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The Effectiveness of Topical Scar-Reducing Therapies Administered for Scarring Due to Burns and Other Causes: a Retrospective Pilot Clinical Research

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The Effectiveness of Topical Scar-Reducing Therapies Administered for Scarring Due to Burns and Other Causes: a Retrospective Pilot Clinical Research ORIGINAL ARTICLE Aksoy et al. / Gulhane Med J 2018;60: 139-144 139 The effectiveness of topical scar-reducing therapies administered for scarring due to burns and other causes: A retrospective pilot clinical research Hasan Mete Aksoy,1 Berna Aksoy,2 Aslı Tatlıparmak,2 Emel Çalıkoğlu3 (1) Bahçeşehir University, School of Medicine, Plastic and Reconstructive Surgery, Istanbul, Turkey (2) Bahçeşehir University, School of Medicine, Dermatology, Istanbul, Turkey (3) Aksaray University, Faculty of Medicine, Dermatology, Aksaray, Turkey Date submitted: ABSTRACT Oct 019, 2017 Aims: Multiple modalities are used to treat scarring; however, data on the efficacy of Date accepted: Aug 25, 2018 the topical scar-reducing treatments most frequently used by patients is insufficient. Online publication date: This study aimed to retrospectively determine the effectiveness of topical scar-reducing December 15, 2018 treatments and patients’ compliance. Methods: The medical records of patients adimitted for the treatment of scarring were retrospectively evaluated. Patient satisfaction with the treatment was assessed via telephone interviews. Each patient also sent recent photographs of their scars. Pre- and Corresponding Author: post-treatment photographs were scored according to the Manchester Scar Scale, and in Berna Aksoy terms of vascularity and scar surface area (modified MSS ). Bahcesehir University, School of Results: The study included 71 patients with a median scar age of 18 days at the time Medicine, Dermatology, Istanbul, treatment was initiated. Mean duration of follow-up was 41 months. The prescribed Turkey [email protected] treatments included onion extract, silicone gel or sheet, and a pressure garment. The patients reported that the treatments were effective, they were satisfied with the treatments, and the treatments were not excessively difficult to apply. MSS and ModMSS scores decreased significantly following treatment. Keywords: Onion extract, scar, Conclusions: The prescribed topical scar-reducing treatments effectively improved the silicone, pressure garment, cosmetic appearance of the patients’ scars and reduced scar-related symptoms. The treatment. effectiveness of the topical scar-reducing therapies increased as scar age decreased. Introduction There are several methods used by clinicians and patients for objective evaluation of scars (1,2). These scar scoring methods The wound healing process consists of 3 phases: inflam- are also used to ensure that studies are comparable to each mation, proliferation, and tissue remodeling (1). This process other and that the results can be standardized (2). The Man- repairs tissue integrity following any damage to the skin (1). chester Scar Scale (MSS) scoring system is one such method Fibrous scar tissue is an imperfect structure, lacking skin ap- (3). A verbal scale (VRAS) (score range: 0-10) is another meth- pendages and normal epidermal and dermal architecture, that od used to evaluate outcomes that was originally used to score is formed as a result of the wound healing process to repair the pain (2). The present study aimed to retrospectively evaluate tissue and prevent wound infection (1). Scars that occurred due to impaired wound healing and tissue remodeling can be vari- the efficacy of topical scar-reducing treatments based on tele- able in architecture; enlarged or contracted; depressed or el- phone interviews with patients, and comparison of current and evated; atrophic or hypertrophic (1). Multiple treatment modali- past scar photographs. ties are used to prevent the formation of abnormal scarring and Methods improve the cosmetic appearance of scars by supporting the remodeling process. Topical onion extract (Contractubex® gel), Patients that presented to the dermatology outpatient clinic silicone layer, silicone gel and pressure garments are among with scarring during the period 2009-2016 were included in this the most frequently used approaches. However, no long-term retrospective study. Lesions that were initially photographed follow-up studies on the efficacy of topical scar-reducing treat- and treated with topical scar-reducing treatments were eval- ment protocols, such as onion extract and silicone gel, have uated. Patient clinical characteristics were obtained from our been published (1). These topical agents are readily available medical records. Demographics, scar age, anatomic scar lo- and can be used by patients following scarring without consult- calization, approximate scar surface area (calculated from the ing a clinician (1). initial photographs), whether or not the scar