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Acta Medica Bulgarica

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Hypertrophic Scars and Keloids – Contemporary Concepts and Treatment Options

Y. P. Yordanov / A. Shef
Published Online: 2014-11-05 | DOI: https://doi.org/10.2478/amb-2014-0008

Summary

Wound reparative process after surgery, burns, injuries, and inflammatory processes results in a spectrum of scar formation ranging from nearly scarless healing to excessive fibrosis or atrophy. Scarring is considered a major medical problem that leads to aesthetic and functional sequelae. Scar tissue is clinically distinguished from normal skin by an aberrant color, rough surface texture, increased thickness (hypertrophy), occurrence of contraction, and firmness. In the last decade, the concept of wound healing kinetics has been developed to describe the delicate balance of cell activity involved in scar formation and remodeling. Hypertrophic scars and keloids are formed as a result of the process of abnormal wound healing. Despite all that has been written on improving the appearance of these types of scars, there are no definitive management protocols. The aim of the present article is to make a brief review of the basic wound healing, while focusing on medicine’s latest understanding of the development and treatment of keloids and hypertrophic scars.

Keywords : wound healing; scar assessment; hypertrophic scars; keloids; treatment

References

  • 1. Ferguson , M. W. et al. Scar formation: the spectral nature of fetal and adult wound repair. - Plast. Reconstr. Surg., 97, 1996, № 4, 854-860.CrossrefGoogle Scholar

  • 2. Vandergriff , T. W. et P. R. Bergstresser. Anatomy and physiology. In: Bolognia JL, Jorizzo JL, Schaffer JV, eds. Dermatology- 3rd ed. - China, Elsevier-Sounders, 2013, 43-54.Google Scholar

  • 3. Gurtner, G. C. et V. W. Wong. Wound healing: normal and abnormal. In: Thorne CH, Chund KC, Gosain AK, et al. eds. Grabb and Smith’s Plastic Surgery. - Philadelphia, LWW, 2014, 13-19.Google Scholar

  • 4. Singer, A. J. et R. A. Clark. Cutaneous wound healing. - N. Engl. J. Med., 341, 1999, № 10, 738-746.Google Scholar

  • 5. Gurtner, G. C. et al. Wound repair and regeneration. - Nature, 453, 2008, № 7193, 314-21.Google Scholar

  • 6. Martin, P. et S. J. Leibovich. Infl ammatory cells during wound repair: the good, the bad and the ugly. - Trends Cell Biol., 15, 2005, № 11, 599-607. Epub 2005 Oct 3.CrossrefGoogle Scholar

  • 7. Simpson , D. M. et R. Ross. The neutrophilic leukocyte in wound repair a study with antineutrophil serum. - J. Clin. Invest., 51, 1972, № 8, 2009-2023.Google Scholar

  • 8. Gordon , S. et P. R. Taylor. Monocyte and macrophage heterogeneity. - Nat. Rev. Immunol., 5, 2005, № 12, 953-964.CrossrefPubMedGoogle Scholar

  • 9. Werner, S. et R. Grose. Regulation of wound healing by growth factors and cytokines. - Physiol. Rev., 83, 2003, № 3, 835-870.Google Scholar

  • 10. Leibovich , S. J. et R. Ross. The role of the macrophage in wound repair. A study with hydrocortisone and antimacrophage serum. - Am. J. Pathol., 78, 1975, № 1, 71-100.PubMedGoogle Scholar

  • 11. He , L. et A. G. Marneros. Macrophages are essential for the early wound healing response and the formation of a fi brovascular scar. - Am. J. Pathol., 182, 2013, № 6, 2407-2417.CrossrefGoogle Scholar

  • 12. Lodish , H. et al. Multicellularity: cell-cell and cell-matrix interactions. In: Lodish H, et al, eds. Molecular Cell Biology, 4th ed. New York, Scientifi c American Books, 1995, 1123-1200.Google Scholar

  • 13. Hynes , R. O. The extracellular matrix: not just pretty fi brils. - Science, 326, 2009, № 5957, 1216-1219.Google Scholar

