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As mentioned, keloids are often strongly underpinned by genetic factors, including ethnic 14 and familial genes: multiple cases of keloid-susceptible families have been reported. 38 , 39 Moreover, several single-nucleotide polymorphisms associate with keloids 40–42: four promote keloidogenesis 40 and one associates with severe keloids. 41 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 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
Several lifestyle factors could exacerbate surgery-induced wound and scar inflammation, including strenuous wound-stretching physical activity. Athletes and manual laborers should rest their wounds. Certain diets and hot baths could aggravate surgery-induced inflammation 46: my experience with thousands of patients suggests they often experience itch and pain after consuming hot and spicy foods or taking hot baths. Early detection and FIRST-LINE hypertrophic scar and keloid treatment
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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. 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 Cream
Hypertrophic scar and keloid diagnosis is often based on clinical features alone. However, malignant tumors such as dermatofibrosarcoma protuberans 15–18 and giant-cell fibroblastoma 19 can be misdiagnosed clinically as keloids. 20 Moreover, analysis of 378 hypertrophic scars and keloids showed that 1.06 percent were other diseases. 20 Thus, biopsy is warranted if malignancy is suspected. 20–22 Prevention of postsurgical Hypertrophic scars and keloids 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. Do not use on large or severe burns or on burns that are infected or bleeding. Seek medical advice in these cases. In Japan, corticosteroid tapes and plasters have long served as a first-line therapy for keloids and hypertrophic scars. Pediatric patients are particularly responsive to this type of treatment. This may reflect the fact children have thinner skin than adults and the steroids are therefore more easily absorbed. The postoperative application of corticosteroid tapes/plasters also significantly prevents the development of keloids and hypertrophic scars after surgery. Steroid tape 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). Fludroxycortide tape is a Group III preparation. The USA has a steroid tape preparation that contains 4 μg/cm 2 flurandrenolide, which is also a Group III preparation. In Japan, two steroid tape formulations are available, namely, the Group III preparation found in the UK (4 μg/cm 2 fludroxycortide tape) and a 20 μg/cm 2 deprodone propionate tape. Deprodone propionate tape is considered to be a Group I or II preparation. In our experience, deprodone propionate tape (Eclar® plaster) is the most effective tape for the treatment and prevention of keloids. KeywordsThe clinical and histologic differences between classic hypertrophic scars and keloids probably reflect differences in the intensity and duration of reticular dermis inflammation. These differences in turn may reflect the presence and severity of local, systemic, genetic, and lifestyle risk factors. 6 , 7 International Differences in Hypertrophic Scar and Keloid Diagnosis
is a Group III preparation. The USA has a steroid tape preparation that contains 4 μg/cm 2 flurandrenolide, which is also a Group III preparation [ 2]. In Japan, two steroid tape formulations are available, namely, the Group III preparation found in the UK (4 μg/cm 2 fludroxycortide tape) and a 20 μg/cm 2 deprodone propionate tape. Deprodone propionate tapeCryosurgery, 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. 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. In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review. Methods: 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, 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
Sukhumthammarat W, Putthapiban P, Sriphrapradang C. Local injection of triamcinolone acetonide: a forgotten aetiology of Cushing’s syndrome. J Clin Diagn Res. 2017;11(6):OR01–2. it can produce strong pruritus and reddens the skin, it can hamper the continuous use of the tape. Take Home Messages Cryosurgery can by an effective treatment in some patients, especially for small scars of recent onset Treated hypertrophic scar and keloid patients should be educated about scar management and followed-up over the long-term. Close follow-up allows early detection and treatment of small recurrences that respond well to steroid tape, plaster, or injection. Thus, patients should be followed up for greater than 18 to 24 months. Follow-up can stop when the scar is flat and soft.judged by using the Japan Scar Workshop Scar Scale 2015 (JSS) [ 5]. The results suggest that the fludroxycortide tape Pediatric patients are particularly responsive to this type of treatment, because children have thinner skin than adults and the steroids are therefore more easily absorbed.
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