No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Percutaneous collagen induction as an additive treatment for scar formation following thermal injuries: Preliminary experience in 47 children
Abstract
Background:
Thermal injuries are one of the most physically and psychologically devastating causes of pediatric trauma. Post-traumatic sequelae such as hypertrophic scars and contractures often result in long lasting morbidity and disfigurement. Conservative therapy, including pressure garments and silicone, is the gold standard for scar management in the pediatric population. Most recently percutaneous collagen induction (PCI) was introduced as an alternative treatment in adults. The aim of this report was to share our experience with PCI in children and adolescents in scar management following thermal injuries.
Patients and methods:
Between July 2013 and February 2016, a total of 99 PCI treatments were performed on forty-seven children and adolescents for scar formation following thermal injuries in this retrospective study. A medical roller device (Dermaroller(®), Dermaroller GmbH, Wolfenbüttel, Germany) with 2.5mm long needles was used. All procedures were carried out under general anesthesia. At the end of the operation vitamin A and vitamin C oil (ENVIRON(®) AVST Body Oil; Environ Skin Care, Pty. Ltd., Cape Town, South Africa) was applied topically. Photographs were taken before and a minimum of 4 weeks after the first PCI in order to document the effect on scar tissue. These images were graded according to the Vancouver Scar Scale (VSS).
Results:
The median age at the time of the first PCI was 8.3 years (range, 0.8-21.2 years). The median time interval between the injury and PCI was 18 months (range, 4-170 months). There were no intraoperative problems noted. Minor postoperative complications occurred in 2 patients (4.3%). All patients reported subjective improvement and were satisfied with the procedure and the results. Pre- and post-treatment photographs were available in 40 patients, and overall VSS scores improved post-treatment in all patients. Following a single PCI treatment, scar vascularity, pliability and height all improved, however there was no statistically significant effect on pigmentation.
Conclusions:
PCI is an enrichment of the armamentarium for scar treatment following thermal injuries in children and adolescents. Further prospective studies are recommended regarding the optimal timing for this treatment and long term outcome in the pediatric population.
... While mortality rates among burn patients have decreased over recent decades due to advancements in treatment and knowledge, post-traumatic complications such as hypertrophic scars (HTSs), keloid formation and contractures often result in long-term discomfort and functional deficits. 1 Scars and burn injuries have significant impacts on patients' lives and the healthcare system. 2 HTSs develop when the natural healing process is disrupted, characterized by increased inflammation and excessive collagen accumulation, leading to prominent, hard, itchy, painful and erythematous lesions. 3 Various treatment methods are employed to manage HTSs, including silicone or hydrogel sheets, compression therapy, ultrasound, surgical incision, tissue expansion, intralesional steroids, chemotherapy with interferon injections, cryotherapy, radiation therapy and photothermolysis. ...
... 16 Managing scars resulting from burn injuries poses significant challenges for patients, caregivers and healthcare professionals. 1,12 Scarring is the body's natural response to damage to the epidermis and dermis, with the scar's final appearance influenced by both the wound bed and the surrounding environment. For example, scars that experience infection may lead to poor healing outcomes, chronic inflammation, and hypertrophic scarring. ...
... 14 Treatment options aimed at improving the appearance and function of HTSs in children include a wide range of conservative methods such as massage, physiotherapy, intralesional corticosteroid injections, silicone application and radiotherapy. 1,8 However, certain treatments may be impractical or unsafe. For instance, corticosteroid injections carry the risk of long-term side effects and are often associated with significant pain and anxiety in children. ...
Managing burn scars in children presents significant challenges. This study investigates effective treatment methods for burn scars, focusing on efficacy, safety, standard protocols and tolerability. Major databases such as PubMed, Scopus and Web of Science were thoroughly searched up to August 2024, emphasizing procedural treatments for burn scars in children. Key data collected included participant demographics, sample sizes, intervention methods, follow‐up protocols, treatment effectiveness and reported adverse events. A total of 256 children were assessed, with all procedural treatments yielding satisfactory outcomes. Among the various methods, trapeze‐flap plasty and percutaneous collagen induction showed improvements in all patients. In the laser treatment group, which included 161 children, the Vancouver Scar Scale (VSS) score reduction ranged from 55.55% to 76.31%, with outcomes rated as good (24.61%) to excellent (60%). Laser treatment using local anaesthesia proved to be well tolerated by children. Our findings indicate that various methods—including trapeze‐flap plasty, percutaneous collagen induction, phototherapy and fractional CO2 laser—demonstrate a relatively good response and an acceptable safety profile. Notably, light‐based therapies/lasers may serve as safe, effective and tolerable options for scar treatment in this age group, often eliminating the need for general anaesthesia.
... The mortality rate in burn victims has decreased in the last decades as a consequence of the advance in knowledge and more effective treatment in the acute phase [1]. However, post-burn sequelae, such as hypertrophic scars, keloids, and contractures, are still highly frequent and cause important aesthetic and functional sequelae [2]. The treatment of these sequelae can promote improved quality of life and increased self-esteem [3,4]. ...
... Conservative nonsurgical measures such as the use of local compression, massage, laser, low-dose radiation therapy, use of silicone plates, microneedling, and corticoid infiltration are recommended therapies especially in the first 2 years after the [5,6]. However, due to the complex nature of the healing process, no treatment is completely effective [2,7]. The microneedling technique, also known as minimally invasive percutaneous collagen induction, was first described in 2002 by Fernandes [8] for the treatment of rhytids and scars. ...
... Optimal clinical outcomes are achieved when needle depths are adjusted to skin location and thickness. The decision for using 2.5 mm microneedles was based on the efficiency to pass through the burn scars and achieve the reticular dermis, based on previous literature reports and personal experience of the senior author (A.G.S.) [2,15]. Lima et al. [16] showed on a porcine model experiment that 3-mm-length needles on a roller device penetrate only 1.5 to 2.0 mm (50-75% of its actual length); Table 2 Burn Scar Assessment Scale (BSAS)-It consists of five criteria with scores from 0 to 2 for each one and the sum will vary from 0 to 10 12 Criteria Score 1 a and b: 8-year-old male patient with 7-month burn scar on the right wrist, dorsal forearm, and hand before microneedling, with limitation of maximum wrist flexion; c and d: Improved texture, hydration, and suppleness 30 days after first microneedling, with significant improvement in movement range Fig. 2 Patients with improvement of mouth opening after microneedling. ...
