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KELOIDS AND HYPERTROPHIC SCARS

Keloids and hypertrophic scars are abnormalities in the normal wound healing characterized by greater and more sustained extracellular matrix deposition that develops after any insult in the dermis.

It can affect the patient's quality of life, both physically and psychologically.

Hypertrophic scars are raised fibrous tissue scars that remains within the boundaries of the wound. Hypertrophic scars that resulted from surgery or trauma are called linear hypertrophic scars while those from burn injuries or extensive tissue trauma and/or infections are called widespread hypertrophic scars.

Keloids are elevated fibrous scars that extend beyond the borders of the original wound. Major keloids resulted from minor trauma while for those from genetic predisposition with autosomal-predominant features are called minor keloids.

 

 

Prevention

  • Management of scars should begin even before the surgical procedure & continue 12-24 months afterwards
  • History of scarring problems should be asked to the patient before surgery
  • Informed consent form should have a discussion about potential for keloid formation
  • Prevention measures should be continued & intensified if the patient develops early hypertrophy in linear scar at 6 weeks to 3 months after surgery or trauma
  • Prevention measures include:
    • Knowing how to prevent scars
    • Learning how to identify them immediately
    • Managing postoperative complications correctly
    • Having a thorough understanding of wound healing & skin biomechanics

Surgical Technique

  • Cornerstone in minimizing scar formation
  • To minimize trauma to the tissue, fine instruments & atraumatic surgical technique should be utilized
    • To avoid crushing injury to delicate tissues, hooks are used in retraction & double grasping w/ forceps should be avoided
  • Wound that has sharply-defined edges & aligned without tension should be achieved in order to have the least amount of scar formed
  • Sutures should be placed at the periphery of the wound so that redundancy can be worked towards the middle
  • Suture material used is essential as some sutures can cause immune reaction
    • Monofilament absorbable synthetic biopolymers produce the least reaction
  • Provide rapid wound closure such as early debridement of dead tissue
  • Decrease risk of infection by thorough rinsing & disinfection
  • After wound closure, tension relief, hydration, taping, occlusion, & pressure garments should be done immediately
  • Optimal dressings that provide moist wound healing &/or early wound coverage is suggested
    • Moisturizing emollient & humectant creams & moisture-retentive dressings may reduce itching in the scars, size & pain or discomfort associated w/ scars as well as improve appearance
  • Careful & meticulous handling of tissue, evacuation of blood from the wound, accurate wound edge alignment during closure, & precise suture placement will decrease inflammation & therefore also scarring
  • A large randomized study done in 40 Japanese patients who had undergone surgery showed that there is a postoperative recurrence rate of 40% in linear & 15% in small-wave incision of hypertrophic scar
  • Intraoperative skin stretching for wound closure after scar excision was found effective & sustainable in a randomized controlled trial
  • In a randomized trial, it was found that non-absorbable skin sutures diminished the risk of hypertrophic scars after midline sternotomy incision

Silicone Therapy

  • First-line non-invasive prophylactic treatment for hypertrophic scars & minor keloids
    • Silicone-based products are also preferred for scar prevention in both low- & high-risk wounds
  • Normalizes the transepidermal water loss by restoring the water barrier through occlusion & hydration of the stratum corneum that helps to prevent excessive scar formation
  • Silicone gels are used for prophylaxis of unpleasant scarring particularly in areas of consistent movement where sheeting will not conform
    • Need to be placed for at least 12 hours a day for 3-6 months
    • It is similarly effective as silicone gel sheeting in the prevention of hypertrophic scars in Asians
    • It is effective in erythematous scars that results from laser exfoliation
    • Preferred due to ease of application, use in high-mobility area (eg joints), use on the face or in humid weather
Intralesional Corticosteroids (eg Triamcinolone acetonide)
  • Concurrent injections of intralesional corticosteroid are recommended in severe case of high-risk wounds
Other Dermatologicals (eg Onion Extract-Based Topical Preparations)
  • Preventive option for patients w/ increased risk for scarring although some studies show negative results

Hypoallergenic Microporous Paper Tape

  • Preventive option that may be considered during the early stages of scar formation
  • Studies showed significant reduction in development of hypertrophic scars after surgery

Pressure Therapy

  • Pressure garments are frequently used for the prevention of excessive scar formation in post-burn cases
  • It is being applied as soon as the wound has closed & the patient can tolerate the pressure

Avoid Sun Exposure

  • Avoid exposure to sunlight & recommend continuous use of sunscreen w/ a high to maximum sun protection factor until the scar has matured
    • Studies have shown that ultraviolet radiation increases scar pigmentation & worsens clinical appearance of scars
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