Treatment of keloid scars

It was noted that the long septic state of the wound, chronic inflammation promotes the appearance of keloid scars, but this is only the tip of the iceberg. As noted above, there are many reasons for the appearance of keloids, that is, this pathological state of the organism is polyethiologic. Hence it is clear why only local agents can not cure keloids, especially in the favorite keloid-dangerous zones. Often, such scars occur in weakened patients, with extensive burns, infected wounds, chronic or acute stress, chronic diseases, endocrinopathy, hereditary predisposition, etc. Therefore, laboratory and instrumental examination, careful collection of anamnesis, treatment of concomitant pathology, substitution therapy with trace elements, vitamins, antioxidants, adaptogens should be included in the mandatory treatment regimen for such patients. And it is understandable, if the reasons causing the predisposition to this pathology are not eliminated, the treatment can not be successful. However, it is not always possible to identify the underlying causes of keloid scars or the causes are known, but it is impossible to get rid of them. In this case, treatment is a big problem.

It is known that surgical excision and polishing of keloid scars without prior therapeutic and postoperative treatment is contraindicated, since a larger scar is usually found on the site of the removed keloid. Therefore, most therapeutic measures are therapeutic. However, there are surgical techniques that can reduce the area of keloid scars and get good results after their excision.

Surgical excision of small keloid scars, taking into account the skin tension lines, can also result in quite aesthetic scarring, especially when pre- and postoperative work with them

Analyzing the main directions of work with keloid scars, we can conclude that most of them are aimed at:

• elimination and neutralization of factors that activate fibroblasts;
• elimination of excess macromolecular components of connective tissue;
• destruction of the volume of pathological tissue with so-called growth sites, which are the source of the formation of "giant" and young fibroblasts with a pronounced tendency to constant growth and slow maturation.

The critical analysis presented in the data table allows us to state that some of these tools and methods have lost their relevance due to the appearance of distant negative treatment results. Part of the tools and methods can be associated with serious complications in the hands of insufficiently professionally trained specialists. Part - is extremely little effective.

For example, overestimation of close-focus X-ray therapy, radiotherapy and Bucca rays can cause long-lasting non-healing wounds on the scars, which are often transformed into highly invasive squamous cell carcinoma, a malignant tumor, the so-called Marjoline ulcer.

Isolated cryodestruction with liquid nitrogen is a painful technique, as a result of which long-lasting non-healing erosions result in the formation of a larger keloid on the site. In this regard, we consider it inexpedient to use it. However, cryodestruction in combination with microwave therapy or Bucci irradiation gives completely different and quite positive results.

Local hormone therapy with its dosed application is very effective. However, on the site of injected corticosteroids, in particular the kenologue - 40, cysts with non-absorbable contents of the drug particles are often formed, it is also possible the appearance of atrophy in overdose of corticosteroids, as well as hypopigmentation.

The use of a red therapeutic laser (wavelength 339-660 nm.) For the prevention and treatment of keloids, based on the mechanism of its stimulating effect on fibroblasts and the production of collagen by them, proves to be inappropriate because of the possibility of provoking increased formation of the pathological scar (8,24,35,164) .

Widely used previously such drugs as lidase and ronidase (nonspecific proteases) accelerate the hydrolysis of proteins and their decay products, but do not affect the pathogenetic mechanisms of scar formation, that is, the collagen-collagenase system, therefore, as a rule, are not accompanied by the desired effects.

In the literature there is information about the use of calcium antagonists (verapamil) for the treatment of keloid scars. A small personal experience with the use of verapamil led to the conclusion that it is not appropriate to use it for the treatment of pathological scars due to severe soreness with injections and the lack of therapeutic effect.

Removal of the scar by laser or surgical excision, without prior conservative treatment and without taking into account the skin tension line, is dangerous by relapse and the appearance of a larger scar on the site of the excised.

Microcurrent therapy, as well as laser therapy, can only be used to stimulate wound healing and improve the penetration of drugs into the wound and scar. For the introduction of drugs into tissues for a long time and successfully used electrophoresis and phonophoresis are much more effective and cheap methods.

