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Facial Plast Surg 2015; 31(04): 386-395
DOI: 10.1055/s-0035-1563694
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Current Strategies in the Treatment of Scars and Keloids

Markus V. Heppt
1   Department of Dermatology and Allergology, Ludwig-Maximilian University, Munich, Germany
,
Helmut Breuninger
2   Department of Dermatology, Eberhard-Karls University Tübingen, Tübingen, Germany
,
Markus Reinholz
1   Department of Dermatology and Allergology, Ludwig-Maximilian University, Munich, Germany
,
Gabriele Feller-Heppt
3   Skin and Face Clinic, Baden-Baden, Germany
,
Thomas Ruzicka
1   Department of Dermatology and Allergology, Ludwig-Maximilian University, Munich, Germany
,
Gerd G. Gauglitz
1   Department of Dermatology and Allergology, Ludwig-Maximilian University, Munich, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
15 September 2015 (online)

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Abstract

Hypertrophic scars (HTSs) and keloids are a major health concern for aesthetic and functional reasons. Despite a plethora of rapidly evolving treatment options and technical advances, the management of pathologic scarring remains difficult. The development of standardized treatment algorithms has been problematic for years due to the lack of sound randomized controlled trials. Expert panels are more and more establishing guidelines to provide an evidence-based framework on a national and international level. This article aims to evaluate the current strategies and upcoming trends in the therapy and prevention of unpleasant scars and keloids from a clinical perspective. There is strong evidence to support a growing role of early combination treatments, particularly the application of 5-fluoruracil adjunct to intralesional steroid injections. Furthermore, the use of fractional ablative laser technologies such as the CO2 laser has recently yielded promising results with respect to aesthetic outcomes and patient satisfaction at tolerable side effects.

Keywords

hypertrophic scar - keloid - aesthetic medicine - CO2 laser - fractional laser
 

  • References

  • 1 Breuninger H. [Dermatofibrosarcoma protuberans. Quality Assurance Committee of the German Society of Dermatology and the Professional Organization of German Dermatologists e. V]. Hautarzt 1998; 48 (Suppl. 01) S46-S48
    PubMedGoogle Scholar
  • 2 Breuninger H. Double butterfly suture for high tension: a broadly anchored, horizontal, buried interrupted suture. Dermatol Surg 2000; 26 (3) 215-218
    CrossrefPubMedGoogle Scholar
  • 3 Mustoe TA, Cooter RD, Gold MH , et al; International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg 2002; 110 (2) 560-571
    CrossrefPubMedGoogle Scholar
  • 4 Gold MH, Berman B, Clementoni MT, Gauglitz GG, Nahai F, Murcia C. Updated international clinical recommendations on scar management: part 1—evaluating the evidence. Dermatol Surg 2014; 40 (8) 817-824
    PubMedGoogle Scholar
  • 5 Gold MH, McGuire M, Mustoe TA , et al; International Advisory Panel on Scar Management. Updated international clinical recommendations on scar management: part 2—algorithms for scar prevention and treatment. Dermatol Surg 2014; 40 (8) 825-831
    PubMedGoogle Scholar
  • 6 Nast A, Eming S, Fluhr J , et al; German Society of Dermatology. German S2k guidelines for the therapy of pathological scars (hypertrophic scars and keloids). J Dtsch Dermatol Ges 2012; 10 (10) 747-762
    PubMedGoogle Scholar
  • 7 Gauglitz GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Mol Med 2011; 17 (1-2) 113-125
    Google Scholar
  • 8 Eberle FC, Krug M, Breuninger H, Häfner HM. Primary wound closure with tension—tips and tricks. J Dtsch Dermatol Ges 2013; 11 (6) 558-560
