PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g.,...

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PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT Dr. Tarek Ahmed Said Professor of Plastic Surgery Cairo University 2015

Transcript of PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g.,...

Page 1: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

PATHOLOGICAL

TYPES OF SCARS

AND THEIR IMPACT

ON TREATMENT

Dr. Tarek Ahmed SaidProfessor of Plastic Surgery

Cairo University

2015

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Pathological Types of Scars

Mixed ScarsMixed Scars

Atrophic ScarsAtrophic Scars NormotrophicNormotrophic ScarsScars HypertrophicHypertrophic Scars & Scars & KeloidsKeloids

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Inflammation and Oedema

Minimal

↓

↓ TGF Beta 1 and 2

↓

↓ Active fibroblasts

↓

Insufficient Collagen Synthesis

↓

Atrophic Scar

Extensive

↓

↑ TGF Beta 1 and 2

↓

↑ Active fibroblasts

↓

Excessive collagen synthesis

↓

Hypertrophic scar

Adequate

↓

Adequate TGF Beta 1 and 2

↓

Active fibroblasts Slightly ↑

↓

sufficient Collagen Synthesis

↓

Normotrophic Scar

Nonhomogenous

↓

Uneven conc. TGF Beta 1 and 2

↓

↑ uneven conc. Active fibroblasts

↓

collagen synthesis in Islets

↓

Mixed scar

Factors affecting scar development

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Factors affecting scar development

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Management of Scars

is a combination therapy

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Normotrophic Scars

Inflammatory stageDebridementOedema Control (alpha chemotrypsin)NSAIDsAntibiotics

Proliferarion StageContractubexCompression silicone sheeting (areas famous for hypertrophic scarring)EnzymotherapyCryodustruction

Maturation StageCompression hydrationDermarollerVit C applications (Ascorbic acid)MicrodermabrasionPeelingEnzymotherapyCryodestructionPDL

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Enzymotherapy

• Proteolytic enzymes dilute necrotic mass

• Hyaluronidase depolymerizes hyaluronic acid.

Occlusive Hydration

• Maximal hydration of the scar formation zone

• Reduction of transepidermal water loss

• Acceleration of cell migration

• Increase of fibroblast proliferation and synthetic activity

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Cryotherapy

• Evens overhanging scar edges

• Reduces interstitial edema

Early Microdermabrasion

• Evens and improves the scar surface

• Clears away the epidermal (lipidic) skin barrier of the scar area along with epidermis, which enables medicinal products to penetrate freely into the skin.

• Scar bottom is elevated by the vacuum to the surrounding skin level, counteracting myofibroblasts

Better avoided in Fitzpatrick skin phototypes 4-6

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Medium & Deep Chemical Peel

• TCA 30-50% sessions

LASER

• NON Ablative PDL for erythematous scars eliminates vascular component

• Fractional CO2 Laser for non-erythematous scars

Collagen Induction Therapy (CIT)Dermaroller

• Creates minute channels stimulating islets of collagen synthesis

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Atrophic Scars

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Types of Atrophic Scars

Page 12: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

Management of Atrophic Scars

Scar considered fresh during 1st year, golden time of treatment is first 7-9 months

Aims• To Smoothen scar demarcation line• To even overhanging scar edges• Transdermal induction of collagen synthesis• To elevate Scar bottom

Tools of management in Fresh atrophic scars?? Enzymotherapy (Proteolytic Serrapeptase, Nattokinase and Hyalorinase) / Topical creamsOcclusive Hydration (Till wound bottom reaches skin level)CryotherapyMicrodermabrasion (NOT FOR ICEPICK ATROPHIC SCARS)DermarollerPeelingLaser Correction

NO CONTRACTUBEX

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Management of Old Atrophic Scars

Tools of management

Dermaroller

Laser Correction of erythematous scars / Laser or Peeling for nonvascularised Scars

Subcision (Nokor needle)

Excision / Punch excision

Hydration

Microdermabrasion

Autofibroblasts

Autologous Fat Transfer / Fillers [only after subcision]