Therefore, studies in the field of treatment modernization, finding remedies for removing excess scar tissue without side effects and with the maximum clinical result are still relevant.

Based on the generalization of clinical, pathomorphological and pathogenetic data on keloid scars, it can be concluded that the main areas of work with them.

Local means and methods of combating keloids are divided into:

1. Methods and technologies with the help of which the proliferative and synthetic activity of fibroblasts is inhibited: mesotherapy, electrophoresis, laser phoresis, phonophoresis with corticosteroid preparations, gamma interferon; Bucci-irradiation, radio-X-ray therapy, etc.
2. Methods that lead to a decrease in the volume of abnormal scar tissue and remove excess water from it: microwave therapy followed by cryotherapy, fermentotherapy, surgical and laser removal, pressing, silicone dressings, pillows, etc.

Methods and technologies applied today:

1. Cryodestruction

It is known that the more free and bound water in tissues, the more sensitive they are to the effect of low temperatures. In keloids, the main mass of the scar is collagen, which in its water-binding properties among biological structures is in second place after DNA. For a long time cryodestruction was a very common procedure in the treatment of keloid scars. However, necrosis of scar tissue after cryodestruction, even with prolonged exposures, is superficial. One of the reasons for the low efficiency of cryodestruction of keloid scars is that bound water is not available to the influence of the coolant.

The erosive surface heals very long (at least 3 weeks). As a result, against the backdrop of prolonged inflammation in the wound, conditions for the relapse of the keloid form. Therefore, after such treatment, in 60-70% of cases there is a relapse of the keloid scar, which also increases in area. In this connection, it is not recommended to use cryodestruction as an isolated procedure outside the combination with Buka-irradiation or microwave therapy.

2. Microwave therapy with subsequent cryodestruction.

This technique was developed under the guidance of VV Shafranov and NG Korotkiy in 1998. This combination of methods is explained by the fact that microwave exposure destabilizes the bound water of the keloid scar, after which it becomes available to the action of the coolant. For this purpose, devices for microwave therapy are used. The duration of exposure in the physiotherapy range is 5 minutes followed by cryodestruction within 7 minutes. Six months after the microwave cryogenic effect, the scar tissue is normalized not only clinically, but also histologically. The scars flatten, morphologically the tissue of the keloid is transformed into a normal scar tissue. Undoubtedly, this method is not a panacea for the treatment of keloid scars. Along with positive results, there are cases of lack of treatment effect and negative results.

3. Electrophoresis with lidase, collagenase, corticosteroids.

In the early stages of the existence of kelodic scars, pathological fibroblasts produce mainly glycosaminoglycans, among which hyaluronic acid predominates. Accordingly, at this time, it is necessary to inject lidase (hyaluronidase) into the scar. As the rumen expands, fibroblasts switch to collagen synthesis with a deficiency of collagenase, so there is a need to introduce collagenase into the scar. Since all polyclinics, hospitals, medical centers and skin-venereal dispensaries are equipped with physiotherapy rooms, the use of a permanent galvanic current (electrophoresis) for the introduction of drugs into the rumen is the most justified for cheapness and accessibility. The alternation of courses of lidase and collagenase No. 4-5 with an interval between courses of 2 weeks leads to a certain decrease in the volume of the scar and in some cases to a halt in its growth.

For the treatment of hypertrophic and keloid scars, as well as for their prevention, glucocorticoids are used.

Pharmacological action of glucocorticoids.

They suppress the function of leukocytes and tissue macrophages, the formation of antibodies, limit the migration of leukocytes to the area of inflammation, reduce the number of circulating lymphocytes (T and B cells), monocytes, eosinophils. Violate the ability of macrophages to phagocytosis, and also to the formation of interleukin-1. They help stabilize lysosomal membranes, thereby reducing the concentration of proteolytic enzymes in the inflammatory region, reduce the permeability of capillaries, inhibit the activity of fibroblasts, and the formation of collagen. Inhibit the activity of phospholipase A2, which leads to suppression of the synthesis of prostaglandins and leukotrienes.

