Technology-enhanced learning interventions on skin-ofcolour dermatology for dermatology trainees and fellows: are they effective or sustainable?

The COVID-19 pandemic diverted medical education within dermatology towards technology-enhanced learning (TEL) delivery. Concurrent societal movements also raised awareness of racial inequalities in health outcomes. This has been highlighted as a priority within dermatology research and education (Guckian J, Ingram J, Rajan N, Linos E. Dermatology is finally talking about race. Br J Dermatol 2021;185: 875-6). The British Association of Dermatology acknowledges that 'the education of undergraduate and postgraduates. . .needs to be updated to better include skin of colour' (https://www.bad. org.uk/healthcare-professionals/inclusivity-and-representation). Numerous distance courses in this domain have been piloted, but there is little published evidence regarding efficacy or sustainability. This study evaluated whether TEL methodologies can facilitate effective and sustainable ethnic dermatology education. The study explored the existing competence and confidence of a cohort of dermatology trainees towards managing dermatology conditions affecting skin of colour, specifically central centrifugal cicatricial alopecia (CCCA) and keloid scarring. The short- and long-term impact of TEL interventions upon trainees' confidence and competence of managing these conditions was investigated. A prospective cohort study was designed and included 14 dermatology registrars and regional fellows across Yorkshire. A Zoom teaching session was provided, covering keloid scarring and CCCA, supported by a 'flipped-classroom' approach via pre-reading materials. Survey methodology was used;three questionnaires were circulated: presession (survey 1), postsession (survey 2) and 6 weeks afterwards (survey 3). These featured multiple choice questions gathering data regarding participant knowledge and questioned confidence and competence. Multiple-choice questions were normed by 15 external trainees to ensure suitable difficulty. Presession, 64% participants felt that, on completion of specialty training, they would be competent in treating patients with ethnic skin. Ninety-three per cent believed that formal outcomes related to ethnic dermatology should be included in the curriculum. Postsession, 42% strongly agreed that the teaching course would change their practice. Fifty per cent felt that the teaching content was 'somewhat new'. Average knowledge scores demonstrated an initial rise then fall (survey 1: 5.67/10;survey 2: 7.83/10;survey 3: 6.36/10). Despite an innovative TEL education session, trainee knowledge did not significantly improve and improvement did not prove sustainable 6 weeks after teaching. Trainees were not confident in adopting newly acquired knowledge on skin of colour into their practice. Results show that the benefit of providing TEL education on ethnic dermatology may prove transient, and there is disparity in the perceived and actual benefit of ethnic dermatology education. Systemic solutions may be warranted, combining both education and human factors, including tackling systemic injustices and social inequalities.

Over 90% of Childhood BCG Vaccine-Induced Keloids in Japan Occur in Women.

INTRODUCTION: Keloids are a fibroproliferative, multifactorial, cutaneous disorder whose pathophysiology is not completely understood. Various factors such as high blood pressure, pregnancy, female gender, mechanical tension of local sites, and prolonged wound healing are known to worsen keloids. Childhood-onset keloids are keloids that form before 10 years of age, before various factors in adulthood come into play, and thus studying childhood-onset keloids may provide additional insight into the underlying mechanisms that lead to keloid formation. METHODS: Retrospective chart review was performed on all patients with childhood-onset keloids who were evaluated at our plastic surgery clinic (one of the largest keloid referral centers in Japan) over a 1-year period. RESULTS: Of the 1443 patients with diagnosis of keloids, 131 patients had childhood-onset keloids. Of these, 106 patients (80.9%) were female, 38.9% of patients had family history of keloids, and 48.9% of patients had allergies or allergy-related conditions (asthma, atopic dermatitis, or allergic rhinitis). Vaccination (47.5%) and chickenpox (19.9%) were the most common triggers. Of vaccinations, BCG was the most common trigger. The majority of keloids from BCG were in female patients (92.9%). The most common location was the chest in male patients (30.0%) and the arm in female patients (41.1%). CONCLUSION: To our knowledge, this is the largest report in the literature on childhood-onset keloids. There was overall female predominance in childhood-onset keloids, and even more significant female predominance in BCG-induced keloids.

Non-invasive treatment of recalcitrant keloids with contact brachytherapy using Phosphorus 32 skin patch and its effectiveness: a pilot study

