Treatment of normotrophic scars

The first doctor who should begin treating a patient with extensive normotrophic scars is a plastic surgeon. And only after the surgeon's work is completed, should a dermatocosmetologist begin working with the remaining scars.

Cryotherapy.

For these purposes, liquid nitrogen with a boiling point of -195.6°C and carbonic acid snow (t - 120°C) are used.

Cryomassage

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

Electrophoresis.

Enzyme therapy. Electrophoresis with enzymes is pathogenetically justified, especially in the early stages of scar tissue formation. The first enzyme preparation that should be prescribed is lidase, since after epithelialization of the skin defect with the formation of a scar, glycosaminoglycans predominate in it. The drug will reduce the content of acidic mucopolysaccharides, thin the scar tissue and improve its blood supply. After a course of treatment with lidase, it is useful to prescribe 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 tissue permeability due to the breakdown of hyaluronic acid to glycosamine and glucuronic acid, which facilitates metabolism in the interstitial substance of the dermis. The drug is available in lyophilized vials, 10 ml each, containing 64 U. The contents of the vial are dissolved in 1-2 ml of physiological solution or 0.5-2% novocaine. It is recommended to take 1 to 3 courses of lidase, depending on the area of the scar and its type. The course is 10-15 procedures every other day. The interval between courses is at least a week. Then 1-3 courses with collagenase in the same mode.

Collagenases.

There are several collagenase-based drugs in the pharmacy network. The first drugs were created at the Leningrad Institute of Vaccines and Serums. These are collalitin and collalisin. Collalitin is a weaker drug, so collalisin was used most often.

Collalysin (synonyms: collagenase, clostridiopeptidase A).

The drug is a proteolytic enzyme obtained from the Clostridium histoliticum culture. Its specific substrate is collagen. In medical practice, it is used in the form of aqueous, colorless, transparent solutions that are prepared immediately before use from a porous white mass (lyophilized form).

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

Method of administration and dosage.

Immediately before using collalysin, the contents of the ampoule are dissolved in a 0.5% solution of novocaine, isotonic sodium chloride solution or water for injection. The drug is administered directly to the lesion using electrophoresis, phonophoresis, and is also used by microinjection and cutaneously.

Before using collalysin, the patient's sensitivity to the drug is checked. Skin tests are performed using the scarification method in therapeutic doses. Control is carried out after 24-48 hours.

For the treatment of normotrophic scars, prevention of recurrence of keloid scars after excision, as well as for the treatment of fresh, growing keloids no more than a year old, the drug is recommended to be used by electrophoresis. Aqueous solutions of collalizin are administered from the positive electrode for 20 minutes at a current of 0.03 - 0.2 mA / cm ² in a concentration of 500-1000 KE in physiological solution or water for injection. The course of treatment is no more than 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 administration by electrophoresis is selected taking into account the size, stage of development of the scar and its clinical manifestations.

For fresh growing keloid scars, as well as after excision of keloid scars in individuals with an increased tendency to excessive proliferation of connective tissue, the drug is prescribed at 1000-2000 KE in 10 ml of water for injection intramuscularly or into the scar. The total dose is 45,000-90,000 KE for 3 courses of treatment. In addition to electrophoresis, the drug can be administered using microcurrent devices, a therapeutic laser. For the treatment of hypertrophic scars, collalysin is prescribed at 500-1000 KE dissolved in 10 ml of water for injection with a total dose of 22,000-45,000 KE.

Release form: Collalizin is available in ampoules of 100, 250, 750, 1000 KE.

Fermencol

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

The drug can be administered by electrophoresis, phonophoresis or microcurrents at a concentration of 4 mg in 2-4 ml of physiological solution per course of 10-15 sessions every other day. The number of courses depends on the type of scar No. 2-4 with an interval of 3-4 weeks. The drug is good, but unreasonably expensive, so preference is given to a drug with similar collagenolytic activity - collagenase KK.

Collagenase KK

The drug created by scientists of the Pacific Institute of Bioorganic Chemistry (TIBOC) in Vladivostok, TU 2639-001-45554109-98. The drug is intended for the hydrolysis of collagen of any type. The drug is obtained from the hepatopancreas of commercial crab species by purification using a combination of chromatographic methods and is a complex of collagenolytic proteinases, the molecular weight of which is within 23-36 kDa. The maximum collagenolytic activity of collagenase from aquatic organisms is manifested at pH 6.5-8.5. The drug is highly soluble in water up to a concentration of 50 mg/ml. The ampoule contains 250 U.

