Treatment of normotrophic scars

The first doctor who should start treatment for a patient with extensive normotrophic scars is a plastic surgeon. And only after the completion of the surgeon's work, the dermatocosmetologist must start the work with the remaining scars.

Cryotherapy.

Liquid nitrogen with a boiling point of 195.6 ° C and carbonic acid snow (t - 120 ° C) are used for this purpose.

Cryomassage

The method is old, good, cheap and partly undeservedly forgotten by dermatologists and dermatocosmetologists, not only for scarring, but also for other dermatocosmetological problems. The mechanism of the action of low temperatures on tissues has been well studied. Short-term action of cold causes first a spasm of the vessels, and then their expansion. As a result, trophic tissue improves, the metabolism in cells increases. In addition, there is an accelerated elimination of dead horn cells, that is, cryopilling. Thus, cryomassage has a beneficial effect on normotrophic scars, which is manifested by smoothing the surface of the scar, increasing its elasticity, and accelerating the normalization of color. For cryomassage in dermatological units and cosmetology centers, liquid nitrogen is most often used. Liquid nitrogen is stored in special Dewar vessels. For work is poured into a thermos or special device. The procedure is performed using the applicator, the duration of the procedure depending on the area of the scar - from 10 to 20 minutes. It is recommended for a course of 10-15 sessions every other day or 2 times a week. The courses can be held 2-3 with an interval of 2-3 weeks. Old scars are less amenable to conservative treatment, so it is desirable to conduct all the therapeutic procedures with scars up to 6 months. It is clear that there is no need for cryodestruction in relation to normotrophic scars.

Electrophoresis.

Fermentotherapy. Electrophoresis by enzymes is pathogenetically justified. Especially in the early stages of scar tissue formation. The first enzyme preparation to be prescribed is lidase, since glycosaminoglycans predominate after epithelization of the skin defect with scar formation. The drug will reduce the content of acidic mucopolysaccharides, dilute scar tissue and improve its blood supply. After a course of treatment with lidase, it is useful to administer electrophoresis with collagenase to reduce the mass of collagen fibers.

Lidase (hyaluronidase).

A specific substrate for it is hyaluronic acid. The enzyme causes an increase in the permeability of tissues due to the breakdown of hyaluronic acid to glycosamine and glucuronic acid, which facilitates metabolism in the dermal interstitial. The drug is available in vials in lyophilized form, a volume of 10 ml, containing 64UE. The contents of the vial are dissolved in 1-2 ml of saline or 0.5-2% of novocaine. It is recommended from 1 to 3 courses of lidase, depending on the area of the scar and its type. On the course of 10-15 procedures every other day. The interval between courses is not less than a week. Then 1-3 courses with collagenase in the same regime.

Collagenase.

Preparations based on collagenase in the pharmacy network are several. The first preparations were created at the Leningrad Institute of Vaccines and Serums. It's collagen and collagen. Collalitin is a weaker drug, so collagen is most often used.

Collagen (synonyms: collagenase, clostridio peptidase A).

The preparation is a proteolytic enzyme obtained from the culture of Clostridium histoliticum. A specific substrate for her is collagen. In medical practice is used in the form of aqueous, colorless transparent solutions, which are prepared immediately before use from a porous mass of white color (lyophilized form).

Collagenin selectively acts on the collagen of connective tissue and scars, causing its destruction.

Method of administration and dose.

Immediately before the use of collagen, the contents of the ampoule are dissolved in 0.5% solution of novocaine, isotonic sodium chloride solution or water for injection. The drug is injected directly into the lesion by electrophoresis, phonophoresis, and also used microinjection and dermatology.

Before applying kollalizina check the sensitivity of the patient to the drug. Carry out skin tests by scarifying method in therapeutic doses. The control is carried out after 24-48 hours.

For the treatment of normotrophic scars, prevention of recurrence of keloid scars after excision, and also for the treatment of fresh, growing keloids that do not last more than a year, the drug is recommended to be applied by electrophoresis. The aqueous solutions of collalysin are injected from the positive electrode for 20 minutes at a current strength of 0.03-0.2 tA / cm ² at a concentration of 500-1000 KE in physiological saline or water for injection. The course of treatment does not exceed 15 procedures every other day. A total of 2-3 courses of treatment with an interval of 2-3 weeks. The dose of the drug for electrophoresis administration is selected taking into account the size, stage of development of the scar and its clinical manifestations.