    PubMedGoogle Scholar
  • 9 Gauglitz GG. Management of keloids and hypertrophic scars: current and emerging options. Clin Cosmet Investig Dermatol 2013; 6: 103-114
    PubMedGoogle Scholar
  • 10 Gauglitz GG, Kunte C. [Recommendations for the prevention and therapy of hypertrophic scars and keloids]. Hautarzt 2011; 62 (5) 337-346
    CrossrefPubMedGoogle Scholar
  • 11 Robles DT, Moore E, Draznin M, Berg D. Keloids: pathophysiology and management. Dermatol Online J 2007; 13 (3) 9
    PubMedGoogle Scholar
  • 12 Barara M, Mendiratta V, Chander R. Cryotherapy in treatment of keloids: evaluation of factors affecting treatment outcome. J Cutan Aesthet Surg 2012; 5 (3) 185-189
    CrossrefPubMedGoogle Scholar
  • 13 Yosipovitch G, Widijanti Sugeng M, Goon A, Chan YH, Goh CL. A comparison of the combined effect of cryotherapy and corticosteroid injections versus corticosteroids and cryotherapy alone on keloids: a controlled study. J Dermatolog Treat 2001; 12 (2) 87-90
    CrossrefPubMedGoogle Scholar
  • 14 Zouboulis CC. Principles of cutaneous cryosurgery: an update. Dermatology 1999; 198 (2) 111-117
    CrossrefPubMedGoogle Scholar
  • 15 Zouboulis CC, Blume U, Büttner P, Orfanos CE. Outcomes of cryosurgery in keloids and hypertrophic scars. A prospective consecutive trial of case series. Arch Dermatol 1993; 129 (9) 1146-1151
    CrossrefPubMedGoogle Scholar
  • 16 Weshahy AH. Intralesional cryosurgery. A new technique using cryoneedles. J Dermatol Surg Oncol 1993; 19 (2) 123-126
    CrossrefPubMedGoogle Scholar
  • 17 Har-Shai Y, Amar M, Sabo E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast Reconstr Surg 2003; 111 (6) 1841-1852
    CrossrefPubMedGoogle Scholar
  • 18 Har-Shai Y, Brown W, Labbé D , et al. Intralesional cryosurgery for the treatment of hypertrophic scars and keloids following aesthetic surgery: the results of a prospective observational study. Int J Low Extrem Wounds 2008; 7 (3) 169-175
    CrossrefPubMedGoogle Scholar
  • 19 van Leeuwen MC, van der Wal MB, Bulstra AE , et al. Intralesional cryotherapy for treatment of keloid scars: a prospective study. Plast Reconstr Surg 2015; 135 (2) 580-589
    CrossrefPubMedGoogle Scholar
  • 20 van Leeuwen MC, Bulstra AE, van der Veen AJ, Bloem WB, van Leeuwen PA, Niessen FB. Comparison of two devices for the treatment of keloid scars with the use of intralesional cryotherapy: an experimental study. Cryobiology 2015; 71 (1) 146-150
    CrossrefPubMedGoogle Scholar
  • 21 Renò F, Sabbatini M, Lombardi F , et al. In vitro mechanical compression induces apoptosis and regulates cytokines release in hypertrophic scars. Wound Repair Regen 2003; 11 (5) 331-336
    CrossrefPubMedGoogle Scholar
  • 22 Van den Kerckhove E, Stappaerts K, Fieuws S , et al. The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring. Burns 2005; 31 (6) 696-702
    CrossrefPubMedGoogle Scholar
  • 23 Macintyre L, Baird M. Pressure garments for use in the treatment of hypertrophic scars—a review of the problems associated with their use. Burns 2006; 32 (1) 10-15
    CrossrefPubMedGoogle Scholar
  • 24 Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis. J Plast Reconstr Aesthet Surg 2009; 62 (1) 77-84
    CrossrefPubMedGoogle Scholar
  • 25 O'Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev 2006; (1) CD003826
    PubMedGoogle Scholar
  • 26 Mustoe TA. Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg 2008; 32 (1) 82-92
    CrossrefPubMedGoogle Scholar
  • 27 Eishi K, Bae SJ, Ogawa F, Hamasaki Y, Shimizu K, Katayama I. Silicone gel sheets relieve pain and pruritus with clinical improvement of keloid: possible target of mast cells. J Dermatolog Treat 2003; 14 (4) 248-252
    CrossrefPubMedGoogle Scholar
