Treatment of keloid scars

It is noted that a long-term septic state of the wound, chronic inflammation contributes to 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 condition of the body is polyetiological. Hence, it is clear why it is impossible to cure keloids only by local means, especially in favorite keloid-dangerous zones. Often, such scars occur in weakened patients, with extensive burns, infected wounds, against the background of chronic or acute stress, chronic diseases, endocrinopathies, hereditary predisposition, etc. Therefore, laboratory and instrumental examination, careful collection of anamnesis, treatment of concomitant pathology, replacement therapy with microelements, vitamins, antioxidants, adaptogens should be included in the mandatory treatment regimen for such patients. And it is clear that if the causes that caused the predisposition to this pathology are not eliminated, the treatment cannot be successful. However, it is not always possible to identify the underlying causes of keloid scars, or the causes are known but impossible to get rid of. In this case, treatment is a big problem.

It is known that surgical excision and grinding of keloid scars without preliminary therapeutic and postoperative treatment are contraindicated, since a larger scar usually grows in place of the removed keloid. Therefore, most treatment measures are therapeutic. However, there are surgical techniques that allow you to reduce the area of keloid scars and get good results after their excision.

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

Analyzing the main areas 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 foci, which are the source of the formation of “giant” and young fibroblasts with a pronounced tendency to constant growth and slow maturation.

A critical analysis of the data presented in the table allows us to state that some of these means and methods have lost their relevance due to the appearance of remote negative treatment results. Some means and methods may be associated with serious complications in the hands of insufficiently professionally trained specialists. Some are extremely ineffective.

For example, excessive doses of close-focus X-ray therapy, radiotherapy and Bucky rays can cause long-term non-healing wounds on scars, which often transform into highly invasive squamous cell carcinoma, a malignant tumor, the so-called Marjolin ulcer.

Isolated cryodestruction with liquid nitrogen is a painful method that results in long-term non-healing erosions, in place of which a larger keloid often forms. In this regard, we consider its use inappropriate. However, cryodestruction in combination with microwave therapy or Bucky irradiation gives completely different and quite positive results.

Local hormonal therapy, when used in doses, is very effective. However, at the site of the administered corticosteroids, in particular Kenolog - 40, cysts with non-absorbable contents of the drug particles are often formed, atrophy may also occur with an 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 their production of collagen, turns out to be inappropriate due to the possibility of provoking increased formation of a pathological scar (8,24,35,164).

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

There is information in the literature about the use of calcium antagonists (verapamil) for the treatment of keloid scars. A small personal experience of using verapamil led to the conclusion that it is inappropriate to use it for the treatment of pathological scars due to severe pain during injections and the lack of therapeutic effect.

Removing a scar using a laser or surgical excision without prior conservative treatment and without taking into account the skin tension line is dangerous due to recurrence and the appearance of a larger scar in place of the excised one.

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. Electro- and phonophoresis, which have long been successfully used for introducing drugs into tissues, are significantly more effective and cheaper methods.

Therefore, research in the field of modernization of treatment, finding means of eliminating excess scar tissue without side effects and with maximum clinical results remains relevant.

Based on the generalization of clinical, pathomorphological and pathogenetic data on keloid scars, we can draw a conclusion about the main directions of work with them.

Local remedies and methods for combating keloids are divided into:

1. Methods and technologies used to inhibit the proliferative and synthetic activity of fibroblasts: mesotherapy, electrophoresis, laserphoresis, phonophoresis with corticosteroids, gamma interferon; Bucky irradiation, radio-roentgenotherapy, etc.
2. Methods that lead to a reduction in the volume of pathological scar tissue and remove excess water from it: microwave therapy followed by cryodetraction, enzyme therapy, surgical and laser removal, pressure, silicone bandages, “pillows”, etc.

Methods and technologies used today:

1. Cryodestruction

It is known that the more free and bound water in tissues, the more sensitive they are to the effects of low temperatures. In keloids, the bulk of the scar is collagen, which is second only to DNA in its water-binding properties among biological structures. Cryodestruction has long been a very common procedure for treating keloid scars. However, necrosis of scar tissue after cryodestruction, even with long exposures, is superficial. One of the reasons for the low efficiency of cryodestruction of keloid scars is that bound water is inaccessible to the influence of the refrigerant.