For new growing keloid scars, and also after excision of keloid scars in individuals with increased tendency to excessive proliferation of connective tissue, the drug is prescribed for 1000-2000 KE in 10 ml of water for injection intramuscularly or into a scar. The total dose - for 3 courses of treatment 45 000-90 000 KE. In addition to electrophoresis, the drug can be injected with microcurrent devices, a therapeutic laser. For the treatment of hypertrophic scars, collagen is prescribed at 500-1000KE, dissolved in 10 ml. Water for injection at a total dose of 22000-45000KE.

Form of issue. Collalysin is produced in ampoules of 100, 250, 750, 1000 KE.

Fermentol

The drug, produced by the company "SPb-Technology" in St. Petersburg. It is a complex enzyme preparation from the hepatopancreas of the Kamchatka crab - (polycollagenase cosmetic).

The preparation can be administered by electrophoresis, phonophoresis or microcurrents at a concentration of 4 mg in 2-4 ml. Physiological solution for a course of 10-15 sessions every other day. The number of courses - depending on the type of scar No. 2-4 with an interval of 3-4 weeks. The drug is good, but not motivated by the road, so the preference is given to a drug with a similar collagenolytic activity - collagenase KK.

Collagenase KK

The drug, created by scientists of the Pacific Institute of Bioorganic Chemistry (TIBOH) in Vladivostok, TU 2639-001-45554109-98. The preparation is intended for the hydrolysis of collagen of any type. The preparation was obtained from hepatopancreas of commercial crab species by purification using a combination of chromatographic methods and is a complex of collagenolytic proteinases, the molecular mass of which is within the range of 23-36 kD. The maximum collagenolytic activity of collagenase from hydrobionts is manifested at a pH of 6.5-8.5. The drug is readily soluble in water to a concentration of 50 mg / ml. The ampoule contains 250 units each.

Both prepparate (fermentol and KK collagenase) are identical in composition and exhibit significantly higher collagenase activity than all the currently known drugs of a similar action. Preparations refer to complex enzyme preparations, not only purposefully fragmenting along the entire length of the collagen molecule, but also acting on keratogialin and other denatured protein structures of the skin. As a result of this highly effective specific effect on scars, their considerable regression occurs, and, with respect to keloid and hypertrophic scars, in the light of further surgical interventions, this effect is also preventive (reduces minimal pathological scar growth after operations). For old scars such procedures are not appropriate.

Kelofibraza (Germany).

The main active components: heparin - sodium (mucosa), urea.

It has, in addition to fibrinolytic, itchy-soothing action due to the introduction of menthol, antioxidants, etc., in order to improve the appearance and elasticity of normotrophic scars in cicatricial contractures, keloid and hypertrophic scars, and also for their prevention.

Phonophoresis

Phonophoresis is introduced by ointment and gel forms. However, it is also possible to administer lyophilized preparations, diluting them in a small amount of saline or water for injection. After this, the drug can be introduced into any conductive gel. All listed enzymes can also be injected with phonophoresis.

Kontraktubeks (Germany).

Ingredients: onion extract, heparin, allantoin. Has fibrinolytic, anti-inflammatory, keratolytic action. Reduces the proliferative activity of fibroblasts with increased metabolism. Due to this has a fibrinolytic effect.

Indications: Treatment of keloid and hypertrophic scars, as well as coarse normotrophic scars.

Gel Kontraktubeks is intended for external use. Scars should be lubricated, easily rubbed, 2-3 times a day for at least 2-3 months. To enhance effectiveness, the drug is injected with phonophoresis. On the course - 10-15 procedures. The number of courses is 3-4 with an interval between them not less than 2-3 weeks. Ultrasound has a softening effect of the tissue and allows deeper insertion of the drug, so the effectiveness of external treatment increases.

Note: In case of an allergic reaction of a delayed type, the use of any drug should be discontinued!

For a long time, one of the known ointment forms recommended for the treatment of scars was madecasol. In the annotation to the drug, you can read that it acts on all scars, including keloids and hypertrophic ones, that is, it has fibrinolytic activity. Accordingly, it could be prescribed to patients with normotrophic scars. However, in the course of their practical activities, doctors often encountered the lack of effectiveness of this drug in relation to gross normotrophic and pathological scars. A detailed study of its composition and mechanism of action clarified the situation. The main active substance of the drug is the extract of the Centell Asiatic plant, which grows in Madagascar. The extract of this plant possesses the stimulating effect of synthetic and proliferative activity of fibroblasts, and consequently the preparation on its basis can not be fibrolytic.

Therefore, it is not shown for keloids, nor for hypertrophic, nor for normotrophic scars. However, it can give a good effect in the treatment of hypotrophic and atrophic scars.

Lasonil (Germany).

