| TREATING SCARS | ARTICLE The author recommends cryotherapy directly before
the administration of intralesional TAC injections, since success rates appear to be increased based on the larger amount of TAC that can be injected, owing to oedema formation caused by cryotherapy. Side-effects include dermal atrophy, telangiectasia, and pain at the site of injection. The latter can be averted by topical anaesthesia and/or regional injections of local anaesthetic around the scars to be injected60
. Despite relatively few randomised,
prospective studies, TAC remains the first-line therapy for the treatment of early keloids, and second-line therapy for the treatment of early hypertrophic scars, if other easier treatments have not been efficacious8
.
Cryotherapy Cryotherapy is believed to induce vascular damage that may lead to anoxia and ultimately, tissue necrosis61
. A In the case of
hypertrophic scars, the timing of surgical treatment is an important consideration in the treatment protocol of scar revision strategies.
.
Success rates of studies using contact or spray cryosurgery with liquid nitrogen vary between 32% and 74% after two or more sessions, with a higher response rate in hypertrophic scars compared with that of keloids8, 62, 63
delay of approximately 3–4 weeks between sessions is usually required for postoperative healing, and commonly occurring side-effects include permanent hypo- and hyperpigmentation, blistering and postoperative pain63, 64
.
The intralesional needle cryoprobe method has been assessed in the treatment of hypertrophic scars and keloids65
, demonstrating increased efficacy compared
with that obtained using contact/spray probes and shorter re-epithelialisation periods65
.
Surgical manipulation Surgical excision remains the traditional treatment for keloids and hypertrophic scars66
. To date, however,
the author is aware of the great recurrence rates (45–100%) of keloids after sole excision without adjuvant therapy, such as post-excisional corticosteroid injections, 5-FU, or radiation8
,
and should therefore be considered with caution. Furthermore, excision may frequently result in a longer scar than the original
keloid, and recurrence in this new area of trauma may lead to an even larger keloid54, 67
. Surgical repair (core
excision with low-tension wound closure, or shave excision) of earlobe keloids with post-surgery corticosteroid injections, postoperative pressure (pressure earrings), or application of imiquimod 5% cream on the incision site, however, usually provide a good cosmetic results68
. In the case of hypertrophic scars, the timing of surgical
treatment is an important consideration in the treatment protocol of scar revision strategies. Hypertrophic scars mature over at least a 1-year period and can show a decrease in contractures, flattening, softening, and repigmentation without any physical manipulation20
Surgical excision might not be needed, even though post-excisional recurrence rates of the original hypertrophic scar are usually low69, 70
.
Radiotherapy Superficial X-rays, electron beam and low- or high-dose-rate brachytherapy have been used in scar reduction protocols, primarily as an adjunct to the surgical removal of keloids, and with good results71
. Radiation is thought to mediate its
effects on keloids through the inhibition of neovascular buds and proliferating fibroblasts, resulting in a decrease in collagen produced20
. Electron beam irradiation is usually
commenced 24–48 hours after keloid excision and the total dose is limited to 40 Gy over a number of administrations in order to prevent side-effects such as hypo- and hyperpigmentation, erythema, telangiectasia, and atrophy72
.
.
. However, since radiotherapy represents a
potential risk in terms of carcinogenesis, particularly in areas such as the breast or thyroid, its use should be handled with caution64, 69
Laser therapy Since their introduction for keloids in the mid-1980s73
,
increasing numbers of lasers with different wavelengths have been studied — with varying degrees of success. Until recently, the most encouraging results have been obtained using the 585 nm pulsed dye laser (PDL), which has been recognised as an excellent therapeutic option for the treatment of younger hypertrophic scars, and keloids in particular74
fluences ranging from 6–7.5 J/cm2 4.5–5.5 J/cm2
. Non-overlapping laser pulses at (7 mm spot) or from
the treatment of hypertrophic scars and keloids75
(10 mm spot) have been recommended for . Two to
six treatments may be necessary to successfully improve scar resolution, including scar colour, height, pliability, and texture74
. As the 585 nm dye
laser selectively addresses smaller blood vessels, 585 nm PDL therapy is believed to interfere with the blood supply of scars and disrupt dissemination
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