Treatment of symptomatic abnormal skin scars with electrical stimulation - MedX Health
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
practice Treatment of symptomatic abnormal skin scars with electrical stimulation l Objective: To evaluate the effect of non-invasive biofeedback electrical stimulation on symptomatic abnormal skin scars. l Method: Thirty patients with over 140 scars with long-term pain and itch were recruited into the study. Patients monitored the intensity of symptoms (pain and itching) on a numerical rating scale. In addition, a modified Manchester scar scale was used to objectively assess digital photographs of each scar in terms of colour, contour, distortion and texture, while a non-invasive spectrophotometric intracutaneous analysis was used to monitor the scars’ physical characteristics. l Results: The electrical stimulation device resulted in a clinically and statistically significant (p
practice
References patterns represent a modification of cell behaviour
1 Rhee, P., Brown, C., Martin, which may also be represented at the central nerv- Table I. Basic demographics (n=19)
M. et al. QuikClot use in
trauma for hemorrhage ous system level. Interactions between the central Sex (male/female) 3/16
control: case series of 103 nervous system and the skin involve neuropeptides,
documented uses. J Trauma. Age (years)
cytokines, hormones and other effector molecules.24
2008; 64: 4, 1093–1099.
It has been proposed that there is an interrelation- l ≤25 7
2 Brown, B.C., Moss, T.P.,
McGrouther, D.A., Bayat, A. ship between the skin, endocrine, immune and cen- l 26–35 3
Skin scar preconceptions tral nervous systems, which has been termed l 36–45 4
must be challenged:
the neuro-immuno-cutaneous-endocrine model. l ≤46 & over 5
Importance of self-
perception in skin scarring. J According to this theory, electrical stimuli at the
Plast Reconstr Aesthet Surg. Ethnicity: Caucasian/other 14/5
2010; 63: 6, 1022–1029.
skin surface can influence all of these systems at
3 Bayat, A., McGrouther, both a local and central level.25 For example, trans- Fitzpatrick skin scale
D.A., Ferguson, M.W. Skin cutaneous electrical nerve stimulation activates opi- l I–III 14
scarring. BMJ. 2003; 326:
oid receptors in the central nervous system, as dem- l IV–VI 5
7380, 88–92.
4 Sund, B. (ed). New onstrated in basic science studies using both high
Developments In Wound and low frequencies.26,27 In mild asthma, electrical Positive abnormal family scar history 2
Care. PJB Publications, 2000. stimulation appears to facilitate neurological adjust-
5 Gangemi, E.N., Gregori, Positive previous history of
D., Berchialla, P. et al. ment of mast cell sensitivity.28 abnormal scarring 4
Epidemiology and risk
factors for pathologic The Fenzian treatment system Past medical history conditions
scarring after burn wounds. Respiratory 3
Arch Facial Plast Surg. An emerging adjuvant therapy is the Fenzian bio- l
l Dermatological 4
2008; 10: 2, 93–102. feedback electrostimulation treatment system
6 Foulds, I.S., Barker, A.T. l Other 5
(Eumedic, UK, Fig 1), which delivers a low-intensity
Human skin battery
potentials and their transcutaneous electrostimulation current to specif-
possible role in wound ic skin areas. It follows the theory that the electrical
healing. British J Dermatol. potential of skin forms a global electrical network,
1983; 109: 5, 515–522.
7 McGinnis, M.E.,Vanable, and that any changes in skin impedance reflect iotherapist) in a protocol that depends on the indi-
J.W. Jr.Voltage gradients in underlying neurological activity.29 The mechanism vidual patient. Patients are treated while sitting or
newt limb stumps. Prog by which this body-wide electrical network might (very occasionally) lying down. This microcurrent
Clin Biol Res. 1986; 210:
231–238. stimulate a healing response is not yet fully under- electrical stimulation uses currents that are in the
8 Barker, A.T., Jaffe, L.F., stood. However, the disruption to these body-wide microampere range, which are a thousand times
Vanable, J.W. Jr. The potential patterns during injury is a likely trigger for lower than transcutaneous electrical nerve stimula-
glabrous epidermis of
cavies contains a powerful tissue repair, in addition to the release of hormones tion (TENS). Pulse widths are also different (average
battery. Am J Physiol. 1982; and numerous chemical medicators.30,31 0.5 seconds), typically 2,500 times longer than a
242: 3, R358–366.