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

2. Microwave therapy followed by cryodestruction.

This method was developed under the supervision of V. V. Shafranov and N. G. 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 refrigerant. For this purpose, microwave therapy devices are used. The duration of exposure in the physiotherapeutic range is 5 minutes with subsequent cryodestruction for 7 minutes. Six months after microwave cryogenic exposure, normalization of the state of the scar tissue is observed not only clinically but also histologically. Scars flatten, morphologically, the keloid tissue is transformed into normal scar tissue. Of course, this method is not a panacea for the treatment of keloid scars. Along with positive results, there are cases of no effect from treatment and negative results.

3. Electrophoresis with lidase, collagenase, corticosteroids.

In the early stages of the existence of keloid scars, pathological fibroblasts produce mainly glycosaminoglycans, among which hyaluronic acid predominates. Accordingly, at this time, it is necessary to introduce lidase (hyaluronidase) into the scar. As the duration of the scar increases, fibroblasts switch to collagen synthesis with a collagenase deficiency, so there is a need to introduce collagenase into the scar. Since all clinics, hospitals, medical centers and dermatovenerologic dispensaries are equipped with physiotherapy rooms, the use of direct galvanic current (electrophoresis) for the introduction of drugs into the scar is the most justified in terms of cheapness and availability. Alternating courses of lidase and collagenase No. 4-5 with an interval between courses of 2 weeks leads to a slight decrease in the volume of the scar and, in some cases, to a stop in its growth.

Glucocorticoids are used to treat hypertrophic and keloid scars, as well as for their prevention.

Pharmacological action of glucocorticoids.

They suppress the function of leukocytes and tissue macrophages, the formation of antibodies, limit the migration of leukocytes to the inflammation area, reduce the number of circulating lymphocytes (T- and B-cells), monocytes, eosinophils. They impair the ability of macrophages to phagocytosis, as well as to form interleukin-1. They promote the stabilization of lysosomal membranes, thereby reducing the concentration of proteolytic enzymes in the inflammation area, reduce capillary permeability, suppress the activity of fibroblasts and collagen formation. They inhibit the activity of phospholipase A2, which leads to the suppression of the synthesis of prostaglandins and leukotrienes.

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

The same treatment can be carried out using laserphoresis and microcurrents.

4. Phonophoresis with corticosteroid ointments, contractubex.

According to some authors, ultrasound as an independent procedure has a positive effect on keloid scars, causing their softening. The use of Lioton-1000 instead of the indifferent conductive gel allows for an additional dehydrating effect from phonophoresis. The introduction of corticosteroid drugs in ointment forms enhances the treatment result. For example, 1% hydrocortisone ointment is prescribed for a course of 10-15 sessions daily or every other day. Contractubex gel is also administered by phonophoresis, the effect of which is enhanced by ultrasound. Treatment with Contractubex alternates with corticosteroid drugs, for a course of 10-15. There may be 3-4 courses depending on the effect and combined therapy.

5. Mesotherapy (injection) of scars.

Due to the inhibitory effect of corticosteroid drugs on fibroblasts, prolonged corticosteroid injections into keloid scar tissue are used to enhance their effectiveness.

Preparations: Kenolog-40, Kenocort, Diprospan.

There are reports in the literature on the use of gamma and alpha interferons for the treatment of keloid scars. Their mechanism of 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 lesion. The drugs are injected into the scar tissue. It is advisable to use insulin syringes with non-removable needles, since any drugs are injected into the keloid scar tissue with great difficulty. Strong pressure on the plunger can lead to the separation of the needle from the syringe and the loss of an expensive drug.

• Cytostatics

Cytostatics are also used to treat keloid scars. Cytostatics should be used with great caution, in a dilution of at least (1:1 with saline solution) and an interval of at least a month should be made between sessions. Otherwise, a sharp atrophy may occur at the site of the former keloid scar. This treatment should be used only if all other methods are ineffective due to the general negative impact of drugs in this group on the body as a whole.

• Calcium antagonists.

The use of drugs of this group is not advisable.

