Hypertrophic Scar And Keloid

hypertrophic scar and keloid

Hypertrophic scar and keloid

  • Keloids are the result of an overgrowth of dense fibrous tissue that usually develops after healing of a skin injury. The tissue extends beyond the borders of the original wound, does not usually regress spontaneously, and tends to recur after excision. The first description of keloids (recorded on papyrus) concerned surgical techniques used in Egypt in 1700 BCE. Subsequently, in 1806, Alibert used the term cheloide, derived from the Greek chele, or crab’s claw, to describe the lateral growth of tissue into unaffected skin.
  •  Hypertrophic scars are characterized by erythematous, pruritic, raised fibrous lesions that typically do not expand beyond the boundaries of the initial injury and may undergo partial spontaneous resolution. Hypertrophic scars are common after thermal injuries and other injuries that involve the deep dermis.

Exam Question

Local recurrence is common after excision 

It appears a few days after surgery

Made up of Dense collagen 

  • riamcinolone acetonide is the drug used for intralesional injection of steroid.
  • Intralesional injection of steroid (Triamcinolone acetate) is now recommended as the first line of t/t for keloids

[Ref Schwartz 9/e p226 (8/e p241)]

  • Intralesional injection of Triamcinolone is also the t/t of choice for intractable hypertrophic scars. Success is enhanced when it is combined with surgical excision [Ref CSDTI 3/e p1105 (11/e, p1243)]
  • Other modalities of tit used for keloids are:

a. Surgery

  • surgical excision alone leads to a high recurrance rate.
  • there are fewer recurrances when surgical excision is combined with other modalities such as intralesional corticosteroid injection, topical application of silicone sheets or the use of radiation or pressure.
  • surgery is recommended for debulking large lesions.

b. Radiation therapy

  • it may produce unpredictable results and has obvious potential side effects including neoplastic degeneration; and has high recurrance rate when used alone.
  1. Silicone sheet application
  2. Pressure application
  3. Topical retinoids

Precancerous leading to cancer

  • There is no evidence of malignancy in keloids.
  • Keloids have equal incidence in both males & females
  • Keloids → It is a scar which shows extreme overgrowth so that scar tissues grows beyond the limits of original wounds and shows no tendency to resolve.
  • Keloids grow on particular sites, these are ?

Central chests (probably most common, not sure)

  1. Back
  2. Shoulder
  3. Earlobes

Other points about Keloids & hvpertrophic scars

  • Hypertrophic scars (FITS) and keloids represent an overabundance of fibroplasia in the dermal healing process. They are both characterized by excessive collagen deposition versus collagen degradation.
  • HTS rise above the skin level but stay within the confines of the original wound and often regress over time.
  • Keloids are defined as scars that grow beyond the border of the original wound and rarely regress spontaneously.
  • Both HTS and keloids occur after trauma to the skin, and may be tender, pruritic, and cause a burning sensation.
  • Keloids are more prevalent among dark pigmented ethnicitics (i.e. Africans, Asians & Hispanics)
  • HTS usually develop within 4 weeks after trauma Keloids tend to occur 3 months to years after the trauma.
  • The long acting steroid Triamcinalone is used for treating keloid.
  • Other treatment modalities include laser, silicone sheets, cryotherapy, interferon, fluorouracil, radiation.
  • Keloids can result from surgery, burns, skin inflammation, acne, chickenpox, zoster, folliculitis, lacerations, abrasions, tattoos, vaccinations, injections, insect bites, ear piercing, or may arise spontaneously.
  • Keloids tend to occur 3 months to years after the initial insult, and even minor injuries can result in large lesions.
  • They vary in size from a few millimeters to large, pedunculated lesions with a soft to rubbery or hard consistency.
  • Although they project above surrounding skin, they rarely extend into underlying subcutaneous tissues.
  • Certain body sites have a higher incidence of keloid formation, including the skin of the earlobe as well as the deltoid, presternal, and upper back regions.
  • They rarely occur on eyelids, genitalia, palms, soles, or across joints.
  • Keloids rarely involute spontaneously, whereas surgical intervention can lead to recurrence, often with a worse result.

Also know

  • Treatment of hypertropic scars/Ref: CSDT13/e pI105 (11/e p1243)]
  • Since nearly all hypertrophic scars undergo some degree of spontaneous regression, they are not t/t in early phases. If the scar is still hypertrophic after 6 months surgical excision and primary closure of the wound is indicated.

Other modalities used for t/t of HTS.

  • Pressure application – particularly useful for burn scars.
  • Silicone sheet application
  • Intralesional injection of triamcinolone is the t/t of choice for intractable HTS
  • riamcinolone acetonide is the drug used for intralesional injection of steroid.
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