Both preparations (fermencol and collagenase KK) are identical in composition and exhibit significantly higher collagenase activity than all currently known preparations of similar action. The preparations are complex enzyme preparations that not only purposefully fragment the collagen molecule along its entire length, but also act on keratohyalin and other denatured protein structures of the skin. As a result of such a highly effective specific action on scars, their significant regression occurs, and, in relation to keloid and hypertrophic scars, in light of further surgical interventions, this effect is also preventive (reduces to a minimum the growth of pathological scars after operations). For old scars, such procedures are not advisable.

Kelofibrase (Germany).

Main active ingredients: heparin sodium (mucose), urea.

In addition to fibrinolytic action, it has an itching-relieving effect due to the introduction of menthol, antioxidants, etc. It is prescribed to improve the appearance and elasticity of normotrophic scars in cicatricial contractures, keloid and hypertrophic scars, as well as for their prevention.

Phonophoresis

Phonophoresis is used to administer ointment and gel forms. However, lyophilized preparations can also be administered by diluting them in a small amount of saline or water for injection. After that, the preparation can be administered in any conductive gel. All of the enzymes listed can also be administered using phonophoresis.

Contractubex (Germany).

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

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

Contractubex gel is intended for external use. It is recommended to lubricate scars by lightly rubbing them in 2-3 times a day for at least 2-3 months. To enhance the effectiveness, the drug is administered using phonophoresis. The course consists of 10-15 procedures. The number of courses is 3-4 with an interval of at least 2-3 weeks between them. Ultrasound has a softening effect on tissues and allows for deeper administration of the drug, thus increasing the effectiveness of external treatment.

Note: If a delayed allergic reaction occurs, the use of any drug should be discontinued!

For a long time, one of the well-known ointment forms recommended for the treatment of scars was Madekasol. In the annotation to the drug, you can read that it acts on all scars, including keloid and hypertrophic, that is, it has fibrinolytic activity. Accordingly, it could be prescribed to patients with normotrophic scars. However, in the course of their practical work, doctors very often encountered the lack of effectiveness of this drug in relation to coarse normotrophic and pathological scars. A detailed study of its composition and mechanism of action clarified the situation. The main active ingredient of the drug is an extract of the Centella asiatica plant, which grows in Madagascar. The extract of this plant has a stimulating effect on the synthetic and proliferative activity of fibroblasts, and therefore a drug based on it cannot be fibrolytic.

Therefore, it is not indicated for keloid, hypertrophic, or normotrophic scars. However, it can give a good effect in the treatment of hypotrophic and atrophic scars.

Lasonil (Germany).

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

Hydrocortisone ointment (Russia).

1% hydrocortisone ointment can be prescribed for normotrophic scars as a preventive measure against their pathological growth, with the aim of slightly flattening and accelerating the normalization of color for 1-2 weeks. As with all ointment forms, the drug is more effectively administered using 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 scars, but can even stimulate their hypertrophic growth.

Microcurrent therapy stimulates the proliferative activity of fibroblasts, promotes stimulation of local immunity by improving trophism, therefore, like laser therapy, it is indicated only for the treatment of surgical sutures and wound surfaces. Thus, laser therapy and microcurrent therapy can be used for the prevention of scars, but not for their treatment.

But laserphoresis, as well as the introduction of various drugs, including lidase and collagenase using microcurrents, is a completely indicated, but not mandatory procedure, since it is economically much more expensive than electro- and phonophoresis.

Mesotherapy.

An alternative to electro- and phonophoresis is mesotherapy. This method has received a ticket to life and is currently an officially recognized direction of dermatocosmetology. Thus, lidase and collagenase can be introduced by microinjection into the thickness of the scar, which is sometimes a much more effective treatment than the above.

Despite the previous allergy tests, the doctor may encounter a massive but rapidly passing swelling of the scar tissue immediately after the procedure. This is not an allergic reaction, but a reaction of sharply increased tissue permeability due to the enzyme. Patients with such a reaction are recommended a salt-free diet and a restriction of protein foods 2 days before the procedure. In addition, it is necessary to prescribe a course of Ascorutin, 1 tablet 3 times a day for at least a month.

In our opinion, microwave therapy does not seem advisable, since blood supply to the scar can be improved by other, more gentle methods.

Vacuum massage.

It can be used in the therapy of normotrophic scars, as well as devices built on this principle, such as Skintonik, LPD, etc. Any cosmetology stand also has a vacuum device that can be used for vacuum massage. This technology improves blood circulation, elasticity of the scar, and somewhat evens it out in relation to the surrounding skin. However, there is no point in talking about any radicalism of this method.

