Scarring / Skin Injuries
Skin Injury always results in fibrotic, non-functional scars in adults. A hundred million individuals worldwide each year acquire scars on their skin due to surgery or trauma, with 15% of these eventually progressing into hypertrophic scars or keloids. Updated scar management practical guidelines: non-invasive and invasive measures – PubMed. Scars with a large surface area not only affect the aesthetics but are also accompanied by pain, itching, sclerosis and scar contracture. Scars can also cause significant physiological distress, including higher rates of anxiety, depression and low self-esteem in individuals. Biopsychosocial impact of keloids on quality of life – PubMedĀ Ā Ā
Scars can be categorised in four distinct types: mature scars, immature scars, hypertrophic scars and keloids International clinical recommendations on scar management – PubMed. Mature scars exhibit a flat appearance and share the same resemblance as healthy tissue, while immature scars manifest during the tissue repair phase of wound healing with redness and swelling with a slight bulge at the injury site. With time, these immature scars can either progress into normal mature scars or develop into hypertrophic scars or keloids. Hypertrophic scars are categorised by a bulging appearance accompanied by persisting redness and swelling. When a scar extends beyond the original wound location and continues to enlarge, it is called a keloid.
Keloid Scars are widely considered one of the most challenging and severe forms of scarring. Their formation is due to a disorganised and fibroproliferative collagen response. Keloids: a review of therapeutic management – PubMed. There are a number of risk factors influencing natural healing.
These include:
- There is a familial aggregation with an increased prevalence in dark-skinned individuals of African, Asian and Hispanic populations compared to Caucasians. Certain genes have been linked to the increased risk of developing keloid scars Genetics of Keloid Scarring – Textbook on Scar Management – NCBI Bookshelf
- Most keloid scars are found between the ages of 11 and 30 with a peak incidence during puberty and early childhood. They can occur at any age but are rare in the extremes of life (young children and old adults) Keloid – StatPearls – NCBI Bookshelf. This is thought to be due to the skin being more active, having a higher collagen production and experiencing greater tension during the healing process.
- Females have a higher risk for the development of keloid scars. This increased risk if thought to be driven by physiological factors, particularly the role of hormones like oestrogen in wound inflammation and collagen production. Genetics of Keloid Scarring – Textbook on Scar Management – NCBI Bookshelf
- Locations. Keloids are more likely to develop in the scapular area, the shoulder and the anterior chest. These regions are subjected to constant or frequent skin stretching due to body movements. The relationship between skin stretching/contraction and pathologic scarring: the important role of mechanical forces in keloid generation – PubMed.Ā
How is it diagnosed?
Keloids are primarily diagnosed clinically based on their shape, colour and patients’ history of trauma or surgery. Rarely they can manifest in the absence of injury or trauma, termed āspontaneous keloidsā Management of Spontaneous and Pruritic Keloids: A Case Report – PMC while hypertrophic scar only develop following injury. The location of the lesion is helpful in confirming a diagnosis; keloids typically manifest on the earlobes, face, chest and back, while hypertrophic scars are more commonly found on the extensor surfaces. Hypertrophic scars remain contained within the area of injury, while keloids grow beyond the borders of the initial injury. Up-to-date approach to manage keloids and hypertrophic scars: a useful guide – PubMed. If the diagnosis is in question, a biopsy is diagnostic but is rarely needed.
How is it treated?
Treatment of hypertrophic scars and keloids can be challenging, often requiring a multimodal approach, as no single therapy is universally effective. Treatment in both cases aims to reduce the size, itching and pain; however, complete resolution is rarely achieved. Treatment options include:
- Silicone gel-based products. These can be an effective topical, non-invasive treatment option: The Efficacy of Silicone Gel for the Treatment of Hypertrophic Scars and Keloids – PMC. They aim to increase the skin hydration, modulate fibroblast and collagen production, protect the scar from bacterial invasion and reduce the itching and discomfort.
- Intralesional injections. Intralesional Corticosteroid (triamcinolone) injections are effective in the treatment of keloids and hypertrophic scars by decreasing local inflammation and reducing collagen synthesis. Treatment of Keloids: A Meta-analysis of Intralesional Triamcinolone, Verapamil, and Their Combination – PubMed. This in turn reduces the size, thickness and associated symptoms of the scars. Treatment usually consists of two to three injections spread 4-6 weeks apart. Potential side effects are rare but can include skin atrophy (thinning), depigmentation (skin colour changes) and infection.
- Intralesional Verapamil injections. As a calcium channel blocker, verapamil inhibits fibroblast activity and collagen production and has been shown to be an effective and safe treatment option for reducing the size, volume and stiffness of keloids and hypertrophic scars Role of verapamil in preventing and treating hypertrophic scars and keloids – PMC.
- Laser Therapy. This is a non-invasive procedure that uses concentrated light energy to minimise the appearance, texture and discomfort of both keloid and hypertrophic scars Laser therapy for treating hypertrophic and keloid scars – PMC. There are two main types: ablative light therapy, used to remove the top skin layers for deep textured scars, and non-ablative light therapy, used to stimulate collagen production by heating the underlying tissue. More information regarding the mode of action and potential side effects can be found here: Laser Revision of Scars – StatPearls – NCBI Bookshelf.
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