6. Sclerolaser treatment.

The mechanism of action of a sclerolaser on keloid scars is based on the selective effect of a laser beam on the superficial network of dilated vessels. The laser beam is absorbed by blood hemoglobin, resulting in the formation of a blood clot that blocks the vessel. If the laser beam also affects the vessels feeding the keloid, some flattening of the scar and elimination of superficial 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 procedures is 3-4 weeks. The effectiveness and necessity of such treatment is quite relative, since similar results can be obtained using other less expensive procedures. This procedure can be used as an additional preventive measure in preparing scars for surgery.

7. Pressure bandages, underwear.

It has been empirically discovered for over 20 years that prolonged pressure in the area of a keloid scar causes its flattening and regression. Silicone pads, pillows, and self-adhesive gel sheets have been used for this purpose. The mechanism of action of these devices has long been unknown. Various versions have been put forward, the most popular of which is the theory of the effect of static electricity on the keloid, which occurs in silicone and gel. At present, scientists are inclined to believe that dystrophic processes occur in pathological scars due to prolonged compression. There is a desolation of the vessels "feeding" the keloid, a violation of tissue trophism, and apoptosis in giant fibroblasts. This leads to the cessation of growth and flattening of the scars.

Today, the range of "pressure devices" has increased significantly. These are:

1. Special pressure underwear made of dense elastic cotton fabric.

In large cities there are companies that can make custom-made bandages or underwear for any scar localization. It is recommended to wear such underwear for at least 6 months.

2. Pressure plates:
   • adhesive silicone gel coatings.
   • self-adhesive dressings with silicone and absorbent coating,
3. Liquid gel products:
   • Liquid collodion-based products with silicone and an active ingredient, such as Scarguard, ScarCare. They contain vitamin E, 0.5% hydrocortisone.
   • based on polysiloxane.

8. Buccal irradiation, close-focus X-ray therapy.

Bucky irradiation is a very effective technology for both treatment and prevention of pathological scar growth. Treatment is carried out on the German device "Dermopan", which, unfortunately, is available in limited quantities in our country and the CIS countries. Young growing keloids respond best to treatment, since the rays primarily act cytostatically and cytolytically on immature poorly differentiated cells and giant fibroblasts of keloid scars. As a preventive measure, the procedure is carried out once a month at a dose of 800 to 1500 rubles immediately after removing the stitches and cleaning the surface of the postoperative scar from secondary crusts. Some authors recommend doses up to 2000 rubles. However, in this case, complications such as atrophy of the surrounding skin, telangiectasia, and scar ulceration occur more often. When treating keloid scars, the number of sessions depends on the activity and age of the scar, the age of the patient and the area of the scar. Keloid scars with signs of maturity, i.e. long-standing, inactive (without a clear clinical picture) can also be treated with Bucky irradiation. In these cases, scars need to be activated. This is done using cryotherapy with liquid nitrogen. 1-2 cryotherapy sessions are performed until a blistering reaction occurs, followed by treatment of the resulting wound surfaces until complete epithelialization and the fall of all crusts. The scar surface must be absolutely clean, without crusts and peeling, since otherwise the rays will not have a therapeutic effect. The crust-free scar surface is treated with Bucky rays.

Treatment conditions: voltage - 9, 20, 23 kV, current - 2.5-10 ta, distance of the tube to the lesion 3-5 cm.

9. Magnetic thermal therapy.

The use of this type of therapy for the treatment of pathological scars is inappropriate. The mechanism of action of magnetic therapy was covered in the previous sections. It comes down to stimulating fibrogenesis, and therefore is applicable only as a means of promoting wound healing, i.e. for the prevention of scars.

10. Microcurrent therapy.

The introduction of corticosteroids and other drugs that help reduce fibroblast activity and destroy collagen and glycosaminoglycans using microcurrents is theoretically and practically possible, but not advisable due to the high cost and low efficiency of the method.

11. Drug therapy for keloid scars.

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

For effective treatment of keloid scars, it is impossible not to take into account known general clinical pathogenetic factors, in particular, endocrinopathies.

