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EUROPEAN TISSUE REPAIR SOCIETY

SCAR CONTROL I

SCAR EVALUATION AND MANAGEMENT: RECOMMENDATIONS

Luc Téot, Montpellier University Hospital, Montpellier, France

THIS paper is inspired by international recommendations undertaken under the authority of Thomas A. Mustoe MD (Chairman, USA), with the participation of Rodney D. Cooter MD (Australia), Michael H. Gold MD (USA), F.D. Richard Hobbs FRCGP (UK), Albert-Adrien Ramelet MD (Switzerland), Peter G. Shakespeare MD (UK), Maurizio Stella MD (Italy), Luc Tιot MD (France), Fiona M. Wood MD (Australia), Ulrich E. Ziegler MD (Germany) for the International Advisory Panel on Scar Management.

Introduction

Scars are commonly characterised by definitions concerning the depth of elevated tissue, the colour, softness, shape and orientation. Evolution of the proliferative process and histopathological differences are also used to differentiate a hypertrophic scar, a process generally limited in time, from a keloid, which involves a permanently evolving production of cells, covering the initial edges and extending beyond the original scar boundary into the surrounding skin. Clinically, some tools can be used in order to help physicians to characterise and monitor the pathologic scar. The Vancouver scale has been validated for burn scars, but it remains difficult to transpose this assesment scale to other types of scars. Some predisposing factors such as the type of skin injury (traumatic, surgical, burns); the anatomical location (face, neck, arms); genetic susceptibility and environmental or nutritional influences are well known.

Clinical evaluation needs to be standardized in order to provide the maximum amount of useful information. This point is important when trying to determine a progression profile and in order to anticipate therapeutic consequences.

In a recent review of the literature1, an independent international panel provided evidence-based recommendations concerning scar management, based on a qualitative overview of over 300 published references using standard methods of appraisal. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations.

Types of scars

Scars can be defined by their contour, colour, shape, measurements, width, orientation following natural lines of strength of the skin, texture, extensibility. Some parameters previously used to evaluate burns scars are decribed here using the same classification.2

1) Contour

Elevated scar tissue can be observed in situations where the scar edge is formed by tissues presenting differences in depth or different lymphatic modes of drainage: a linear scar can present a step-wise aspect; a post-operative suture following excision of a large piece of skin can present irregularities at the extremities. Flaps, mainly circular, will present a centripetal retraction, due to an apparent excess of tissue. Differences in the structure and depth of two areas of skin where one originates from a different anatomical region will lead to a scar having a tendency not to follow the usual lines of tension of the grafted area. The aesthetic aspect following any type of flap placement must often be analysed dynamically because most of these flaps become bulky or create retractions when moving inside the recipient area.

Hypertrophic scars can be defined as areas containing an excessive number of collagen fibres remaining inside the scar limits, the scars presenting an abnormal depth. Progression with time characterises this type of pathologic scar. The hypertrophic process generally starts four to six weeks after the injury, increases during three to seven months, with the scar stabilising after this time and regressing in colour and volume after one year. Clinically, hypertrophic scars are red, covered by a thin epithelium, pain is variable, hardness is palpable and surrounding tissues present moderate inflammation. These scars are more prone to develop in certain areas like the thorax, neck, arms and legs, and are less prone to develop on the ear concha or the plantar aspect of the foot. The presence of bone immediately below the affected skin can be considered as a preventive factor. Hypertrophic scars do not develop on sites where pressure ulcers appear. Scars crossing natural skin lines of tension are more frequently affected by hypertrophy. Joints and other mobile areas are more involved and the mechanical factor seems to be predominant.

Keloid scars are defined as a progressive accumulation of scar tissue, extending over the original scar edges, a pseudo-tumoral proliferation. The causes are not clear. A genetic factor has been hypothesized, as well as the body skin colour. Individuals with dark skin present higher risks, but fair-skinned individuals are also considered as presenting some risk of keloid development. A specific hormonal environment has been frequently reported, elderly people presenting a lower risk of keloid formation than teen-agers or adults. The aspect of a keloid can be similar initially to that of a hypertrophic scar, but its evolution is constantly progressing during the first six months, resulting in a pseudotumor appended to the scar by a narrow base.

Depressed scars, atrophic scars and spread scars are characterised by the absence of underlying structure below the epidermis. These situations are more often observed either after loss of dermal-epidermal substance and skin grafting over an aponeurosis, or when some tension exists on the edges of the scar, as after naevus resection on the back.