passed through © Gülhane Faculty of Medicine 2018 / doi: 10.26657 / gulhane.00039 140 Aksoy et al. / Gulhane Med J 2018;60: 139-144 mobile skin areas, whether or not any surgical operation per- formed, whether or not the scar was located parallel to Langer’s lines, the trauma that preceded scar formation, and if the trau- MODIFIED MANCHESTER SCAR SCALE - PHOTOGRAPHY ma was a burn the degree of burn were recorded. Scar-related General appearance of the scar – VAS symptoms designated in patients’ records, including pigmen- Excellent Poor tation disorder, lymphedema, puffiness, depression, hardness, 0 l----------------------------------------------------------------------l 10 erythema/redness, infection, occupation of a large (>10 cm2) Color (Relative to the surrounding normal skin) surface area, irregularity of scar contours, chronic wound, pain, 1 Perfect □ hypopigmentation □ stinging, tingling, itching, xerosis, tightness, sweating imbal- 2 Slight mismatch □ hyperpigmentation □ ance, change in hair density, and limitation of motion, were also 3 Obvious mismatch □ mixed □ assessed. 4 Gross mismatch □ Patients with small scars (<5-10 cm2) that healed within 2 Surface appearance weeks of wounding were prescribed silicone gel at the clini- 1 Matte □ cal visit when the wounds were already healed, as silicone gel 2 Shiny □ packs are smaller (10-15 gr) than onion extract gel and enough Contour (Relative to the surrounding normal skin ) for 1-3 months treatment of a small scar. In patients with medi- 1 Flush with surrounding skin □ um-sized scars (5-50 cm2) that healed within 2 weeks of wound- 2 Slightly proud / intended □ ing we prescribed onion extract gel at the clinical visit when the 3 Hypertrophic □ wounds were already healed as onion extract gel packs (100 4 Keloid □ gr) are bigger than silicone gel packs and sufficient for the en- Surface distortion tire treatment period of medium-sized scars. We recommended 1 None □ combination treatments consisted of pressure garment with a silicone sheet inside after healing in patients with large (>50 2 Mild □ cm2) burn scars in appropriate anatomical locations that last- 3 Moderate □ ed longer than 2 to 3 weeks to heal following wounding and 4 Severe □ in some cases we combined this modality with onion extract MSS score: …………………… gel especially in scars showing early signs of hypertrophy. In Vascularity (Relative to the surrounding normal skin) large scars located in areas inappropriate to use pressure gar- 1 Normal □ ments, or in some medium sized scars amenable to use silicon 2 Pink □ sheets; the patients were prescribed silicon sheets to be used 3 Red □ at least 20 hours a day. All of the patients were prescribed scar 4 Purple □ reducing treatments after completion of epithelization/wounds Scar surface area (Relative to the original wounding area ) healed, when they applied at various time points post-injury. 1 Similar □ Patients were contacted by telephone and administered 2 Expansion □ survey questions about the duration of treatment, frequency 3 Contraction □ of treatment application, treatment side effects, and final scar 4 Mixed □ symptoms. In addition, patients were asked to evaluate the effi- ModMSS score: ……………………….. cacy of the treatment, the level of difficulty in applying the treat- ment and the level of satisfaction with the treatment (patient outcome measures). Some of the patients agreed to come to Figure 1. Modified MSS score sheet. the clinic and were evaluated and photographed by a doctor; for each scar photograph. The study protocol was approved by other patients self-photographed the final state of their scar and the Local Ethics Committee (KU GOKAEK 2016/77). The study e-mailed them to the researchers. was conducted in accordance with the Declaration of Helsinki. Initial and post-treatment scar photographs were scored by Participants gave verbal informed consent to participate in the 2 independent clinicians (one-blinded) that were unaware of study during telephone survey. which treatment was given to each patient and the patients’ Statistical analysis survey question answers. Photographs were scored using the MSS photographic scoring method. MSS rates photographs of Data were analyzed using SPSS Statistics for Windows scars based on 5 criteria: general appearance, color (compared v.22.0 (IBM Corp., Armonk, NY). Mean ± SD, median, range, to surrounding skin), surface appearance, contour, and surface frequency, percentage and ratio values were used for descrip- irregularity (3). MSS total scores range from 4 to 24 (3). As tive statistics. The normality of the distribution of the variables stated earlier, vascularity and scar surface area are addition- was determined via the Kolmogorov-Simirnov test. The Wil- al important parameters for scoring photographs of scars (4). coxon test was used to analyze dependent quantitative data. Vascularity was rated using the Vancouver Scar Scale (VSS), Spearman’s correlation analysis was
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