scars is still challenging as there is no universally accepted treatment regimen. Compare the efficacy intralesional verapamil hydrochloride and triamcinolone acetonide separately as well as combination of both drug in treatment of hypertrophic scars and keloids.Methods: A retrospective study was carried out at the general surgery department (plastic surgery unit) at the JNUIMSRC Jaipur, Rajasthan. Total of 150 patients (60 males and 90 females) between 18 to 60 years of age were enrolled fulfilling the inclusion criteria. They were randomly categorized in to three groups (group A, B and C), based on treatment they received viz. verapamil alone, triamcinolone alone and combination of both drugs respectively. Assessment of the scars were done prior to or on the day of the first injection and at 24 weeks after the end of injection scheme by Vancouver scar scale (VSS). The decreasing values reflected clinical improvement of the scar.Results: Better improvement observed in all four parameters: height, vascularity, pliability and pigmentation among patients receiving combination of both triamcinolone-verapamil drugs as compare to those patients receiving drugs separately either verapamil or triamcinolone alone. For parameters height, pliability and pigmentation, the improvement was found to be statistically significant (p<0.05)Conclusions: Study highlights that the combined verapamil and triamcinolone therapy scheme causes remarkable scar improvement in keloid and hypertrophic scars in comparison to single drug scheme.
... Calcium channel blockers, especially intralesional verapamil (phenylalkylamine), inhibits the production of interleukin-6 and vascular endothelial growth factor (VEGF) by fibroblasts. [65][66][67] It leads to changes on calcium metabolism, alters extracellular matrix contraction (ECM) and protease production, and delays the production of connective tissue. [68][69][70] It has been used to treat keloids as monotherapy or in combination therapy. ...
... 75 Its combination with intralesional triamcinolone (triamcinolone 40 mg/ mL and verapamil 2.5 mg/mL), resulted on fewer side effects compared with triamcinolone alone. 66,[76][77][78] Corticosteroid drugs ...
Keloids (K) and hypertrophic scars (HS) are abnormal responses to wound healing that occur as the result of dermal inflammation. Despite the advances on their treatment, many patients still suffer from the negative effects of excessive scarring; its approach is impaired by the lack of objective data on different treatments and the large genetic variability among patients and the difficulties in producing multicentre studies. Their incidence among the Brazilian population is high, as the result of an admixture of Amerindians, Europeans and Africans ancestral roots. With the aim of producing multicentre studies on K and HS, a panel of senior Brazilian dermatologists focused on their treatment was invited to contribute with the K and HS Treatment Brazilian Guidelines. In the first part of this study, different treatment modalities for keloids and HS are fully reviewed by the panel. The second part of the study presents a consensus recommendation of treatment for different types of lesions. More than a literature review, this article aims to show the pitfalls and pearls of each therapeutic option, as well as a therapeutic approach by the Panel of Experts on keloids and Scars on a highly mixed population, providing simple guidelines.