Hyperandrogenemia. If the clinical picture and laboratory examination of patients reveal elevated levels of free testosterone, it is necessary to prescribe testosterone antagonists. Almost without laboratory examination, one can speak of the need for antiandrogen therapy in patients with acne-keloid clinical picture and keloid scars in seborrhoeic zones - the upper chest, shoulder girdle, which are difficult to treat. These zones are rich in sebaceous glands, the cells of which have receptors for androgens. Free testosterone in the blood, under the influence of alpha-reductase, is converted into 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 inflammation zone. Such female patients should be examined and monitored by gynecologists. Women of childbearing age are prescribed antiandrogen drugs such as Cyanide-35, Janine, Yarina. Women of pre- and post-menopausal age are prescribed hormone replacement therapy (cycloprogenova, angelique, klimonorm, etc.). Men - indrocur 50 mg per day. Long-term prescription of antiandrogen therapy to men is not indicated due to the possibility of decreased sexual potency.

Elevated levels of thyroid and thyroid-stimulating hormones stimulate the synthetic and proliferative activity of fibroblasts, which can also stimulate the tendency to keloid scars.

Accordingly, finding out the condition of the pituitary gland and thyroid gland using laboratory and instrumental research methods (including echoencephalography, MRI, sella turcica imaging, thyroid gland examination with radioactive iodine, determination of the level of thyroid hormones in the blood) can give the doctor the key to solving the problem of keloid scars of this patient together with endocrinologists.

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

Chronic diseases can also become the underlying cause of the tendency to keloid scars, as they lead to decreased reactivity, oxidative stress, deficiency of vitamins and microelements. Accordingly, sanitization of foci of chronic infection, treatment by related specialists, prescription of microelement-vitamin complexes, antioxidants, can make a significant contribution to the treatment of keloid scars and their prevention.

If the examination and anamnesis do not allow to determine the cause of the tendency to keloid scars or a genetic predisposition is traced, it is necessary to prescribe vitamin-microelement complexes, antioxidants, sanitize teeth, tonsils; treat dysbacteriosis, prescribe hepatoprotectors. This entire complex will be useful when prescribing local treatment or performing surgical removal.

There is a report on the treatment of keloid scars with retinoids (retinol palmitate daily dose of 10,000 IU/kg once a day 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 of receptors of the same name on their cell wall. Therefore, as agents accelerating wound healing, these drugs are very useful, but not for the treatment of keloid scars (88,163).

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

Pyrotherapy.

Pyrogenal (Russia) belongs to the group of bacterial protein-free lipopolysaccharides. It is a means of stimulating factors of non-specific and specific resistance of the body, as well as prodigiosan. The activity of pyrogenal is calculated in minimum pyrogenic doses (MPD). The drug activates the function of the adrenal cortex, the production of interferons. Pyrogenal has a pyrogenic effect, increasing body temperature to 40 °, after which the collagen of keloid scars becomes more accessible to the action of metalloproteases. Previously, the drug was widely used to treat keloid scars. Currently, interest in this method has significantly decreased, despite the fact that in some cases its use actively contributes to the regression of keloid scars. This is partly due to the fact that the use of pyrogenal is desirable in a hospital setting, but pyrotherapy is also possible in an outpatient setting. The drug is administered intramuscularly every other day, starting with 25-50 MPD, gradually increasing the dose to 1000 MPD. It is advisable to administer the drug 2 times a week. If the first dose caused a high temperature reaction (37.8-38°), the second injection is administered at the same dose as the first. If the temperature increase did not exceed 37.5°, the next dose is increased by 15-25-50 MPD. The maximum dose for adults is 1000 MPD, for children - 500 MPD. The number of injections is 8-15.

It is produced in ampoules containing 100, 250, 500 and 1000 MPD in 1 ml of physiological solution.

Prodigiosan (Russia).

Also belongs to the group of high-molecular bacterial lipoproteins. It is administered intramuscularly. The initial dose for adults is 15 mcg, for children - 10 mcg of 0.005% injection solution. If well tolerated, adults are administered 25 mcg 2 times a week, increasing the dose to 100 mcg, children - 10-20 mcg. The course is 8-10 injections.

Contraindications for pyrotherapy:

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

12. External treatment of keloid scars:

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

This:

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

The Spenko gel plate is a pad made of translucent gel, consisting of pure silicone. The plate has dimensions of 10x10 cm.

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

• Self-adhesive dressings with silicone and an absorbent coating, such as Mepitel, Mepiform (Sweden) are preferable to gel sheets. By applying these coatings to young scars, their moisture capacity increases, cells more easily transmit information to each other about the excess of collagen and autocatalytic processes come into action, leading to the dissolution of collagen by the body's own enzyme system. Dressings do not need to be fixed, which is convenient for patients:
• Liquid products based on collodion with silicone and an active substance, such as polysiloxane.

