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Radiotherapy is particularly effective as a surgery adjunct. Recent meta-analysis of 72 studies 119 showed that surgery plus radiotherapy is associated with fewer recurrences (22 percent) than radiation monotherapy (37 percent). Notably, this surgery plus radiotherapy rate is higher than the rate in our center (<10 percent). 112 This may reflect the fact that the meta-analysis examined studies published from 1957 to 2014. 112 Refinements in surgery, radiotherapy, and postoperative care techniques probably all contribute to our low recurrence rate. A meta-analysis 99 of five trials showed that bleomycin injections improved hypertrophic scars and keloids more effectively than triamcinolone acetonide and/or 5-fluorouracil injections. A 14-study review on topical onion extract gel (a nonsteroidal antiinflammatory drug) reported that 11 detected beneficial effects on hypertrophic scars and keloids. 100 The most effective treatment is intralesional steroid therapy,using triamcinolone acetonide as follows: Prospective Evaluation of the Use of Intralesional Cryotherapy for Treatment of Keloid and Hypertrophic Scars Many other treatments have been used including photodynamic therapy, laser therapy, radiotherapy, intralesional bleomycin andintralesional 5-FU
Oral tranilast (an antiallergic drug) improves inflammatory diseases with few adverse effects. It has long been used in Japan to treat hypertrophic scars and keloids. 5 , 101–103 Randomized controlled trials showed that tranilast improved hypertrophic scars and keloids and reduced the redness of new postsurgical hypertrophic scars. 104 keloid Treatment Laser therapy such as PDL, CO 2 and Nd:YAG have been associated with a high rate of recurrence at 6–24 months. 111, 113 – 115 However, optimal results can be achieved with combination treatment especially with intralesional TAC injections. 116 – 118 Kumar and co-workers conducted a cohort study on 17 patients with keloids previously treated with an Nd:YAG laser and reported complete scar resolution and flattening in seven patients only when intralesional TAC was used after laser therapy. 41 Moreover, combined therapy with PDL and TAC 119 and PDL, TAC and 5-FU 36 were shown to produce better clinical results. In a recent study that evaluated and compared the efficacy of combination therapy of fractional CO 2 laser and intralesional TAC injection or TAC injection alone in keloid and hypertrophic scars, statistically significant improvements were reported in overall scar quality with the combined treatment options compared to TAC monotherapy. 120 Moreover, combined CO 2 laser and IFN-α-2b injections given to patients with auricular keloids resulted in no recurrence in 66% of patients three years after treatment. 121 Laser therapy can also be combined with other laser treatment, topical corticosteroids and cyanoacrylate glue 98 and have shown promising results; however, larger, controlled clinical studies are needed to further evaluate their efficacy and safety. Several genetic diseases associate with keloidogenesis, including Rubinstein-Taybi syndrome 43 , 44: a cross-sectional study 44 reported that 24 percent of such patients had spontaneously growing keloids. Multiple hereditary exostoses also associate with keloidogenesis. 45 Treatment of hypertrophic scars with deprodone propionate plaster. ( Left) Pretreatment view. ( Right) Three years after starting deprodone propionate plaster. A 50-year-old woman had several hypertrophic scars as a result of cesarean delivery. She was provided with deprodone propionate plaster and told to apply it 24 hours per day until further notice. She was instructed to peel it off while taking a bath and then reapply it. When the plaster lost its adhesiveness, it was replaced by a new plaster. After 6 months, the scar became soft. After 3 years, the scar became completely flat and its tone was close to that of the surrounding skin. Corticosteroid Ointment and CreamAfter a period, the dressing will dry out; this is normal and a sign of its proper function. Remove and replace the dressing if necessary. Cryosurgery, which involves freezing early scars with liquid nitrogen to prevent them from growing, is another effective keloid scar treatment. After surgery, your doctor may then recommend corticosteroid injections to reduce inflammation and lower the risk of the keloid returning.
