Treatment of hypertrophic scars

Despite the fact that hypertrophic scars, as well as keloid scars, are usually considered pathological, they have more common features with normal, physiological scars than with keloid scars. The issue of differential diagnostics of keloid and hypertrophic scars in this regard seems very relevant. This is explained by the fact that therapeutic measures acceptable and possible for hypertrophic scars are unacceptable for keloid scars. Therefore, establishing an accurate diagnosis is the key to a therapeutic effect.

1. Cryodestruction.

It is one of the early technologies for working with hypertrophic scars. Liquid nitrogen was preferred over carbonic acid snow as a refrigerant for working with scars. For this purpose, either cotton applicators or flood-type devices with nozzles of different diameters were used. The mechanism of action of cryodestruction is associated with the crystallization of intracellular and extracellular water. Ice crystals damage the cell from the inside, resulting in apoptosis and cell death, destruction and thrombosis of capillaries, small vessels, which leads to the appearance of foci of ischemia and necrosis. Clinically, erythema occurs immediately after the procedure, in place of which a blister with serous-blood contents appears within a short time. In the case of repeated extinguishing with a 5% KMnO ₄ solution, the blister may not appear, and then the resulting scab after cryodestruction should be recommended to be lubricated 3-4 times a day with a solution of potassium permanganate. In case of a blister, the cover should be cut off and the resulting wound surface should be treated with modern wound dressings. In light of the fact that other, more modern technologies currently exist, this method is somewhat outdated. In addition, it is very traumatic and painful for the patient. The inflammatory process after cryodestruction lasts at least 3 weeks, the scab lasts for the same amount of time. As a result, decay products and free radicals accumulate in the wound, hypoxia occurs, that is, there are factors that provoke hypertrophic growth of scar tissue. If the patient also has predisposing factors to hypertrophic scars, the probability of re-growth of a similar scar will be quite high. Nevertheless, this technique has a right to exist and gives good results in approximately 60-70% of cases.

2. Electrophoresis.

Electrophoresis with lidase is indicated at the early stages of hypertrophic scar formation. During this period, fibroblasts actively synthesize hyaluronic acid. Therefore, in order to reduce the volume of the scar, it is necessary to act on it with a specific enzyme - hyaluronidase (lidase).

A solution of lidase is prescribed at least 2 courses of 10 sessions daily or every other day with a 1-2-week break. The lyophilized preparation (64 U) is diluted in a physiological solution and administered from the positive pole. At later stages of the scar's existence, electrophoresis with collagenase is indicated 2-3 courses of 10 sessions daily or every other day. It can be combined with electrophoresis of prednisolone or dexamethasone, also 10 sessions daily or every other day. Corticosteroids reduce the synthetic and proliferative activity of fibroblasts; block enzymes involved in collagen synthesis; reduce the permeability of the vascular wall, which leads to cessation of scar growth. Instead of corticosteroids, gamma interferon, which is an inhibitor of cell division, can be administered.

3. Phonophoresis.

Corticosteroids, for example 1% hydrocortisone ointment, are also successfully administered using phonophoresis. A course of 10-15 sessions daily or every other day. Contractubex gel can be administered using ultrasound, the administration of which should be alternated with hydrocortisone ointment, for a course of 10-15 sessions. Simple lubrication with Contractubex has practically no effect.

4. Laserphoresis, laser therapy.

Laserphoresis can be an alternative to electrophoresis of drugs. The procedures are absolutely adequate in terms of effectiveness. Laser therapy is used for selective photocoagulation of dilated vessels on the surface of scars.

5. Microcurrent therapy.

Despite the fact that there are authors who suggest treating all scars with microcurrents, this procedure is contraindicated for hypertrophic scars, as it can cause activation of scar growth. But it is possible to administer medications on the appropriate program, if iontophoresis and electrophoresis are not available.

6. Magnetic thermal therapy.

Contraindicated due to the possibility of scar stimulation.

7. Mesotherapy.

Mesotherapy is indicated by enzymes and corticosteroids (hydrocortisone, dexamethasone). Prolonged corticosteroids (kenolog-40, kenocort, diprospan) can also be administered mesotherapeutically, but diluted with saline 2-3 times to avoid overdose and tissue atrophy. Kenolog-40 and diprospan are poorly soluble in water and are a suspension, so before use they must be shaken very thoroughly until uniform suspension. However, even vigorous shaking does not exclude the possibility of formation of small retention cysts with white inclusions (undissolved particles of the drug) at the injection site. Of the listed prolonged corticosteroid drugs, we give preference to diprospan due to the fact that it is a thinner suspension and practically does not leave behind retention cysts.

Of the enzymes used, lidase and collagenase preparations are used. The procedure is carried out by injecting the surface of the scar to a depth of 3-4 mm.