Aim/Introduction: The keloids are benign dermal fibroproliferative tumors. Recalcitrant keloids are those that are unresponsive or recurred multiple times on the standard routine treatment. We analyzed the effect of the 32P skin patch on recalcitrant keloids in the Indian population. Material(s) and Method(s): 32P skin patch was applied locally for 3 hours, so to deliver 30 Gy of total radiation dose to the patients. Then patients were follow-up at 2 months, 4 months, and 6 months intervals. On each follow-up, HR USG was done for assessing the change in the dimensions of the lesion (thickness, length, and breath). VAS scores of pain and pruritis were also noted in all patients. Result(s): We found that there is a reduction in the thickness of recalcitrant keloids after applying a 32P skin patch with 30 Gy of the total dose in this single-arm trial using RM Anova with the post hoc test. Friedman's test was used for analyzing the VAS for pain and pruritis. Because of missed follow-ups in COVID, we analyzed the patients as two datasets: one with 6 months followup (recalcitrant lesions, n=9) and another with 4 months follow-up (n=24). There was a significant difference in thickness of recalcitrant keloids over 6 months and 4 months(p<0.01). The percent change from baseline on first, second, and third follow-up was 21%,28%, and 43%, respectively, for 9 recalcitrant keloids. The percent change from baseline on first and second follow-up was 22.1 % and 31.1%, respectively, for 24 recalcitrant keloids. So upon 30 Gy of dose by P32 skin patch, it showed a 22- 43% reduction in recalcitrant keloid thickness. However, visually, all patients showed complete resolution. There is a decrease in pruritis upon patch application over 4 months. The pain was uncommentable because 20/27 lesions had no pain during the baseline (VAS score of 0/10). All the patients experienced subjective symptomatic relief in pain and pruritis after the patch therapy. Conclusion(s): The decrease in thickness implies the effect of the 32P skin patch on recalcitrant keloids. Hence there was an optimum change of thickness from baseline with 6 months follow-up. No recurrence up to 6 months was observed during the follow-up. All the patients experienced subjective symptomatic relief in pain and pruritis after the patch therapy. So 32P skin patch is a cheap, non-invasive, effective treatment for recalcitrant keloids.

Postauricular Incision Keloid: An Unintended Consequence of COVID-19 Mask Precautions

Introduction: Keloids of the head and neck can result in significant disfigurement and psychological stress. Here we report a novel case of keloid formation at a well-healed postauricular incision presenting after a year of daily ear loop mask use and discuss unique considerations for management. Method(s): This is a retrospective case review of a 35-year-old African American man with Klinefelter syndrome, type 2 diabetes mellitus, and a history of hypertrophic scar formation who presented to otology clinic in 2015 with chronic left otitis media and cholesteatoma. He underwent left tympanoplasty and mastoidectomy in 2016 through a postauricular incision 1 cm posterior to retroauricular sulcus in a standard fashion. In 2018, the patient was noted to have a hypertrophic scar without extension beyond the borders of the incision that was stable until 2021. Result(s): In 2021, the patient was noted to develop a 12A 7-cm postauricular keloid in the setting of mechanical irritation from his mask worn throughout the COVID-19 pandemic. Given the disfiguring cosmesis and resulting challenges securing an ear loop mask, he elected to undergo complete excision of the postauricular keloid with tension-free primary closure of the wound, intralesional corticosteroid injection (triamcinolone acetonide 40 mg/mL), and pressure dressing. The patient was counseled on options for mask wearing to avoid contact with the postauricular incision. Conclusion(s): When designing postauricular incisions in patients prone to hypertrophic scar or keloid formation, the point of postauricular contact of ear loop masks is a novel consideration to minimize risk of future pressure-related injury. Counseling on alternative face masks that tie behind the head or anchoring ear loops to buttons sewn onto a hat or headband are other preventative pressures.

Aesthetic Reconstruction of Auricular Keloids with a Novel Hemi-keystone Flap.

Surgical management of helical and retroauricular keloids has been rarely discussed. This study aims to introduce our successful reconstruction of helical and retroauricular keloids using a novel hemi-keystone flap. The current study is a retrospective review of patients with pathologically confirmed helical and retroauricular keloids. All keloid cases were completely excised. We covered the defect with a hemi-keystone flap followed by a single fraction of 10 Gy radiation therapy at postoperative day 0 or postoperative pressure therapy using magnets for four months. Treatment outcome was recorded as recurrence or nonrecurrence. A follow-up period of a minimum of 12 months was required in all patients. Of 45 keloids in 33 patients, none of the cases had a recurrence of their auricular keloids and the postoperative course was uneventful. We successfully reconstructed helical and retroauricular keloids using our modified hemi-keystone flaps without any keloid recurrence in one-year follow-ups. This is especially useful during the COVID-19 pandemic when facial mask wearing is mandatory. LEVEL OF EVIDENCE IV: 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 .

The renin-angiotensin system in cutaneous hypertrophic scar and keloid formation.

Hypertrophic scar and keloid are two types of fibroproliferative conditions that result from excessive extracellular matrix production. The underlying pathological mechanism is not entirely clear. Activation of the renin-angiotensin system (RAS) is associated with fibrosis in various organs. RAS components including angiotensin II (Ang II), angiotensin AT1 and AT2 receptors, and angiotensin-converting enzyme (ACE) are expressed in the skin and act independently from the plasma RAS. AT1 receptors, which are usually the dominating receptor subtype, promote fibrosis and scar formation, while AT2 receptors inhibit the aforementioned AT1 receptor-coupled effects. Elevated angiotensin II (Ang II) levels acting on the AT1 receptor contribute to skin scar formation through increased expression of inflammatory factors such as interleukin-6 (IL-6), angiogenic factors such as vascular endothelial growth factor (VEGF) and fibrinogenic factors such as transforming growth factor-ß1 (TGF-ß1) and connective tissue growth factor (CTGF), while at the same time suppressing the anti-fibrotic tissue inhibitors of matrix metalloproteinase (TIMPs). First, small clinical trials have provided evidence that inhibition of the ACE/Ang II/ AT1 receptor axis may be effective in the treatment of hypertrophic scars/keloids. This review provides a detailed overview of the current literature on the RAS in skin, wound healing and scar formation and discusses the translational potential of targeting this hormonal system for treatment and prevention of hypertrophic scars and keloids.