The treatment of hypertrophic scars and keloids

Keloid and hypertrophic scarring develop as a result of a proliferation of dermal tissue following skin injury. It is generally thought that tension plays a major pathophysiologic role. These proliferative scars are characterized by increased collagen and glycosaminoglycan content, as well as increase collagen turnover. The therapeutic management of hypertrophic scars and keloids includes occlusive dressings, compression therapy, intralesional corticosteroid injections, cryosurgery, excision, radiation therapy, laser therapy, interferon therapy and other promising, lesser known therapies directed at collagen synthesis. Although the most commonly used occlusive dressings include silicone based materials, the anti-keloidal effect is the result of the occlusion and hydration effected rather than the silicone itself. Pressure devices, through local tissue hypoxia, have proven effective in reducing scar height. Intralesional steroids decrease the connective tissue components and scar volume. Post-operative steroid injections reduce keloid recurrence to less than 50%. Cryosurgery is most effective when combined with intralesional corticosteroids. Excision only of hypertrophic scars and keloids results in 45-100% recurrence. Radiation therapy, using various protocols, has been a safe and efficacious modality in reducing recurrence. The CO2, Nd:YAG, and Argon lasers have been used as destructive modalities for the treatment of proliferative scarring. The pulsed-dye laser offers symptomatic improvement and reduces the erythema associated with these scars. Intralesional interferon -gamma and -alpha 2b have been used successfully to decrease scar height and reduce the number of post-operative recurrences.