The Fenzian system detects the skin’s electrical TENS unit, and often below the sensation thresh-
9 Jaffe, L.F.,Vanable, J.W. Jr.
Electric fields and wound impedance using a microcurrent generator. The out- old.33 The device has a 45 x 22mm electrode, which
healing. Clinics in going transformer signal is measured across a con- is brushed or physically held in contact with the
dermatology. 1984; 2: 3, centric electrode, and a biofeedback impulse is skin for the duration of treatment. Impulses are of
34–44.
10 Ojingwa, J.C., Isseroff, applied (this comprises a sequence of electrical short duration (~10µs) and of relatively high ampli-
R.R. Electrical stimulation impulses, the sizes of which depend on alterations in tude (80V).
of wound healing. J Invest skin response).32 The user is guided to optimal bio-
Dermatol. 2003; 121: 1,
1–12. feedback sites by a numerical depiction of the outgo- Background to the evaluation
11 Nuccitelli, R. A role for ing signal characteristics. When this shows that bio- Many scars have a chronic inflammatory compo-
endogenous electric fields feedback is complete (by reaching an unchanging nent, either with erythematous colouration34 or as a
in wound healing. Curr Top
Dev Biol. 2003; 58: 1–26. electrical state), an audible bell sounds and the result of acute sensitisation of nociceptors and/or
12 Zhao, M., Song, B., Pu, J. device is then moved to another site, or the treat- activation of puriceptors,35 although the exact
et al. Electrical signals ment may be complete (depending on the protocol). underlying mechanism is not fully understood.36
control wound healing
through Fenzian is applied to a patient’s skin by a specially Previous retrospective case note reviews32 and
phosphatidylinositol-3-OH trained medical practitioner (a doctor, nurse or phys- controlled pilot studies28 of the Fenzian system have
kinase-gamma and PTEN. demonstrated a persistent pattern of improved
Nature. 2006; 442: 7101,
457–460. symptoms across a wide range of conditions, includ-
13 Song, B., Gu,Y., Pu, J. et ing asthma and traumatic cutaneous injuries.
al. Application of direct We conducted an open-label observational study
current electric fields to
cells and tissues in vitro and to assess the subjective benefits and objective
modulation of wound changes in symptomatic, raised, dermal scars treat-
electric field in vivo. Nat ed with the Fenzian system. This is the first study to
Protoc. 2007; 2: 6,
1479–1489. formally evaluate its use in cutaneous scars. Prob-
Fig 1.The Fenzian treatment system lematic scarring was chosen because of the extent of
448 j o u r n a l o f wo u n d c a r e v o l 1 9 , n o 1 0 , OCTOBER 2 0 1 0practice
pain and pruritic symptoms endured by some Assessment 14 Wang, E., Zhao, M.,
Forrester, J.V., McCaig, C.D.
patients, and the poor range of non-invasive man- Subjective and objective outcome measures were Bi-directional migration of
agement options currently available. recorded by a single unblinded therapist (first author, lens epithelial cells in a
DP) and then evaluated by the senior author (AB). physiological electrical field.
Exp Eye Res. 2003; 76: 1,
Materials and method l At every visit, we recorded the patient’s subjective
29–37.
Patients attending the specialist scar service clinic at rating of perceived pain and intensity of itch over 15 Zhao M, Bai H., Wang, E.
the University Hospital of South Manchester (UHSM) the past 24 hours, using the validated 11-point et al. Electrical stimulation
directly induces
NHS Foundation Trust between January 2009 and numerical rating scale (NRS, where 0 = no pain/itch, pre-angiogenic responses in
June 2009 were eligible for recruitment. Inclusion 10 = worst possible pain/itch). We also noted wheth- vascular endothelial cells by
criteria were: er the symptom was constant or intermittent signaling through VEGF
receptors. J Cell Sci. 2004;
l Patients with one or more cutaneous scars that had l Digital photographs were taken and the scar sites
117: 3, 397–405.
not responded to previous treatment, such as steroid were clinically evaluated at all treatment visits using 16 Li, X., Kolega, J. Effects
injections, surgical excision and silicone gel therapy a modified Manchester Scar Score (mMSS).38 This of direct current electric
fields on cell migration and
(based on unsatisfactory scar appearance and/or includes assessment of scar colour, contour, distor- actin filament distribution
symptoms), or for which the patient had requested tion and texture. Each parameter is scored on a lin- in bovine vascular
further non-invasive management ear scale of 1–4, with increasing scar severity scoring endothelial cells. J Vasc Res.