Post-burn hypertrophic scars are an important cause of physical discomfort, limitation of movements, psychological disorders, low self-esteem and reduced quality of life. Treatment for this condition is complex and involves several options. Microneedling, also known as minimally invasive percutaneous collagen induction, is an affordable minimally invasive option that can be combined with other treatments, including ablative ones.
The goal of this study was to present our microneedling approach for the treatment of hypertrophic scars after burns.
A prospective study of 15 patients with post-burn hypertrophic scars was conducted between October 2016 and June 2022. All patients were treated with microneedling and drug delivery of triamcinolone. Scars were evaluated using Vancouver Scar Scale (VSS), Burn Scar Assessment Scale (BSAS) and angle measurement for amplitude of movement evaluation of joints.
A significant improvement in the VSS score was obtained after microneedling (8.8 ± 0.44 to 4.1 ± 0.98; p = 0.012), especially in the acute group (less than 1 year after burns): 9.3 ± 0.49 to 3.5 ± 1.36; p = 0.041. There was a significant and progressive improvement of the scars throughout the treatment sessions in all criteria evaluated and in the ranges of joint movement (p = 0.012).
Our microneedling protocol promoted a significant improvement of post-burn scars, especially in acute hypertrophic scars, and in the amplitude of joint motion. Sequential treatments provided progressive improvement.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
... Both percutaneous collagen induction (PCI) and ablative fractional carbon dioxide (CO 2 ) laser therapy (AFL) have emerged as treatment options in the adult burn population. However, neither has been used widely in the pediatric burn population due to a lack of established guidelines and protocols and limited data regarding outcomes [64,65]. They cause collagen remodeling, with a significant decrease in type I collagen and an increase in type III collagen, leading to increased scar pliability [65]. ...
... However, neither has been used widely in the pediatric burn population due to a lack of established guidelines and protocols and limited data regarding outcomes [64,65]. They cause collagen remodeling, with a significant decrease in type I collagen and an increase in type III collagen, leading to increased scar pliability [65]. PCI involves creating numerous perforations in the scar to activate the wound healing cascade and stimulate collagen production [65]. ...
... They cause collagen remodeling, with a significant decrease in type I collagen and an increase in type III collagen, leading to increased scar pliability [65]. PCI involves creating numerous perforations in the scar to activate the wound healing cascade and stimulate collagen production [65]. A retrospective study of 47 children and adolescents who underwent PCI showed that scar vascularity, pliability, and height all improved significantly following a single treatment [65]. ...
Purpose of the Review
Burn injury is a leading cause of morbidity and mortality in children. This review article will attempt to provide the most up-to-date information on pediatric burn care.
Recent Findings
Scald burns are the most common cause of thermal injury in pediatric patients. Resuscitation and wound care are essential in the initial management. However, there is tremendous variability in practice among burn centers. There is a general decrease in hospitalization for children with burn injuries, but morbidity remains high, such as infections, hypertrophic scarring, and insufficient donor tissue. In addition to wound complications, a hypermetabolic state is also observed in pediatric patients and has been shown to have long-lasting effects. The use of dermal substrates and laser therapy are promising areas of research to improve outcomes.
Summary
Most literature on burn care is within the adult population. Future research with prospective studies will allow for advances in pediatric burn care.
... Microneedling is a technique consisting of cutaneous micro perforations to allow nutrients and drugs absorption into the deep skin layers. 22 The micro injuries from the needles might help in improving facial pores. The percutaneous needle pricks create multiple dermal microbruises and commence a cascade of growth factors that ultimately result in multiplication of fibroblasts and increase in collagen and elastin production. ...
Background:
Enlarged facial pores and seborrhea are common cosmetic problems. Mesobotox has been proved to be effective safe therapeutic option.
Objective:
To compare the efficacy and longevity of intradermal mesobotox injection versus its topical application with microneedling for treatment of wide facial pores and seborrhea.
Materials and methods:
This split face study was conducted on 20 patients with enlarged facial pores and seborrhea. One side of the face was treated with intradermal injection of botulinum toxin, the other was treated with its topical application following microneedling. Patient evaluation was performed after 1 month then after 4 months.
Conclusion:
Microbotox can effectively and safely minimize enlarged facial pores with no downtime. Intradermal injection showed more patient satisfaction on the basis of greater efficacy, longevity of treatment than its topical application following microneedling.
... Como não há lesão epidérmica, com a aplicação correta do equipamento, os riscos de manchas ou lesões maiores são quase inexistentes. Sua ação se dá a partir de uma lesão proposital, causada pelas agulhas, que geram uma inflamação controlada e consequentemente leva o organismo a promover a neocolagênese na região (Alster & Li, 2020;Kubiak & Lange, 2017). ...
As estrias são lesões da camada dérmica da pele, comumente ocasionada por um estiramento repentino da pele, sendo agravada por fatores hormonais, extrínsecos e intrínsecos. Classificam-se em rubras e albas, sendo causada por uma lesão aguda e crônica, respectivamente. O presente estudo buscou verificar os efeitos da associação da radiofrequência bipolar não-ablativa com o microagulhamento no tratamento de estrias albas. Trata-se de um ensaio clínico cego randomizado, realizado no laboratório de eletrotermofototerapia da Universidade Federal de Pernambuco. A amostra foi dividida em dois grupos, denominados de grupo MICRO e RF+MICRO, que realizou a terapia de microagulhamento, e radiofrequência associado ao microagulhamento, respectivamente. Ambos os grupos tiveram um total de 3 sessões. As avaliações foram feitas com fotografias convencionais e termográficas, a partir da aplicação de questionário de qualidade de vida, anamnese, avaliação física e questionário final sobre a visão da participante após o término da pesquisa. Não houve diferença significativa entre os grupos quanto ao aumento da temperatura local. A dor e o score final do questionário de qualidade de vida em dermatologia também não apresentou distinção. Os resultados analisados a partir de fotografias convencionais também não foram significativos. Portanto, não houve diferença entre o microagulhamento comparado à associação da radiofrequência e o microagulhamento no tratamento de estrias albas.
