Treatment of hypertrophic scars

Despite the fact that hypertrophic scars, as well as keloids, are usually classified as pathological, they have more in common with normal, physiological scars than with keloid scars. The issue of differential diagnosis of keloid and hypertrophic scars in this connection is very relevant. This is explained by the fact that therapeutic measures are permissible and possible for hypertrophic scars, are unacceptable for keloids. Therefore, the formulation of an accurate diagnosis is the key to the therapeutic effect.

1. Cryodestruction.

It is one of the early technologies, when working with hypertrophic scars. Preference was given to liquid nitrogen, rather than to carbonic acid snow, as a coolant for working with scars. For this purpose, either cotton applicators or jellied-type instruments with nozzles of different diameters were used. The mechanism of action of cryodestruction is associated with the crystallization of intracellular and extracellular water. Crystals of ice damage the cell from the inside, resulting in apoptosis and cell death, destruction and thrombosis of capillaries, small vessels, which leads to the emergence of foci of ischemia and necrosis. Clinically, immediately after the procedure, there is erythema, in the place of which for a short time there is a blister with serous-bloody contents. In the case of multiple extinguishing with a 5% KMnO ₄ solution, the bubble may not appear and then the formed scab after cryodestruction should be recommended to be lubricated 3-4 times a day with a solution of manganese-acid potassium. In the case of a bubble, the tire should be cut and the wound surface formed should be kept under modern wound covers. In the light of the fact that at the moment there are other, more modern technologies, this method is somewhat outdated. In addition, he is very traumatic and painful for the patient. Inflammatory process after cryodestruction lasts not less than 3 weeks, as much as the scab keeps. As a result, disintegration products, free radicals accumulate in the wound, hypoxia takes place, that is, there are factors that provoke hypertrophic growth of scar tissue. If, in addition, the patient has predisposing factors to hypertrophic scars, the likelihood of repeated growth of a similar scar will be quite large. Nevertheless, this technique has the right to exist and approximately 60-70% of the cases give good results.

2. Electrophoresis.

Electrophoresis with lidase is shown in the early stages of the formation of hypertrophic scars. 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 Lidazum is prescribed minimally 2 courses of 10 sessions daily or every other day with a 1-2-week break. The lyophilized preparation (64 UE) is diluted in physiological solution and injected from the positive pole. At later stages of the scar's existence electrophoresis with collagenase of 2 -3 courses is shown for 10 sessions daily or every other day. You can combine with prednisolone or dexamethasone electrophoresis, also 10 sessions daily or every other day. Corticosteroids decrease the synthetic and proliferative activity of fibroblasts; block enzymes involved in the synthesis of collagen; lower the permeability of the vascular wall, which leads to the cessation of the growth of the rumen. 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 introduced by phonophoresis. On a course daily or every other day 10-15 sessions. Ultrasound can enter the gel kontraktubeks, the introduction of which it is advisable to alternate with hydrocortisone ointment, on the course number 10-15. Simple lubrication kontraktubeksom practically has no effect.

4. Laser phoresis, laser therapy.

Lazerforez can be an alternative to electrophoresis of drugs. The effectiveness of the procedure is absolutely adequate. Laser therapy is used for selective photocoagulation of dilated vessels on the surface of the scars.

5. Microcurrent therapy.

Despite the fact that there are authors offering to treat all scars with microcurrents, this procedure is contraindicated for hypertrophic scars, since it can cause activation of cicatricial growth. But you can introduce medications on the corresponding program, in the event that there is no iontophoresis and electrophoresis.

6. Magneto-thermal therapy.

Contraindicated because of the possibility of stimulation of the scar.

7. Mesotherapy.

Mesotherapy is indicated by enzymes and corticosteroid drugs (hydrocortisone, dexamethasone). Prolonged corticosteroids (kenolog-40, kenocort, diprospan) can also be administered mesoterapevticheski, but diluting them with saline 2-3 times to avoid overdose and atrophy of tissues. Kenolog-40 and diprospan are poorly soluble in water and are a suspension, so before using them, shake them very carefully to a uniform suspension. However, even vigorous shaking does not exclude the possibility of formation at the injection site of small retention cysts with white inclusions (undissolved particles of the drug). Of the listed prolonged corticosteroid preparations, we prefer diprospan due to the fact. That it is a thinner suspension and practically does not leave behind the retention cysts.

