Continuing medical educationCutaneous scarring: Pathophysiology, molecular mechanisms, and scar reduction therapeutics: Part II. Strategies to reduce scar formation after dermatologic procedures
Section snippets
Antiscarring strategies
A cutaneous scar results from overgrowth of fibrous tissue after damage to the skin after injury or surgery and represents an exuberant healing response.1 The type of scar depends on how exuberant the healing response is, with hypertrophic scars not extending beyond the wound borders and keloids extending. The former are clinically more favorable than the latter because they are more amenable to treatment and often even regress spontaneously.2 Both types of cutaneous scarring are underpinned by
Practical prophylactic considerations
Key points Identifying high risk is paramount to preventing hypertrophic scarring after dermatologic procedures Certain high-pressure body sites are more likely to show exaggerated scarring, and patients of Afro-Caribbean descent and those with personal or family history of scarring are at increased risk of engaging in such a response Minimizing skin tension and the inflammatory response after surgery by using the appropriate materials and ascertaining clean surgery and good wound care are simple practical
Nonsurgical scar reduction strategies
Key points There are numerous antiscarring agents available over the counter, including silicone dressings, onion extract, and vitamin E–based remedies, none of which are supported by a sufficient evidence base There is some evidence base underpinning the use of intralesional corticosteroids, 5-fluorouracil, and bleomycin
There is a multitude of commonly used over the counter scar treatment products that have little evidence-based efficacy.20, 21 Among these, silicone dressings, onion extract, and vitamin
Surgery, lasers, and radiation
Key points The surgical revision of hypertrophic scars is rarely performed because of high recurrence rates, but cryotherapy has been widely used with success Lasers are widely used in practice, and pulsed-dye laser therapy has shown efficacy, has a low-risk adverse effect profile, and is becoming increasingly popular as a pre- and postsurgery scar reduction modality Radiotherapy tends to be reserved as a late resort for resistant scars and is used sparely because of concerns over carcinogenic potential
Innovative medical approaches
Key points Avotermin, human recombinant interleukin-10, and to a lesser extent mamnose-6-phosphate are novel agents showing promising results in randomized controlled trials and are likely to change practice when they become commercially available Insulin, mitomycin C, topical tamoxifen, systemic methotrexate, topical imiquimod, retinoic acid, botulinum toxin A, calcineurin inhibitors, and calcium channel blockers have been tested only sporadically and in small-scale studies (some randomized) More extensive
Conclusion
It should be noted that lack of adequate evidence does not necessarily imply evidence of inadequacy. The present review is not an exhaustive account of evidence-based scar reduction strategies. The selectively discussed conventional modalities are widely available and commonly used, and there is some evidence in support of their use. Each patient is nonetheless different, and the practicing dermatologist must formulate a treatment strategy having considered guidelines on a par with personal
References (110)
Keloid and hypertrophic scarring may result from a mechanoreceptor or mechanosensitive nociceptor disorder
Med Hypotheses
(2008)- et al.
Over-the-counter scar products for postsurgical patients: disparities between online advertised benefits and evidence regarding efficacy
J Am Acad Dermatol
(2009) Topical scar modification: help or hype?
Aesthet Surg J
(2005)The use of pressure garments on hypertrophic scars
J Tissue Viability
(2002)- et al.
The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis
J Plast Reconstr Aesthet Surg
(2009) - et al.
A prospective study in children: pre- and post-surgery use of vitamin E in surgical incisions
J Plast Reconstr Aesthet Surg
(2010) - et al.
Differential regulation of fibulin, tenascin-C, and nidogen expression during wound healing of normal and glucocorticoid-treated mice
Exp Cell Res
(1996) - et al.
Novel genomic effects of glucocorticoids in epidermal keratinocytes: inhibition of apoptosis, interferon-gamma pathway, and wound healing along with promotion of terminal differentiation
J Biol Chem
(2007) - et al.