... O microagulhamento é capaz de melhorar a flexibilidade e a elasticidade, como já demonstrado por outros estudos. [30][31][32] Em 2018, um estudo utilizou a POSAS para avaliação da melhora de cicatrizes após microagulhamento, e os resultados apontam uma melhora na qualidade da cicatriz com uma tendência significativa à pele normal. A opinião geral apresentou uma melhora de 51% tanto do paciente quanto do observador, correspondendo aos valores encontrados neste estudo. ...
Introdução: As cicatrizes inestéticas podem desencadear repercussões sintomáticas, funcionais,
estéticas e emocionais. Entre os principais tratamentos atualmente encontrados
está o microagulhamento.
Objetivo: Estudo prospectivo, quantitativo, avaliando os benefícios do tratamento de cicatrizes
com uma única sessão de microagulhamento.
Métodos: Foi realizado uma única sessão de microagulhamento em cicatrizes de 28 pacientes.
Antes da realização do procedimento com cilindros contendo 192 agulhas de
2,5mm e 90 dias após, as cicatrizes foram fotografadas de modo padronizado, tendo sido
aplicada a Escala de Avaliação Cicatricial do Paciente e Observador. Por meio da pontuação
fornecida realizou-se uma avaliação quantitativa através da análise dos parâmetros
-sendo eles vascularização, pigmentação, espessura, relêvo, maleabilidade, área de superfície,
dor, prurido, cor, rigidez, altura e irregularidade-, além do escore total e opinião geral do
paciente e do observador.
Resultados: Todas as variáveis obtiveram melhora, exceto a dor, dando destaque à maleabilidade
e à altura. Além disso, a opinião geral do paciente e do observador apresentou
melhoria de 51%.
Conclusões: O microagulhamento é um tratamento seguro, de baixo custo, minimamente
invasivo, apresentando resultados eficazes em uma única sessão.
... Such increase might also further improve the facial pore sizes Finally, the microinjury from the needle might have shared in such improvement. What makes this debate even more interesting is that percutaneous needle pricks themselves have been reported to create multiple microbruises in the dermis, and these actually initiate a complex cascade of growth factors that eventually result in collagen production (17)(18)(19), again proven by the OCT measurements on both sides (with and without the BoNT-A). ...
Background: Enlarged facial pores are becoming a matter of cosmetic concern. Injections of (botulinum toxin type A) have an increasing popularity among cosmetic procedures.
Objective: To determine the efficacy and safety of intradermal injection of botulinum toxin in treatment of excess sebum secretion and enlarged facial pores .
Materials and methods: This split face controlled pilot study was conducted on 20 patients with enlarged facial pores and seborrhea. One cheek was treated by intradermal injection of botulinum toxin, the other was injected by saline. Patient assessment was performed after 1 then after 4 months.
Results: At 1 month assessment, both sides showed significant reduction in their sebum and pore scores (P =0.001), with significantly more improvement on the botulinum toxin treated side. Dermoscopy documented significant decrease in the average size of facial pores (P < 0.001) and the OCT demonstrated a significant increase in the dermal thickness (P< 0.001) with non-significant deference between both sides. Four months after treatment, the botulinum toxin treated side maintained its improvement in both scores.
Conclusion: Intradermal injection of botulinum toxin is an effective and safe procedure for management of excess sebum and facial pores with acceptable results lasting for an average of 4 months.
... 12 A number of animal and human studies have stressed the importance of skin preparation in order to maximise the results of needling treatments using daily topical vitamin A and C for a period between 3 weeks and 3 months. 5,13,14 Vitamin A controls 350-1000 genes responsible for cell proliferation/differentiation, angiogenesis as well as neocollagenesis; vitamin C is similarly important in collagen synthesis and both vitamins act in concordance with a number of growth factors involved in the healing processes inherent to needling action including fibroblast growth factor, platelet-derived growth factor and transforming growth factor (TGF) β. 15 The effectiveness of PCI is based on the stimulation of a controlled inflammatory/healing reaction and the remodelling of collagen by virtue of growth factor release (such as vascular endothelial [VEGF]/epidermal/ fibroblast and platelet-derived growth factor, as well as TGF). The latter family of factors has been implicated intensely in the regenerative mechanisms of needling. ...
Introduction
Percutaneous collagen induction (PCI) or needling techniques are increasingly popular in the reconstructive and aesthetic arena. The underlying mechanisms of action rest on producing a pattern of non-ablative and non-confluent puncture wound pattern to the dermis with a resulting regenerative effect to the skin.
Methods
A detailed English literature review was conducted using PubMed Medline, Embase and Web of Science; the manuscripts were appraised and classified according to level of evidence as well risk of bias. Results are presented in descending order of evidence for non-atrophic scars.
Discussion
On the basis of level 1 evidence currently available, the combination of needling and silicone gel can improve the short-term pliability, height and vascularity of hypertrophic and keloid scars. According to level 2 evidence, needling alongside spray keratinocytes can produce a statistically significant improvement to patient/observer scar ratings and improve pigmentation in hypopigmented burn scars at 12-month follow-up. Results from mixed cohort studies also point towards needling having a beneficial effect on fat graft retention. Level 3 data suggest that needling can render significant resurfacing effects to both mature and actively hypertrophic burn scars at 12-month follow-up based on objective scar scales; furthermore, favourable histological changes are seen, including better collagen alignment in the dermis and increased epidermal thickness.
Conclusion
Needling techniques are promising adjuncts to non-atrophic scar management. Further research with long-term follow-up and comparative design protocols incorporating other resurfacing modalities is warranted before the exact value of needling is delineated in scar management protocols.
The microneedling technique was initially introduced for skin rejuvenation in cosmetology. The technique is minimally invasive and therefore explored for the treatment of multiple dermatological conditions. High effectiveness, very less side effects and quick recovery time are the benefits of skin microneedling as a cosmetic, and medical treatment. Over the last two decades, the applications of microneedling in skin science have grown drastically. The technique is effective in the treatment of acne scar, vitiligo, alopecia, melasma, and skin cancer. The current review focuses on the cosmetic as well as therapeutic applications of microneedling for the treatment of various skin problems.