2) Degree of congestion, colour, vascularity

A parameter comprising these aspects has been defined in the Vancouver scale3 and three different abnormal stages have been proposed :

0: normal colour that closely resembles the colour over the rest of the body.

1: pink. This colour, usually observed during a transient period of time in most of the normal maturation processes, becomes a warning signal of pathological scar when it remains present after the second month of evolution.

2: red. A red aspect is linked to a scar hypervascularization. This colour becomes obvious 4 to 8 weeks after complete healing and is a good sign of pathologic evolution. Usually, a red scar is combined with a progressive elevation, defining a scar hypertrophy.

3: purple. A purple scar is observed in highly vascularized scars, like burn scars or at the initial stage of a keloid process.

One of the main interests of these categories is in the use of vasopression as a tool to evaluate the scar vascularity. The time of recoloration after a provoked digital pressure on the scar can be measured and this time has been considered as a reflection of the scar evolution. This characteristic has also also been used to assess the effects of localised treatments (silicone gel sheets, corticosteroid injections, compressive garments).

3) Pigmentation.

This charactetristic is more applicable to burn scars which extend over a large surface and have been subjected to different degrees of injury. Problems of pigmentation following dermabrasion (traumatic or therapeutic) have also been reported.

0: normal skin
1: hypopigmentation
2: hyperpigmentation

4) Shape

Various shapes of scar can be encountered. A good analysis of the scar shape is useful in determining which therapeutic mode should be proposed. Some shapes can be conservatively treated, trying to obtain an attenuation of the aesthetic aspect without complete removal of the area, others can just be excised (subsequent coverage can be made using several techniques). Scar shape can be linear or curved, trap-door, semi-circular, web or broken line, stellate, ice-pick or pitted, overhanging or avulsed.

5) Anatomical location

Scars crossing mobile areas like joints are more prone to retract and to provoke contractures. Direction is important and scars crossing Langer lines are prone to retract. The anterior and posterior thoracic areas are more prone to develop hypertrophy. This may be due to the major mechanical forces applied by the great mobility of the skin or by the weight of the breasts in females. However, in the neck area, the relative absence of underlying mechanical resistance also leads to the development of hypertrophic scars. It is important to determine local biomechanical factors, either before or after creating a surgical scar, in order to propose a corrective solution.

6) Width

Scars subjected to mechanical forces will enlarge to some degree, depending on their anatomical location (shoulder, thorax, back). This enlargement can be associated with atrophy (frequently observed after the excision of naevi), or with hypertrophy (thermal burns).

7) Height

The Vancouver scale promoters proposed a classification of height changes in burn scars, which can be extended to other types of scars, including negative values for atrophic scars. Evaluation can be made using different tools, such as clinical evaluation or photospectroscopy. An increase in height is a useful sign of a pathologic scar and is related to an excessive amount of collagen synthesis.

0: normal
1: height (h) <2mm
2: 2mm < h <5mm
3: h >5mm

8) Texture, consistency, extensibility, pliability

Multiple situations can be observed with regard to the scar texture and its pathogenicity. Usually, stages 3 and 4 require local treatment, but for stage 5 surgery needs to be considered.

0: normal,
1: supple: flexible with minimal resistance,
2: yielding: giving way to pressure,
3: firm: inflexible, not easily moved, resistant to manual pressure,
4: banding: producing striations which blanche on stretching but with no limit to the range of motion,
5: contracture of any type of scar limiting the range of motion.

Clinical assessement strategy

The Vancouver scale3 was proposed in 1990 to rate burn scars. Pigmentation, vascularity, pliability and scar height were assessed independently, with an increasing score being assigned to the more serious pathologic condition. This scale has proved to be useful for classifying burn scars, and has been validated in this context. The extension of the use of this scale to other types of scars remains subject to discussion.4–7,9,10

How can one score a depressed scar observed in the postoperative period in certain anatomical locations? Should the thermal burn scar progression curve be considered as a general feature adaptable to all scar situations? The main difficulty remains to determine as early as possible whether a scar will become pathologic.

We propose a scheme for gradual assessment, from month to month, with the initial clinical evaluation being made at the end of the first month after complete healing.

1) First month evaluation

a) Clinical assessment will determine the general scar features, focusing on colour and elevation. At this stage, colour and vascularity seem to be the most important parameters for evaluating the scar correctly. If a scar is red and hypervascular, the risk of hypertrophic evolution is considerable. Preventive measures such as silicone gel sheets will be useful.

b) Laser doppler evaluation can be proposed as a complementary technique to assess hypervascularisation.