Dexamethasone induction of keloid regression through effective suppression of VEGF expression and keloid fibroblast proliferation
J Invest Dermatol
(2006) Intra and postoperative steroid injections for keloids and hypertrophic scars
Br J Plast Surg
(1992)
Evaluation of various methods of treating keloids and hypertrophic scars: a 10-year follow-up study
Br J Plast Surg
Keloidal scars: a review with a critical look at therapeutic options
J Am Acad Dermatol
Intralesional 5-fluorouracil in the treatment of keloids: an open clinical and histopathologic study
J Am Acad Dermatol
Inhibition of fibroblast collagen synthesis and proliferation by levamisole and 5-fluorouracil
Eur J Cancer
Regulation of lysyl oxidase mRNA in dermal fibroblasts from normal donors and patients with inherited connective tissue disorders
Arch Biochem Biophys
Surgical revision
Dermatol Clin
Treatment of keloid sternotomy scars with 585 nm flashlamp-pumped pulsed-dye laser
Lancet
Effects of x-irradiation on survival and extracellular matrix gene expression of cultured keloid fibroblasts
J Dermatol Sci
Role of ionizing irradiation for 393 keloids
Int J Radiat Oncol Biol Phys
Keloids treated with excision followed by radiation therapy
J Am Acad Dermatol
Postoperative strontium-90 brachytherapy in the prevention of keloids: results and prognostic factors
Int J Radiat Oncol Biol Phys
Prophylactic administration of avotermin for improvement of skin scarring: three double-blind, placebo-controlled, phase I/II studies
Lancet
Management of keloids and hypertrophic scars
Am Fam Physician
Treatment of keloids and hypertrophic scars
Arch Facial Plast Surg
Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis
FASEB J
Keloids and hypertrophic scars
A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management
Dermatol Surg
A randomized, controlled trial to determine the efficacy of paper tape in preventing hypertrophic scar formation in surgical incisions that traverse Langer’s skin tension lines
Plast Reconstr Surg
Prevention of hypertrophic scars by long-term paper tape application
Plast Reconstr Surg
Toll-like receptors expressed by dermal fibroblasts contribute to hypertrophic scarring
J Cell Physiol
Tissue adhesives for closure of surgical incisions
Cochrane Database Syst Rev
A review of sutures and suturing techniques
J Dermatol Surg Oncol
Intradermal buried vertical mattress suture as sole skin closure: evaluation of 149 cases
Acta Derm Venereol
The mattress sutures: vertical, horizontal, and corner stitch
Am Fam Physician
Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations
Pediatr Emerg Care
A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures
Acad Emerg Med
Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds
Arch Facial Plast Surg
Do absorbable sutures exacerbate presternal scarring?
Tex Heart Inst J
Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: a meta-analysis
Pediatr Emerg Care
The role of suture material in hypertrophic scar formation: monocryl vs. vicryl-rapide
Ann Plast Surg
Review of over-the-counter topical scar treatment products
Plast Reconstr Surg
Silicon gel sheeting for preventing and treating hypertrophic and keloid scars
Cochrane Database Syst Rev
International clinical recommendations on scar management
Plast Reconstr Surg
Medical and surgical therapies for keloids
Dermatol Ther
Release and activation of matrix metalloproteinase-9 during in vitro mechanical compression in hypertrophic scars
Arch Dermatol
Antiinflammatory effects of onions: inhibition of chemotaxis of human polymorphonuclear leukocytes by thiosulfinates and cepaenes
Int Arch Allergy Appl Immunol
Effect of quercetin and Albizzia saponins on rat mast cell
Indian J Physiol Pharmacol
Effect of quercetin on the growth of mouse fibroblast cells in vitro
Pol J Pharmacol
Antimicrobial properties of garlic oil against human enteric bacteria: evaluation of methodologies and comparisons with garlic oil sulfides and garlic powder
Appl Environ Microbiol
Therapeutic values of onion (Allium cepa L.) and garlic (Allium sativum L.)
Indian J Exp Biol
Cited by (132)
Optimizing wound healing and cosmesis of surgical closures on rhinophymatous skin
2024, JAAD Case ReportsDisturbing cytoskeleton by engineered nanomaterials for enhanced cancer therapeutics
2023, Bioactive MaterialsA Stitch in Time: Operative and Nonoperative Laceration Repair Techniques
2022, Primary Care - Clinics in Office PracticeCitation Excerpt :Anecdotal reports suggest using vitamin E lotion for 6 months may reduce ultraviolet-induced scarring and hyperpigmentation. Onion extract preparations (eg, brand-name Mederma cream) may accelerate wound healing by exerting effects on mast cells and fibroblasts in the inflammatory cascade to decrease inflammation.32 The bioflavonoid component from the onion extract further has antiproliferative effects through antihistamine properties; this normalizes or decreases collagen production by fibroblasts leading to reduced dermal scar volume and relative normalization of the scar maturation process leading to less inflammation, erythema, and scar hypertrophy.34
TEM1/endosialin/CD248 promotes pathologic scarring and TGF-β activity through its receptor stability in dermal fibroblasts
2024, Journal of Biomedical ScienceEffects of botulinum toxin type A in the prevention and treatment of facial hypertrophic scars: A meta-analysis
2024, International Wound Journal