8-15 sessions are prescribed no more than 3 times a week.

Peelings.

Peels are chemical compounds that remove the upper layers of skin (epidermis) and thereby smooth out the scar relief. The word peeling comes from the English word to peel - to remove the skin. To improve the appearance of normotrophic scars, it is better to use trichloroacetic, enzyme, salicylic, resorcinol peels. These peels have a dehydrating effect, due to which the epidermis, upper layers of scar tissue are exfoliated and the relief of the scars is smoothed out. This procedure allows you to smooth out the surface of normotrophic scars, align them with the surrounding skin.

Different types of therapeutic dermabrasion:

• sandblasting dermabrasion,
• ultrasonic dermabrasion,
• dermabrasion with Kotz currents,
• with a stream of water and gas.

Dermabrasion, unlike peeling, is a mechanical technology used to smooth out the skin or scar relief. It can be used in patients with various types of allergic diseases.

The first devices for therapeutic dermabrasion that appeared on foreign and domestic markets were devices for sandblasting dermabrasion, in particular from the Italian laboratory MATTIOLI ENGINEERING. The Ultrapeel MATTIOLI ENGINEERING devices were patented by the international US patent No. 5,810,842 in 1996, received FDA approval, and are marked with the CE mark.

Controlled microdermabrasion is a non-surgical and non-aggressive technique that offers controlled, safe skin resurfacing. with virtually no risk of complications. It is an excellent alternative to laser resurfacing and chemical peels, as it has virtually no contraindications and side effects. It is a fast, virtually painless method that does not require local anesthesia. The Ultrapeel system uses highly purified inert microcrystals of aluminum oxide (corundum), the size of which corresponds to the size of the cells of the upper layers of the skin.

The operation of Ultrapeel devices is schematically as follows:

A stream of microcrystals through a closed system of tubes with a hand-held sterilizable tip is fed to the skin surface using a vacuum, “knocking out” the epidermal cells, primarily the cells of the stratum corneum. The spent powder together with the epidermal cells is collected in a special flask protected by a filter. The depth of the impact can be controlled by the degree of negative pressure (vacuum) and the exposure of the tip nozzle on the skin surface or scar.

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

The Pepita device - modification of Ultrapeel is designed for a wide range of procedures in beauty salons, the vacuum power in it is up to 3.5 Bar. The depth of grinding is usually limited by the 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 dermatocosmetology clinics, plastic aesthetic surgery departments of clinics around the world. The device uses a vacuum of up to 5.5 Bar. Thanks to the presence of a pressure regulator and a pedal, you can get an abrasive effect adequate to surgical laser dermabrasion. In this case, "blood dew" appears - an indicator of grinding to the basal membrane.

Corundum powder is packed in 1.5 kg jars, in 340 g sterile packages. The devices are simple and easy to use, equipped with a filter system. Ultrapeel technology uses glass, glass ceramic and plastic tips, which are easily removed and sterilized.

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

• Scars (normotrophic, hypertrophic, atrophic).
• Hyperkeratosis.
• Hyperpigmentation.
• Stretch marks.
• Acne (post-acne condition).
• Age-related changes.
• Photoaging.

For specialists dealing with scars, it is important to be able to gradually improve the appearance of a scar by smoothing its relief with the surrounding skin without the need for the patient to be on sick leave or in hospital.

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

Microdermabrasion and dermoelectroporation.

The latest generation of Transderm microcrystalline dermabrasion devices are equipped with an additional “electroporation attachment” that allows various preparations to be introduced into the skin or scar after dermabrasion, using electrical impulses to increase the permeability of cell membranes. Vibration makes the cell membrane more permeable to many hydrophilic molecules that previously could not enter the cell. Easily permeable areas for molecules to pass through are formed in the cell membranes – pores. Once formed, these pores remain for a long time. Microdermabrasion reduces the thickness of the layer, making it possible to absorb active substances applied to the skin. The microdermabrasion procedure, immediately followed by dermaelectroporation using active cosmetics, opens up new possibilities in the transdermal delivery of active substances and allows for better results.

The method used in the Transderm device is qualitatively different from all currently existing ones, such as, for example, microcurrents or iontophoresis. The action of Transderm is based on the use of pulsating currents with a range from 0.5 to 5 mA with a frequency of 2200 Hz, which, unlike microcurrents, are capable of delivering the injected drugs directly into the cell. The difference from iontophoresis is that the injected molecules are not divided into positive and negative ions, but are delivered into the cell entirely, including even very large molecules.

Jet Peel manufactured by TavTech (Israel)

It is another version of devices for therapeutic dermabrasion, which has recently entered the domestic market.