Liquid forms harden on the scar and turn into a film that compresses the scar. They are applied to thicken the film twice a day.

Zeraderm Ultra Scar Treatment Gel is a high molecular weight polysiloxane preparation, with additives that have a protective effect against ultraviolet radiation and are enriched with vitamins and coenzymes.

When in contact with air, Zeraderm Ultra forms an invisible, water-repellent, but air-permeable membrane. Cosmetics can be used over the applied Zeraderm Ultra.

Zeradenn Ultra is a more preferable preparation compared to silicone pads and plasters, as it forms an invisible protective, gas-permeable and impermeable to microorganisms film, and does not require fixation.

Zeraderm Ultra is easy to use, especially in the facial area and when treating children.

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

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

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

Treatment:

It begins immediately after epithelialization or removal of sutures.

Should be used twice daily for several weeks to several months.

Scarguard

ScarGuard is a quick-drying liquid that forms a transparent film on the scar surface, protecting the tissue from irritation and simultaneously creating pressure on it and providing hydrocortisone, vitamin E and silicone to the problem area. It is applied with a brush, just like nail polish, directly to the skin surface, and does not require a bandage or other means of fixation. ScarGuard is applied independently twice a day for 1-6 months. As a result of the polymerization of the composition, a hermetic 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 plates and pressure bandages is well studied. It is based on a violation of the nutrition of scar tissue and cells with increased metabolism (fibroblasts). Due to the fact that the basis of the preparation also includes medicinal agents (hydrocortisone and vitamin E), the preparation, which hardens on the skin and turns into a pressure bandage, acts as a medical compress, due to the action of which the introduction of medicinal components into the scar tissue is facilitated. Vitamin E is a powerful antioxidant, and hydrocortisone suppresses the proliferative and synthetic activity of fibroblasts, promotes the appearance of mature fibroblasts that synthesize collagenase.

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

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

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

13. Surgical treatment.

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

Surgeons have a real opportunity to help patients with large keloid scars by gradually reducing the scar area, cutting it out from the inside in small sections, without going beyond its boundaries. The interval between surgeries depends on the elasticity of the tissues around the scar. If necessary, expanders can be installed. Between surgeries, the patient must wear special tight-elastic underwear. When the scar is reduced as much as possible, it can be excised using various techniques, such as counter triangular flaps to obtain a Z-shaped scar, preferably after preliminary therapeutic preparation, since even in a Z-shaped form it can become keloid. After the surgery, immediately after removing the stitches and the secondary crusts coming off, it is necessary to conduct a session of Bucky therapy or close-focus X-ray radiotherapy. With this combination of surgical and therapeutic methods of treatment, there is a high probability of obtaining a normotrophic scar.

Surgical treatment of keloid scars is also possible with lasers. This method of treatment should use CO, laser, since the keloid must be removed to its full thickness, to the subcutaneous fat, completely removing the 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 this technology causes significantly greater tissue overheating, traumatization, which worsens the healing of wound surfaces and leads to a higher percentage of relapses than with laser removal. But if immediately after the healing of the wound surfaces to conduct several sessions of electrophoresis with collagenase preparations and sessions of Bucky irradiation, the probability of a positive result will be significantly higher. This is due to the fact that collagen after heating becomes more accessible to the action of metalloproteases.

A comprehensive approach to the treatment of keloid scars, using several treatment options, usually gives the best effect, but does not completely solve the problem, so only a creative, comprehensive and individualized approach can give optimal results.

However, if a patient has one keloid scar, not located in a keloid-dangerous zone, caused by poor wound treatment or secondary infection, there are no general predisposing factors and genetic predisposition, then such a scar can be cured fairly quickly with 2-3 injections of diprospan or 1-2 sessions of Bucky irradiation and there is no need to prescribe other longer and more expensive treatment.

If a patient has a tendency to keloid scars (there are similar scars on the body that have appeared earlier) or the scar, even one, is localized in the sternum or upper shoulder girdle (keloid-dangerous zones), only a comprehensive approach should be used for such patients. That is, prescribe general internal therapy, corrective therapy together with related specialists and, finally, local treatment.

