Management of keloids and hypertrophic scars: current and emerging options

Abstract

In the context of growing aesthetic awareness, a rising number of patients feel disappointed with their scars and are frequently seeking help for functional and aesthetic improvement. However, excessive scarring following surgery or trauma remains difficult to improve despite a plethora of advocated treatment strategies as frequently observed in daily clinical routine. It is thus still preferable to prevent scarring by minimizing risk factors as much as possible. Hence, it remains crucial for the physician to be aware of basic knowledge of healing mechanisms and skin anatomy, as well as an appreciation of suture material and wound closure techniques to minimize the risk of postoperative scarring. Next to existing, well known prophylactic and therapeutic strategies for the improvement of excessive scarring, this article discusses emerging techniques such as intralesional cryotherapy, intralesional 5-fluorouracil, interferon, and bleomycin. Some of them have been successfully tested in well-designed trials and already have extended or may extend the current spectrum of excessive scar treatment in the near future. Innovative options such as imiquimod 5% cream, photodynamic therapy, or botulinum toxin A may also be of certain importance; however, the data currently available is too contradictory for definite recommendations.

Keywords: TGF-β; intralesional cryotherapy; lasers; triamcinolone acetonide.

Figure 1

Baseline photograph at presentation in our scar clinic before initiation of combination therapy with cryotherapy directly followed by intralesional TAC (10 mg/mL) (A and B). Result after three cycles of combined cryo/intralesional TAC therapy before initiation of PDL (C). Result after four PDL applications (D). No signs of recurrence or reactivation at follow-up 6 months after the last laser treatment (E and F). Abbreviations: PDL, pulsed dye laser; TAC, triamcinolone acetonide.

Figure 2

Patient with keloid in the presternal area resistant to cryotherapy and TAC, silicone gel sheeting, surgery and postoperative radiotherapy (recurrence) suffering from severe pruritus at baseline (A). Significant reduction of pruritus and flattening after 1 week of injection with 5-FU (50 mg/mL) and TAC (40 mg/mL), 3:1 (B). Result at 6 months after the last injection (two injections total), with no signs of recurrence, no pruritus (C). Abbreviations: 5-FU, 5-fluorouracil; TAC, triamcinolone acetonide.

Figure 3

With intralesional cryotherapy, a specially designed cryoneedle is inserted (under translesional local anesthesia) into the long axis and mid height of the respective keloid. Notes: The cryoneedle is then connected by an adaptor to a cryogun filled with liquid nitrogen, which is introduced into the cryoprobe, thereby freezing the keloid. After complete freezing of the lesion, the cryoprobe defrosts and is withdrawn.

Figure 4

Result at baseline (A and C) and after 3 and 6 years, respectively (B and D) post-intralesional cryotherapy.Adapted with permission from Har-Shai Y. Intralesional cryosurgery for enhancing the involution of hypertrophic scars and keloids. A new effective technology based on experimental and clinical data. Journal of wound Technology. 2012;15:8–9.