  • 14. Atiyeh , B. S., M. Costagliola et S. N. Hayek. Keloid or hypertrophic scar: the controversy: review of the literature. - Ann. Plast. Surg., 54, 2005, № 6, 676-680.CrossrefGoogle Scholar

  • 15. Volk , S. W. et al. Diminished type III collagen promotes myofi broblast differentiation and increases scar deposition in cutaneous wound healing. - Cells Tissues Organs, 194, 2011, № 1, 25-37.Google Scholar

  • 16. Desmoulière , A., C. Chaponnier et G. Gabbiani. Tissue repair, contraction, and the myofi broblast. - Wound Repair Regen, 13, 2005, № 1, 7-12.Google Scholar

  • 17. Gabbiani , G. Evolution and clinical implications of the myofi broblast concept. - Cardiovasc. Res., 38, 1998, № 3, 545-548.CrossrefGoogle Scholar

  • 18. Woodley, D. T. Reepithelialization. In: Clark RAF, ed. The Molecular and Cellular Biology of Wound Repair. - New York, Plenum, 1996, 339-350.Google Scholar

  • 19. Marinkovich , M. P. et al. Cellular origin of the dermal-epidermal basement membrane. - Dev. Dyn., 197, 1993, № 4, 255-267.Google Scholar

  • 20. Buck , D. W. et R. D. Galiano. Wound Care. In: Thorne CH, Chund KC, Gosain AK, et al. eds. Grabb and Smith’s Plastic Surgery. - Philadelphia, LWW, 2014, 20-28.Google Scholar

  • 21. Thomas , J. R. et M. Somenek. Scar revision review. - Arch. Facial. Plast. Surg., 14, 2012, № 3, 162-174. CrossrefGoogle Scholar

  • 22. Gantwerker, E. A. et D. B. Hom. Skin: histology and physiology of wound healing. - Clin. Plast. Surg., 39, 2012, № 1, 85-97.CrossrefGoogle Scholar

  • 23. Russell , S. B. et al. Reduced growth factor requirement of keloid-derived fi broblasts may account for tumor growth. - Proc. Natl. Acad. Sci. USA, 85, 1988, № 2, 587-591.CrossrefGoogle Scholar

  • 24. Nirodi , C. S. et al. Chemokine and chemokine receptor expression in keloid and normal fi broblasts. - Wound Repair Regen, 8, 2000, № 5, 371-382.CrossrefGoogle Scholar

  • 25. Tuan , T. L. et L. S. Nichter. The molecular basis of keloid and hypertrophic scar formation. - Mol. Med. Today, 4, 1998, № 1, 19-24.Google Scholar

  • 26. Rockwell , W. B., I. K. Cohen et H. P. Ehrlich. Keloids and hypertrophic scars: a comprehensive review. - Plast. Reconstr. Surg., 84, 1989, № 5, 827-837.CrossrefGoogle Scholar

  • 27. Rekha , A. Keloids: a frustrating hurdle in wound healing. - Int. Wound J., 1, 2004, № 2, 145-148.Google Scholar

  • 28. Har - Shai , Y., M. Amar et E. Sabo. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. - Plast. Reconstr. Surg., 111, 2003, № 6, 1841-1852.Google Scholar

  • 29. Chodon , T. et al. Keloid-derived fi broblasts are refractory to Fas-mediated apoptosis and neutralization of autocrine transforming growth factor-beta1 can abrogate this resistance. - Am. J. Pathol., 157, 2000, № 5, 1661-1669.Google Scholar

  • 30. Mustoe , T. A. et al. International clinical recommendations on scar management. - Plast. Reconstr. Surg., 110, 2002, № 2, 560-571.CrossrefGoogle Scholar

  • 31. Reish , R. G. et E. Eriksson. Scars: a review of emerging and currently available therapies. - Plast. Reconstr. Surg., 122, 2008, № 4, 1068-1078.CrossrefGoogle Scholar

  • 32. Durani , P., D. A. McGrouther et M. W. Ferguson. Current scales for assessing human scarring: a review. - J. Plast. Reconstr. Aesthet. Surg., 62, 2009, № 6, 713-720.CrossrefGoogle Scholar

