Treatment of a Postburn Keloid Scar with Topical Captopril: Report of the First Case

Abstract

Sir: Hypertrophic scar and keloid are the two main disfiguring complications of wound healing. Distinct pathogenesis is poorly understood and few effective therapeutic options are currently available.1 It is currently known that the local renin-angiotensin system in the skin plays a role in the control of collagen biosynthesis and wound healing.2 We have previously shown that captopril effectively prevents hypertrophic scar formation in New Zealand White rabbits.3 This article represents the first human case successfully treated with topical captopril as a new antikeloid agent. An 18-year-old female patient with a history of a burning accident caused by boiling water approximately 5 months before her first visit to our clinic presented with a keloid lesion on the dorsal side of the left hand between her first and second fingers and the dorsum of the second finger (Fig. 1, above).Fig. 1.: Photographs of an 18-year-old female patient with a postburn scar on the dorsal side of her first and second fingers (above). Twice-daily application of topical 5% captopril for a period of 6 weeks led to a moderate to marked improvement of the keloid lesion and significantly decreased the redness, scaling, and itchiness (below).Written informed consent was obtained and then the patient was provided with 5% captopril (Sigma Chemicals, Buchs, Switzerland) solution in cold cream. After 6 weeks of twice-daily application of the cream, a marked improvement of the keloid lesion was achieved as the height of the lesion decreased from 9 to 11 mm to 2 to 4 mm, the redness and scaling were noticeably eliminated, and she has not complained of itchiness (Fig. 1, below). The patient's blood pressure was measured by using a sphygmomanometer (ALPK2, Japan) at the time of the first application; at 5, 15, 30, and 60 minutes after application; and at 2, 4, 12, and 24 hours after application. The patient was warned about all predictable side effects. The topical application of captopril was not associated with any cutaneous or systemic side effects and the product was well tolerated by the patient. The distinct pathogenesis of keloid and hypertrophic scar formation is poorly understood; however, it is characterized histologically by increased fibroblast proliferation and collagen fiber deposition4 in diverse forms of normal tissue. As a result, suppression of overwhelming and uncontrolled fibroblast activity and degradation of already produced collagen fibers may be the crucial step in the method of keloid and hypertrophic scar treatment. The inhibition of angiotensin-converting enzyme by captopril in the skin could theoretically result in the blockage of angiotensin II formation which, in turn, suppresses the expression of transforming growth factor-β15 and the release of interleukin-6. Eventually, these processes block fibroblast proliferation and collagen production and precipitate matrix metalloproteinase activity. As our previous study has shown, topical application of 5% captopril could effectively reduce the height of scar formation and increase the organization of deposited collagen at the site of wounding in the ears of New Zealand White rabbits.3 In this study, as the first phase of a clinical trial, we have shown the efficacy of topical 5% captopril in a human patient. Consequently, a vehicle-controlled double-blind clinical trial is warranted to evaluate the clinical efficacy and presumed side effects of topical captopril as a novel, effective, safe, and easy-to-use treatment against hypertrophic scar and keloid formation. Gholamreza Safaee Ardekani, M.D. Department of Dermatology Jahrom University of Medical Sciences Jahrom, and Endocrinology and Metabolism Research Center Shiraz University of Medical Sciences Shiraz, Iran Shahin Aghaie, M.D. Department of Dermatology Jahrom University of Medical Sciences Jahrom, Iran Mohammad Hassan Nemati, M.D. Department of Cardiac Surgery Farhad Handjani, M.D. Department of Dermatology Shiraz University of Medical Sciences Shiraz, Iran Behrooz Kasraee, M.D. Department of Dermatology Jahrom University of Medical Sciences Jahrom, Iran, and Department of Dermatology Geneva University Hospital Geneva, Switzerland