2002; 39: 5, 391–404.
l Patients with any problematic scar type, such as more highly. This also records each scar’s matte or 17 Kloth, L.C. Electrical
keloid, hypertrophic, or history of scarring such as shiny appearance, with 1 = matte and 2 = shiny. stimulation for wound
trauma, surgery, acne. Scores are totalled and range from 5 (clinically well- healing: a review of
evidence from in vitro
Exclusion criteria were: healed scar) to 18 (clinically poor scar).38 studies, animal experiments,
l Patients taking medication that reduce electrical l At multiple time points throughout treatment and and clinical trials. Int J Low
Extrem Wounds. 2005; 4: 1,
activity of the skin, such as antibiotics and steroids)37 on consistently selected scar site areas, objective
23–44.
l Patients with implanted electrical devices, such as spectrophotometric intracutaneous analysis (SIA) or 18 Poltawski, L., Watson, T.
pacemakers and cochlear implants Bioelectricity and
l For cautionary reasons, patients who were preg- microcurrent therapy for
Table 2. Presenting abnormal scar data tissue healing – a narrative
nant or planning to conceive review. Phys Ther Rev. 2009;
There were no exclusion criteria relating to sex, Scar details No. 14: 2, 104–114.
age or past medical history. 19 Sebastian, A., Syed F,
Location
Sternum/breast 8 McGrouther, D.A. et al. A
novel in vitro assay for
Shoulder girdle 4
The intervention electrophysiological
Other 7 research on human skin
The biofeedback electrical stimulation therapy was fibroblasts: degenerate
administered by a single therapist as part of the Scar cause Surgery 13 electrical waves
patient’s routine care. The battery-operated Fenzian Trauma 2 downregulate collagen I
Acne/spots 4 expression in keloid
system is both CE approved and US FDA 510(k) reg- fibroblasts. Exp Dermatol.
istered, and it passed the UHSM Trust Medical Engi- Scar age 3 years 5 the electric field associated
However, all patients gave written informed con- with mouse and human
Scar type
Keloid 11 skin wounds. Wound Repair
sent for the image/photographic monitoring of Regen. 2008; 16: 3, 432–441.
Hypertrophic scar 5
their scars. Other 2 21 Pullar CE. The biological
Treatment was administered according to stand- basis for electrical
New wound (previous
stimulation as a therapy to
ardised local (scar location) or global (whole body) hypertrophic/keloid) 1 heal chronic wounds. J
protocols, depending on the anatomical site affect- Wound Technol. 2009; 1: 6,
Lesion history Primary 11 20–24.
ed and the physiological systems linked with the
Recurring 8 22 Pui-Ching, N.S.,Yee-Men,
individual’s scar history (for instance, targeting low- J.A. Skin impedance at
er abdominal hormonal sites in relation to acne Symptoms No symptoms 5 acupuncture point
scarring). Pain only 3 dingchuan in subjects with
Itch only 5 and without asthma.
Treatment times were dictated by the device via Chinese Rehabilitation
its biofeedback electrical mechanism (average 20 Pain and Itch 6 Medicine. 2009; 24: 6,
481–484.
minutes in duration) and administered by a single Modified Manchester 23 Kramer, S., Winterhalter,
clinician. For the first 3–4 weeks, treatments were scar score (5–18)* 14 (8–17) K., Schober, G. et al.
administered twice weekly. Further treatments and Characteristics of electrical
review appointments continued for up to 6 months, NRS Pain (0–10)* 0 (0–9) skin resistance at
acupuncture points in
on a monthly basis. NRS Itch (0–10)* 5 (0–9) healthy humans. J Altern
Patients did not receive any other forms of scar Complement Med. 2009;
15: 5, 495–500.
therapy during the course of bioelectrical stimula- Results are presented as median (range)
tion treatment.
s
j o u r n a l o f wo u n d c a r e v o l 1 9 , n o 1 0 , o c to b e r 2 0 1 0 449practice
24 O’Sullivan, R.L., Lipper, between time points. The statistical package SPSS
G., Lerner, E.A. The
neuro-immuno-cutaneous-
Table 3. Symptomatic response to version 15.0 was used, and all analyses were carried
endocrine network: treatment out using the conventional 5% significance level.
