Editing Wound healing (section)

== Hypertrophic scars/keloids ==

* Excessive net collagen deposition
* Keloids '''grow beyond borders of original wounds'''
** Rarely regress
** Aetiology
*** Much more prevalent in dark skin
*** Genetics
** Pathogenesis
*** Disorganised type I and III collagen
** Clinical features
*** Often form at previous minor trauma/scars e.g. earlobes from piercings
*** Generally get bigger over time, do not regress
*** Often a/w pain and pruritis
** Treatment
*** Medical
**** Topical/intralesional corticosteroids
**** Radiotherapy (often in conjunction with surgery, however one big study didn't show any difference to recurrence rates if it was included)
*** Surgical
**** Consider if refractory to medical treatment for 12 months
**** Leads to recurrence of 45-100%
* Hypertrophic scars are raised scars '''within confines of original wound'''
** Occur with prolonged inflammation and tension
** Frequently regress spontaneously
** Well-organised type III collagen
** Prevent by avoiding wound tension, hydration/occlusion, and use of taping/pressure garments
*** Indicated in severe burns, mechanical trauma, necrotising infections, or grafting
** Treatment:
*** 6-12 weeks: pressure therapy
*** >6mo: silicone therapy, intralesional corticosteroids (triamcinolone acetonide, 10-40mh/mL injected into papillary dermis every 2-4 weeks until flat. Works >50% of patients
* Approach to hypertrophic scars/keloids:
** History - including other scars, family history
** Examination - can use Vancouver scar scale to give objective measure of scar
** Counsel patient about difficult nature of problem and define goals of therapy:
*** Relief of symptoms
*** Reduction of scar volume
*** Functional or cosmetic improvement
** Initial trial of intra-lesional triamcinolone acetonide at a concentration of 10 to 40mg/mL
*** Reduces volume
*** Improves pain and pruritis
*** Repeat treatment several times at 4-6 week intervals
*** Injections are painful. Can cause dermal atrophy, skin ulceration, hyperpigmentation, telangiectasia.
** Can try combination fluouracil and triamcinolone - 50-96% had a good response in one meta-analysis - but these studies are of low quality. Can cause pain and hyperpigmentation.
** Can trial pressure - there are special devices for earlobes. Limited evidence. May be beneficial in combination with surgery.
** Surgery - recurrence approaches 100% - however is probably lower if combined with peri-operative triamcinolone or fluorouracil
** Post-op radiation therapy. Evidence from retrospective observational trials.

[[Category:Skin, soft tissue and wounds]]
[[Category:Intern education]]