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Topiramate and scars

  • Author(s): Rakesh, Bharti
  • Lovedhi, Agarwal
  • et al.
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Topiramate and scars
Bharti Rakesh and Agarwal Lovedhi
Dermatology Online Journal 11 (3): 42

BDC Research Center, Amritsar. rakesh.bharti1@gmail.com

Abstract

Topiramate may be a safe and effective treatment for scars. Shapira et al. reported an open label study on ten adult subjects with discolored or raised scars at least 2 years old who were given topiramate in an oral dosage of 15 mg per day for 1 month. The dosage was then increased to 30 mg per day if there was minimal or no improvement [1]. Based on that study, BDC Research Centre treated 91 patients with various scarring conditions including post acne, varicella, dermatitis scars, melasma, hypertrophic scars, and keloids. Excellent to good results were observed in post-acne and post-varicella scars.



Introduction

Scars are the visible reminders of injury (trauma, acne, infections) and tissue repair. Two types of true scars exist.

  • Depressed areas such as ice pick scars
  • Raised thickened tissue such as keloids and hypertrophic scars

For depressed scars, modalities like subscision, dermal abrasion or punch grafting are in fashion.

Clinicians may find it difficult to treat hypertrophic scars and keloids. Multiple treatments have been proposed, often backed by anecdotal evidence alone. Some treatments, such as topical vitamin E, have been widely promulgated in the popular press as effective. Other agents have been marketed directly to the consumer despite a lack of evidence [2].

Intralesional corticosteroids, topical applications, cryotherapy, surgery, laser therapy, and silicone sheeting are widely used options. Radiation therapy can also help in cases of recalcitrant keloids. Most recently, pulsed-dye laser has been successfully used to treat keloids and hypertrophic scars. There are no set guidelines for the treatment of keloids. Treatment has to be individualized depending upon the distribution, size, thickness, and consistency of the lesions and association of inflammation. A combination approach to therapy seems to be the best option [2].

Based on the report of Shapira et al.[1] we (BDC Research center, Amritsar) tried Topimarate for various types of scars in patients visiting our center during 2004.


Material and methods

All the patients attending BDC research center, Amritsar during the calendar year 2004 with post-acne scars, post-varicella scars, post-dermatitis pigmentation , post-traumatic scars followed by injuries of minimum 2 months, hypertrophic scars , keloids, and melasma were selected for treatment with topiramate 25 mg daily. Pregnant and lactating mothers, children of less than age 14 were not included. Patients on some sort of anti-epileptic drugs and those with neurological disorders were excluded. All the patients were followed up for 3 months minimum; those who could not maintain followup were deleted from this study. An evaluation by the patient and consultant was done individually at fortnightly basis. An improvement in terms of percentages as per the consensus of patient and consultant was recorded as follows:

  • 0-25 percent—none
  • 25-50 percent—average
  • 50-75 percent—good
  • 75 percent—excellent

Photographs were attempted at the beginning and end but there was not full compliance. These patients were still included in the study based on satisfactory criteria described above.


Results


Figure 1 Figure 2

91 patients (40 males and 51 females) of various age groups (Table 1) were included for the study. There were 33 patients with post acne scars (PAS), 27 with post dermatitis scars (PDS), 12 with post traumatic scars (PTS), 6 with post varicella scars (PVS), 2 with hypertrophic scars, 5 with keloids, and 6 with melasma. (Table 2)

Overall good to excellent response was found in 65 (71 %) patients. There was an excellent response in all the patients with post varicella scars. The response in post acne scars was also encouraging (93 % had good to excellent result). The response in keloids was not good. In melasma the response was average (Table 3). No side effects were observed in any of the patients.


Discussion

Scars are the unpleasant looking visible marks of past trauma (acne, burn, infection, accident etc.). Although the formation and healing of scars has been studied over 2000 years [3], there continues to be need for new treatment because current technique and technologies offer inconsistent and often limited results [4]. Current treatment for scars include cryosurgery, dermabrasion, laser camouflage, physical therapy, radiotherapy, silicon gel sheets, steroid injections, surgery, tissue implantation, and topical products (such as onion extract gel)[5].

Topiramate[2,3:4,5-bis-O-(1-methylethylidene)-B-D-fructopyranose sulphamate] is a novel agent approved for the treatment of epilepsy, which does not have the typical weight gain liability of antiepileptic. Common side effects of topiramate include fatigue, difficulty concentrating, parathesia, somnolence, ataxia, dizziness, weight loss, and an increased incidence of nephrolithiasis consistent with the fact that topiramate is a carbonic anhydrase inhibitor. Several possible mechanism of action have been identified for topiramate: (1) state-dependent blockade of voltage activated Na+ channels; (2) facilitation of GABergic activity at a non benzodiazepine sit on gamma amino butyric acid (GABA) receptors; and (3) antagonism of kalinate/AMPA-type glutamate receptors [6].

Shapira et al.[7] observed decreased skin picking and apparent improved healing of open lesions and scars with topiramate in their patients of PWS (Prader Willi Syndrome). In light of their observation they hypothesized that topiramate will also be effective in scar therapy and based on this they conducted a 3-month open-label study in ten adults with discolored or raised scars at least 2 years old giving 15 mg od topiramate for first month and then increasing it to 30 mg if there was no or minimal improvement. They found topiramate to be safe and effective treatment for scar therapy.In conditions like acne too we believe there can be some sort of self injurious behavior, most notably skin picking due to psychogenic effects of acne in many patients. With this observation and based on results of Shapira et al., we at BDC Research center also undertook the present study.

In this study we had good results especially in post acne scars and post varicella scars but we believe the results need further verification by larger double blind trials. This particular report should draw the attention of others to this indication of Topiramate.

References

1. Shapira NA, Lessig M, Murphy TK, Annis AM, Lazoritz M. Evaluation of open-label topiramate for scar therapy. Dermatol Online J. 2003 Dec; 9(5):3.

2. Mutalik S.Treatment of Keloids and hypertrophic scars. Indian J DermatolVenereol Leprol 2005; 71:3-8.

3. Fu X, Wang Z, Seng Z.Advances in wound healing research in China: from antiquity to the present. Wound Repair Regen.2001 Jan-Feb;9(1):2-10.PubMed

4. Wittenberg GP,Fabin BG,Bogomilsky,et al.Prospective,single blind,randomized,controlled study to assess the efficacy of the 585-nm flash lamp-pumped pulsed dye laser and silicone sheeting in hypertrophic scar treatment.Arch Dermatol,1999;135:1049-1055.

5. Menter A, Niroomand F.Wounds and scars: Therapeutic options. A supplement to drug topics.1998; 3:1-15.

6. Privitera MD (1997).Topiramate: a new antiepileptic drug.Annals of Pharmacology 31, 1164-1173.

7. Shapira NA, Lessig M, MurphyTK, Driscoll DJ and Goodman. Topiramate attenuates self Ðinjurious behaviour in Prader-Willi syndrome.Inernational J of neuropsychopharmacology (2002), 5,141-145.

© 2005 Dermatology Online Journal