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ARTICLE | TREATING SCARS |


infiltrate decreases over time, remain within the


original wound margins and often regress over time. However, only a few studies on the pathophysiology of keloid and hypertrophic scar formation have been published directly comparing these two entities. Multiple studies on hypertrophic scar or keloid


formation, however, have led to a plethora of therapeutic strategies in order to prevent or attenuate keloid and hypertrophic scar formation. In 2002, Mustoe et al published the International clinical recommendations on scar management, which still serve as an outline for most of the currently recommended therapies for the aesthetic and functional improvement of hypertrophic scars and keloids8


. A number of different approaches have been


used in an effort to manage scarring post-surgery or trauma, ranging from non-invasive, mainly prophylactic


Figure 1 Hypertrophic scars do not extend beyond the initial site of injury (A), while keloids typically project beyond the original wound margins (B). Atrophic scars are frequently seen after acne on the cheeks, shoulder and back


Studies on hypertrophic scar or


keloid formation have led to a plethora of strategies to prevent keloid and hypertrophic scar formation.


techniques, including silicone gel (sheeting), onion extract-containing creams, pressure garments, hydrating creams and ointments, to invasive approaches (intralesional triamcinolone acetonide (TAC), cryosurgery, radiation, laser therapy, interferon (INF), 5-fluorouracil (FU), and surgical excision) (Table 1). Emerging therapies support earlier interventions in excessive scar-prone patients by modulating predominantly single cytokines or signalling receptors.


Atrophic scarring Atrophic scars commonly form after persisting inflammation in the deep dermis or subcutaneous tissue, and are thus are frequently seen after acne on the cheeks, shoulder and back. Atrophic scars are characteristically depressed and cause a valley or hole in the skin (Figure 2). They may be further differentiated based on their appearance as ice pick scars (< 2 mm ø), boxcar scars (1.5–4 mm ø), or rolling scars (4–5 mm ø). A number of treatment approaches have been successfully used for the therapy of atrophic scarring, including deep chemical peels, dermabrasion, and a variety of different lasers.


Prophylaxis of excessive scarring Preventing pathologic scarring is undoubtedly more effective than treating it. Therefore, avoiding all unnecessary wounds in patients, who are keloid or hypertrophic scar-prone, remains an obvious but imperfect solution9


10–14 days is known to increase the incidence of hypertrophic scarring dramatically8


, achievement of


rapid epithelialisation is paramount to avoid excessive scar formation. In particular, wounds subjected to tension as a result of motion, body location, or loss of tissue are at an increased risk of scar hypertrophy and spreading9


. Therefore, in the case of cutaneous injury, the 18 ❚


Figure 2 Atrophic scars are characteristically depressed and cause a valley or hole in the skin


January/February 2012 | prime-journal.com


goal for rapid primary closure of wounds under little to no tension cannot be overstated. It is also vital to adequately debride contaminated wounds, obtain good haemostasis, handle tissue gently, and limit foreign bodies in the form of debris or braided polyfilamentous suture, such as polyglactin or silk9


.


. As delayed epithelialisation beyond


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