2) Second month evaluation

a) Clinically, changes in width, height and colour are more evident. Local treatments may be indicated in the presence of hypertrophy, redness and increased width.

b) Laser Doppler evaluation can confirm the scar hypervascularisation.

3) Third month evaluation Signs are generally obvious. Hypertrophy is visible, troubles in pliability and texture are patent.

Prevention

Reiffel has proposed the systematic preventive use of adhesive sutures after any surgical incision. In a randomised controlled study, he demonstrated the utility of such preventive measures. A strategy of early clinical assessment can be considered as a good precautionary measure to prevent the pathologic evolution of scars, whatever be the origin of the scar and the intensity of the pathologic process.

Treatment

On the topic of scar management, too many solutions have been proposed, some of them showing insufficient evidence in terms of the analysis of results. The authors of the review1 concluded that silicone gel sheeting and intralesional corticosteroids are the only treatments for which sufficient evidence exists to make evidence-based recommendations in the management of a wide variety of abnormal scars. Other standard practices and new emerging therapies need large-scale studies with long-term follow-up before being recommended as alternative therapies. Where studies are insufficient, this paper reports the expert consensus on best practices from an international group with extensive experience and interest in the treatment of scarring1. While focussing primarily on the management of hypertrophic scars and keloids, the recommendations are internationally applicable in a range of clinical situations.

1) Surgery

Surgical excision of hypertrophic scars or keloids is a common management option when used in combination with steroids and/or silicone gel sheeting. However, excision of keloids on its own results in a high rate of recurrence (45– 100%).11–14 Combining surgery with steroid injections reduces the recurrence rate of keloids to less than 50% while the combination of surgery with perioperative radiation therapy reduces recurrence to 10%.11,15

Hypertrophic scarring resulting from excessive tension or wound complications, such as infection or delay in healing, can be treated effectively with surgical excision combined with surgical taping and silicone gel sheeting. Scars that are subject to tension require substantial physical support. The authors of the review1 agreed that the most effective way of splinting scars is by surgical closure with intradermal sutures for at least six weeks, and, when tension is substantial, for up to six months. Surgical techniques, such as W-plasty and Z-plasty, improve the appearance and mobility of contracted burn scars but are not appropriate for immature hypertrophic scars.16 Special procedures (e.g., prefabricated flaps) have been proposed in exceptional situations.17

2) Corticosteroid injections

Despite relatively few randomised, prospective studies there is a broad consensus that injected triamcinolone is effective and should be first-line therapy for the treatment of keloids and second-line therapy for the treatment of hypertrophic scars if other easier treatments have failed.15,18–24 Despite the use of corticosteroids in scar management since the mid-1960s their principal mechanism of action remains unclear.25,26 Response rates vary from 50–100% with a recurrence rate of 9–50%.19 Results are improved when corticosteroids are combined with other therapies such as surgery 11,13,27 and cryotherapy.28,29

Intralesional corticosteroid injection is associated with injection pain, even with standard doses of insoluble triamcinolone (40 mg/ml), and up to 63% of patients experience side-effects that include skin atrophy, depigmentation and telangiectasias.30 Topical steroid creams have been used with varying success,30 but absorption through an intact epithelium into the deep dermis is limited. A prospective, randomised study shows that topical steroids do not reduce scar formation in post-burn deformities.31

3) Silicone gel sheeting

Silicone gel sheeting has been a widely used clinical management option for hypertrophic scars and keloids since the early 1980s.33–38 Despite initial scepticism, there is now good evidence of its efficacy and silicone gel sheeting has become standard care for plastic surgeons. Results from at least eight randomised, controlled trials and a metastudy of 27 trials39 have demonstrated that silicone gel sheeting is a safe and effective management option for hypertrophic scars and keloids.40–49 Totally occlusive dressings (e.g., polyethylene films) and semi-occlusive dressings, such as polyurethane films have not shown evidence of efficacy and evidence for the effectiveness of other materials such as glycerine and other non-silicone based dressings is mixed.50,51,52

Silicone gel sheeting may be especially useful in children and people who cannot tolerate the pain of other management procedures. Silicone products vary considerably in composition, durability and adhesion. To date, most conclusive trials have been undertaken on pure adherent silicone gel sheeting. It is not known whether these results are transferable to other fabric/polyurethane dressings with silicone adhesive or to non-adherent silicone products.53 Some formulations of silicone oil have been shown to be effective on minor hypertrophic scars although these studies have limitations in their design.40,54