  • 28 Reish RG, Eriksson E. Scars: a review of emerging and currently available therapies. Plast Reconstr Surg 2008; 122 (4) 1068-1078
    CrossrefPubMedGoogle Scholar
  • 29 Phan TT, Lim IJ, Chan SY, Tan EK, Lee ST, Longaker MT. Suppression of transforming growth factor beta/smad signaling in keloid-derived fibroblasts by quercetin: implications for the treatment of excessive scars. J Trauma 2004; 57 (5) 1032-1037
    CrossrefPubMedGoogle Scholar
  • 30 Phan TT, See P, Tran E , et al. Suppression of insulin-like growth factor signalling pathway and collagen expression in keloid-derived fibroblasts by quercetin: its therapeutic potential use in the treatment and/or prevention of keloids. Br J Dermatol 2003; 148 (3) 544-552
    CrossrefPubMedGoogle Scholar
  • 31 Cho JW, Cho SY, Lee SR, Lee KS. Onion extract and quercetin induce matrix metalloproteinase-1 in vitro and in vivo. Int J Mol Med 2010; 25 (3) 347-352
    PubMedGoogle Scholar
  • 32 Chanprapaph K, Tanrattanakorn S, Wattanakrai P, Wongkitisophon P, Vachiramon V. Effectiveness of onion extract gel on surgical scars in Asians. Dermatol Res Pract 2012; 2012: 212945
    PubMedGoogle Scholar
  • 33 Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg 2006; 32 (7) 891-896
    CrossrefPubMedGoogle Scholar
  • 34 Koc E, Arca E, Surucu B, Kurumlu Z. An open, randomized, controlled, comparative study of the combined effect of intralesional triamcinolone acetonide and onion extract gel and intralesional triamcinolone acetonide alone in the treatment of hypertrophic scars and keloids. Dermatol Surg 2008; 34 (11) 1507-1514
    PubMedGoogle Scholar
  • 35 Jablonka EM, Sherris DA, Gassner HG. Botulinum toxin to minimize facial scarring. Facial Plast Surg 2012; 28 (5) 525-535
    Article in Thieme ConnectPubMedGoogle Scholar
  • 36 Sherris DA, Gassner HG. Botulinum toxin to minimize facial scarring. Facial Plast Surg 2002; 18 (1) 35-39
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Gassner HG, Brissett AE, Otley CC , et al. Botulinum toxin to improve facial wound healing: a prospective, blinded, placebo-controlled study. Mayo Clin Proc 2006; 81 (8) 1023-1028
    CrossrefPubMedGoogle Scholar
  • 38 Liu RK, Li CH, Zou SJ. Reducing scar formation after lip repair by injecting botulinum toxin. Plast Reconstr Surg 2010; 125 (5) 1573-1574 , author reply 1575
    PubMedGoogle Scholar
  • 39 Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair: a double-blinded, randomized, vehicle-controlled clinical trial. PLoS ONE 2014; 9 (12) e115690
    CrossrefPubMedGoogle Scholar
  • 40 Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair. Plast Reconstr Surg 2014; 134 (3) 511-516
    CrossrefPubMedGoogle Scholar
  • 41 Zhibo X, Miaobo Z. Intralesional botulinum toxin type A injection as a new treatment measure for keloids. Plast Reconstr Surg 2009; 124 (5) 275e-277e
    CrossrefPubMedGoogle Scholar
  • 42 Shaarawy E, Hegazy RA, Abdel Hay RM. Intralesional botulinum toxin type A equally effective and better tolerated than intralesional steroid in the treatment of keloids: a randomized controlled trial. J Cosmet Dermatol 2015; 14 (2) 161-166
    CrossrefPubMedGoogle Scholar
  • 43 Haubner F, Leyh M, Ohmann E, Sadick H, Gassner HG. Effects of botulinum toxin A on patient-specific keloid fibroblasts in vitro. Laryngoscope 2014; 124 (6) 1344-1351
    CrossrefPubMedGoogle Scholar
  • 44 Gauglitz GG, Bureik D, Dombrowski Y, Pavicic T, Ruzicka T, Schauber J. Botulinum toxin A for the treatment of keloids. Skin Pharmacol Physiol 2012; 25 (6) 313-318
    CrossrefPubMedGoogle Scholar
  • 45 Akaishi S, Koike S, Dohi T, Kobe K, Hyakusoku H, Ogawa R. Nd:YAG laser treatment of keloids and hypertrophic scars. Eplasty 2012; 12: e1
    PubMedGoogle Scholar
  • 46 Alster TS, Williams CM. Treatment of keloid sternotomy scars with 585 nm flashlamp-pumped pulsed-dye laser. Lancet 1995; 345 (8959) 1198-1200