Active components: heparoid, hyaluronidase. Effective in the early stages of scar formation. Assign for local treatment, lubricating the scars 2-3 times a day. The effectiveness of the drug is much higher when administered by phonophoresis.

Hydrocortisone ointment (Russia).

1% hydrocortisone ointment can be prescribed for normotrophic scars as a prophylaxis for their pathological growth, with the purpose of slight flattening and acceleration of normalization of color for 1-2 weeks. As well as all ointment forms, the drug is more effectively administered by ultrasound.

It is known that red light stimulates fibroblasts, so the therapeutic laser is effective for the treatment of wounds, trophic ulcers, and is not only useless for scarring, but can even stimulate their hypertrophic growth.

Microcurrent therapy stimulates the proliferative activity of fibroblasts, promotes stimulation of local immunity by improving trophism, therefore, just as laser therapy is indicated only for the treatment of surgical sutures and wound surfaces. Thus, laser therapy and microcurrent therapy can be used to prevent scarring, and not to treat them.

But laser injection, as well as the introduction of various drugs, including lidase and collagenase with the help of microcurrents, is a fully shown, but not an obligatory procedure, as it is economically much more expensive than electro- and phonophoresis.

Mesotherapy.

An alternative to electrophoresis and phonophoresis is mesotherapy. This method has received a start in life and is by far the officially recognized direction of dermatocosmetology. Thus, lidase and collagenase can be injected into the body by a microinjection method, which is sometimes a much more effective treatment than the above.

Despite the conduct of previous allergic tests, the doctor may face a massive but soon-passing swelling of the scar tissues immediately after the procedure. This is not an allergic reaction, but a reaction of sharply increased permeability of tissues from the action of the enzyme. Patients with this reaction are recommended a salt-free diet and protein food restriction 2 days before the procedure. In addition, it is necessary to prescribe a course of ascorutin for 1 tablet 3 times a day for at least a month.

Conducting microwave therapy, in our opinion, is not advisable, as to improve blood supply to the scar can be other more prone methods.

Vacuum massage.

It can be used in the therapy of normotrophic scars, as well as devices built on this principle, for example Skintonik, LPD, etc. Any cosmetology rack also has a vacuum device that can be vacuum-massageed. This technology improves blood circulation, elasticity of the scar, somewhat leveling it in relation to the surrounding skin. However, there is no need to speak about any radicality of this method.

It is prescribed 8-15 sessions not more than 3 times a week.

Peelings.

Peelings are chemical compounds that allow you to remove the upper layers of the skin (epidermis) and thereby smooth out the relief of the rumen. The word peeling comes from the English word to peel - peel off. To improve the type of normotrophic scars, it is better to use trichloroacetic, enzymatic, salicylic, resorcinol peels. These peelings have a dehydrating effect, due to which exfoliation of the epidermis, upper layers of scar tissue and alignment of the relief of scars occur. This procedure allows to smooth the surface of normotrophic scars, align them with the surrounding skin.

Various options for therapeutic dermabrasion:

• sandblast dermabrasion,
• ultrasonic dermabrasion,
• dermabrasion with Koca currents,
• a stream of water and gas.

Dermabrasion, unlike peelings, is a mechanical technology used to smooth out the relief of the skin or scar. Can be used in patients with various variants of allergic diseases.

The first devices for therapeutic dermabrasion that appeared on foreign and domestic markets were devices for sandblasting dermabrasion, in particular the Italian laboratory MATTIOLI ENGINEERING. Ultrapeel MATTIOLI ENGINEERING devices are patented by the international patent of the USA N 5.810.842, in 1996, they obtained the FDA approval, marked with the CE badge.

Controlled microdermabrasion is a non-surgical and non-aggressive technique that offers adjustable, safe skin resurfacing. Practically without the risk of complications. It is an excellent alternative to laser grinding and chemical peels, since it has almost no contraindications and side effects. It is a quick, practically painless method that does not require local anesthesia. In the Ultrapeel system, inert alumina microcrystals (corundum) of high purity are used, the sizes of which correspond to the dimensions of the cells of the upper layers of the skin.

Schematically, the work of Ultrapeel devices looks like this:

The flow of microcrystals through a closed system of tubes with a hand-sterilized tip is applied to the surface of the skin with the help of vacuum, "knocking out" of the epidermal cells, and, first of all, the cells of the stratum corneum. The spent powder together with the epidermis cells is collected in a special flask, protected by a filter. The depth of impact can be controlled by the degree of negative pressure (vacuum) and the exposure of the nozzle tip on the surface of the skin or scar.

The group of devices of the Ultrapeel system includes the Pepita and Crystal devices.