Thermische Verletzungen im Kindesalter sind häufig und insbesondere Kleinkinder sind gefährdet. Behandelnde Ärzte stehen oft vor Fragen und Herausforderungen. Was kann am- bulant, was muss stationär therapiert werden? Welche Wundauflage ist geeignet, welcher Verlauf normal? Wann sollte die Zuweisung in ein Schwerbrandverletztenzentrum erfolgen? Auffällige Verletzungsmuster müssen erkannt und dokumentiert werden, die Dunkelziffer nichtakzidenteller Verletzungen ist hoch.
Background:
This study introduced a novel method to reconstruct large areas of scarring caused by burns via combining autologous scar-related tissue with spit-thickness skin grafting (ASTCS).
Methods:
25 patients underwent reconstruction after scar resection surgeries around the joints were analyzed between Jan 2012 and Jan 2018. Patient demographics and clinical parameters were collected, autologous scar-related tissue was modified to meshed structure, and the split-thickness skin was acquired from the scalp. The scar was resected and punched by a meshing machine with a thickness of 0.3-0.5 mm at a ratio of 1:1. The secondary wounds were covered by the epidermis from a donor site. The surgical areas were bandaged for 7-10 days before the first dressing change.
Results:
25 patients (mean [SD] age, 26.4 [18.8] years; 16 [64%] men) underwent wounds reconstructive operations due to scar resection were reviewed. Wound location of 9 (22%), 8 (19.5%), 9 (22%), 7 (17.1%) and 8 (19.5%) cases were reconstructed in axillary, hand and wrist, popliteal fossa, elbow and neck, respectively. 39 sites of transplanted tissues survived well, and 2 sites were cured after two weeks of dressing changes. Except the analysis of injury causes, nutritional status, wound area and hospital days, patients with scar deformities in joint areas achieved satisfactory function by assessing the Vancouver Burn Skin Score and the Barthel Index Scale Scores after 12-month follow-up.
Conclusions:
Combining autologous scar-related tissue with skin grafting provided a novel method for treating large areas of burn scars with better functional outcomes.
Introduction, Objectives, Purpose of the Study:
Scars may have a functional problem but, much more often, patients’ requests are aesthetic. Development of high number of scar improvement procedures have opened the door to regenerative medicine and combination with the synergic techniques. Combination of PRP and microneedling, vampire scar technique, was choosen for scars treatment.
Materials and Methods:
PRP and microneedling combination protocol in different scars treatment has been developed.
Conclusions:
There are three key points to obtain the best results in scar treatment synergic role of combined noninvasive, regenerative medicine treatments is the first key. An adequate patient selection of should have proper expectations. Communication is important to prepare correctly the patient on results and timing. Finally, this treatment can be done in a medical office with no relevant expenses. That is why Vampire scars technique, outpatient method, based on combination of PRP and needling, can be widely used in a practice of aesthetic doctors.KeywordsRegenerative medicinePRPNeedlingScarVampireAcneBurn
Background:
Microneedling is a minimally invasive procedure that stimulates collagen and elastin proliferation. It is used in the treatment of various skin pathologies, that is, scarring, photodamage, and hair loss; however, its safety profile has yet to be comprehensively reviewed.
Objective:
This review will discuss the reported side effects of microneedling in the current literature and delineate factors that increase the risk of complications.
Materials and methods:
A literature search in August 2019 was conducted using the PubMed database to identify studies reporting adverse events (AEs) after microneedling therapy.
Results:
Eighty-five articles were included in this systematic review. The most common reported AEs are transient procedural events that are expected postprocedure lasting up to 7 days, such as transient erythema/edema and pain, postinflammatory hyperpigmentation (PIH), dry skin/exfoliation, lymphadenopathy, and irritant contact dermatitis. Persistent serious adverse effects included PIH, tram-track scarring, and granulomatous reactions. Factors that increase the risk of events are active infections, darker skin, and metal allergies.
Conclusion:
Microneedling is a relatively safe therapy. Most reported AEs are minimal, resolving quickly and spontaneously. Caution should be taken in patients with active infection, darker skin types, metal allergies, and when used in conjunction with products not approved for intradermal use.
Zu klassischen Notfällen der Kindertraumatologie gehören das Schädel-Hirn-Trauma, das stumpfe Bauchtrauma sowie die Frakturen der oberen und unteren Extremität, die Fremdkörperingestion und -aspiration. Auch Bissverletzungen und Pfählungsverletzungen sowie thermische Verletzungen sind häufig. Viele der Kinder werden initial beim Kinder- und Jugendarzt vorgestellt. Dieses Kapitel ermöglicht einen prägnanten Überblick der Blickdiagnosen, stellt die wichtigsten diagnostischen Schritte sowie chirurgischen Behandlungen vor und bietet so eine fundierte Grundlage für die Anschlussbetreuung der Patienten.
Demand for safe, less aggressive and cost-efficient treatment modality to improve skin quality and appearance following scarring or photoaging is increasing steadily. A treatment modality that preserves the epidermis while promoting regeneration rather than cicatrization would be ideal. Percutaneous collagen induction (PCI) therapy or microneedling is claimed to approach this ideal objective. The current comprehensive literature review is intended to analyze the scientific basis supporting this therapeutic modality and to evaluate the efficacy of PCI microneedling therapy versus no treatment of patients with photoaged skin and scars of various etiologies on aesthetic skin rejuvenation, skin tightening and scar quality in prospective, retrospective and experimental studies. Twenty-five published studies were identified and included in this review. Four publications are experimental animal studies; most clinical reports are case series or small cohort non-randomized studies or trials lacking methodological unity with a heterogenous mix of scars, wrinkles and skin laxity being treated. The majority are studies about management of scars of various etiologies while only 4 specifically investigated the effect of PCI on wrinkles and aging skin. One study compared burn scar erythema in the treated area to the untreated area, and 5 studies included histologic evaluation of biopsies. Despite PCI promising therapeutic benefits and its increasing cosmetic applications, the current literature review unfortunately revealed a limited number of high-quality studies mostly experimental. Data and conclusions of clinical studies must be carefully interpreted before translating the evidence presented into clinical recommendations. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Background
In recent years, microneedling has been increasingly used to treat a number of dermatologic conditions, including scars. Although initial studies demonstrated improvement of (mostly) atrophic scars with microneedling, the number of patients evaluated was relatively small, and the devices and treatment protocols used and posttreatment follow-up varied widely. Through this prospective observational study, the results of microneedling on 20 patients with a variety of scars are described.