    CrossrefPubMedGoogle Scholar
  • 47 Paquet P, Hermanns JF, Piérard GE. Effect of the 585 nm flashlamp-pumped pulsed dye laser for the treatment of keloids. Dermatol Surg 2001; 27 (2) 171-174
    CrossrefPubMedGoogle Scholar
  • 48 Wittenberg GP, Fabian BG, Bogomilsky JL , et al. Prospective, single-blind, randomized, controlled study to assess the efficacy of the 585-nm flashlamp-pumped pulsed-dye laser and silicone gel sheeting in hypertrophic scar treatment. Arch Dermatol 1999; 135 (9) 1049-1055
    CrossrefPubMedGoogle Scholar
  • 49 Manuskiatti W, Fitzpatrick RE. Treatment response of keloidal and hypertrophic sternotomy scars: comparison among intralesional corticosteroid, 5-fluorouracil, and 585-nm flashlamp-pumped pulsed-dye laser treatments. Arch Dermatol 2002; 138 (9) 1149-1155
    CrossrefPubMedGoogle Scholar
  • 50 Manuskiatti W, Fitzpatrick RE, Goldman MP. Energy density and numbers of treatment affect response of keloidal and hypertrophic sternotomy scars to the 585-nm flashlamp-pumped pulsed-dye laser. J Am Acad Dermatol 2001; 45 (4) 557-565
    CrossrefPubMedGoogle Scholar
  • 51 Bowes LE, Nouri K, Berman B , et al. Treatment of pigmented hypertrophic scars with the 585 nm pulsed dye laser and the 532 nm frequency-doubled Nd:YAG laser in the Q-switched and variable pulse modes: a comparative study. Dermatol Surg 2002; 28 (8) 714-719
    CrossrefPubMedGoogle Scholar
  • 52 Chan HH, Lam LK, Wong DS, Kono T, Trendell-Smith N. Use of 1,320 nm Nd:YAG laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians. Lasers Surg Med 2004; 34 (2) 98-103
    Google Scholar
  • 53 Manuskiatti W, Wanitphakdeedecha R, Fitzpatrick RE. Effect of pulse width of a 595-nm flashlamp-pumped pulsed dye laser on the treatment response of keloidal and hypertrophic sternotomy scars. Dermatol Surg 2007; 33 (2) 152-161
    CrossrefPubMedGoogle Scholar
  • 54 Kono T, Erçöçen AR, Nakazawa H, Nozaki M. Treatment of hypertrophic scars using a long-pulsed dye laser with cryogen-spray cooling. Ann Plast Surg 2005; 54 (5) 487-493
    CrossrefPubMedGoogle Scholar
  • 55 Nouri K, Elsaie ML, Vejjabhinanta V , et al. Comparison of the effects of short- and long-pulse durations when using a 585-nm pulsed dye laser in the treatment of new surgical scars. Lasers Med Sci 2010; 25 (1) 121-126
    CrossrefPubMedGoogle Scholar
  • 56 Alster T. Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. Dermatol Surg 2003; 29 (1) 25-29
    CrossrefPubMedGoogle Scholar
  • 57 Keller R, Belda Júnior W, Valente NY, Rodrigues CJ. Nonablative 1,064-nm Nd:YAG laser for treating atrophic facial acne scars: histologic and clinical analysis. Dermatol Surg 2007; 33 (12) 1470-1476
    CrossrefPubMedGoogle Scholar
  • 58 Lee DH, Choi YS, Min SU, Yoon MY, Suh DH. Comparison of a 585-nm pulsed dye laser and a 1064-nm Nd:YAG laser for the treatment of acne scars: a randomized split-face clinical study. J Am Acad Dermatol 2009; 60 (5) 801-807
    CrossrefPubMedGoogle Scholar
  • 59 Koike S, Akaishi S, Nagashima Y, Dohi T, Hyakusoku H, Ogawa R. Nd:YAG laser treatment for keloids and hypertrophic scars: an analysis of 102 cases. Plast Reconstr Surg Glob Open 2014; 2 (12) e272
    PubMedGoogle Scholar
  • 60 Gupta S, Kalra A. Efficacy and safety of intralesional 5-fluorouracil in the treatment of keloids. Dermatology 2002; 204 (2) 130-132
    CrossrefPubMedGoogle Scholar
  • 61 Kontochristopoulos G, Stefanaki C, Panagiotopoulos A , et al. Intralesional 5-fluorouracil in the treatment of keloids: an open clinical and histopathologic study. J Am Acad Dermatol 2005; 52 (3, Pt 1) 474-479
    CrossrefPubMedGoogle Scholar
  • 62 Nanda S, Reddy BS. Intralesional 5-fluorouracil as a treatment modality of keloids. Dermatol Surg 2004; 30 (1) 54-56 , discussion 56–57