Apparatus Pepita - modification Ultrapeel is intended for a wide range of procedures in cosmetic salons, the vacuum power in it is up to 3,5 bar. The depth of grinding, as a rule, is limited to a granular layer of the epidermis.

The Crystal device is a medical modification of the Ultrapeel technology. This is a powerful device that is used in dermatocosmetological clinics, departments of plastic aesthetic surgery clinics around the world. The device uses a vacuum of up to 5.5 bar. Due to the presence of a pressure regulator and a pedal, it is possible to obtain an abrasive effect adequate to operative laser dermabrasion. In this case, "blood dew" appears - the index of grinding to the basal membrane.

Corundum powder is packed in 1.5 kg jars, in 340 g sterile bags. The devices are simple and convenient to use, equipped with a filter system. The technology Ultrapeel uses glass, glass-ceramic and plastic tips, easily removable and sterilizable.

Indications for the use of Ultrapeel devices are the same as with other therapeutic dermabrasion options.

• Scars (normotrophic, hypertrophic, atrophic).
• Hyperkeratosis.
• Hyperpigmentation.
• Stria.
• Acne sickness (post-acne condition).
• Age changes.
• Photoaging.

For specialists involved in scars, it is important to gradually improve the appearance of the scar by smoothing its relief with the surrounding skin without the need for the patient to stay on the hospital sheet or in the hospital.

The number of sessions for this type of treatment of scars depends on the relief and age of the rumen, but not less than 8-10 with an interval of 7-10 days. It is advisable to proceed to a second session after the crusts and scales fall off.

Microdermabrasion and dermoelectroporation.

Devices of the latest generation for microcrystalline dermabrasion Transderm are equipped with an additional instrument "electroporation nozzle" that allows after dermabrasion to inject various preparations into the skin or scar, using the technique of electrical impulses to increase the permeability of cell membranes. Vibration makes the cell membrane more permeable to a variety of hydrophilic molecules that previously could not enter the cell. In cell membranes are formed easily permeable for the passage of molecules areas - pores. Once formed, these pores persist for a long time. Microdermabrasion reduces the thickness of the layer, allowing absorption of active substances applied to the skin. The procedure of microdermabrasion, immediately continued by dermoelectroporation with the use of active cosmetics, opens new possibilities in transdermal delivery of active substances and allows to achieve better results.

The technique used in the Transderm apparatus is qualitatively different from all existing at this time, such as, for example, microcurrents or iontophoresis. The effect of Transderm is based on the use of pulsating currents having a range of 0.5 to 5 mA with a frequency of 2200 Hz, which unlike microcurrents are able to deliver the drugs directly into the cell. The difference from ionophoresis lies in the fact that the introduced molecules are not divided into positive and negative ions, but are delivered into the cell entirely, including even very large molecules.

Jet Peel production TavTech (Israel)

It is another option for therapeutic dermabrasion. Not so long ago released on the domestic market.

The device is interesting in that dermabrasion is carried out with the help of two natural components - water and air. Due to the treatment with a gas-liquid jet, the skin surface is not only cleaned, but moistened and massaged. The device supplies compressed gas to the tube. The gas pressure is no more than 6-8 atm., It flows through the tube into the nozzle with a built-in supersonic nozzle, which accelerates the gas to a speed of 1.8 Max.

When the gas flows through the tube, conditions are created for sucking the liquid from a separate tank. A microneedle is built along the central axis of the nozzle, liquid (isotonic 0.9% solution of sodium chloride - saline solution) is fed into the zone after the nozzle in the form of drops. Drops are picked up by the gas flow and accelerated to 200-300 m / sec. At this speed, the drop has a large kinetic energy, practically being a solid body.

In the focus of the jet, a deformation in the form of a hole forms on the skin, erosion is formed on the bottom as a result of layer-by-layer removal of epidermal cells. The depth of exfoliation is provided by the orientation of the nozzle relative to the skin surface and exposure time. Thus, mechanical dermabrasion is implemented, which dermatologists and dermatocosmetologists can use to treat a number of diseases and skin problems. With reference to the subject of this monograph, JetPeel successfully allows to treat normotrophic, hypertrophic, hypotrophic and atrophic scars. This device is the device for therapeutic dermabrasion of the latest generation. The gas-liquid jet allows not only humanely and gently to produce mechanical dermabrasion, but also intradermally injecting liquid medicinal substances and gas (oxygen in particular). Massage with a gas-liquid jet, injection of oxygen and drugs under pressure are additional positive factors that improve the effectiveness of scar treatment, especially for atrophic and hypotrophic scars.