Just as in the treatment of hypertrophic scars, electrophoresis can be administered prednisolone or dexamethasone 10-15 sessions daily or every other day, alpha and gamma interferon.

The same treatment can be carried out with the help of laser phoresis and microcurrents.

4. Phonophoresis with corticosteroid ointments, contractubecase.

Ultrasound, according to some authors, as an independent procedure has a positive effect on keloid scars, causing their softening. Using instead of an indifferent conductive gel, Lyoton-1000 allows creating an additional dehydration effect from phonophoresis. The introduction of corticosteroid preparations in ointment forms enhances the result of treatment. For example, 1% hydrocortisone ointment is assigned to the course daily or every other day 10-15 sessions. Phonophoresis also introduces gel kontraktubeks, the effect of which is enhanced by ultrasound. Treatment kontraktubeksom alternates with corticosteroid drugs, the course number 10-15. The course can be 3-4 depending on the effect and combination therapy.

5. Mesotherapy (chipping) of scars.

In connection with the inhibitory effect of corticosteroids on fibroblasts, to enhance their effectiveness, injection of prolonged corticosteroids into the tissue of keloid scars is used.

Preparations: kenolog-40, kenokort, diprospan.

In the literature, there are reports of use for the treatment of keloid scars of gamma and alpha interferons. The mechanism of their action is associated with the inhibition of the synthetic and proliferative activity of fibroblasts and collagenolysis. It is more expedient to use these drugs by mesotherapy, since in this way we bring the active substance directly to the source. The drugs are injected into the tissue of the rumen. It is advisable to use insulin syringes with non-removable needles, since any drugs are injected into the tissue of the keloid scar with great difficulty. Strong pressure on the piston can lead to the separation of the needle from the syringe and the loss of an expensive drug.

• Cytotoxic agents

Cytotoxic drugs are also used to treat keloids. Use cytostatics should be done with great care, in breeding, at least (1: 1 with saline) and make an interval between sessions for at least a month. Otherwise, sharp atrophy may occur at the site of the former keloid scar. This treatment should be used only in the absence of effectiveness from all other methods because of the general negative effects of drugs of this group on the body as a whole.

• Calcium antagonists.

The use of drugs in this group is inappropriate.

6. Treatment with sclerolaser.

The mechanism of action of the sclerolaser with keloid scars is based on the selective action of the laser beam on the surface network of dilated vessels. The laser beam is absorbed by the hemoglobin of the blood, resulting in the formation of a blood clot that clogs the vessel. If, in this case, the laser beam affects the vessels feeding the keloid, then some flattening of the scar and elimination of the surface dilated vessels may occur. A green-yellow spectrum of laser radiation with a wavelength of 480 nm to 590 nm is used. The number of sessions is 3-5, the interval between the procedures is -3-4 weeks. The effectiveness and need for such treatment is very relative, since similar results can be obtained using other less expensive procedures. This procedure can be used as an additional preventive measure when preparing scars for surgery.

7. Pressing dressings, linen.

For more than 20 years, it has been empirically found that prolonged pressure in the area of the keloid scar causes its flattening and regression. For this purpose, silicone pads, pillows, self-adhering gel plates began to be used. The mechanism of action of these devices for a long time was unknown. Various versions were voiced, the most popular of which was the theory of the action on the keloid of static electricity arising in silicone and gel. At the moment, scientists are inclined to view the dystrophic processes that arise in pathological scars from prolonged squeezing. There is a desolation of "feeding" keloid vessels, a violation of tissue trophism, apoptosis in giant fibroblasts. Which leads to the cessation of growth and flattening of scars.

To date, the spectrum of "pressing devices" has increased significantly. It:

1. Special pressing clothes from dense-elastic cotton fabric.

In large cities, there are companies in which you can sew a bandage or underwear for any scar location. It is recommended to wear such clothes for at least 6 months.

2. Pressing plates:
   • adhering silicone gel coatings.
   • Self-adhesive dressings with silicone and absorbent coating,
3. Liquid gel means:
   • liquid products on the basis of collodion with silicone and active substance, for example Scarguard, ScarCare. They contain vitamin E, 0.5% hydrocortisone.
   • based on polysiloxane. 