Methods
One hundred twenty consecutive patients (skin phototypes I through VI) with facial and nonfacial scars from a variety of etiologic sources (acne, trauma, surgery) were treated using a mechanical microneedling device. No additional treatments (topical or intralesional) were applied. Two assessors blinded to treatment protocol rated clinical improvement of scars 1, 3, 6, and 12 months after treatment on a five-point scale. Side effects were monitored and tabulated.
Results
Patients received one to six consecutive monthly microneedling treatments. All scars improved at least 50 percent after an average of 2.5 treatments. Over 80 percent of patients had 50 to 75 percent improvement, and 65 percent of patients demonstrated over 75 percent improvement. No significant clinical differences were observed in treatment responses of facial scars versus nonfacial scars nor between responses of atrophic acne scars and traumatic or surgical scars.
Conclusions
This study supports the use of microneedling for various facial and nonfacial scars across a broad range of skin phototypes with minimal risk of adverse effects. Further studies will help to establish standardized protocols to optimize treatment outcomes for different scar types.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, IV.
Verbrennungen im Kindesalter gehören zu den psychisch und physisch am stärksten traumatisierenden Verletzungen. Sie können eine lebenslange Stigmatisierung durch Narbenbildung hinterlassen. Die konservative Narbentherapie schließt direkt an die Akutbehandlung an, kann jedoch die Ausbildung von hypertrophen oder kontrakten und damit bewegungseinschränkenden Narben nicht immer verhindern. Besonders am kindlichen wachsenden Organismus müssen die Narben jahrelang behandelt und beobachtet werden, um die Entwicklung des Kindes nicht zu beeinträchtigen.
The superficial injection needling botulinum (SINB) technique is the dermal injection of microdoses of botulin toxin, not by traditional syringe but with needling technique that consists in multiple microdroplets by electrical device. The intention is to decrease sweat and sebaceous gland activity to improve skin texture and sheen and to target the superficial layer of muscles that find attachment to the undersurface of the dermis causing visible rhytides. The technique is for treatment of face and neck by the injection of the botulin toxin into the dermis or in subdermal plane to improve skin texture, smoothen horizontal creases, and decrease vertical banding of the neck as well as to achieve better apposition of the platysma to the jawline and neck, improving contouring of the cervicomental angle. The botox solution is hyperconcentrated when compared to traditional dilution or compared to microbotox or mesobotox. Furthermore, the injection technique is different because spreading superficial microdroplets are not performed, but small, homogeneous, and controlled amounts of solution are injected. Each 0.8-mL syringe contains 50 units of onabotulinumtoxinA. The solution is delivered intradermally, using an electrical needling pen and setting the depth penetration of the needles at 3 to 3.5 mm. The 2 conjugated techniques play a 2-fold action on the skin. The technique was applied to a group of 63 patients dealing with face, forehead, cheekbones, and neck.
Background
Pediatric burn injuries are one of the most psychologically and physically traumatizing injuries. They can cause lifelong stigma due to scarring. Conservative therapy for scar management follows on directly from acute burn treatment. However, it is not always possible to prevent the development of hypertrophic scars and scar contractures.
Methods
This article describes the principles of percutaneous collagen induction (PCI) and its successful use as a minimally invasive method in scars following thermal injuries in children and adolescents.
Results
Between November 2013 and March 2018, a total of 122 PCI treatments were performed on 43 children and adolescents. A medical roller device (Dermaroller®, Dermaroller GmbH, Wolfenbüttel, Germany) with 2.5 mm long needles was used and the procedures were carried out under general anesthesia. All patients applied a 0.5% vitamin-A ointment on the treated scars every evening over a period of 4 weeks. Post-treatment scar assessments in 20 patients performed with an integrated skin testing device (DermaLab® Combo, Cortex Technology, Hadsund, Denmark) with high frequency ultrasound showed improved collagen synthesis after only one PCI.
Conclusions
PCI with medical needling is an effective method for scar treatment following thermal injuries, having a maximum effect on scar elasticity and patient satisfaction. It provides an ideal treatment option for pediatric and adolescent burn survivors whishing to avoid surgery due to their history of suffering, but still desire a functional or aesthetic improvement of their scars.
Treatment of hypertrophic scars arising as a result of thermal burns in children is still a big problem. The results of the treatment are not satisfactory for patients and parents, and new methods of treatment are still investigated.
We present the use of one of the most modern carbon dioxide (CO2) lasers (Lumenis Encore laser equipped with a Synergistic Coagulation and Ablation for Advanced Resurfacing module) in the treatment of hypertrophic scars in children after burns.
From March to April of 2013, a group of 47 patients aged 6 to 16 years underwent 57 laser surgery treatments. The average time from accident was 7.5 years. The results of treatment were investigated in 114 areas. The assessed areas were divided into 2 groups: 9-cm² area 1, where the thickness of the scar measured by physician was the lowest and 9-cm² area 2, where the thickness of the scar was the biggest. The results were considered on the Vancouver Scar Scale (VSS) independently by the surgeon and by parents 1, 4, and 8 months after the procedure. In addition, ultrasound evaluation of the scar thickness before and after laser procedure was made.
VSS total score improved in all areas assessed by both the physician and parents. The biggest change in total VSS score in area 1 in the evaluation of the investigator was obtained at follow-up after the 1st month of treatment (average 7.23 points before and 5.18 points after the 1st month after surgery—a difference of 2.05 points). Scar ratings by parents and the physician did not differ statistically (P < 0.05). In the ultrasound assessment, the improvement was statistically significant, more frequently for both minimum and maximum thickness of the scars (B-mode measures) (P < 0.05).