Of the enzymes, lidaz and collagen preparations are used. The procedure is performed by rubbing the surface of the rumen to a depth of 3-4 mm.

In addition, good results can be obtained by working with homeopathic preparations - traumeel, graphite, ovarium compositum, lymphomyositis.

8. Peelings.

Peelings are not indicated for hypertrophic scars, since deep peelings should be used to eliminate (+) tissue, which are carried out by high concentrations of TCA or phenol. Influence of peeling means completely not touching intact skin is almost impossible. In addition, such drugs act toxic on the tissues, causing the appearance of a large number of free radicals, which creates conditions in the wound surface for prolonged inflammation and recurrence of the hypertrophic rumen.

9. Microwave therapy.

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

10. Vacuum massage.

All procedures that cause stimulation of rumen trophism can lead to an increase in its growth, therefore, as an independent procedure, vacuum massage is not shown. However, if after a vacuum massage or after a course of procedures on an apparatus for dermotonia, operative dermabrasion is planned, the result after such a combined treatment will be better than after one dermabrasion.

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, in order to prevent hypertrophic growth, their use is more justified. It is recommended to do 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 is 120-150 kV, the current strength is 4mA, the filter is 1-3mm aluminum, the distance from the anode to the irradiated surface is 3-5 cm. On the field is given 300-700 rub. On the course up to 6000 r. The surrounding skin is protected by lead rubber plates. The use of radiorentgenotherapy is limited due to a sufficient number of complications: atrophy of the surrounding skin, telangiectasia, depigmentation, radiation dermatitis, malignant transformation of the rumen tissues.

12. Bucci rays.

Bucca rays refer to ultra-soft X-rays. In the spectrum of electromagnetic oscillations take place between ultraviolet and X-rays and have a wavelength of 1.44 to 2.19 A. 88% of Bucca rays is absorbed by the surface layers of the skin, 12% penetrates to the subcutaneous fat. Treatment is carried out on the apparatus "Dermopan" by Simens (Germany). The voltage used is 9 and 23 kV, the current strength is from 2.5 to 10 mA. Single dose up to 800 r. Irradiation is carried out once a month. The mechanism of action is the inhibition of the synthetic and proliferative activity of cells. Particularly sensitive to X-rays are young, active cells. Some of them undergo apoptosis. In addition to cytostatic and cytolytic action, Bucca 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, children under 16 years of age are contraindicated.

13. Pressing dressings, linen (clips, silicone plates).

Can be used, as well 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 erosive surfaces formed. Thorough treatment of scars with antiseptic means before and after dermabrasion, the use of moisturizing wound coatings containing antiseptics, antibiotics gives rapid epithelization of the polished part of the scar. The number of sessions of therapeutic dermabrasion depends on the depth of grinding during the procedure, the height of the scar and the reactivity of the organism. By the next procedure, the surface of the scar should be completely cleansed of crusts, peeling and inflammation. Optimal procedure for the devices for microcrystalline dermabrasion and water-air jet.

15. Operative dermabrasion.

Dermabrasion by Schuman's milling cutter, various types of lasers are shown. However, even more carefully than in the sessions of therapeutic dermabrasion, the wound surfaces formed after removal of the (+) tissue of the hypertrophic rumen should be performed. Quickly remove the inflammatory reaction and zaepitelizovat wound surfaces - then get a good result of treatment. Otherwise, a relapse of the hypertrophic rumen is possible. To accelerate postoperative rehabilitation, it is necessary to carry out preoperative preparation (see prevention of scarring).

16. Use of medicinal cosmetics.

The optimal means of treatment of hypertrophic scars are:

• mezolechenie diluted in a ratio (1: 1) prolonged corticosteroid drug (diprospan);
• or phonophoresis hydrocortisone ointment;
• subsequent, not earlier than 2 months, operative dermabrasion;
• monotherapy with surgical or therapeutic dermabrasion;
• home care by local means (kelofibraza, contractubecs, lyoton-100).

Note. An important point is the care of the wound surfaces with the help of moisture-intensive modern wound coverings.