Original article Comparison between Dermoscopic and Histopathological Features of Keloids and Hypertrophic Scars Before and After Different Treatment Modalities Hanan H. Sabry a, Mohebat H. Gouda b, Ahmed H. Abd Elkareem a, Safaa ElBaathy a a Department of Dermatology Abstract and Andrology, Benha faculty of medicine, Benha University, Background: Keloids and hypertrophic scars (HTS) are abnormal b Egypt. Department of wound responses. Lack of knowledge about their basic biology had Pathology, Benha faculty of medicine, Benha University, prevented development of a targeted approach to the treatment of Egypt. keloids and hypertrophic scars. Aim of the work: The study aimed to Correspondence to: Mohebat evaluate the dermoscopic and histopathological features of keloids H. Gouda, Department of Pathology, Benha faculty of and hypertrophic scars before and after different treatment modalities. medicine, Benha Methods: Thirty-two patients with keloids and hypertrophic scars were included in the study for clinical, dermoscopic and Email: histopathological examination. Patients received treatment in form of [email protected] Fractional Co2 laser or 5FU or verapamil. Examination of slides Received: 21 December 2019 stained by H&E and the special stain (Masson trichrome) was Accepted: 12 June 2021 performed; also CD31 immunohistochemistry was performed in all cases. The histopathological examination of slides both HTS and keloid before and after treatment was done. The pattern of collagen fibers was determined by hematoxylin and eosin stained sections and Masson Trichrome stained sections. The pattern and extent of vascularity demonstrated by CD31 immunostaining was evaluated. Results: Vancouver scar scale showed significant improvement in all patients. histopathological improvement (the collagen fibers detected by Masson trichrome in the upper dermis of HTS cases become thinner and the MVD detected by CD31 IHC staining showed increased vascularity after treatment). Hypertrophic scars showed better improvement than keloids in all groups. Arborizing and linear vessels showed significant improvement in group 1&2. Linear vessels showed significant improvement in group 3. Conclusion: Fractional Co2 laser combined with 5FU is an excellent choice of treatment in keloids and hypertrophic scars. Keywords: HTS, keloid, Masson trichrom, CD31. 750 Dermoscopic and Histopathological Features of Keloids and HTS, 2021 Introduction Keloids and hypertrophic scars are Inflammation of the reticular dermis is macroscopic cutaneous scarring resulted stimulated by many intrinsic and extrinsic from disturbance of wound healing, that factors. The features, amount, and course of occurs on predisposed individuals (1). It keloids and HTS are affected by these shows a kind of over-healing, producing stimuli (7). It is suggested that the intensity, over abundant wound matrix responsible for duration and frequency of these stimuli raised, inflexible red scar tissue, that causes determine the rate of scar formation, the pain and itching (2-3). Also, it can lead to direction and speed of growth, symptoms serious functional and cosmetic concerns. intensity. The stimuli are variable, including Excessive scarring following trauma that local, systemic and genetic factors. It is causes tissue loss is identified into two concluded that the difference between types; keloid and hypertrophic scars (4). keloids and HTS clinically may be due to difference in the intensity, frequency and Keloids and hypertrophic scars resulted duration of inflammation of the reticular from skin injury and irritation, including dermis (8). trauma, insect bite, surgery, burn, Hypertrophic scars remain confined to the vaccination, skin piercing, acne, folliculitis, boundaries of the original lesion, regressing herpes zoster and chicken pox infection. The spontaneously after the initial injury. They injuries that don not affect the reticular may produce scar contractures when located dermis not cause keloid or hypertrophic over joints (9). Most hypertrophic scars do scars (5). This may denotes that the not recur after surgical excision. Keloids pathological scars are caused by cutaneous develop from either a deep or a superficial injury and subsequent excessive wound injury. They are also red and itchy, exceed healing. Such excessive wound healing is the boundaries of the initial injury as they do characterized by progressive and localized not regress with time, or with high recurrent inflammation, leading to presence of rate after surgical excision, and usually do proliferated inflammatory cells, fibroblasts, not provoke contractures (10). excessive collagen deposition and newly formed blood vessels in the dermis (6). There are many histopathological differences between keloid and