8. Bucci-irradiated, close-focus X-ray therapy.

Bucca irradiation is a very effective technology, both for treatment and for the prevention of the growth of pathological scars. Treatment is carried out on the German apparatus "Dermopan", which, unfortunately, is available in a limited number in our country and the CIS countries. The treatment is best suited to young growing keloids, since the rays primarily act cytostatically and cytolytically on immature malodifferentiated cells and giant fibroblasts of keloid scars. Preventive procedure is carried out once a month at a dose of 800 to 1500 r. Immediately after removing the joints and cleaning the surface of the postoperative scar from the secondary crusts. Some authors recommend doses up to 2000 r. But in this case, such complications as atrophy of nearby skin, telangiectasia, ulceration of the scar are more frequent. In the treatment of keloids, the number of sessions depends on the activity and age of the scar, the patient's age and the area of the scar. Keloid scars with signs of maturity, that is, long-existing, not active (without a vivid clinical picture) can also be treated with Bucca-irradiation. In these cases, scars need to be activated. This is done by cryotherapy with liquid nitrogen. 1-2 sessions of cryotherapy before a vesicular reaction are carried out, followed by treatment of the wound surfaces created before complete epithelialization and the fall of all crusts. The surface of the scar should be absolutely clean, without crusting and peeling, since otherwise the rays will not have a therapeutic effect. The crust-free surface of the rumen is treated with beech rays.

Conditions of treatment: voltage - 9, 20, 23 kv, current intensity - 2.5-10 ta, distance of the tube to the focus 3-5 cm.

9. Magneto-thermal therapy.

The use of this type of therapy for the treatment of pathological scars is inexpedient. In the previous sections, the mechanism of the action of magnetotherapy was highlighted. It boils down to stimulating fibrogenesis, and therefore is only applicable as a means of promoting wound healing, that is, for the prevention of scarring.

10. Microcurrent therapy.

The introduction of microcurrent corticosteroid and other drugs that reduce the activity of fibroblasts and destroy collagen and glycosaminoglycans is theoretically and practically possible, but not expedient because of the high cost and low efficiency of the method.

11. Medicinal therapy of keloid scars.

The use of enzymes (collagenase, collagen, hyaluronidase, lidase) and corticosteroids was discussed in detail above. These drugs are used exclusively for local treatment.

For the effective treatment of keloid scars, one can not ignore known common clinical pathogenetic factors, in particular, endocrinopathies.

Hyperandrogenemia. If a finding in the clinical picture and in the laboratory study of patients data on an elevated level of free testosterone, the appointment of testosterone antagonists is necessary. Practically even without a laboratory test, we can talk about the need for antiandrogenic therapy in patients with an acne-keloid clinic and with keloid scars in the seboroid zones - the upper part of the chest, the shoulder belt, which are difficult to treat. These zones are rich in sebaceous glands, on the cells of which there are receptors for androgens. Free testosterone blood under the influence of alpha-reductase is converted to dihydrotestosterone, which binds to the cells of the sebaceous glands, causing their proliferation and hypersecretion, which contributes to the inflammatory reaction and the formation of keloid scars in the area of inflammation. Such female patients should be examined and observed by gynecologists. Women of childbearing age are prescribed such anti-androgenic drugs as Cyan-35, Janine, Yarina. Women of pre- and post-menopausal age are prescribed hormone replacement therapy (cycloprogen, angelik, klimonorm, etc.). Men - indrokur at 50 mg per day. Long-term use of anti-androgen therapy for men is not indicated because of the possibility of reducing sexual potency.

An increased level of thyroid and thyroid-stimulating hormones stimulates the synthetic and proliferative activity of the phyroblasts, which can also stimulate a tendency to keloid scars.

Accordingly, clarification with the help of laboratory and instrumental research methods (including echoencephalography, MRI, a picture of the Turkish saddle, research of the thyroid gland with radioactive iodine, determination of the level of thyroid hormones in the blood), the condition of the pituitary and thyroid gland can give the doctor the key to the decision together with endocrinologists, problems of keloid scars of this patient.

