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ARTICLE | TREATING SCARS | of mediators up-regulating the production of matrix


components via the blood stream. Local ischaemia and collagen fever heating is thought to induce collagen remodelling, as well as the release of histamine and other factors that influence fibroblast activity76–78


.


Adverse effects include transient hypo- or hyperpigmentation, blistering77, 78


reactivation of keloids, as experienced in daily practice and in other studies79


, and occasionally, . From the author’s experience,


combination with intralesional corticosteroid injection directly prior to PDL treatment or the application of a extractum cepae, heparin and allantoin-containing scar cream or a silicone gel twice daily beginning 1 week after PDL treatment, is easily feasible and may help to prevent reactivation — and therefore improve the outcome of the treated keloid. Similar results have been demonstrated by Cassuto and colleagues combining silicone gel sheeting and a 532 nm millisecond laser for the therapy of excessive scars80


. A variety of different lasers have been suggested for


the treatment of atrophic scars. Ablative treatments (e.g. conventional ablative devices such as CO2


lasers


(10 600 nm) and Erbium: yttrium-aluminum-garnet (Er:YAG; 2940 nm) lasers) have substantially diminished since their inception owing to significant patient ‘downtime’ and adverse events, such as oedema, burning, crusting, erythema lasting up to 6 months after treatment, pigmentary changes, and even additional scarring. These difficulties have led to the development of a new laser device that relies on a novel concept coined ‘fractional photothermolysis’ (FP)81


. FP uses a device to deliver a


laser beam divided into thousands of microscopic treatment zones (MTZs) that target a fraction of the skin at a time. The first fractional laser marketed was the Fraxel® device. Today, both non-ablative and ablative fractional lasers are available82


. Fractional lasers have


been used successfully and safely in the treatment of acne scars, demonstrating significant improvement in texture, atrophy, and overall appearance83–87


. While


macular, superficial and medium-depth scars respond well, deep scars and ice pick scars may improve only marginally. In cases with severe scarring, combination with other approaches such as chemical peels, subcision or surgical dermabrasion, may be necessary88


. Despite Results 24 ❚


have been demonstrated by Cassuto and colleagues combining silicone gel sheeting and a 532 nm millisecond laser for the therapy of excessive scars.


January/February 2012 | prime-journal.com Key points


■ An increasing number of patients are disappointed with their resulting scars and would value any opportunity to improve or minimise scarring following surgery or trauma


■ Despite a number of novel therapeutic approaches for the treatment of excessive scarring, preventing pathologic scarring undoubtedly remains more effective than treating it


■ Unfortunately, well-designed prospective studies on preventive and therapeutic strategies are widely missing


■ To date, the combination of different treatment approaches appears more successful with lasers, intralesional 5-FU, Imiquimod and botulinum toxin A extending the current spectrum


■ Based on current data excessive scars remain difficult to treat


the reported safety of fractional lasers in post-acne scarring, transient erythema or oedema, dryness, scabbing, milia or acne, pigmentary changes, prolonged healing, or infection may still occur. Therefore, sufficient counselling of patients and appropriate adjuvant medical treatment are essential. The author’s group predominately uses ablative fractional lasers for the treatment of atrophic scars, favouring the CO2


fractional


laser owing to its high success rates, patient satisfaction, and low side-effect profile.


Emerging therapies 5-fluorouracil 5-FU is a pyrimidine analogue that is used as an antimetabolite in cancer chemotherapy54


. 5-FU is


converted intracellularly to its active version, which is suggested to directly increase fibroblast apoptosis by inhibiting DNA synthesis in preferentially rapidly proliferating and metabolising cells89, 90 Fitzpatrick91


. In 1999, was the first to report on using 5-FU to


effectively reduce scarring, administering more than 5000 injections to more than 1000 patients in his 9-year experience. Ever since, the use of intralesional 5-FU in combination or as a sole agent for the treatment of keloids has been shown to be effective. In a prospective, randomised trial including 28 consecutive patients with keloids of varying size and duration, weekly intralesional 5-FU injections (50 mg/mL) for 12 weeks resulted in a reduction in scar size of at least 50% in the majority of the patients, with no patients showing a failure to therapy or recurrence of symptoms within the follow-up period of 24 months92


. Side-effects included pain, ulceration, and a


burning sensation. Blood count monitoring for anaemia, leukopoenia and thrombocytopoenia is recommended. Therapy in pregnant women or patients with bone marrow suppression should be avoided. Intralesional 5-FU treatment has also been used for the


treatment of inflamed hypertrophic scars and appears to be both effective and safe91


and Wu94 . Most studies use the


high-dose version of 5-FU therapy (40–50 mg/ml), aiming to destroy the keloid. In 2006, Liu93


promoted a


‘low-dose’ therapy using 1.4–3.5 mg/ml 5-FU in 35 patients with 51 keloids. In 2008 and 2009, the same group could demonstrate the effectiveness of this therapy in 83 patients with a total of 166 keloids on the ear95


. The author


is following a similar dosing regimen with very good results and a minimal side-effect profile.


Bleomycin Bleomycin sulphate, another antineoplastic agent that was found to directly inhibit collagen synthesis via decreased stimulation by TGF-β196


for the reduction of scars in the mid-1990s97


, was first investigated . After


administering three to five intralesional injections of bleomycin within a 1-month period, the authors demonstrated complete regression in 69.4% of the keloids. Subsequent studies revealed similar results with significant improvement in hypertrophic scar and keloid height and pliability, as well as a reduction in erythema, pruritus, and pain96, 98, 99


. Occasionally, development of


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