relationship of mind and
skin. Arch Dermatol. 1998; Pain Itch
134: 11, 1431–1435. Results
25 Brazzini, B., Ghersetich, No. No. Demographics
I., Hercogova, J., Lotti, T. The Thirty patients with more than 140 (52 evaluated)
neuro-immuno-cutaneous- Initial symptom
endocrine network: scars were treated with the biofeedback electrical
relationship between mind
0 10 8 stimulation system (the test treatment). Patient
and skin. Dermatol Ther.
demographic details are given in Table 1. Eleven
2003; 16: 2, 123–131.
26 Ainsworth, L., Budelier,
1–3 0 1 participants were excluded from the basic statistical
K., Clinesmith, M. et al. analysis due to either failing to complete a basic
Transcutaneous electrical 4–6 4 5
course of treatment (minimum five sessions) or
nerve stimulation (TENS)
reduces chronic 7–10 5 5 because they started medication known to reduce
hyperalgesia induced by the therapeutic effects of the test treatment. This
muscle inflammation. Pain. Response at 1 week (with score ≥1 at baseline) resulted in an observational case series sample of 19
2006; 120: 1–2, 182–187.
27 Sluka, K.A., Deacon, M., Increased 2 2 patients with 31 monitored scars, of which 19 were
Stibal, A. et al. Spinal included in the statistical analysis.
blockade of opioid Decreased 4 6
receptors prevents the
Patients had a mean age of 37 years (range 15–85),
analgesia produced by a modal Fitzpatrick skin classification of type II (fair
Same 3 3
TENS in arthritic rats. J skin, burns easily and tans poorly) and 84% were
Pharmacol Exp Ther. 1999;
289: 2, 840–846. Overall response to biofeedback electrical female. Co-existing dermatological conditions were
28 Cooper, C.B., Boscardin, stimulation by 2 months (with score ≥1 common, and included eczema, psoriasis and acne.
W.J., Colthurst, J.R., at baseline)
Kleerup, E.C. Treatment of
mild persistent asthma by Increased 0 0 Presenting complaint
cutaneous electronic The 19 individuals included presented with a range
stimulation. Eur Respir J. Decreased but of abnormal skin scars (Table 2), primarily due to
2009; 34: 2, 515–517. continued symptom 4 4
29 Becker, R.O. Some
surgery. Acne keloid scarring or a strong propensity
observations indicating the for keloid disease accounted for the majority of self-
Same 0 0
possibility of longitudinal defined ‘problematic’ scars. Most scarring was kel-
charge-carrier flow in the
peripheral nerves. In: Symptom resolved 5 7 oid in nature, affecting the sternum/breast, and was
Bernard, E.E., Kare, M.R. over 3 years in duration (median 2 years, range one
(eds). Biological Prototypes week to 30 years).
And Synthetic Systems.
Plenum, 1962. On entry into the study, most individuals had a
30 Frank, C.B., Szeto, A.Y. A SIAscopy (Siascope, Astron Clinica Ltd, Cambridge, primary abnormal scar lesion (not previously
review of UK) was performed. Using a non-invasive light- excised). However, one new wound also received
electromagnetically
enhanced soft tissue based technology probe, the quantities of light treatment, following repeat debulking surgery.
healing. IEEE Eng Med Biol remitted by the skin at different wavelengths are At the start of treatment, five patients had no pain
Mag. 1983; 2: 4, 27–32.
determined,39 providing a photographic pigmentary or itch, five complained of itch only, three of pain
31 Watson, T. Electrical
stimulation for wound status and quantitative numerical values for the only, and six of itch and pain together. At baseline,
healing: a review of current constitutional elements of the first 2mm of skin the median NRS pain score was 0 (range 0–9) and
knowledge. In: Kitchen, S. (melanin, haemoglobin and collagen).40 the median NRS itch score was 5 (range 0–9). In gen-
(ed). Electrotherapy:
Evidence-Based Practice. Additionally, basic demographic data were col- eral, a high proportion of scars were rated ‘clinically
Churchill Livingstone, 2002. lected from the patient notes for cross analysis pur- poor’ using the mMSS (median 14, range 8–17).