Page 14: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

Nokor needle

Page 15: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

Pathological Scars

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Pathological Scars

ReddishBlueFast Blue collagen stain

↑ Calcium

↑ Magnesium

↑ Mucinous ground substance

↓ Fibroblasts

No Foreign body reaction

↓ Calcium

↓ Magnesium

↓ Mucinous ground substance

↑ Fibroblasts

↑ Foreign body reaction

Content

UnknownTension ??Aetiology

RareFrequentIncidence

May take monthsSoon after injuryTime of Development

Rarely subsidesSubsides with timeNatural History

Areas of little motion

Sternum, shoulders, ear lobules

Areas of Motion

Scars crossing joints or skin lines

Sites

PoorGoodResponse to treatment

Outgrows wound areaWithin woundExtension

10-30 YearsChildrenAge

Females NoneSex

Related to skin ColourNoneRace

PresentNoneGenetic Predisposition

KeloidsHypertrophic ScarsFeature

Page 17: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

Management of Hypertrophic Scars & Keloids

Aims:

Reduction of Scar Mass +/- Induction of new proper collagen synthesis

Improving texture and elasticity of scar

Treatment options are similar but Hypertrophic scars have better prognosis

A solitary tool of management seldom works

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Management of Hypertrophic Scars & KeloidsNon InvasiveOcclusive dressings / Compression therapy

Intralesional corticosteroid injections (decreases TGF Beta 1 and Inflammatory mediators)Intralesional Immunomodulators (Interferon) injections: Inhibits type I,II,IV Collagen synthesis

Intralesional Calcium Channel Blockers (Verapamil): ↓ collagen synthesis & ↑ collagenase production

Intralesional Antineoplastic Agents 5FU, Belomycin, Tamoxifen & Doxorubicin

Topical Immunosuppressant Tacrolimus ointment: Inhibits TNF alpha

Topical Retinoic Acid (Retin-A): Inhibits DNA synthesis in fibroblasts and lymphocytes (Not FDA approved)

Topical Imiquimod 5% cream “Aldara” (Immune response modifier): Decreases collagen synthesis (Not FDA approved)

Botulinum toxin

Minimally InvasiveCryosurgery for small lesions (affects microvasculature causing cell damage via intracellular crystals, leading to anoxia)

Radiation therapy

Light therapy (IPL)

Laser therapy (Non Ablative PDL & Fractional)

Surgical Excision

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Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone

Radiation therapy alone or Postsurgical, May cause cancer, hyperpigmentation, paresthesias

Postsurgical intralesional interferon, Expensive; May cause pruritus, altered pigmentation, pain

Bleomycin tattooing, Effective; May cause pulmonary fibrosis, cutaneous reactions

Intralesional Fluorouracil, Effective; May cause hyperpigmentation, wound ulceration

Intralesionl Verapamil and silicone sheeting

Pulsed dye laser

“Triple keloid therapy” (surgery, corticosteroids, and silicone sheeting)

Combined cryotherapy and intralesional corticosteroid injection

Surgical excision, If alone, can be followed by more aggressive growth in up to 84% of cases

Second-line and alternative treatment

Pressure dressing for six to 12 months

Silicone sheeting

Intralesional corticosteroids.,May cause discomfort, skin atrophy, telangiectasia

Cryotherapy, May cause hypopigmentation, pain

First-line treatment

Management of Hypertrophic Scars & Keloids

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Compression• Mechanically holds growth

• Compresses scar vasculature leading to anoxia

Dermabrasion

• Microdermabrasion and rotation dermabrasion have little value

• Might stimulate collagen synthesis

• Sandabrasion may have a role

Radiation

• Effect disputable

• Risk of malignancy

• Age and site restrictions

Page 21: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

Pulsed Dye Laser (585 nm)Induces photothermolysis, resulting in microvascular thrombosis

Limited value, best if used early in combination with other modailities

Page 22: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

Promising therapies that aim at decreasing collagen synthesis

Antiangiogenic factors, including vascular endothelial growth factor (VEGF) inhibitors

Phototherapy (photodynamic therapy [PDT]

UVA-1 therapy, narrowband UVB therapy)

Transforming growth factor (TGF)–beta3

Tumor necrosis factor (TNF)-alpha inhibitors (etanercept)

Recombinant human interleukin (rhIL-10)

Page 23: PATHOLOGICAL TYPES OF SCARS AND THEIR IMPACT ON TREATMENT · Onion extract topical gels (e.g., Contractubex, Mederma), Limited effect alone Radiation therapy alone or Postsurgical,

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