Deficiency of corticosteroids, adrenocorticotropic hormone of the pituitary gland against a background of chronic stress, leads to an increase in the synthetic and proliferative activity of fibroblasts, fibrogenesis, an increase in the number of glycosaminoglycans and an inclination to keloid formation. Accordingly, if based on anamnesis, laboratory data, the main reason is this variant of endocrinopathy, the treatment is carried out jointly by neuropathologists and endocrinologists.

Chronic diseases can also become the underlying cause of propensity to keloid scars, as they lead to a decrease in reactivity, oxidative stress, deficiency of vitamins and trace elements. Accordingly, sanitation of foci of chronic infection, treatment with related specialists, the appointment of microelement-vitamin complexes, antioxidants, can make a significant contribution to the treatment of keloid scars and their prevention.

In case the examination and anamnesis does not provide an opportunity to find out the cause of propensity to keloid scars, or a genetic predisposition is traced, it is necessary to prescribe vitamin-microelement complexes, antioxidants, sanitize teeth, tonsils to patients; treat dysbiosis, prescribe hepatoprotectors. This whole complex will prove useful in the appointment of a local treatment or the deployment of surgical removal.

There is a report on the treatment of keloid scars with retinoids (retinol palmitate daily dose of 10,000 IU / kg once daily for 20-30 days) and hyaluronic acid. However, it is known that retinoids and hyaluronic acid can stimulate the activity of fibroblasts, due to the presence on their cell wall of the same-named receptors. Therefore, as agents that accelerate wound healing, these drugs are very useful, but not for the treatment of keloid scars (88,163).

In the literature, there is mention of the treatment of keloid scars with calcium antagonists (Verapamil and Trifluoperazin). The mechanism of action is depolymerization of actinic filaments of fibroblasts and induction of procollagenase synthesis.

Pyrotherapy.

Pyrogenal (Russia) belongs to the group of bacterial protein-free lipopolysaccharides. It is a tool that stimulates the factors of nonspecific and specific resistance of the organism, as well as prodigiosans. Activity pyrogenal is calculated in minimal pyrogenic doses (MTD). The drug activates the function of the adrenal cortex, the production of interferons. Pyrogenal has a pyrogenic effect, raising the body temperature to 40 °, after which the collagen of keloid scars becomes more accessible for the impact of metalloproteases. Previously, the drug was widely used to treat keloid scars. At present, interest in this method has been significantly reduced, in spite of the fact that in a number of cases its use actively promotes regression of keloid scars. Partly this is due to the fact that the use of pyrogenal is desirable in a hospital environment, however, in outpatient settings, pyrotherapy is also possible. The drug is administered intramuscularly every other day, starting at 25-50 MTD, gradually increasing the dose to 1000 MTD. It is more expedient to administer the drug 2 times a week. If the first dose caused a high temperature reaction (37.8-38 °), the second injection is produced in the same dose as the first one. If the temperature increase did not exceed 37.5 °, the next dose rises by 15-25-50 MTD. The maximum dose for adults is 1000 MTD, for children - 500 MTD. The number of injections is 8-15.

It is produced in ampoules containing 100,250,500 and 1000 MTD per ml. Physiological solution.

Prodigiosan (Russia).

It also belongs to the group of high-molecular bacterial lipoproteins. It is administered intramuscularly. The initial dose for adults is 15 μg, for children - 10 μg 0.005% solution for injection. With good tolerance, adults are injected 25 μg twice a week increasing the dose to 100 μg, children - 10-20 μg. On the course of 8-10 injections.

Contraindications for pyrotherapy:

Pregnancy, acute infectious diseases, diabetes, CNS lesions, myocardial infarction, acute coronary insufficiency.

12. External treatment of keloid scars:

Currently, the market for preparations for the treatment of hypertrophic and keloid scars has a limited range of products, some of which are very expensive and not very effective, some are effective and very expensive. In addition, not all the products listed here can be purchased in the pharmacy chain, often they can only be purchased through intermediary firms.