32 Colthurst J, Giddings P. poses. If patients presented with more than one
A retrospective case note
review of the Fenzian scar, the most problematic scars were selected for Therapeutic outcomes
electrostimulation system: a objective monitoring. Patients were also monitored The 19 patients received a median of nine (range
novel non-invasive,
for any adverse reactions. 5–16) treatments over a median 70-day period
non-pharmacological
treatment. The Pain Clinic. (range 27–138).
2007; 19: 1, 7–14. Statistical analysis Outcome data were selected and grouped into
33 Mercola, J.M., Kirsch, Descriptive statistics were used to document trends specific one-week, and one, two and three-month
D.L. The basis for
microcurrent electrical between demographic characteristics and variables time point ranges for simplification. The latter time
therapy in conventional where group size prevented inferential statistical point was omitted from statistical analysis as only
medical practice. J Adv Med.
1995; 8: 2, 107–120.
testing. Only one scar per subject (defined by the 11 patients had follow-up data at this time.
highest pain, itch and scar scores) was selected for
inclusion in the statistical analysis. Non-parametric Symptomatic outcome
Wilcoxon signed rank tests were applied to assess dif- Patient-perceived symptomatic outcomes are dis-
ferences in pain, itch, scar score and chromophores played in Table 3. Of the nine patients with pain at
450 j o u r n a l o f wo u n d c a r e v o l 1 9 , n o 1 0 , OCTOBER 2 0 1 0practice
baseline, four (44%) reported decreased pain at one
a b
week. Symptoms more frequently decreased in itch
sufferers, with six (55%) of the 11 with itch at base-
line reporting improvement. In all, four scars had
an initial exacerbation of symptoms (three by one
NRS point and one by two NRS points). For those
patients in whom pain and itch improved, median
reductions of four (range 2–6) and 2.5 (range 1–7)
NRS points were observed for pain and itch respec-
tively, following initial treatment.
By one month, of the nine patients with pain at
baseline, three had no pain and the remaining six
had reduced pain. Of these six patients, two had no
pain by 2 months. Therefore, resolution of pain was
achieved by 2 months for five (56%) of the nine
patients with pain at baseline, after a median of six
treatments (range: 5–8). Of the four patients with
continuing pain, pain scores had reduced by a medi-
an of 2.5 (range: 1–6). i ii iii iv
Of the 11 patients with itch at baseline. Five had
no itch by one month, and the remaining six had
reduced symptoms. By 2 months, resolution of itch
was achieved in a total of seven (64%) patients after
a median of six treatments (range: 5–14). Of the
remaining four patients, itch scores had reduced by
a median of 3.5 (range: 2–6). v vi vii viii
Median scores and ranges are displayed in Table 4,
together with Wilcoxon test results, which show Fig 2. Four month old raised facial scar before treatment (a) and 6 weeks’
that statistically significant changes from baseline post-initial treatment (b). SIAmetrics chromophore images (ordered plain
occurred at one and 2 months for both pain and photograph, haemoglobin, melanin and collagen) taken from the scar region
itch scores. highlighted depict changes before (i–iv) and after (v–viii).
Observed scar score outcomes a b
A positive response was observed in 24 of the 31
scars affecting the 19 patients. Only two patients
had no observed alteration in their scar characteris-
tics during adjuvant therapy.
Overall, the mMSS had reduced by a median of
three (range: 0–5) at two months. We observed sta-
tistically significant reductions in total scar scores at
one week, one month and two months (see Table 4).
Scar score reductions recorded using the mMSS
were largely due to objective reduced scores in the
‘colour’ and ‘texture’ categories, but also in the ‘mat-
te/shiny’ appearance. Figs 2–4 display example plain
photographs and colour, haemoglobin, melanin and
i ii iii iv
collagen SIAmetric images of three scars before ini-
tial Fenzian application and after treatment.
Objective melanin, haemoglobin and collagen
chromophore analysis
No known widespread normative quantitative val-
ues of melanin, haemoglobin and collagen chromo- v vi vii viii
phores exist in new wounds or abnormal scarring.