4) Pressure therapy

Pressure therapy has been used in the management of hypertrophic scars and keloids since the 1970s.55 It has been standard therapy for hypertrophic burn scars and is still first-line therapy in many centres.56–62

It is generally recommended that pressure be maintained between 24–30 mmHg for 6–12 months for this therapy to be effective; however, this advice is largely empirical. 19,63 There are mixed reports on long-term compliance, but it remains a significant issue as effectiveness seems to be related directly to the duration of pressure.64,65,66 The evidence supporting the speed of scar maturation and enhancement of cosmetic outcome is variable. For example, in a prospective randomised study in 122 burns patients, pressure garments did not increase the speed of wound maturation or decrease the duration of the hospital stay.67

5) Radiotherapy

Radiotherapy has been used as monotherapy, and in combination with surgery, for hypertrophic scars and keloids. However, monotherapy remains controversial 15,67 because of anecdotal reports of carcinogenesis following the procedure. Response to radiotherapy alone is 10–94% with a keloid recurrence rate of 50–100%.11,13 Such high recurrence rates are understandable given the resistance of these cases to other management options. Best results have been achieved with 1500–2000 rads over 5–6 sessions in the early postoperative period.68,69 There have been mixed results from radiotherapy after surgical excision of keloids with a significant objective response reported in 25–100% of patients.19,71,72

Radiotherapy is difficult to evaluate as most studies are retrospective, do not define the term ‘recurrence’, and use a variety of radiation techniques with varying periods of follow- up (6–24 months). In addition, there are no randomised, prospective studies with long-term follow-up. Most investigators agree that radiotherapy should be reserved for adults for keloids resistant to other management modalities. Nevertheless, radiotherapy with informed consent remains a valuable therapeutic option and is the most effective treatment available in severe cases of keloids, providing there is appropriate shielding of non-affected tissues.

6) Laser therapy

Laser therapy has been used for non-specific destruction of tissue to produce less scarring but this is largely discredited following mixed results in larger long-term trials with carbon dioxide and argon lasers. Carbon dioxide lasers showed early promise in the excision of keloids 72 but failed to suppress keloid growth and recurrence in later studies.74,75

Two newer types of CO2 laser are now in use. Small non-controlled studies, limited by lack of long-term follow- up, suggested that high-energy short-pulsed CO2 lasers and scanned continuous wave CO2 lasers were effective in post-surgical hypertrophic/keloidal, traumatic, acne and varicella scars.76,77 Scanning CO2 lasers have been used to debride burn wounds, but without clinically improved scar outcome.78 However, these early reports have not been widely substantiated, and currently the CO2 laser is not widely accepted for the treatment of keloids because of the high late recurrence rates

Argon lasers were first used in the 1970s for the management of keloids, but studies failed to show long-term improvements.74,79 They produce more non-specific thermal damage than CO2 lasers and are associated with higher levels of keloid recurrence.77

More recent wavelength-specific lasers (YAG and pulsed dye lasers) have been used to selectively ablate blood vessels. Nd:YAG lasers (neodymium:yttrium-aluminiumgarnet) have response rates between 36–47%.80 In a recent study of 17 patients with keloids, nearly 60% of keloids were flattened following one session of Nd:YAG laser treatment. These patients remained free of keloid scarring at 18 months to 5 years follow-up.81 The remaining 7 patients required further laser treatment and intralesional corticosteroids to flatten the keloids completely. Recurrence of keloids occurred in three patients, all of whom responded to further laser treatment. A recent study in 36 patients has shown that the pulsed erbium:YAG laser is an effective and safe treatment option for hypertrophic and depressed scars.82 Further large comparative studies with longer follow-up are now required.

Flashlamp-pumped pulsed dye lasers have shown promise in the elimination of erythema and in flattening atrophic and hypertrophic scars.83–86 Intense pulsed-light source devices are usually considered in the same category as pulsed-dye lasers. Improvements in the appearance of hypertrophic scars and keloids have been noted in 57–83% of cases,83 with further improvements seen in combination with intralesional corticosteroids.87 A pilot study has suggested that laser treatment in combination with intralesional corticosteroids is effective in healing previously resistant keloids.88 A recent study in 106 patients (171 anatomical sites) has shown fast resolution of scar stiffness and erythema and improvement in the quality of scarring when preventive treatment with flashlamppumped pulsed dye lasers is started within two weeks after surgery.89 However, a recent single-blind randomised controlled study in twenty patients with hypertrophic scars showed no improvements in hypertrophic scars following laser therapy.90 Laser therapy remains an emerging technology with limited follow-up and a lack of controlled studies. Further studies are required to define its role. However, many dermatologists, and some of the authors, have seen benefits of laser surgery in erythematous hyper-trophic scars in speeding resolution, and perhaps improving long-term outcomes.