The device is also interesting because it provides a gas cooling system, thanks to which anesthesia of the treated area is provided. In addition, the cooled gas acts on the surface vasculature, causing vasoconstriction followed by vasodilatation of the arterioles and capillaries, which further improves the trophism of the scars.

Effects of gas-liquid spray or skin:

• abrasive;
• antibacterial;
• immunocorrective;
• activating blood circulation;
• regulating the functional and metabolic activity of cells;
• anesthetic;
• improving trophic;
• drainage.

Indications:

• Preoperative preparation of skin and scars; 
• correction of atrophic, hypertrophic, hypotrophic and normotrophic scars:
• correction of the striae;
• hyperpigmentation.

To improve the type of normotrophic scars with the help of sandblast and gas-liquid dermabrasion, it is necessary to conduct at least 10 procedures 1-2 times a week, depending on the depth of impact. In the case of abundant scaling and crusts, the interval between sessions is extended to 10 days. Skin and scars after the sessions are recommended to be treated with panthenol with application for 8-10 minutes. Between sessions, the skin and scars are treated with curiosin, chitosan gel, solcoseryl ointment or panthenol 2 times a day.

To variants of devices for therapeutic dermabrasion it is possible to carry a bouffsage or a brush peeling, which enters a separate device into any cosmetic stand. With the help of rotating brushes, with certain efforts, it is also possible to gradually improve the relief of the rumen. The number of sessions with this technology will not be less than 25-30, two or three times a week, since the passage gives an insignificant depth of impact.

All the listed variants of therapeutic dermabrasion allow dosed and purposefully to smooth out those areas of scars that need it. Therefore, these technologies are more preferable than peelings. The number of procedures depends on the characteristics of the relief of scars and the depth of impact.

The more superficially the procedure is performed, the more sessions will be large.

Operative dermabrasion.

Can be implemented:

• Schuman's cutter,
• carbon dioxide laser.
• erbium laser.
• a thermocouter.

Operative dermabrasion is often preferable to peelings and therapeutic options for dermabrasion because of the shortening of treatment times. Surgical dermabrasion with an erbium laser is most preferable for working with normotrophic scars. This is due to the fact that normotrophic scars most often do not have much difference in the relief with the level of the surrounding skin. The unevenness that inevitably exists in any scar should be smoothed with a small number of laser beam "passes", which removes a layer of tissue approximately 0.1 micron per pass. Due to such a thin layer-by-layer removal of the rumen volume, it is possible to achieve equalization of the relief of any thinnest normotrophic rumen, which even approaches its atrophic thickness in its thickness.

Complete epithelization after operative dermabrasion of normotrophic scar occurs from 8 to 10 days. After falling off the wound coverings and complete epithelization of the surface of the scar, the pink color of the ground surface disappears after 4-10 weeks. Lotions of 2% boric acid, treatment with hydrocortisone ointment, gel Auriderm XO somewhat accelerate the normalization of the color of the scar.

After therapeutic and operative dermabrasion, patients are advised to use for a period of 1.5-2 months photoprotective agents with an SPF of at least 30, especially for patients with skin types III and IV Fitzpatrick.

Scars after therapeutic and dermatological surgery receive a significant smoothness of the surface, which can be camouflaged with make-up, of which the means of dermatological laboratories are preferred. So the French companies La Rosh Pose, Aven produce medicinal make-up products, which include different-colored sticks. Pencils and powders on a dermatological basis.

I would like to mention one more and very important moment - the time for dermatological surgery with scars. In this moment there are very important differences with surgeons. For the surgical removal of scars, surgeons are not taken in the period of their existence up to 6 months. Explanation - the scar should mature otherwise the insufficiency of the seams and, consequently, the deterioration of the results of surgical reconstruction may turn out to be. With this it is difficult to argue, since really up to 6 months in the rumen still retains a lot of intercellular substance and vessels, which ensures the looseness of the tissue. However, for dermatosurgical treatment, it is up to 6 months that are optimal for the same reason. And the earlier the therapeutic treatment is started, including operative dermabrasion, the better the results.

Therapeutic treatment of old (after 6-8 months) normotrophic scars does not give practically no visible changes in the clinical picture. Such patients are shown a different kind of peeling and all the variants of therapeutic and surgical dermabrasion. They make it possible to smooth out the irregularities in any scarcest scar, which is one of the most desirable facts for patients.

The optimal means of treatment of normotrophic scars are:

• fermentotherapy with mesotherapy or phonophoresis;
• means and methods that improve microcirculation;
• subsequent therapeutic or operative dermabrasion;
• ointment forms for home care (kontraktubeks, kelofibraza, lyoton-100, lazonil).