The use of a CO2 laser in the treatment of hypertrophic scars in children is an effective and safe method. The use of a CO2 laser improves the appearance and morphology of scarring assessed using the VSS by both the parents and the physician. The treatment also reduced the thickness of scars evaluated by ultrasound.
Background:
Problematic scarring remains a challenging aspect to address in the treatment of burns and can significantly affect the quality of life of the burn survivor. At present, there are few treatments available in the clinic to control adverse scarring, but experimental pharmacological anti-scarring strategies are now beginning to emerge. Their comparative success must be based on objective measurements of scarring, yet currently the clinical assessment of scars is not carried out systematically and is mostly based on subjective review of patients. However, several techniques and devices are being introduced that allow objective analysis of the burn scar. The aim of this article is to evaluate various objective measurement tools currently available and recommend a useful panel that is suitable for use in clinical trials of anti-scarring therapies.
Methods:
A systematic literature search was done using the Web of Science, PubMed and Cochrane databases. The identified devices were then classified and grouped according to the parameters they measured. The tools were then compared and assessed in terms of inter- and intra-rater reproducibility, ease of use and cost.
Results:
After duplicates were removed, 5062 articles were obtained in the search. After further screening, 157 articles which utilised objective burn scar measurement systems or tools were obtained. The scar measurement devices can be broadly classified into those measuring colour, metric variables, texture, biomechanical properties and pathophysiological disturbances.
Conclusions:
Objective scar measurement tools allow the accurate and reproducible evaluation of scars, which is important for both clinical and scientific use. However, studies to evaluate their relative performance and merits of these tools are scarce, and there remain factors, such as itch and pain, which cannot be measured objectively. On reviewing the available evidence, a panel of devices for objective scar measurement is recommended consisting of the 3D cameras (Eykona/Lifeviz/Vectra H1) for surface area and volume, DSM II colorimeter for colour, Dermascan high-frequency ultrasound for scar thickness and Cutometer for skin elasticity and pliability.
Purpose:
To automatically identify which spectral-domain optical coherence tomography (SD-OCT) scans will provide reliable automated layer segmentations for more accurate layer thickness analyses in population studies.
Methods:
Six hundred ninety macular SD-OCT image volumes (6.0 × 6.0 × 2.3 mm(3)) were obtained from one eyes of 690 subjects (74.6 ± 9.7 [mean ± SD] years, 37.8% of males) randomly selected from the population-based Rotterdam Study. The dataset consisted of 420 OCT volumes with successful automated retinal nerve fiber layer (RNFL) segmentations obtained from our previously reported graph-based segmentation method and 270 volumes with failed segmentations. To evaluate the reliability of the layer segmentations, we have developed a new metric, segmentability index SI, which is obtained from a random forest regressor based on 12 features using OCT voxel intensities, edge-based costs, and on-surface costs. The SI was compared with well-known quality indices, quality index (QI), and maximum tissue contrast index (mTCI), using receiver operating characteristic (ROC) analysis.
Results:
The 95% confidence interval (CI) and the area under the curve (AUC) for the QI are 0.621 to 0.805 with AUC 0.713, for the mTCI 0.673 to 0.838 with AUC 0.756, and for the SI 0.784 to 0.920 with AUC 0.852. The SI AUC is significantly larger than either the QI or mTCI AUC (P < 0.01).
Conclusions:
The segmentability index SI is well suited to identify SD-OCT scans for which successful automated intraretinal layer segmentations can be expected.
Translational relevance:
Interpreting the quantification of SD-OCT images requires the underlying segmentation to be reliable, but standard SD-OCT quality metrics do not predict which segmentations are reliable and which are not. The segmentability index SI presented in this study does allow reliable segmentations to be identified, which is important for more accurate layer thickness analyses in research and population studies.
Objective To assess mature burn scars treated with a fractional carbon dioxide laser for changes in histological architecture, type I to III collagen ratios, density of elastic tissue, and subjective measures of clinical improvements.
Design Uncontrolled, prospective study of patients with mature burn scars, from a clinical and histological perspective. Biopsy specimens were obtained before and 2 months after 3 treatment sessions. The tissue was prepared with Verhoff von Giesen (VVG) stain to discern elastic tissue and Herovici stain to differentiate types I and III collagen.
Setting Subjects were recruited from the Grossman Burn Centers.
Participants Of 18 patients with mature burn scars, 10 completed the entire treatment protocol.
Intervention Participants received 3 treatments with a fractional carbon dioxide laser.
Main Outcome Measures Vancouver Scar Scale and Patient and Observer Scar Assessment Scale survey scores. In histological analysis, imaging software was used to measure changes in collagen subtype and elastic tissue. A rating scale was developed to assess normal vs scar architecture.
Results The first hypothesis that significant histological improvement would occur and the second hypothesis of a statistically significant increase in type III collagen expression or a decrease in type I collagen expression were confirmed. There were no significant changes in elastic tissue. Statistically significant improvements were seen in all survey data.
Conclusions Treatment with a fractional carbon dioxide laser improved the appearance of mature burn scars and resulted in a significant improvement in collagen architecture following treatment. Furthermore, in treated skin specimens, a collagen subtype (types I and III collagen) profile resembling that of nonwounded skin was found.
The use of ablative fractional carbon dioxide laser therapy and pulsed dye laser therapy has led to significant improvements in the rehabilitation of hypertrophic burn scars. However, laser procedures are associated with appreciable pain among pediatric patients. Clinical consensus suggests using general anesthesia for pediatric laser procedures; however, guidelines for perioperative care are lacking. The objective of this quality improvement study is to determine whether a difference exists in postoperative pain outcomes in pediatric patients who receive intraoperative opioid regimens compared with patients who receive opioid-sparing regimens for laser therapy of hypertrophic burn scars. A retrospective review of patients who received laser therapy at a pediatric burn center from April 2014 to May 2015 was performed. Overall, 88 of the 92 procedures reviewed were included. A statistically significant difference was not found between the likelihood of postoperative pain when intraoperative opioid regimens (n = 63) were given compared with opioid-sparing regimens (n = 25) X (1, n = 88) = 2.870, P = .0902. There was also no difference between short-acting (n = 48), long-acting (n = 9), or combination (n = 6) intraoperative opioids compared with opioid-sparing regimens (n = 25) in the likelihood of postoperative pain. Despite the small sample size, the low number of postoperative pain cases is encouraging. Ultimately, these data provide a foundation for developing anesthetic guidelines for pediatric laser procedures. Specifically, clinicians should consider the potential to deliver adequate perioperative care via an opioid-sparing regimen ± adjuvant.
