AN ALGORITHMIC APPROACH TO HYPERTROPHIC SCARS REVIEW An Algorithmic Approach to Hypertrophic Scars and Keloids: Maximizing Nonsurgical Options Shauna Kranendonk, MD; Suzan Obagi, MD Hypertrophic scars and keloids are very common concerns among dermatologic patients, whether from a medical or cosmetic standpoint. The treatment of these lesions is challenging and associated with variable response or recurrence. The authors of this study review the most current literature on the treatment of hypertrophic scars and keloids ranging from intralesional therapies to laser and surgical modalities. The authors describe a treatment algorithm employing combination therapies while aiming to limit the use of surgical intervention. Representative case reports are presented to illustrate the use of solo orCOS combination therapy. DERM ypertrophic scars and keloids are rou- keloidal scarring and result in superior cosmetic and tinely encountered in the cosmetic der- functional outcomes. matology setting. Patients either present This article will review factors contributing to hyper- Dowith cosmetic concernsNot or have symp- trophic Copyscars and keloids and present an algorithmic toms of pain and/or pruritus associated approach for treatment of these lesions (Figure 1). The Hwith these lesions. Occasionally, there may be a func- emphasis will be on maximizing nonsurgical interven- tional component if the scar interferes with movement tion due to the risk of recurrence associated with exci- of the involved area. sion of these lesions. Intralesional corticosteroids have been a mainstay of treatment, but numerous alternative modalities are BACKGROUND available. Proper sequential use of these modalities, Hypertrophic scars differ clinically from keloids, in that particularly when used early in the course of disease, hypertrophic scars do not grow beyond the boundaries can impede the development of hypertrophic and of the original wound, while keloids grow horizontally beyond the margins of the original wound.1 Hypertro- Dr. Kranendonk is dermatologist, private practice, Palm Beach phic scars are less likely to recur after treatment and Gardens, Florida, and former Cosmetic Dermatologic Surgery Fellow, show no racial predilection.2 Hypertrophic scars University of Pittsburgh Medical Center, Pennsylvania. Dr. Obagi and keloids occur more frequently on the face, neck, and is Associate Professor of Dermatology, Associate Professor of chest, but can occur at any anatomic location. Surgery-Division of Plastic Surgery, and Director, Cosmetic Surgery & Risk factors for development of hypertrophic scars Skin Health Center, University Pittsburgh Medical Center. or keloids include trauma, mechanical forces (namely The authors report no conflict of interest in relation to this article. increased wound tension or stretching), infection, Correspondence: Suzan Obagi, MD, Cosmetic Surgery & Skin inflammation, and foreign body reaction.3 Genetic sus- Health Center, Blaymore II, 1603 Carmody Ct, Ste 103, Sewickley, ceptibility also is a factor with increased incidence of PA 15143 ([email protected]). keloids in Fitzpatrick skin types IV to VI. 28 Cosmetic Dermatology® • JANUARY 2011 • VOL. 24 NO. 1 www.cosderm.com Copyright Cosmetic Dermatology 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. AN ALGORITHMIC APPROACH TO HYPERTROPHIC SCARS Histologically, hypertrophic scars display a nonspecific types of scars is similar so we will refer to these lesions dermal fibroblastic proliferation, thickened dermis, and as hypertrophic scars/keloids (HTS/K). The first signs of epidermal atrophy. Hypertrophic scars are more cellular impending HTS/K are erythema, pruritus, and tenderness, than keloids, which in contrast display characteristic hypo- often manifesting as early as 1 to 2 weeks after the initiat- cellular, glassy, hyalinised, eosinophilic collagen fibers.4 It ing event. Following skin resurfacing with peels, derm- is possible that hypertrophic scars and keloids represent a abrasion, or laser, impending scar formation may simply continuum of the same fibroproliferative process.5 present with intense erythema (substantially more redness than typically encountered at the 1- to 2-week point) or an PATIENT EVALUATION area of delayed wound healing. In most cases, tenderness In most instances, a history of recent surgery or trauma or pruritus will accompany the intense erythema, helping with clinical findings of flesh-colored to erythematous to distinguish early HTS/K from normal postprocedural fibrotic plaques is sufficient to make a diagnosis, and a erythema. Once a diagnosis of HTS/K or impending HTS/K biopsy becomes unnecessary. Malignant tumors, includ- has been established, we