  • 33. Sullivan , T. et al. Rating the burn scar. - J. Burn. Care Rehabil., 11, 1990, № 3, 256-260.CrossrefGoogle Scholar

  • 34. Van Zuijlen , P. P. et al. Scar assessment tools: implications for current research. - Plast. Reconstr. Surg., 109, 2002, № 3, 1108-1122.Google Scholar

  • 35. Druit , R. Modern Surgery. Philadelphia, Lea and Blanchard, 1844.Google Scholar

  • 36. Ogawa , R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. - Plast. Reconstr. Surg., 125, 2010, № 2, 557-568.CrossrefGoogle Scholar

  • 37. Darzi , M. A. et al. Evaluation of various methods of treating keloids and hypertrophic scars: a 10- year follow-up study. - Br. J. Plast. Surg., 45, 1992, № 5, 374-379.Google Scholar

  • 38. Malaker, A., F. Ellis et C. H. Paine. Keloid scars: a new method of treatment combining surgery with interstitial radiotherapy. - Clin. Radiol., 27, 1976, № 2, 179-183.CrossrefGoogle Scholar

  • 39. Pérez - Bustillo , A., B. González-Sixto et M. A. Rodríguez-Prieto. Surgical principles for achieving a functional and cosmetically acceptable scar. - Actas Dermosifi liogr., 104, 2013, № 1, 17-28.Google Scholar

  • 40. Tsao , S. S. et al. Scar management: keloid, hypertrophic, atrophic, and acne scars. - Semin. Cutan. Med. Surg., 21, 2002, № 1, 46-75.Google Scholar

  • 41. Fitzpatrick , R. E. Treatment of infl amed hypertrophic scars using intralesional 5-FU. - Dermatol. Surg., 25, 1999, № 3, 224-232.CrossrefGoogle Scholar

  • 42. Manuskiatti , W. et R. E. Fitzpatrick. Treatment response of keloidal and hypertrophic sternotomy scars: comparison among intralesional corticosteroid, 5-fl uorouracil, and 585-nm fl ashlamppumped pulsed-dye laser treatments. - Arch. Dermatol., 138, 2002, № 9, 1149-1155.Google Scholar

  • 43. Atiyeh , B. S. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. - Aesthetic. Plast. Surg., 31, 2007, № 5, 468-92.Google Scholar

  • 44. Sproat , J. E. et al. Hypertrophic sternal scars: silicone gel sheet versus Kenalog injection treatment. - Plast. Reconstr. Surg., 90, 1992, № 6, 988-992.CrossrefGoogle Scholar

  • 45. George , W. M. Linear lymphatic hypopigmentation after intralesional corticosteroid injection: report of two cases. - Cutis, 64, 1999, № 1, 61-64. Google Scholar

  • 46. Niessen , F. B. et al. On the nature of hypertrophic scars and keloids: a review. - Plast. Reconstr. Surg., 104, 1999, № 5, 1435-1458.CrossrefGoogle Scholar

  • 47. Wilgerow, A. D. et al. New innovations in scar management. - Aesthetic. Plast. Surg., 24, 2000, № 3, 227-234.Google Scholar

  • 48. Gibbons , M. et al. Experience with silastic gel sheeting in pediatric scarring. - J. Burn. Care Rehabil., 15, 1994, № 1, 69-73.CrossrefGoogle Scholar

  • 49. Van den Kerckhove , E. et al. Silicones in the rehabilitation of burns: a review and overview. - Burns, 27, 2001, № 3, 205-214.Google Scholar

  • 50. Chan , K. Y. et al. A randomized, placebo-controlled, double-blind, prospective clinical trial of silicone gel in prevention of hypertrophic scar development in median sternotomy wound. - Plast Reconstr. Surg., 116, 2005, № 4, 1013-1020.CrossrefGoogle Scholar

  • 51. Atiyeh , B. S. et al. Improving scar quality: a prospective clinical study. - Aesthetic. Plast. Surg., 26, 2002, № 6, 470-476.Google Scholar

  • 52. Musgrave , M. A. et al. The effect of silicone gel sheets on perfusion of hypertrophic burn scars. - J. Burn Care Rehabil., 23, 2002, № 3, 208-214.CrossrefGoogle Scholar