A variety of conservative treatments for burn scars are available, but there is no clear consensus on the evidence. The purpose of this study was to summarize the available literature on the effects of conservative treatments of burn scars in adults. RCTs and CCTs were sought in three databases, reference lists of retrieved articles and relevant reviews. The Scottish Intercollegiate Guidelines Network scoring system was used to assess the quality of the selected studies. Information on the study characteristics, results and interventions was extracted. Twenty-two articles were included into the review and categorized in six topics: 5 on massage therapy, 4 on pressure therapy, 6 on silicone gel application, 3 on combined therapy of pressure and silicone, 3 on hydration and 1 on ultrasound. Pressure and silicone therapy are evidence-based conservative treatments of hypertrophic scar formation after a burn producing clinically relevant improvement of scar thickness, redness and pliability. Massage therapy could have a positive result on scar pliability, pain and pruritus, but with less supporting evidence. The use of moisturizers and lotions could have an effect on itching, but the findings are contradictory. Of all other non-invasive treatments such as splinting, casting, physical activity, exercise and mobilizations no RCTs or CCTs were found.
Objective: To characterize the presentation of burns in children and risk factors associated with their occurrence in a developing country as a basis for future prevention programs.
Design: Case-control study.
Setting: Burn unit of the National Institute of Child Health (Instituto Nacional de Salud del Niño) in Lima, Peru.
Methods: A questionnaire was administered to all consenting guardians of children admitted to the burns (cases) and general medicine (controls) units during a period of 14 months. Guardians of patients were questioned regarding etiology of the injury, demographic and socioeconomic data.
Results: 740 cases and controls were enrolled. Altogether 77.5% of the cases burns occurred in the patient's home, with 67.8% in the kitchen; 74% were due to scalding. Most involved children younger than 5 years. Lack of water supply (odds ratio (OR) 5.2, 95% confidence interval (CI) 2.1 to 12.3), low income (OR 2.8, 95% CI 2.0 to 3.9), and crowding (OR 2.5, 95%CI 1.7 to 3.6) were associated with an increased risk. The presence of a living room (OR 0.6, 95% CI 0.4 to 0.8) and better maternal education (OR 0.6, 95% CI 0.5 to 0.9) were protective factors.
Conclusions: To prevent burns interventions should be directed to low socioeconomic status groups; these interventions should be designed accordingly to local risk factors.
Export Date: 18 October 2014
The benefits and risks of singular and repetitive microneedling (1 mm) have not been thoroughly investigated. The aim of this study was to evaluate the benefits and risks of singular and repetitive skin needling with a microneedling device in an animal model with and without skincare. 30 Sprague Dawley rats were randomized to five groups: control, skin-care only (Vitamin A & C), 1× needling 1 mm, 4× needling 1 mm, 4× needling 1 mm with skin-care. All animals were euthanized after 10 weeks. Skin specimens were stained with HE and Masson's trichrome. Additionally, gene expression analysis with microarray technique for various growth factors (TGFβ1–3, FGF, EGF, VEGF, TNF-α) and real time reverse transcription PCR for collagen I & III were conducted. We showed that singular microneedling matches and repetitive microneedling sessions superposition epidermal and dermal benefits such as an increase of epidermal thickness (up to 658% increase, p value 0.0008) and dermal connective tissue—even more so when combined with skin-care with vitamin A and C. Juvenile collagen I showed itself up-regulated in all groups, while collagen III was down-regulated. Singular and repetitive PCI with a microneedling device can achieve and supersede the results already shown with medical needling.
Over the past decade, numerous preclinical and retrospective human studies have reported that the provision of anesthetic and sedative agents to infants and children may be associated with adverse neurodevelopmental outcomes. These data have gained widespread attention from professional and regulatory agencies, including the public at large. As such, pediatric anesthesiologists are being increasingly questioned by parents about the risks of anesthetic agents on their children's neurocognitive development. To impart a framework from which anesthesiologists may address the apprehensions of parents who actively bring up this issue, we review the data supporting anesthetic neurotoxicity and discuss its strengths and limitations. As many parents are not yet aware and do not actively raise these concerns, we also discuss whether such a conversation should be undertaken as a part of the consent process.
Hypertrophic scars and keloids are challenging to manage, particularly as sequelae of burns in children in whom the psychologic burden and skin characteristics differ substantially from adults. Prevention of hypertrophic scars and keloids after burns is currently the best strategy in their management to avoid permanent functional and aesthetical alterations. Several actions can be taken to prevent their occurrence, including parental and children education regarding handling sources of fire and flammable materials, among others. Combination of therapies is the mainstay of current burn scar management, including surgical reconstruction, pressure therapy, silicon gels and sheets, and temporary garments. Other adjuvant therapies such as topical imiquimod, tacrolimus, and retinoids, as well as intralesional corticosteroids, 5-fluorouracil, interferons, and bleomycin, have been used with relative success. Cryosurgery and lasers have also been reported as alternatives. Newer treatments aimed at molecular targets such as cytokines, growth factors, and gene therapy, currently in developing stages, are considered the future of the treatment of postburn hypertrophic scars and keloids in children.
This study aims to evaluate percutaneous collagen induction (PCI) in post-burn scarring.
Patients with scarring after burn frequently request help in improving the aesthetic appearance of their residual cicatricial deformity. Their scars are generally treated by tissue transfer, W- and Z-plasties, flaps, cortisone injections or ablative procedures that injure or destroy the epidermis and its basement membrane and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis.
A total of 16 consecutive patients (average age: 37+/-15.5 years, average body mass index (BMI): 25.7) in Germany with post-burn scarring.
PCI using the Medical Roll-CIT (Vivida, Cape Town, South Africa). This device was designed to multiply-puncture the skin to the level of the dermal scar to institute remodelling. Patients were prepared with topical vitamin A and C cosmetic creams for a minimum of 4 weeks preoperatively to maximise collagen stimulation.