Hence, data were examined for cumulative and sig- Fig 3. Eight month old recurring keloid sternal scar before treatment (a) and 2
nificant patterns within individuals. No statistically months post-initial treatment (b). SIAmetrics chromophore images (ordered
significant changes in haemoglobin levels, collagen plain photograph, haemoglobin, melanin and collagen) taken from the scar
and melanin were observed (see Table 4). region highlighted depict changes before (i–iv) and after (v–viii).
s
j o u r n a l o f wo u n d c a r e v o l 1 9 , n o 1 0 , OCTOBER 2 0 1 0 451practice
Table 4. Symptomatic outcomes scores
Variable Baseline 1 week 1 month 2 months
34 Köse, O., Waseem, A.
Pain (n=9) 7 (4–9) 5 (0–9) 3 (0–8)** 0 (0–7)**
Keloids and hypertrophic
scars: are they two different Itch (n=11) 6 (3–9) 4 (0–8) 2 (0–6)** 0 (0–4)**
sides of the same coin?
Dermatol Surg. 2008; 34: 3, Scar score (n=19) 14 (8–17) 13 (8–17)* 12 (6–17)** 11 (6–17)**
336–346.
35 Schmelz, M. Itch and Haemoglobin (n=19) 191 (16–224) 196 (14–244) 190 (14–244) 184 (9–236)
pain. Neurosci Biobehav
Rev. 2010; 34: 2, 171–176. Collagen (n=19) 192 (129–226) 190 (135–293) 200 (132–301) 195 (146–233)
36 Cheng, B., Liu, H.W., Fu,
X.B. et al. Coexistence and Melanin (n=19) 216 (117–842) 202 (139–842) 212 (103–842) 228 (120–842)
upregulation of three types
of opioid receptors, mu,
delta and kappa, in human
hypertrophic scars. Br J Scores are presented as median (range)
Dermatol. 2008; 158: 4, *ppractice
al elements in the epidermis (melanin, haemoglob- rently available valid and reliable clinician-rated 40 Cotton, S.D. A
in and collagen) for general pattern changes, as no instrument for use with all scar types. However, non-invasive imaging
system for assisting in the
current literature exists to suggest the extent and some of its rating categories can prove ambiguous in diagnosis of malignant
specificity of cellular changes following biofeedback practice, especially the ‘contour’ category, for which melanoma. PhD Thesis,
University of Birmingham,
electrical stimulation treatment. An electro-thera- ‘keloid’ has the maximum ranking. This categorical 1998.
peutic, pro-inflammatory response can be observed rating lacks clinical significance, as some keloid 41 Goodman, G.
initially, as haemoglobin increases, and it has been lesions may be morphologically flat and widespread Acne--natural history, facts
in contrast to extensively raised hypertrophic scars, and myths. Aust Fam
suggested that this may stimulate chronically
Physician. 2006; 35: 8,
inflamed tissue to progress to resolution.28,31 Previ- which would in practice achieve lower scores. 613–616.
ous data suggest that low frequency electrical stimu- The current study would have benefited from 42 Farrar, J.T.,Young, J.P. Jr.,
lation increases blood flow, causing vasodilation by independent evaluation and scar scoring of the LaMoreaux, L. et al. Clinical
importance of changes in
the release of neuropeptides from the terminal end- images taken at treatment appointments, to reduce chronic pain intensity
ings of excited axons through C fibres.48 Hence, we possible bias. This was not attempted, as our treat- measured on an 11-point
numerical pain rating scale.
postulate a mechanistic path for altered scar symp- ment facilities were changed part way through the Pain. 2001; 94: 2, 149–158.
toms with biofeedback electrical stimulation. case series, which dramatically affected the lighting 43 Eishi, K., Bae, S.J., Ogawa,
At 3 months, greater improvements were noted in of photos and could have led to the interpretation F. et al. Silicone gel sheets
relieve pain and pruritus
symptoms and scar scores, perhaps signalling resolu- of variances. All treatments and objective data col-
with clinical improvement
tion of the acute inflammatory response. No scars lections were completed by the same individual, so of keloid: possible target of
grew larger in response to the treatment.49 Fluctua- we assume that any errors were standardised mast cells. J Dermatolog
Treat. 2003; 14: 4, 248–252.
tions in the scar collagen levels recorded may account throughout the study, negating their impact. Given
44 Van Loey, N.E., Bremer,
for the raised collagen levels in these individuals. the risk of bias with an unblinded assessor, we used M., Faber, A.W. et al. Itching
Overall, a chromophore’s trend response to the objective scar measurement tools and independent following burns:
epidemiology and predictors.
treatment can only be postulated, due to the lack of statistical analysis methods. British J Dermatol. 2008; 158:
published scar data and questions of the suitability Our sample group consisted largely of individuals 1, 95–100.
of the instrument used in this preliminary study. with long histories of problematic scarring and 45 Salemi, S., Aeschlimann,
A., Reisch, N. et al.