7) Cryotherapy

Cryotherapy alone results in keloid flattening in 51–74% of patients after two or more sessions and it is beneficial for the management of severe acne scars.91–94 Limitations include the delay of several weeks required for postoperative healing and the commonly occurring side-effect of permanent hypopigmentation. Other side-effects include hyperpigmentation, moderate skin atrophy and pain.95 As a result, cryotherapy is generally limited to the management of very small scars.

8) Adhesive microporous hypoallergenic paper tape

The consensus of the authors1 was that applying paper tape with an appropriate adhesive to fresh surgical incisions and for several weeks after surgery was useful. The mechanism of this benefit is unknown, but may in part be mechanical (analagous to pressure therapy) and occlusive (analagous to silicone gel therapy). However, only two uncontrolled studies confirm its efficacy.96,97 The authors also felt that this treatment was less effective than more established treatments such as silicone gel, but it could be used as a preventive treatment in low risk patients, or prior to silicone gel use in fresh incisions. Tape with an elastic component may be useful for scars over mobile or complex surfaces, including joints.

9) Miscellaneous therapies

There are anecdotal reports on a number of additional therapies for scarring, but there is no adequate published information on which the authors can evaluate their efficacy and safety or make recommendations. They fall into three categories: Firstly, popular treatments that either have no randomised studies or for which there are negative studies suggesting lack of efficacy. These include topical vitamin E,32,98,99 onion extract cream,100 allantoin-sulfomucopolysaccharide gel,101,102 glycosaminoglycan gel,103 and creams containing extracts from plants such as Bulbine frutescens and Centella asiatica.104.

The second category includes classical therapies with anecdotal success, but significant side-effects or therapies which lack supporting studies. These include topical retinoic acid,105 colchicine,106 and systemic antihistamines. 107 The third category includes newer therapies with anecdotal reports that do not yet have a history. Although these may develop into useful therapies in the future, the authors cannot make any recommendations at this time. These include skin equivalents which incorporate artificial dermis constructs, cyclosporin,108 and intralesional verapamil.109

Other physical management options include hydrotherapy, massage, ultrasound, static electricity and pulsed electrical stimulation. Hydrotherapy is widely used in several European countries for the treatment of hypertrophic burn scars (using high pressure). Massage has been widely used by physical therapists, occupational therapists, and other allied health-care professions. However, further longterm studies are required before recommendations can be made regarding their efficacy.

Promising therapies

The following therapies provide emerging evidence of efficacy:

  • Interferon (IFN-α, IFN-β and IFN-γ)110–116
  • Intralesional 5-fluorouracil (5-FU)15,117
  • Bleomycin injections 118–122

Interferon (IFN-α, IFN-β and IFN-γ) has been shown to increase collagen breakdown.110,111,112 Tredget et al. found that IFN-α2b injections three times weekly resulted in significant mean rates of improvement of hypertrophic scars versus control and also reduced serum transforming growth factor-beta (TGF-β) levels which remained lower post-treatment.115 Interferon injections are reported to be significantly better than triamcinolone acetonide injections in preventing post-surgical recurrence of keloids (18.7% vs 58.5% recurrence).116 However, these painful injections may require regional anaesthesia.

Intralesional 5-fluorouracil has been used successfully to treat hypertrophic scars and keloids both as a monotherapy and in combination with intralesional corticosteroids15,117 Physicians experienced in its use show great enthusiasm for 5-fluorouracil. The rationale for its use is sound, and it lacks side-effects. It may warrant further investigation and wider use as an alternative to steroid injections in difficult-to-treat patients.