hypertrophic 751 Benha medical journal, vol. 38, issue 2, 2021 scar. Among these differences, keloid scar is understanding the pathogenesis of these characterized by the presence of thick, lesions; their differentiation and hyalinized collagen bundles or ‘keloid interpretation of the clinical behavior. collagen’ with mucinous ground substance Material and methods: and few fibroblasts, but in hypertrophic scar, This was a follow up prospective study little or no keloidal collagen is found (11). approved by the Research Ethics Committee Hypertrophic scar is characterized by the of Benha Faculty of Medicine, Benha presence of nodules containing a high University. All patients provided a written density of cells and collagen. The collagen informed consent before initiating the study fibers are cigar-shaped and run parallel to procedures. A total of 32 egyptian patients the surface of the skin, located in the middle with hypertrophic scar or keloids or deeper layer of the scar, and oriented (Fitzpatrick skin type III to IV), who along the tension lines of the scar. Such attended out-patient clinic of Dermatology nodules are absent in keloid scars. Also, Department, Benha University hospitals in hypertrophic scars are characterized by the the period between November 2015 to presence of numerous fibroblasts but few January 2017 were enrolled in this study. glassy collagen bundles and scanty Exclusion criteria for study participation mucinous ground substance, their collagen were pregnancy or breastfeeding, patients fibers are oriented parallel to the long axis of using oral retinoid six months prior to this the scar, but in keloid, collagen is arranged study or active infection at site of lesion. in a haphazard pattern (12). Lesions suspicious for malignancy and Aim of the work: patients suffering from cardiac diseases This study aimed to identify the were also excluded. morphological features in depth; the A complete history was taken from the possible diagnostically relevant differences patients (including personal history, history between keloid and hypertrophic scar before of scars, history of other skin diseases or and after treatment through using drug intake) and general clinical and histopathological, special stains, and cutaneous examination for size and location immunohistochemical studies. Such of the scars and digital photography was distinctive features may help in performed before and after treatment. 752 Dermoscopic and Histopathological Features of Keloids and HTS, 2021 Baseline scar assessment was made using paraffinization was carried out through three Modified Vancouver Scar Scale. Cases were changes of fresh xylene. Each change was randomly classified into three treatment for 5 minutes, then dehydration was carried protocols groups. Group 1 (Co2 laser + 5- through absolute alcohol series, each for 5 Fluorouracil), Group 2 (Co2 laser + topical minutes. Peroxide block (Biogenex life verapamil hydrochloride), Group 3 (CO2- science Pvt.Ltd.,CA,USA) was used to Laser). block the endogenous peroxidase for 15 minutes at room temperature. Washing with Skin specimens from all cases with keloids distilled water, followed by citrate buffer and hypertrophic scars were taken before (pH 6.0) wash for 10 min. Biogenex antigen and 6 months after Co2 laser sessions. The retrieval system was used for antigen samples were fixed in 10% formalin for 24 retrieval. Dipping of the sections in citrate hours at room temperature, embedded in buffer solution, they were put in Biogenex paraffin, and sectioned at 5 µm for antigen retrieval system and warmed for 15 conventional histological examination. minutes. The system was put under tap Histological analysis and photographs were running water for cooling, and then the carried out using Leica Research microscope slides were washed with distilled water for 5 (Model no DM 1000 LED, Germany). minutes. Sections were incubated with a Sections were stained with hematoxylin- blocking agent for blocking the endogenous eosin (H&E), Masson’s trichrome to biotin for 15 minutes. Then incubation of the highlight the orientation and thickness of section with the primary monoclonal collagen fibers. Sections were stained with antibody of CD31 (dilution 1: 50, Biogenex anti-CD31 antibody to determine the pattern life Science Pvt Ltd., CA, USA) for 1 hour, and extent of vascularity. was done. The slides were washed Immunohistochemical staining for CD31: thoroughly with citrate buffer. DAB Sections of three micron were cut and chromagen was prepared just before the use, carried to aminopropyl triethoxy silane and then it was added for 5 minutes on the (Sigma-Aldrich Chemical Co., USA) coated sections. Then the sections were washed in slides and incubated overnight at room buffer followed by water.