The outcome was measured rating (visual analogue scale (VAS) and Vancouver Scar Scale (VSS)), histological specimen 12 months after intervention.
On average, patients rated their improvement as a mean of 80% better (+/-15.5) than before treatment. Histologic examination revealed considerable increase in collagen and elastin deposition 12 months postoperatively. The epidermis demonstrated 45% thickening of stratum spinosum and normal rete ridges as well as the normalisation of the collagen/elastin matrix in the reticular dermis at 1 year postoperatively.
This pilot study shows that PCI appears to be a safe method for treating post-burn scarring without destroying the epidermis. The procedure can be repeated safely and is also applicable in regions where laser treatments and deep peels are of limited use. However, it is necessary to initiate an efficacy trial to prove the data of this pilot study.
In percutaneous collagen induction, an alternative to laser resurfacing, the skin receives multiple punctures with a drum-shaped device that has fine protruding needles, to encourage the production of collagen and elastin. According to the author, advantages include preservation of the epidermis, thicker skin, a short healing phase, and use of local anesthetic alone. (Aesthetic Surg J 2002;22:315-317.).
Photoaging is generally treated by ablative procedures that injure the epidermis and basal membrane and lead to fibrosis of the papillary dermis. Damaging the epidermis significantly can cause potential adverse effects such as dyspigmentation. It was recently shown in clinical trials that percutaneous collagen induction therapy is an alternative for safely treating wrinkles and scars and for smoothening the skin without the risk of dyspigmentation.
The purpose of this study was to increase current knowledge regarding whether percutaneous collagen induction therapy presents an effective means for skin rejuvenation without risk of dyspigmentation, as the authors' clinical data suggested. Fifty-six rats were assigned to three groups: group A (n = 24), percutaneous collagen induction therapy plus skin care; group B (n = 24), skin care; and group C (n = 8) controls. The authors evaluated the effect of percutaneous collagen induction therapy on the epidermis, melanocytes, and the pigmentation markers interleukin-10 and melanocyte-stimulating hormone.
Percutaneous collagen induction therapy left the epidermis intact without any damage to the stratum corneum, any other layers of the epidermis, or the basal membrane. No signs of dermabrasive reduction of epidermal thickness were evident 24 hours after the procedure. The number of melanocytes neither increased nor decreased in any of the groups. DNA microarray experiments demonstrated that interleukin-10 was increased in percutaneous collagen induction therapy-treated skin after 2 weeks. Concerning the MC1R (melanocyte-stimulating hormone) gene, gene expression microarray analysis indicated a faint down-regulation both 24 hours and 2 weeks after percutaneous collagen induction therapy.
Percutaneous collagen induction therapy offers a modality with which to rejuvenate and improve skin appearance and quality without risk of dyspigmentation.
Although hypertrophic scarring commonly occurs following burns, many aspects such as incidence of and optimal treatment for scar hypertrophy remain unclear. This review will focus on hypertrophic scar formation after burn in particular, exploring multiple treatment options and describing their properties as well as effectiveness. To evaluate treatment efficacy and scar development, clinical scar assessment is of eminent importance. Furthermore, recommendations regarding the classification of hypertrophy in the daily practice and in clinical trials are implemented.
A reliable, objective, and universal method of assessing burn scars does not exist in today's burn literature. Such a method is necessary to provide a descriptive terminology for the comparison of burn scars and the results of treatment. The method should be applicable to patients both within an institution and between burn centers. A burn scar assessment has been devised based on physical parameters. These relate to the healing and maturation of wounds, cosmetic appearance, and the function of the healed skin. Pigmentation, vascularity, pliability, and scar height are assessed independently, with increasing score being assigned to the greater pathologic condition. Normal skin has a score of 0. Seventy-three patients were assessed by three separate occupational therapists and the findings subjected to statistical analysis for interrater reliability. For each parameter a Cohen's kappa statistic of approximately 0.5 +/- 0.1 indicates a statistically significant agreement between observers. These values were found to improve with time. This appears to be a useful tool for the assessment of burn scars, allowing objective comparison of the same scar by different observers.
A new method of subcuticular underming for the treatment of depressed cutaneous scars and wrinkles is introduced.
To define the newly coined term "Subcision" and to describe this minor surgical procedure for treating depressed scars and wrinkles.
A tri-beveled hypodermic needle is inserted through a puncture in the skin surface (hence, "incisionless" surgery), and its sharp edges are maneuvered under the defect to make subcuticular cuts or "-cisions."
The depression is lifted by the releasing action of the procedure, as well as from connective tissue that forms in the course of normal wound healing.
This technique is useful in treating a variety of cutaneous depressions, including scars and wrinkles.
A 6-year retrospective review of burn victims hospitalized at a major burn center was conducted to determine the etiology and outcome of pediatric burns. Four hundred forty-nine patients under age 16 years were identified and stratified by age, sex, burn size, presence or absence of inhalation injury, cause of burn, and county of residence. The mean patient age was 4.3 +/- 0.2 years, and the male:female ratio was 1.9:1. There were 21 deaths overall (4.7%), the majority of which (18) were among children under 4 years of age. With respect to large burns, defined as > and = 30% total body surface area (TBSA), the mortality rate for children under age 4 was significantly higher than that for older children (46.9% v 12.5%; P < .01), despite the nearly identical mean burn size of the two groups. Except for burn incidence, there were no significant differences between males and females. The mean burn size was 15.1% +/- 0.7%, and was significantly larger for nonsurvivors than survivors (55.3% +/- 5.7 v 13.1% +/- 0.5%; P < .01). Inhalation injuries were strongly associated with large burns and were present in all 15 flame-burn fatalities. Scalds were the most common type of burn among children under 4 years of age; flame burns predominated in older children. There were 6 deaths related to scalds, all of which occurred in children under 4. Burn type, size, and mortality rate did not differ between children from urban and rural counties. Large burn size was the strongest predictor of mortality, followed by (in order) age less than 4 and the presence of inhalation injury. Infants and young children have the highest risk of death from burn injury. Burns smaller than 30% TBSA without an inhalation injury (such as small scald injuries) occasionally are lethal in infants and small children, despite modern therapy.