Hypertrophic scars are detected several weeks after injury ( Fig. 1). They grow for 3 to 6 months; if risk factors are minor, they then plateau and regress spontaneously. This process can be accelerated by the following conservative therapies, which reduce hypertrophic scar volume and suppress pain and itch. Hypertrophic scars rarely require surgery unless they contract and cause joint dysfunction 49 , 50; in this case, reconstructive surgery is indicated. Compression Therapy Pre-clinical and clinical studies have shown that under moist conditions, wounds can heal faster and scab formation is prevented. This is because moist wound healing, which is used in hospitals for many years, is available in the following three countries in different preparations. In the UK, the commercially available formulation comprises a fludroxycortide-impregnated tape (4 μg/cm 2) [ 1]. Fludroxycortide tape Several corticosteroids can be used for the treatment of scars including triamcinolone acetonide (TAC), hydrocortisone acetate, dexamethasone and methyl prednisolone. 24 However, since 1961, 25 TAC has been the most widely used corticosteroid for the treatment of keloids. 26, 27 Intralesional TAC injections have been shown to reduce scar volume and height, improve scar pliability, and diminish associated scar pain and itching 8 as well as prevent recurrence. 3 Corticosteroids have anti-inflammatory and anti-mitotic properties. 1 Several other mechanisms have been reported by which corticosteroids reduce keloid scar including inhibition of fibroblast growth, attenuation of procollagen and glycosaminoglycan synthesis, reduction of endothelial budding and enhancement of collagen and fibroblast degeneration. 28, 29 Corticos-teroids inhibit TGF-β1 expression and induce apoptosis in fibroblasts, inhibit VEGF and alpha-globulins, which are involved in the wound healing process. 28 – 31 VEGF, which promotes angiogenesis, was reported to be highly expressed in keloid fibroblasts compared to controls but exogenous addition of the glucocorticoid dexamethasone suppressed its expression in vitro. 32 Furthermore, VEGF expression was overexpressed in keloid tissue which later reduced following intralesional TAC injections in vivo. 33In Japan, corticosteroid tapes and plasters have long served as a first-line therapy for keloids and hypertrophic scars. can also be used in combination with other therapies such as corticosteroid injection. This is particularly suitable for adults with keloids and hypertrophic scars. The patients can apply the steroid tape/plaster every day in their homes and undergo the injection when they can go to the hospital. In our hospital, we succeeded in reducing the number of hospital visits of patients with pathological scars by adopting this approach. Indeed, many
These risk factors cannot be obviated. Thus, patients with familial history and genetic diseases should be treated carefully during and after surgery. The relatively low frequency of keloid-associated single-nucleotide polymorphisms means that testing for them is impractical. Lifestyle The patient should be treated by a health professional who has had the necessary training and is able to perform skin surgery to a high standardwill only have the same effect as 24-hr/day deprodone propionate plaster if the ointment is applied to the affected area 4 times a day and is covered with an occlusive dressing technique (ODT) Gel sheets are soft and self-adhesive. A meta-analysis (20 trials) 27 reported that continuous gel sheeting improves hypertrophic scar maturation. A new meta-analysis 51 on this question is currently underway: it will be of interest to learn their findings. These problems can be overcome by using steroid tapes/plasters. Most pediatric and older patients can be treated by steroid tapes/plaster alone due to their thinner skin, which means that the steroids are easily absorbed. Reduce Your Scars and Reclaim Your Skin – Silicone sheets for scars by Medi Grade are designed to enhance scar appearance, resulting in thinner, softer, less red scars. Ideal for c-section, keloid scar reduction, and more All patients undergoing surgery on susceptible body areas should be monitored closely for hypertrophic scars and keloids for 3 to 12 months. If induration is observed, steroid tape and plaster should be started and replaced with steroid injection if the induration prevails. Systemic
The type of material may not matter: a randomized controlled trial 52 showed that silicone and hydrocolloid matrix gel sheets reduce hypertrophic scar dimensions equally well. More important may be patient education: a randomized controlled trial 53 on burn and hypertrophic scar patients suggests that instructional handouts and videotapes increase gel sheet effectiveness. Computer analysis suggests that gel sheets may prevent hypertrophic scar formation and promote hypertrophic scar maturation by limiting wound and scar tension. 54 Scar MassageTreatment of a chest wall acne keloid by using Z-plasty and postoperative radiotherapy. ( Above, left) Preoperative view. ( Above, right) Immediately after total keloid excision. ( Below, left) Immediately after surgery. ( Below, right) Two years after surgery. A 60-year-old man developed a chest-wall keloid as a result of acne. It was excised completely and the wound was closed with Z-plasties to release the tension on the scar. The surgery was followed with electron beam radiotherapy (18 Gy, in three fractions, over 3 days). The inflammation dropped uneventfully and the scar became mature over 18 months. Silicone gel / sheets, used post operatively for several months will reduce scar formation in some patients Cryosurgery can by an effective treatment in some patients, especially for small scars of recent onset Laser therapy for keloid treatment was introduced in the 1980s. 97 Since then, different systems have been used for the treatment of keloid and hypertrophic scars. 48, 98 These lasers target skin chromophores like haemoglobin and melanin, based on the principle of selective photothermolysis. 99 Lasers can be classified as ablative and non-ablative. The most common ablative lasers include the 2940-nm erbium-doped yttrium aluminium garnet (Er:YAG) laser and the 10,600-nm carbon dioxide (CO 2) laser. These emit a laser beam that is absorbed by water in the skin leading to local tissue destruction and reduction of lesion volume. 3 Common examples of non-ablative lasers include 585-nm or 595-nm PDLs, 1064-nm neodymium-doped:yttrium-aluminium-garnet (Nd:YAG) laser, 532-nm neodymium-doped:vanadate (Nd:Van) laser and 1064 nm Q-switched Nd:YAG laser with low fluence. 100 These lasers induce thermal injury to the scar’s microvasculature leading to thrombosis and ischaemia which result in collagen denaturation and collagen fibre realignment. 101 – 103 Silicone Scar Gel On a Roll – You receive a 2-meter roll of scar reduction plasters. The elastoplast scar reducer can be cut to size using the perforated lines. No greasy residue, odors, or irritation, these silicone strips scar provide ‘next to skin’ comfort
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