follow a treatment algorithm ing dermatofibromasarcoma protuberans,6,7 and giant beginning with pulsed dye laser (PDL)(Figure 1). cell fibroblastoma,8 along with infections and sarcoidosis should be considered in the differential diagnosis in the Vascular Laser absence of supportive findings. Lobomycosis, or lacazio- The PDL is a mainstay for treatment of early HTS/K. The sis, is a granulomatous fungal infection caused by Lacazia PDL treatment is beneficial in reducing erythema and loboi that presents with keloidlike scarring. Lacazia loboi helps prevent the development of HTS/K.10 Through is endemic in Central and South America, particularly the the concept of selective photothermolysis, the PDL is Amazon basin, and has been reported in dolphins.9 Soil believed to damage the microvasculature of the impend- and vegetation are likely sources of infection. ing scar.11 Selective photothermolysis refers to the specific PostproceduralCOS impending scarring often presents DERMas targeting of a structure or tissue through the use of a pre- an area of erythema or induration. This is especially cise wavelength of light at the proper pulse width to heat true in post–skin resurfacing patients. When intense or the desired target while minimizing unnecessary heating prolonged postprocedural erythema is seen, infection or of the normal surrounding tissue. contact dermatitis should be considered in the differential Studies of keloids show the 585-nm PDL decreases diagnosis. Bacterial skin infection is due most frequently fibroblast proliferation and type III collagen deposition.12 to Staphylococcus aureus and may present with erythema, Pulsed dye laser treatment has been associated with down- warmth, discharge, and/or pustules. Bacterial infections regulation of transforming growth factor-beta 1 (TGF-␤1) Do Not Copy␤ with gram-negative organisms, such as Pseudomonas expression. Transforming growth factor- 1 is thought aeruginosa, are less frequently encountered. Yeast infec- to induce and regulate collagen formation.13,14 Down- tions due to Candida species may be seen, especially with regulation of TGF-␤1 also has been linked to an increase prolonged use of petrolatum-based emollients or recent in matrix metalloproteinase-13 (collagenase-3) function.15 use of antibiotics. Herpes simplex infection also may The authors began treatment with a 595-nm PDL be seen and presents with burning or tenderness along (Perfecta or VBeam, Candela Corporation), as early as with vesicles, erosions, and/or crusting. Allergic contact 1 to 2 weeks postexcision or surgery, with settings of dermatitis can develop to topical antibiotics or topical 10-mm spot, 1.5-millisecond pulse duration and flu- emollients used in the postoperative setting. Appropriate ences of 5.0 to 7.5 J/cm2, cryogen 30/20 delay/duration cultures for fungus, virus, and/or bacteria, along with in millisecond. While some physicians may use higher history of topical applications, should be obtained. Treat- fluences when treating HTS/K, several studies using ment of the etiology behind the postprocedural erythema higher fluences have not shown notable differences in may halt progression of this area to an organized scar. outcomes.16-18 A more recent article suggested fluences However, should the area remain erythematous, aggres- used to treat HTS/K should range from 4.5 to 7.5 J/cm2 sive management is required to minimize or prevent with spot sizes of 5- to 10-mm (smaller spot size used hypertrophic or keloidal scarring from occurring. higher fluences).19 Patients with Fitzpatrick skin types V and VI should be approached with caution, using lower TREATMENT APPROACHES fluences and reduced cryogen cooling to prevent injury The key to successful treatment of hypertrophic scars to the skin. Alternatively, Nd:YAG lasers can be used in or keloids is early intervention. Our approach to both these patients so as to minimize the competition of the laser VOL. 24 NO. 1 • JANUARY 2011 • Cosmetic Dermatology® 29 www.cosderm.com Copyright Cosmetic Dermatology 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. AN ALGORITHMIC APPROACH TO HYPERTROPHIC SCARS Scar-Confirm rule out other diagnoses Erythema, flat or Raised scar impending scar Fitzpatrick skin Fitzpatrick skin Facial Location Nonfacial Intralesional TMC types I-III types IV-V Intralesional TMC mixed with 5- FU Pulsed dye laser Nd:YAG laser re- +/- silicone gel repeat at 2–4 week peat at 2–4 week sheeting +/- silicone gel sheeting intervals + topical intervals + topical corticosteroids corticosteroids Repeat at Repeat at 2–4 week 2–4 week No Improvement intervals until flat intervals until flat Ablative Progession to Resolved fractionated laser Resolved