In addition, good results can be obtained by working with homeopathic preparations - Traumeel, Graphites, Ovarium compositum, Lymphomyosot.

8. Peelings.

Peels are not indicated for hypertrophic scars, since deep peels, which are carried out with high concentrations of TCA or phenol, must be used to remove (+) tissue. It is almost impossible to use peeling agents without touching the intact skin. In addition, such drugs have a toxic effect on tissues, causing the appearance of a large number of free radicals, which creates conditions for prolonged inflammation and relapse of the hypertrophic scar in the wound surface.

9. Microwave therapy.

Microwave therapy is not used as an independent method in the treatment of hypertrophic scars. The combination of this method with subsequent cryodestruction gives positive results with proper management of the wound surfaces formed after cryodestruction. It is believed that microwave therapy helps to transfer the bound water of the scar into a free state, in which it is easier to remove by cryodestruction.

10. Vacuum massage.

All procedures that stimulate scar trophism can lead to an increase in its growth, so vacuum massage is not indicated as an independent procedure. However, if surgical dermabrasion is planned after vacuum massage or after a course of procedures on dermotonia devices, the result after such combined treatment will be better than after dermabrasion alone.

11. Close-focus X-ray therapy

Close-focus X-ray therapy is used to treat hypertrophic scars. X-rays affect fibroblasts, reducing their synthetic and proliferative activity. However, their use is more justified for the prevention of hypertrophic growth. It is recommended to perform a single irradiation along the line of postoperative sutures after their complete cleansing from crusts in patients with a tendency to hypertrophic scars.

The voltage used is 120-150 kV, current strength 4 mA, filter 1-3 mm aluminum, distance from the anode to the irradiated surface 3-5 cm. Per field is given 300-700 rubles. For a course up to 6000 rubles. The surrounding skin is protected by lead rubber plates. The use of radiotherapy is limited due to a sufficient number of complications: atrophy of the surrounding skin, telangiectasia, depigmentation, radiation dermatitis, malignant transformation of scar tissue.

12. Bukki rays.

Bucky rays are ultra-soft X-rays. In the spectrum of electromagnetic oscillations they occupy a place between ultraviolet and X-rays and have a wavelength from 1.44 to 2.19 A. 88% of Bucky rays are absorbed by the superficial layers of the skin, 12% penetrate to the subcutaneous fat. Treatment is carried out on the Dermopan device by Siemens (Germany). The voltage used is 9 and 23 kV, current from 2.5 to 10 mA. A single dose is up to 800 rubles. Irradiation is carried out once a month. The mechanism of action is to suppress the synthetic and proliferative activity of cells. Young, actively dividing cells are especially sensitive to X-rays. Some of them undergo apoptosis. In addition to the cytostatic and cytolytic effect, Bucky rays have a fibrinolytic effect, due to which they are effective for the treatment and prevention of hypertrophic scars. Despite the superficial effect of these rays and the lack of a general effect on the body, these procedures are contraindicated for children under 16 years of age.

13. Pressure bandages, underwear (clips, silicone plates).

Can be used in the same way as in the treatment of keloid scars (see treatment of keloid scars).

14. Therapeutic dermabrasion.

All types of therapeutic dermabrasion can be successfully used to treat hypertrophic scars. It is important to care for the resulting erosive surfaces. Careful treatment of scars with antiseptic agents before and after dermabrasion, the use of moisturizing wound dressings containing antiseptics, antibiotics provides rapid epithelialization of the polished part of the scar. The number of sessions of therapeutic dermabrasion depends on the depth of polishing during the procedure, the height of the scar and the reactivity of the body. By the next procedure, the scar surface should be completely cleared of crusts, peeling and inflammation. It is optimal to carry out the procedure on devices for microcrystalline dermabrasion and a water-air stream.

15. Surgical dermabrasion.

Dermabrasion with a Schumann cutter and various types of lasers is indicated. However, it is necessary to manage the wound surfaces formed after removal of the (+) tissue of the hypertrophic scar even more carefully than during therapeutic dermabrasion sessions. Quickly removing the inflammatory reaction and epithelializing the wound surfaces means getting a good treatment result. Otherwise, a relapse of the hypertrophic scar is possible. To speed up postoperative rehabilitation, it is necessary to carry out preoperative preparation (see scar prevention).

16. Use of medicinal cosmetics.

The optimal treatments for hypertrophic scars are:

• mesotherapy with a prolonged-release corticosteroid drug (diprospan) diluted in a ratio of 1:1;
• or phonophoresis with hydrocortisone ointment;
• subsequent, no earlier than 2 months later, surgical dermabrasion;
• monotherapy using surgical or therapeutic dermabrasion;
• home care with local remedies (kelofibrase, contractubex, lyoton-100).

Note: An important point is the care of wound surfaces using moisture-absorbing modern wound dressings.