It:

• Gels: contractubex, lyoton-1000;
• ointments: 1% hydrocortisone ointment, kelofibrease;
• silicone gel coatings (Spenco), Cica-Care;

The gel plate "Spenko" is an overlay of a translucent gel, consisting of pure silicone. The plate has dimensions of 10x10 cm.

"Spenko" is intended for the permanent treatment of already existing and new hypertrophic and keloid scars. For prevention purposes, it can be used on closed wounds to prevent the growth of hypertrophic scars and keloids. The plate is washed 2 times a day and worn constantly, fixing an elastic bandage, plaster or other compression products. The total treatment time is from 2 to 4 months.

• Self-adhesive bandages with silicone and absorbent coating, such as Mepitel, Mepiform (Sweden) are preferred to gel plates. Thanks to the application of these coatings to young scars, their moisture capacity increases, the cells more easily transfer information to each other about the excess of collagen and the autocatalytic processes that lead to the dissolution of collagen, the enzyme's own system, come into play. Bandages do not need to be fixed, which is convenient for patients:
• liquid products on the basis of collodion with silicone and active substance, for example, polysiloxane.

Liquid forms freeze on the cicatrix and turn into a crunching scar. Apply to seal the film 2 times a day.

Gel for the treatment of scars Zeraderm Ultra is a preparation of high molecular weight polysiloxane, using additives that have a protective action against ultraviolet and enriched with vitamins and coenzymes.

Upon contact with air, Zeraderm Ultra forms an invisible, water-repellent, but permeable membrane. Over application of Zeraderm Ultra, it is possible to use cosmetics.

Zeradenn Ultra is a more preferred preparation compared to silicone overlays and a patch, since it forms an invisible protective, gas permeable and impermeable to microorganisms film, does not require fixation.

Zeraderm Ultra is easy to use, especially in the face and in the treatment of children.

Contains: Vitamin K, Vitamin E, Coenzyme Q10, Zinc Oxide.

Has: anti-inflammatory, epithelizing, antioxidant, photoprotective, improves the energy potential of cells, reduces erythema.

It is indicated for the treatment of keloid and hypertrophic scars. In addition, it is effective in telangiectasias, which can appear as side effects after treatment with corticosteroids and cytostatics.

Treatment:

It begins immediately after epithelialization or removal of sutures.

Should be used twice a day for several weeks to several months.

Scarguard

ScarGuard is a fast-drying liquid that forms on the surface of the scar a transparent film that protects the tissue from irritation and simultaneously creates pressure on it and provides access to the problem area of hydrocortisone, vitamin E and silicone. It is applied with a brush, just like nail polish, directly on the surface of the skin, does not require bandaging or other means of fixation. The drug ScarGuard is applied independently twice a day for 1-6 months. As a result of the polymerization of the formulation, a hermetically sealed coating is formed, simultaneously protecting the problem area of the skin and creating pressure on it, thus, the drug serves as a pressure bandage. The mechanism of action of silicone wafers and pressing dressings has been thoroughly studied. At the heart is the disruption of nutrition of scar tissue and cells with increased metabolism (fibroblasts). Due to the fact that the medication is also based on medicinal products (hydrocortisone and vitamin E), the drug that solidifies on the skin and turns into a pressure bandage acts as a medical compress, thanks to which the introduction of curative components into the scar tissue is facilitated. Vitamin E is a powerful antioxidant, and hydrocortisone inhibits the proliferative and synthetic activity of fibroblasts, contributes to the emergence of mature fibroblasts that synthesize collagenase.

Thus, as a result of a diverse therapeutic effect on pathological scars, their flattening, color normalization, and the cessation of subjective sensations occur.

The use of ScarGuard for prophylaxis in patients with a tendency to keloid and hypertrophic scars is also necessary, since it helps to prevent the appearance of pathological scars.

Pressures are used for a long time, several months, depending on the rate of regression of the scar.

13. Surgery.

We have already said that the traditional surgical removal of keloid scars almost always ends with a relapse and an increase in the initial size of the scar. Therefore, without preliminary therapeutic work with these scars and without taking into account the direction of the lines of skin stretching, it is not recommended to remove them surgically.