A variant of a local treatment regimen for extensive keloid scars

Stage 1. Reduction of scar size, elimination of contractures, restoration of organ and tissue function.

Reducing the area of a scar by excising its tissue from the central part (without going onto healthy skin) in several stages is a little-known but well-proven method, provided that the nearby healthy skin is well stretched.

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

Stage 2. Introduction of lidase into scars using various available methods due to the high content of glycosaminoglycans and hyaluronic acid in a young scar.

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

Note.

Old scars that have existed for more than a year are much less responsive to enzymatic treatment, so it is necessary to increase the number of sessions and courses (up to 5-7) to achieve a satisfactory clinical effect. It should also be noted that enzymatic treatment, despite its effectiveness and harmlessness, is a long process that requires a lot of time from the patient. In addition, with a significant improvement in the clinical picture, smoothing of the scar with the surrounding tissues is not always achieved, which is undoubtedly the most desirable result of treatment. Therefore, to enhance the effectiveness of treatment, patients use a comprehensive approach, which consists, in addition to treatment with collagenase drugs, of ultrasound treatment with contractubex and intra-scar administration of prolonged-action corticosteroids (kenalog-40, diprospan).

Stage 4. Introduction of Contractubex or hydrocortisone ointment using ultrasound.

Recommendations to patients to lubricate scars with Contractubex have practically no effect and require a large amount of the expensive drug, so the combination of Contractubex and ultrasound is optimal. The drug acts at a greater depth, in addition, ultrasound has a fibrolytic effect.

If at this stage of treatment the scar has flattened and there are no clinical signs of keloid, treatment can be stopped. The patient should remain under observation, as the scar may start growing at any time and then the fifth stage of treatment will be required.

5 etan. If the patient notes the presence of subjective unpleasant sensations in the scar area and it 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. It is undesirable to do more than 4-5 injections. It is necessary to take a break for 2-3 months and if the scar still bothers, add irradiation with Bucky rays or pyrotherapy.

Stage 6. At the final stage of complex therapeutic treatment of keloids, it is sometimes necessary to remove dilated vessels on its surface and reduce the intensity of the color. The color of a keloid scar is the last sign to disappear. Dilated vessels on the surface of scars can be eliminated using a sclerosing laser, which simultaneously affects the deep vessels, worsening the nutrition of the scar and causing its dystrophy.

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

14. Use of medicinal cosmetics.

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

SYNCHRO - regenerating nourishing base cream. The cream contains unsaturated fatty acids, fat-soluble (A, E) and water-soluble vitamins of group B. vitamins C, H, antioxidants. anti-inflammatory components, trace elements (potassium, magnesium), amino acids.

IMMUNO - Regenerating nourishing base cream.

Composition: unsaturated fatty acids, amino acids and trace elements.

CYTOBI - Super-regenerating nourishing cream.

Ingredients: vitamins A, C, E, H and B group, amino acids (methionine, glycine, valine, isoleucine, proline, lysine, serine, threonine, alanine, cysteine, glutamine, arginine, histidine, tyrosine), trace elements (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 microelements and vitamins, and nourishes the skin.

CELLS LIFE - Serum for normalizing oxidation-reduction processes in the rumen.

CELLS LIFE serum consists of active substances based on proteoglycans and hyaluronic acid. Being components of the main 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 main processes of skin and scar cell life.

The main components of the serum: mucoglycoprotein complex (chondroitin sulfate, hyaluronic acid), hydroxyproline, peptides, epidermocyte and fibroblast growth factors.

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

First, apply a thin layer of SYNCHRO. Approximately 3-5 minutes after applying SYNCHRO, apply CYTOB1 on top. The preparations are left on the skin and are not washed off. After 3-4 months from the start of treatment, a small amount of IMMUNO or CELLS LIFE can be added (if the effect of treatment is poorly visible). The preparations are used 2 times a day, morning and evening, with an interval of approximately 12 hours.

Treatment of old hypertrophic and keloid scars.

SYNCHRO + IMMUNO - 1/1, preferably used 2 times a day.

CYTOBI - will accelerate the action of the active components of the SYNCHRO preparation. It is applied locally in a thin layer to the entire surface of the scar. The treatment period for old scars is from 6 months to 1 year.