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New Treatments for Scars and Keloids

Injury or surgery in a predisposed individual can result in an abnormally large scar. A hypertrophic scar is inappropriately large but remains confined to the wound site and in time regresses; a keloid extends beyond the margins of injury and usually is constant and stable without any tendency to subside. There are histologic differences between hypertrophic scars and keloids. Keloids are often symptomatic, and complaints arise because of tenderness, pain, and hyperesthesia, particularly in the early stages of development. Keloids are most common on the shoulders and chest, but they may occur on any skin surface. Blacks are more susceptible and sometimes are victims of facial keloids. Some patients with cystic acne of the back and chest form numerous keloidal scars.

Treatment.

There is no routinely effective therapy for all keloids, but a variety of treatment methods exists, including intralesional steroid injection, surgical correction, cryotherapy, compression therapy, and irradiation.

Intralesional steroid injections.

Fresh, small, and narrow lesions are treated with intralesional injections of corticosteroids at least once every 4 weeks. When the lesion shrinks to near the skin surface, the frequency and concentration of injections should be decreased to avoid overcompensation and telangiectasia. Inducing atrophy with an intralesional injection of triamcinolone acetonide (Kenalog) 10 to 40 mg/ml is adequate for most small lesions.

Surgery and intralesional steroid injections.

Surgical removal alone is associated with a 55% to 100% recurrence rate, but better results are realized when intralesional steroids are used following surgery. A typical treatment program involves injecting triamcinolone acetonide 10 to 40 mg/ml into the wound edges after excision. Treatment of the healed site is repeated at 2- to 4-week intervals.

Cryotherapy.

In one study, cryotherapy with a hand-held liquid nitrogen spray unit resulted in complete flattening in 73% of keloids, most of which were less than 2 years old. At each treatment session, the entire lesion was treated with two or three freeze-thaw cycles. Lesions required 2 to 10 treatment.

Silastic gel sheeting.

Chronic hypertrophic and keloid scars respond to silicone gel sheeting (e.g., Sil-K, Epi-Derm). These dressings can also prevent keloids from recurring after surgery. In a controlled analysis of fresh surgical incisions, silicone gel sheeting significantly inhibited the formation of hypertrophic scars. Sheeting is used for at least 12 hours daily for 2 months.

Compression.

Very wide scars or those that can be treated easily with pressure are subjected to compression therapy. Compression devices can be fabricated to treat any area.

Radiation therapy with surgery.

Different protocols are reported. Radiation is usually given within 24 hours after surgery to subdue the second-generation fibroblasts. The response rate varies between 92% and 73%. Irradiation at a later time.