Surgeons have a real opportunity to help patients with keloid scars of a large area due to a gradual reduction in the area of the scar, carving it from within by small areas, without going beyond it. The interval between operations depends on the extensibility of the tissues around the rumen. If necessary, expanders can be supplied. Between operations, the patient must wear special tugoelastic underwear. When the scar is maximally reduced, it is possible for it to be excised with various techniques, for example, counter triangular flaps with a Z-shaped scar, preferably after preliminary therapeutic preparation, since it can also become keloid in the Z-shape. After the operation immediately after the removal of the sutures and the separation of the secondary crusts, it is necessary to conduct a session of Bucci therapy or close-focus X-ray radiotherapy. With this combination of surgical and therapeutic methods of treatment, there is a high share of the likelihood of obtaining a normotrophic scar.

Surgical treatment of keloid scars is possible with the help of lasers. With this method of treatment, CO, laser should be used, since the keloid must be removed to its full thickness, to the subcutaneous fat, while completely removing tissue with growth zones. In fact, we are dealing with laser excision. By analogy with laser removal of keloids, electroexcision can also be used, but with this technology, tissue overheating and traumatization take place, which worsens healing of wound surfaces and leads to a greater percentage of relapses than laser removal. But if several sessions of electrophoresis with collagenase preparations and Bucca irradiation sessions are performed immediately after the healing of the wound surfaces, the probability of a positive result will be much higher. This is due to the fact that collagen after heating becomes more accessible to the effects of metalloproteases.

The complex approach in the treatment of keloids, using several options of therapy, usually gives the best effect, but does not completely solve the problem, therefore only a creative, integrated and individualized approach can give optimal results.

However, if the patient has one keloid scar that is not located in the keloid-dangerous zone that has arisen due to poor wound treatment or secondary infection, there are no common predisposing factors and genetic predisposition, then this scar can be quickly treated with 2-3 injections of diprospan or 1- 2 sessions of Bucca-irradiation and there is no need to prescribe another longer and more expensive treatment.

If a patient has a tendency to keloid scars (there are already similar scars on the body), or a scar, even one, is located in the sternum or upper humeral zone (keloid-dangerous zones), these patients need only an integrated approach. That is, to prescribe general internal therapy, corrective therapy together with related specialists and, finally. Local treatment.

Variant of the scheme of local treatment of extensive keloid scars

Stage 1. Reducing the size of scars, eliminating contractures, restoring the function of organs and tissues.

Reduction of the scar area due to excision of its tissues from the central part (without going to healthy skin) in several stages is a little-known, but well-proven method, provided a good stretching of the nearby healthy skin.

After a 1-3-fold excision from the inside, for several months, an extensive keloid scar or the operation with counter flaps, a keloid scar of smaller size remains, which requires therapeutic help. Patients are constantly in special clothes and take it off only for washing and carrying out procedures.

2 stage. The introduction of lidase into the scars, by various available methods due to the high content of glycosaminoglycans in the young rumen and hyaluronic acid.

Stage 3. Introduction of collagenase at the stage of synthesis by collagen fibroblasts. After the course of enzyme therapy with lidase. Lidase and collagenase can also be administered mesoterapically (microinjection), the effectiveness of the procedure increases.

Note.

Old scars, existing for more than a year, are much less amenable to enzymatic treatment, therefore, an increase in the number of sessions and courses (up to 5-7) is required to obtain a satisfactory clinical effect. It should also be noted that enzymatic treatment, despite its effectiveness and harmlessness, is a long process, requiring a patient a lot of time. In addition, with a significant improvement in the clinical picture, the scar of the surrounding tissues is not always achieved, which is undoubtedly the most desired result of the treatment. Therefore, to enhance the effectiveness of treatment, patients use a complex approach, which consists in addition to treatment with collagenase preparations, from ultrasound treatment with contractubex and intra-operative administration of prolonged-acting corticosteroids (kenalog-40, diprospan).

4 th stage. Introduction by ultrasound contractubex or hydrocortisone ointment.