Additionally, the proposed body-wide mechanism symptomatic distress, in whom previous routine Detection of kappa and
of action of this treatment prevents determination treatments had either ‘failed’ or achieved inade- delta opioid receptors in
of the extent of any changes, as there is no opportu- quate results. Therefore, initial symptom scores skin--outside the nervous
system. Biochem Biophys
nity for a subject to act as his or her own control. were high. Post-surgical scars represented the largest Res Commun. 2005; 338: 2,
Skin, endocrine and immune system interactions aetiological group, including scars from both pri- 1012–1017.
involve a number of neuropeptides, cytokines, hor- mary surgery and previous scar revision. Due to the 46 Scott, J.R., Muangman,
P.R., Tamura, R.N. et al.
mones and other effector molecules.24 Therefore, nature of keloids, these secondary lesions have a Substance P levels and
stimuli at the skin’s surface have influence both high risk of recurrence. It is possible that the rela- neutral endopeptidase
locally and centrally. A growing body of evidence tively high representation of these scars in our sam- activity in acute burn
wounds and hypertrophic
suggests that interaction between the skin and nerv- ple group skewed the statistical analysis. The rela- scar. Plast Reconstr Surg.
ous system contributes greatly to wound healing.50 tively low representation of some other groups 2005; 115: 4, 1095–1102.
The nervous system can modulate locally induced restricts other analysis possibilities. For instance, a 47 Akaishi, S., Ogawa, R.,
Hyakusoku, H. Keloid and
inflammatory responses in the skin through the cross analysis of treatment outcome against propen- hypertrophic scar:
release of neuropeptides.25 sity for scarring (considering family history, or per- neurogenic inflammation
This was a small, open label observational case sonal scarring history) was not possible. Analysis hypotheses. Med hypotheses.
2008; 71: 1, 32–38.
series study designed to gather preliminary data to was further restricted by the strict statistical analysis 48 Dusch, M., Schley, M.,
help guide future applications of this modality. methods employed, as only one scar could be Rukwied, R., Schmelz, M.
Obvious study limitations exist. These include the included from each patient. Rapid flare development
evoked by current
limited follow-up period, due to the new therapeu- frequency-dependent
tic service studied in this case series, and the possi- Conclusion stimulation analyzed by
full-field laser perfusion
ble placebo effect in certain cases. Hence, in order to All patients with symptomatic scars had a positive
imaging. Neuroreport.
establish evidence of any long-term, symptomatic outcome. Individuals with keloid scars showed the 2007; 18: 11, 1101–1105.
and objective benefits, future standard follow-up greatest pain relief, those with hypertrophic scars 49 Koshihara,Y., Honda,Y.
assessments should be completed using a larger had the best improved itch symptoms, while scar Age-related increase in
collagen production in
sample group, and a RCT or a prospective compara- score reduction was better achieved in hypertrophic cultured human
tive cohort study be performed. and surgical scar cases. Our results suggest that osteoblast-like periosteal
cells. Mech Ageing Dev.
A number of different measurement tools were patient age and the number of problematic scars 1994; 74: 1–2, 89–101.
used in this study. Although the NRS has no intrinsic present affects response to biofeedback electrical 50 Ansel, J.C., Armstrong,
meaning, it is easy for patients to understand, quick stimulation. Further controlled studies are warrant- C.A., Song, I. et al.
Interactions of the skin and
to apply and clinically valid. Hence, the NRS presents ed. The current study provides encouraging early
nervous system. J Investig
a useful research tool in gauging the main focus of evidence of the use of biofeedback electrical stimu- Dermatol Symp Proc. 1997;
symptomatic change. For additional objective moni- laton in the successful management of symptomatic 2: 1, 23–26.
toring, the Manchester Scar Score is the only cur- abnormal skin scarring. n
j o u r n a l o f wo u n d c a r e v o l 1 9 , n o 1 0 , OCTOBER 2 0 1 0 453You can also read