  • 53. Ricketts , C. H. et al. Cytokine mRNA changes during the treatment of hypertrophic scars with silicone and nonsilicone gel dressings. - Dermatol. Surg., 22, 1996, № 11, 955-959.CrossrefGoogle Scholar

  • 54. Sawada , Y. et K. Sone. Hydration and occlusion treatment for hypertrophic scars and keloids. - Br. J. Plast. Surg., 45, 1992, № 8, 599-603.Google Scholar

  • 55. Niessen , F. B. et al. The use of silicone occlusive sheeting (Sil-K) and silicone occlusive gel (Epiderm) in the prevention of hypertrophic scar formation. - Plast. Reconstr. Surg., 102, 1998, № 6, 1962-1972.CrossrefGoogle Scholar

  • 56. Linares , H. A., D. L. Larson et B. A. Willis-Galstaun. Historical notes on the use of pressure in the treatment of hypertrophic scars or keloids. - Burns, 19, 1993, № 1, 17-21.Google Scholar

  • 57. Bombaro , K. M. et al. What is the prevalence of hypertrophic scarring following burns? - Burns, 29, 2003, № 4, 299-302.CrossrefGoogle Scholar

  • 58. Staley, M. J. et R. L. Richard. Use of pressure to treat hypertrophic burn scars. - Adv. Wound Care, 10, 1997, № 3, 44-46.Google Scholar

  • 59. Nedelec , B. et al. Control of wound contraction. Basic and clinical features. - Hand Clin., 16, 2000, № 2, 289-302.Google Scholar

  • 60. Essellman , P. C. et al. Burn rehabilitation: state of the science. - Am. J. Phys. Med. Rehabil., 85, 2006, № 4, 383-413.CrossrefGoogle Scholar

  • 61. Rayner, K. The use of pressure therapy to treat hypertrophic scarring. - J. Wound Care, 9, 2000, № 3, 151-153.Google Scholar

  • 62. Macintyre , L. et M. Baird. Pressure garments for use in the treatment of hypertrophic scars-a review of the problems associated with their use. - Burns, 32, 2006, № 1, 10-15.Google Scholar

  • 63. Van den Kerckhove , E. et al. The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring. - Burns, 31, 2005, № 6, 696-702.Google Scholar

  • 64. Giele , H. et al. Anatomical variations in pressures generated by pressure garments. - Plast. Reconstr. Surg., 101, 1998, № 2, 399-406.CrossrefGoogle Scholar

  • 65. Ward , R. S. Pressure therapy for the control of hypertrophic scar formation after burn injury. A history and review. - J. Burn Care Rehabil., 12, 1991, № 3, 257-262.CrossrefGoogle Scholar

  • 66. Alster, T. S. et T. O. McMeekin. Improvement of facial acne scars by the 585 nm fl ashlamppumped pulsed dye laser. - J. Am. Acad. Dermatol., 35, 1996, № 1, 79-81.CrossrefGoogle Scholar

  • 67. Alster, T. S. Improvement of erythematous and hypertrophic scars by the 585-nm fl ashlamppumped pulsed dye laser. - Ann. Plast. Surg., 32, 1994, № 2, 186-190. CrossrefGoogle Scholar

  • 68. Alster, T. S. et C. M. Williams. Treatment of keloid sternotomy scars with 585 nm fl ashlamppumped pulsed-dye laser. - Lancet, 345, 1995, № 8959, 1198-1200.Google Scholar

  • 69. Alster, T. Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. - Dermatol. Surg., 29, 2003, № 1, 25-29.Google Scholar

  • 70. Khatri , K. A., D. L. Mahoney et M. J. McCartney. Laser scar revision: A review. - J. Cosmet. Laser Ther., 13, 2011, № 2, 54-62.CrossrefGoogle Scholar

  • 71. Kim , H. S. et al. Comparison of the effectiveness of nonablative fractional laser versus ablative fractional laser in thyroidectomy scar prevention: A pilot study. - J. Cosmet. Laser Ther., 14, 2012, № 2, 89-93.CrossrefGoogle Scholar