Advice to patients to lubricate scars with contractabiabetes practically do not give any effect and require a large amount of expensive drug, so the combination of contractubex and ultrasound is optimal. The drug acts at great depth, in addition, ultrasound has a fibrotic effect.

In the event that at this stage of treatment the scar has been paid, there are no clinical signs of a keloid, the treatment may be discontinued. The patient must remain under observation, as the growth of the scar can begin at any time and then the fifth stage of treatment will be required.

5 ethane. In the event that the patient observes the presence of subjective unpleasant sensations in the scar area and is located above the level of the surrounding skin, there is (+) tissue, this stage is mandatory. The number of injections, which are carried out once a month, can be from one to 4-5. Do more than 4-5 injections undesirable. It is necessary to take a break for 2-3 months and if the scar, as before, is concerned to add irradiation to Bucca rays or pyrotherapy.

Stage 6. At the final stage of the complex therapeutic treatment of keloids, it sometimes appears necessary to remove the dilated vessels on its surface and reduce the intensity of the color. The color of the keloid scar is the sign that passes the last. Eliminate the dilated vessels on the surface of the scars by using a sclerosing laser, which simultaneously acts on deep vessels, worsening the nutrition of the scar and causing its dystrophy.

Currently, clinical trials are underway to modify the final surgical stage of treatment using laser excision and subsequent transplantation to the polished surface of the patient's autologous keratinocytes (see Chapter 7).

14. Use of medicinal cosmetics.

In addition to pharmacopoeial drugs, in the world practice there is experience in the use of cosmeceutical drugs for the treatment of keloid scars. So the French company Gernetic, which produces professional cellular cosmeceuticals, recommends a number of preparations for the treatment of keloid scars.

SYNCHRO is a regenerating nutritional base cream. The composition of the cream includes unsaturated fatty acids, fat-soluble (A, E) and water-soluble vitamins of group B. Vitamins C, H, antioxidants. Anti-inflammatory components, oligoelements (potassium, magnesium), amino acids.

IMMUNO - Regenerating Nourishing Base Cream.

Ingredients: unsaturated fatty acids, amino acids and oligoelements.

CYTOBI - Supergensensitive nourishing cream.

Ingredients: vitamins A. C, E, H and group B, amino acids (methionine, glycine, valine, isoleucine, proline, lysine, serine, threonine, alanine, cysteine, glutamine, arginine, histidine, tyrosine), oligoelements (zinc, cobalt , manganese, iron, copper, potassium, calcium, magnesium).

Stimulates metabolism, improves the skin's water balance, strengthens the antioxidant defense system, replenishes the deficiency of trace elements, vitamins, nourishes the skin.

CELLS LIFE - Serum, for the normalization of redox processes in the rumen.

Serum CELLS LIFE consists of active substances, the basis of which are proteoglycans and hyaluronic acid. Being components of the basic substance, they improve the penetration of hydrophilic molecules of active components into the scar tissue, promote information interaction between cells and their active movement. Growth factors, amino acids and proteins normalize the basic processes of vital activity of skin and scar cells.

The main components of the serum: mucoglikoprotein complex (chondroitin sulfate, hyaluronic acid), hydroxyproline, peptides, growth factors of epidermocytes and fibroblasts.

Treatment of fresh and growing keloid scars up to 6 months.

First, apply a thin layer of the drug SYNCHRO. Approximately 3-5 minutes after application SYNCHRO is applied on top of CYTOB1. Preparations are left on the skin, do not rinse. After 3-4 months from the start of treatment, you can add a small amount of IMMUNO or CELLS LIFE (if the effect of treatment is poorly noticeable). The drugs are used 2 times a day, in the morning and in the evening, with an interval of approximately 12 hours.

Treatment of old hypertrophic and keloid scars.

SYNCHRO + IMMUNO - 1/1, it is advisable to use 2 times a day.

CYTOBI - will accelerate the action of the active components of the preparation SYNCHRO. It is applied locally by a thin layer on the entire surface of the rumen. Term of treatment of old scars from 6 months to 1 year.