Treatment of symptomatic abnormal skin scars with electrical stimulation - MedX Health

 
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)
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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,
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                                  cytokines, hormones and other effector molecules.24
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                                  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
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Plast Reconstr Aesthet Surg.                                                                         Ethnicity: Caucasian/other                          14/5
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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
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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,
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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

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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

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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

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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

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                                        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,                 *p
practice

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                                                                                         453
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