    CrossrefPubMedGoogle Scholar
  • 63 Khan MA, Bashir MM, Khan FA. Intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. J Pak Med Assoc 2014; 64 (9) 1003-1007
    PubMedGoogle Scholar
  • 64 Huang L, Cai YJ, Lung I, Leung BC, Burd A. A study of the combination of triamcinolone and 5-fluorouracil in modulating keloid fibroblasts in vitro. J Plast Reconstr Aesthet Surg 2013; 66 (9) e251-e259
    CrossrefPubMedGoogle Scholar
  • 65 Huang L, Wong YP, Cai YJ, Lung I, Leung CS, Burd A. Low-dose 5-fluorouracil induces cell cycle G2 arrest and apoptosis in keloid fibroblasts. Br J Dermatol 2010; 163 (6) 1181-1185
    CrossrefPubMedGoogle Scholar
  • 66 Wu XL, Gao Z, Song N, Liu W. [Clinical study of auricular keloid treatment with both surgical excision and intralesional injection of low-dose 5-fluorouracil and corticosteroids]. Zhonghua Yi Xue Za Zhi 2009; 89 (16) 1102-1105
    PubMedGoogle Scholar
  • 67 Darougheh A, Asilian A, Shariati F. Intralesional triamcinolone alone or in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. Clin Exp Dermatol 2009; 34 (2) 219-223
    CrossrefPubMedGoogle Scholar
  • 68 Davison SP, Dayan JH, Clemens MW, Sonni S, Wang A, Crane A. Efficacy of intralesional 5-fluorouracil and triamcinolone in the treatment of keloids. Aesthet Surg J 2009; 29 (1) 40-46
    CrossrefPubMedGoogle Scholar
  • 69 Haurani MJ, Foreman K, Yang JJ, Siddiqui A. 5-Fluorouracil treatment of problematic scars. Plast Reconstr Surg 2009; 123 (1) 139-148 , discussion 149–151
    CrossrefPubMedGoogle Scholar
  • 70 Hatamipour E, Mehrabi S, Hatamipour M, Ghafarian Shirazi HR. Effects of combined intralesional 5-fluorouracil and topical silicone in prevention of keloids: a double blind randomized clinical trial study. Acta Med Iran 2011; 49 (3) 127-130
    PubMedGoogle Scholar
  • 71 Tierney EP, Hanke CW. Treatment of CO2 laser induced hypopigmentation with ablative fractionated laser resurfacing: case report and review of the literature. J Drugs Dermatol 2010; 9 (11) 1420-1426
    PubMedGoogle Scholar
  • 72 Morton LM, Dover JS, Phillips TJ, Krakowski AC, Uebelhoer NS. Treatment of ulcers with ablative fractional lasers. Semin Cutan Med Surg 2015; 34 (1) 37-41
    CrossrefPubMedGoogle Scholar
  • 73 Choi JE, Oh GN, Kim JY, Seo SH, Ahn HH, Kye YC. Ablative fractional laser treatment for hypertrophic scars: comparison between Er:YAG and CO2 fractional lasers. J Dermatolog Treat 2014; 25 (4) 299-303
    CrossrefPubMedGoogle Scholar
  • 74 Cervelli V, Gentile P, Spallone D , et al. Ultrapulsed fractional CO2 laser for the treatment of post-traumatic and pathological scars. J Drugs Dermatol 2010; 9 (11) 1328-1331
    PubMedGoogle Scholar
  • 75 Qu L, Liu A, Zhou L , et al. Clinical and molecular effects on mature burn scars after treatment with a fractional CO(2) laser. Lasers Surg Med 2012; 44 (7) 517-524
    CrossrefPubMedGoogle Scholar
  • 76 Ozog DM, Liu A, Chaffins ML , et al. Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser. JAMA Dermatol 2013; 149 (1) 50-57
    CrossrefPubMedGoogle Scholar
  • 77 van Drooge AM, Vrijman C, van der Veen W, Wolkerstorfer A. A randomized controlled pilot study on ablative fractional CO2 laser for consecutive patients presenting with various scar types. Dermatol Surg 2015; 41 (3) 371-377
    CrossrefPubMedGoogle Scholar
  • 78 Asilian A, Darougheh A, Shariati F. New combination of triamcinolone, 5-fluorouracil, and pulsed-dye laser for treatment of keloid and hypertrophic scars. Dermatol Surg 2006; 32 (7) 907-915
    CrossrefPubMedGoogle Scholar
  • 79 Heppt W, Breuninger H, Bootz F , et al. Facial Plastic Surgery: Skin Defects and Wound Care. IMC International Medical Service; 2015
    Google Scholar