  • 72. Shef , A. et M. Kadurina. Vascular anomalies: port wine stains and child’s hemangioma. Light and laser therapy as an effective approach in their treatment. Dermatology and Venereology, 50, L, 1 [Article in Bulgarian]Google Scholar

  • 73. Chen , M. A. et T. M. Davidson. Scar management: prevention and treatment strategies. - Curr. Opin. Otolaryngol. Head Neck Surg., 13, 2005, № 4, 242-247.CrossrefGoogle Scholar

  • 74. Dinh , Q., M. Veness et S. Richards. Role of adjuvant radiotherapy in recurrent earlobe keloids. - Australas J. Dermatol., 45, 2004, № 3, 162-166.CrossrefGoogle Scholar

  • 75. Malaker, K. et al. Retrospective analysis of treatment of unresectable keloids with primary radiation over 25 years. - Clin. Oncol. (R Coll Radiol), 16, 2004, № 4, 290-298.CrossrefGoogle Scholar

  • 76. Ogawa , R. et al. Postoperative radiation protocol for keloids and hypertrophic scars: statistical analysis of 370 sites followed for over 18 months. - Ann. Plast. Surg., 56, 2007, № 6, 688-691.Google Scholar

  • 77. Ogawa , R. et al. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months. - Plast. Reconstr. Surg., 111, 2003, № 2, 547-53.CrossrefGoogle Scholar

  • 78. Har - Shai , Y., M. Amar et E. Sabo. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. - Plast. Reconstr. Surg., 111, 2003, № 6, 1841-1852.Google Scholar

  • 79. Rusciani , L., G. Rossi et R. Bono. Use of cryotherapy in the treatment of keloids. - J. Dermatol. Surg. Oncol., 19, 1993, № 6, 529-534.CrossrefGoogle Scholar

  • 80. Apikian , M. et G. Goodman. Intralesional 5-fl uorouracil in the treatment of keloid scars. -Australas J. Dermatol., 45, 2004, № 2, 140-143.CrossrefGoogle Scholar

  • 81. Ya mamoto , T. Bleomycin and the skin. - Br. J. Dermatol., 155, 2006, № 5, 869-875.Google Scholar

  • 82. Lebwohl , M. From the literature: intralesional 5-FU in the treatment of hypertrophic scars and keloids: clinical experience. - J. Am. Acad. Dermatol., 42, 2000, № 4, 677.CrossrefGoogle Scholar

  • 83. España , A., T. Solano et E. Quintanilla. Bleomycin in the treatment of keloids and hypertrophic scars by multiple needle punctures. - Dermatol. Surg., 27, 2001, № 1, 23-27.Google Scholar

  • 84. Saray, Y. et A. T. Güleç. Treatment of keloids and hypertrophic scars with dermojet injections of bleomycin: a preliminary study. - Int. J. Dermatol., 44, 2005, № 9, 777-784.CrossrefGoogle Scholar

  • 85. Copcu , E., N. Sivrioglu et Y. Oztan. Combination of surgery and intralesional verapamil injection in the treatment of the keloid. - J. Burn Care Rehabil., 25, 2004, № 1, 1-7.CrossrefGoogle Scholar

  • 86. Giugliano , G. et al. Verapamil inhibits interleukin-6 and vascular endothelial growth factor production in primary cultures of keloid fi broblasts. - Br. J. Plast. Surg., 56, 2003, № 8, 804-809.Google Scholar

  • 87. Borgognoni , L. et U. M. Reali. Intralesional hyaluronic acid treatment of pathological scars. - Ann. Plast. Surg., 38, 1997, № 3, 308, 7A.Google Scholar

  • 88. Kapoor, M., R. Howard, I. Hall et I. Appleton. Effects of epicatechin gallate on wound healing and scar formation in a full thickness incisional wound healing model in rats. - Am. J. Pathol., 165, 2004, № 1, 299-307. Google Scholar

About the article

Published Online: 2014-11-05

Published in Print: 2014-06-01


Citation Information: Acta Medica Bulgarica, ISSN (Online) 0324-1750, DOI: https://doi.org/10.2478/amb-2014-0008.

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