Bleomycin injections show evidence of efficacy in managing surgical/traumatic hypertrophic scars.118,119 Patients with older scars resistant to intralesional corticosteroids showed good response to bleomycin, 0.01% injections every 3–4 weeks. A recent pilot study in 13 patients showed complete flattening (6 patients) or significant flattening (>90%; 6 patients) of hypertrophic scars and keloids following administration of bleomycin (1.5 IU/ml) using a multiple-puncture method on the skin surface.120 Although published research is limited, there is considerable clinical experience in using this modality in some European countries. The rationale for the use of bleomycin, which is another chemotherapeutic agent, is similar to that of 5- fluorouracil. A comparative study of the two agents with steroids is warranted. Adverse effects of bleomycin for treating traumatic hypertropic scars have not been reported, although side-effects in the treatment of warts with bleomycin include nail loss and Raynaud’s phenomenon. 121,122

Bleomycin and intralesional 5-FU have been used by some of the authors with considerable success. Despite a strong theoretical rationale, larger scale-prospective studies with appropriate follow-up are needed before these treatments can be considered as standard therapy.

Experimental animal studies suggest that there may be a role for transforming growth factor (TGF) modulators in control of scarring.123–125 TGF-β has been implicated in several scarring conditions including pulmonary fibrosis, glomerulonephritis and cutaneous scarring. There are three isoforms, and there is some evidence that the ratio is critical for optimising scar outcome. In addition to blocking TGF-β effects with antibodies, researchers have proposed blocking TGF-β activation via the mannose-6- phosphate receptor, and adding the TGF-β3 isoform. These approaches have demonstrated efficacy in animal models.125,126,127 Early human trials are in progress for some of these strategies.

Another area of active research is interference with collagen synthesis. Historically, penicillamine and other non-specific inhibitors of collagen synthesis were used as inhibitors, but they showed unacceptable toxicity. In recent years, several companies have looked for specific nontoxic inhibitors of collagen synthesis that could be applied locally. Animal trials have been promising.128 Overall, there has been a substantial effort in the pharmaceutical and biotechnology industry to develop more effective anti-scarring therapies, and it seems likely that new therapies will be available within the next five years.

Scar management

Appropriate therapy should be selected based on scar classification and patient history. Scar classification is the primary decision criteria for treatment selection. Patient history provides important information about the risk of the scar worsening. Erythema is of great importance in predicting the activity of the scar and its response to therapy.

1) Red scars

If erythema persists after the first month, the risk of true hypertrophy increases and management should be as for a hypertrophic scar as appropriate. Silicone gel sheets are useful, laser therapy is sometimes proposed.

2) Hypertrophic scars

Silicone gel sheeting should be used as first-line therapy, consistent with results from randomised, controlled trials. If the scar is resistant to silicone therapy, or the scar is more severe and pruritic, further management with corticosteroid injections is indicated. For severe cases, consideration may be given to the use of some of the second-line therapies mentioned above. If silicone gel sheeting, pressure garments and intralesional corticosteroid injections are not successful after twelve months of conservative therapy, surgical excision with post-operative application of silicone gel sheeting should be considered.

An option for more severe scars is re-excision with layering of triamcinolone acetonide, long-term placement of intradermal sutures and subsequent corticosteroids. Specific wavelength laser therapy and cryotherapy have been used by the authors but require further controlled studies.

3) Burn hypertrophic scars

Widespread burn scars should be treated with the firstline therapy of silicone gel sheeting and pressure garments, although there remains limited significant evidence for the efficacy of pressure garments. The treatment of burn scars is difficult and often requires a combination of techniques including individualised pressure therapy, massage and/or physical therapy, silicone gel sheeting, corticosteroids on particularly difficult areas, and surgical procedures such as Z-plasty, excision and grafting or flap coverage. A variety of adjunctive therapies such as massage, hydrocolloids and antihistamines to relieve pruritus are also used. Pulseddye laser therapy may have a role.

4) Keloids

These form the most challenging clinical problem and some are resistant to any treatment. The patient must be informed that the therapy should be considered in the case of treatment failures. Bleomycin and 5-flourouracil may have a future role as well as current investigational strategies that interfere with TGF-β or collagen synthesis. These patients are best treated by clinicians with a special interest in scars. Prevention after surgery: excision + radiation + corticosteroid injections are essential components of the therapy.

Pain and itchiness

Pain and itchiness are commonly associated with scarring. Evidence of management methodologies for pruritus remains anecdotal. Pulsed-dye lasers may have value in the reduction of itching although more cost-effective options are preferred at this stage. Moisturisers, silicone gel sheeting, systemic antihistamines, topical corticosteroids, antidepressants, massage and hydrotherapy have been shown to improve symptoms

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Prof Luc Tιot

Prof Luc Tιot
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