Part I: Keloid and Hypertrophic scars before and after treatment
For the treatment of keloid scars, as well as hypertrophic scars (pathological scars) the following methods are used:
Treatment of keloid scars by surgical excision
Treatment of keloid scars by surgical excision as an independent method leads to recurrence in 70-90% cases.
Therefore surgical excision is used to treat keloids only in combination with the first-line treatments such as silicone sheeting, pressure dressings, and corticosteroid injections. In the treatment of hypertrophic scars the excision produces an acceptable result.
Fig.1. Dynamics keloid recurrence after surgical excision. One week after surgery (left), ten weeks (medium) and 4 months (right)
Treatment of keloid scars with radiation therapy (X-ray therapy)
Efficacy is quite disputable. This method give reccurences in 50-100% when applied as mono therapy. Carcinogenic effect is not fully proven, but this method is seldom applied in view of inefficacy. Usually X Ray therapy uses in combination with other methods. Treatment of keloid scars with radiation therapy is not applied in children and in adults on the head, face and breast. X Ray therapy as method of treatment of keloid scars is most effective direct after surgical excision.
Treatment of keloid scars with compression
The continuous compression of 20-40 mm of mercury is applied for 12-24 hours per day in course of 3-12 months. On the one hand, it resists the scar tissue growth, holding it mechanically within limited space. On the other, by compression of the scar vessels blocks its nutrition, which results in termination of its growth and regression.
Silicone sheets in the treatment of keloid scars
Mechanism of action of silicone sheeting has not been fully investigated. It is assumed that silicone sheeting moisten the scar, compress capillaries, block the delivery of inflammatory mediators, reduced collagen synthesis due to oxygen starvation.
Fig.2. Post-burn keloids. Treatment with silicone scar sheets
Fig.3. Hypertrophic scar before and after treatment with silicone scar sheets
Scar cream and scar gels for hypertrophic and keloid scars treatment
Some creams and gels can reduce a hypertrophic scar but there is no “scar cream” or “scar gel” which can resolve keloid scar. Different creams and gels are applied depending on functional purpose: antibacterial, normalizing blood circulation, reducing or stimulating collagen synthesis, increasing wound immunity, etc. To this end Kelo-cote, Dermatix, Strataderm, MedGel, Kelofibrase, Scarguard, Contractubex, Aldara, among others are applied. Each individual case surely requires a consultation with the attending physician to select the necessary cream or ointment. There is because, the some gels can not improve, but worsen the condition of the scar.
Treatment of keloid scars by laser
Ablative lasers produce a high relapse rate (90-100%) when applied in hypertrophic scars and keloids treatment. Clinical efficacy with vascular (non-ablative) laser applied in hypertrophic scars treatment constitutes 75-95%, keloids – 60-70%. Primary task of laser treatment is to fuse the vessels providing nutrition to the scar.
Fig. 4. Postoperative active keloid on the right arm before and after 2 vascular laser procedures
Fig.5. Post-traumatic scars before and after vascular laser treatment and cryoablation
Treatment of keloid scars by corticosteroid injections
Corticosteroids are administered locally (to prevent keloid formation) by intralesional injections of crystalline suspension to treat active keloids and old hypertrophic scars. Corticosteroid injections reduce collagen synthesis not only by inhibiting fibroblast mitosis (cells synthesizing collagen), but along with collagenase (collagen-resolving enzyme) concentration increase. Besides, steroids possess a strong anti-inflammatory action.
Fig.6. Hypertrophic scar of the pubic area before and after corticosteroid injections
Fig.7. Removal of chest keloids with corticosteroid injections
Treatment of keloid scars by liquid nitrogen – cryoablation (cryodestruction)
Treatment of keloid scars by liquid nitrogen is similar to the freezing of a glass bottle of water in a freezer. The bottle is a keloid scar. When the contents freeze, the bottle will burst. The same happens with the cell membranes in the keloid tisse. When freezing, the cytoplasm and organelles of cells break the cell membrane, which causes their death. Cryodestruction of keloid scars causes the death of both the collagen fibers themselves and the cells (fibroblasts) that synthesize these fibers. As an independent method of treatment of keloid scars liquid nitrogen shows positive results with the absence of relapse in 51% of cases. In combination with other methods liquid nitrogen gives a positive dynamic in 76% cases.