The device is interesting because dermabrasion is carried out using two natural components - water and air. Thanks to the gas-liquid jet treatment, the skin surface is not only cleaned, but also moisturized and massaged. The device supplies compressed gas into the tube. The gas pressure is no more than 6-8 atm., it enters the tube into the nozzle with a built-in supersonic nozzle, which accelerates the gas to a speed of 1.8 Mach.

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

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

The device is also interesting because it has a gas cooling system, which provides pain relief for the treated area. In addition, the cooled gas acts on the superficial vascular network, causing vasoconstriction with subsequent vasodilation of arterioles and capillaries, which further improves scar trophism.

Effects of exposure to gas-liquid jet on skin:

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

Indications:

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

To improve the appearance of normotrophic scars using sandblasting and gas-liquid dermabrasion, it is necessary to carry out at least 10 procedures 1-2 times a week depending on the depth of exposure. In case of abundant peeling and crusts, the interval between sessions is extended to 10 days. After the sessions, it is recommended to treat the skin and scars with panthenol with an 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.

The options for devices for therapeutic dermabrasion include brush peeling or brush peeling, which is a separate device in any cosmetology stand. Using rotating brushes, with a certain amount of effort, you can also gradually improve the relief of the scar. The number of sessions with this technology will be at least 25-30, two or three times a week, since brush peeling provides an insignificant depth of impact.

All the listed options of therapeutic dermabrasion allow for dosed and targeted smoothing of those areas of scars that need it. Therefore, these technologies are more preferable than peelings. The number of procedures depends on the features of the scar relief and the depth of impact.

The more superficial the procedure is performed, the greater the number of sessions will be.

Surgical dermabrasion.

It can be carried out:

• with a Schumann cutter,
• carbon dioxide laser.
• erbium laser.
• with a thermal cauterizer.

Surgical dermabrasion is often preferable to peels and therapeutic dermabrasion options due to the shorter treatment time. Surgical dermabrasion with an erbium laser is the most preferable for working with normotrophic scars. This is due to the fact that normotrophic scars most often do not have a large difference in relief with the level of the surrounding skin. The irregularities that are inevitably present in any scar need to be smoothed out with a small number of "passes" of the laser beam, which removes a layer of tissue approximately 0.1 microns in one pass. Thanks to such a thin layer-by-layer removal of the scar volume, it is possible to achieve smoothing of the relief of any thinnest normotrophic scar, which is even close in thickness to an atrophic one.

Complete epithelialization after surgical dermabrasion of normotrophic scar occurs from 8 to 10 days. After the wound coverings fall off and the scar surface is completely epithelialized, the pink color of the polished surface disappears in 4-10 weeks. Lotions with 2% boric acid, treatment with hydrocortisone ointment, and Auriderm XO gel somewhat accelerate the normalization of the scar color.

After therapeutic and surgical dermabrasion, patients are advised to use sun protection products with an SPF of at least 30 for 1.5-2 months, especially for patients with Fitzpatrick skin phototypes III and IV.

Scars after therapeutic and dermatosurgical treatment acquire a significant smoothness of the surface, which can be camouflaged by makeup products, of which products from dermatological laboratories are preferable. Thus, the French companies La Rosh Pose, Aven produce medical makeup products, which include sticks of various colors, pencils and powders on a dermatological basis.

I would like to dwell on another very important point - the time frame for dermatosurgical work with scars. There are very important differences of opinion with surgeons on this point. Surgeons do not undertake surgical removal of scars if they have existed for up to 6 months. The explanation is that the scar must mature, otherwise the sutures may fail and, accordingly, the results of surgical reconstruction may deteriorate. It is difficult to argue with this, since, indeed, up to 6 months, a scar still contains a lot of intercellular substance and vessels, which ensures tissue looseness. However, for dermatosurgical treatment, it is precisely the time frame of up to 6 months that is optimal for the same reason. And the earlier therapeutic treatment is started, including surgical dermabrasion, the better the results.

Therapeutic treatment of old (after 6-8 months) normotrophic scars does not give practically any visible changes in the clinical picture. Such patients are shown various types of peeling and all types of therapeutic and surgical dermabrasion. They allow smoothing out the irregularities present in any, even the most inconspicuous scar, which is one of the most desirable facts for patients.

The optimal treatments for normotrophic scars are:

• enzyme therapy using mesotherapy or phonophoresis;
• means and methods that improve microcirculation;
• subsequent therapeutic or surgical dermabrasion;
• ointment forms for home care (contractubex, kelofibrase, lyoton-100, lazonil).