Name Withheld A. These vaccines are covered only under Medicare Part D prescription plans. You have three choices here: 1? Become a Medicare provider for Part D vaccines to receive payment differently; 2 Write a prescription for the patient to receive these vaccines at a pharmacy; or 3 Provide the vaccines at a direct cost to the patient. If you choose the last option, then you should provide the patient with a printed CMS to submit to the Part D plan for any benefits payable for out-of-network services.
Note: If you mix the corticosteroid with an anesthetic, such as lidocaine, there is no additional HCPS code for the lidocaine medication. You should use code intralesional injection up to seven lesions. Note: You can only report one unit per seven lesions even if multiple injections are required for some lesions.
Disclaimer: JUCM and the author provide this information for educational purposes only. Health Details: Applies to triamcinolone: injection powder for suspension extended release, injection suspension. Side effects requiring immediate medical attention. Along with its needed effects, triamcinolone the active ingredient contained in Kenalog may cause some unwanted effects. Although not all of these side effects may occur, if they do occur cpt injection scar tissue.
Health Details: Kenalog has been used quite successfully, off-label, by dermatologists and plastic surgeons for scar tissue for over 50 years. It works, but since it is quite powerful, it must be injected by an expert. The dose, quantity, method of injection, doctor's skills, etc all will affect the final result. Health Details: Kenalog Scar Treatment active ingredient: triamcinolone is an injection that reduces inflammation of your raised scars. The medication causes the scar to flatten and allows dark scars to lighten in some cases.
Kenalog is a common non-surgical option for the treatment of these types of scars. Health Details: Kenalog Injections For Keloid Keloid is a type of scar typically characterized by tissue overgrowth often in the form of a smooth raised area that is pink or purple in colour. During the wound-healing process fibroblasts a type of cell in our connective tissue synthesizes the protein collagen, to stimulate the wound healing process. Health Details: Kenalog is given through a needle and can be injected into different areas of the body: into a muscle, into the space around a joint or tendon, or into a lesion on the skin.
A healthcare provider will give you this injection. Not every brand of Kenalog is used for the same conditions or injected into the same body areas. Health Details: Background: One of the first-line options to treat keloid scars is corticosteroid injection after excision of the existing scar.
If you choose the last option, then you should provide the patient with a printed CMS to submit to the Part D plan for any benefits payable for out-of-network services. Note: If you mix the corticosteroid with an anesthetic, such as lidocaine, there is no additional HCPS code for the lidocaine medication.
You should use code intralesional injection up to seven lesions. Note: You can only report one unit per seven lesions even if multiple injections are required for some lesions. Disclaimer: JUCM and the author provide this information for educational purposes only. Remember Me. Lost your password? Username or E-mail:.
What is the appropriate administration code for a Medicare patient who receives influenza, Pneumovax, and tetanus vaccinations? Health Details: Applies to triamcinolone: injection powder for suspension extended release, injection suspension. Side effects requiring immediate medical attention. Along with its needed effects, triamcinolone the active ingredient contained in Kenalog may cause some unwanted effects.
Although not all of these side effects may occur, if they do occur cpt injection scar tissue. Health Details: Kenalog has been used quite successfully, off-label, by dermatologists and plastic surgeons for scar tissue for over 50 years.
It works, but since it is quite powerful, it must be injected by an expert. The dose, quantity, method of injection, doctor's skills, etc all will affect the final result. Health Details: Kenalog Scar Treatment active ingredient: triamcinolone is an injection that reduces inflammation of your raised scars.
The medication causes the scar to flatten and allows dark scars to lighten in some cases. Kenalog is a common non-surgical option for the treatment of these types of scars. Health Details: Kenalog Injections For Keloid Keloid is a type of scar typically characterized by tissue overgrowth often in the form of a smooth raised area that is pink or purple in colour. During the wound-healing process fibroblasts a type of cell in our connective tissue synthesizes the protein collagen, to stimulate the wound healing process.
Health Details: Kenalog is given through a needle and can be injected into different areas of the body: into a muscle, into the space around a joint or tendon, or into a lesion on the skin. A healthcare provider will give you this injection. Not every brand of Kenalog is used for the same conditions or injected into the same body areas.
Health Details: Background: One of the first-line options to treat keloid scars is corticosteroid injection after excision of the existing scar.
As a class I device, the device will be exempt from premarket notification requirements. In a prospective, randomized, placebo-controlled, clinical trial that examined the use of silicone gel in preventing hypertrophic scar development in median sternotomy wound, Chan et al concluded that the effect of silicone gel in the prevention of hypertrophic scar development in sternotomy wounds is promising.
In a recent review on keloid pathogenesis and treatment, Al-Attar and colleagues noted that established treatment strategies for keloids include surgery, steroid, and radiation silicone was not listed as an established treatment for keloids. There is weak evidence of a benefit of silicon gel sheeting as a prevention for abnormal scarring in high risk individuals but the poor quality of research means a great deal of uncertainty prevails.
Stavrou et al stated that hypertrophic and keloid scars still are among the banes of plastic surgery. In the treatment arsenal at the disposal of the plastic surgeon, topical silicone therapy usually is considered the first line of treatment or as an adjuvant to other treatment methods. Yet, knowledge concerning its mechanisms of action, clinical efficacy, and possible adverse effects is rather obscure and sometimes conflicting. The author summarized the existing literature regarding the silicone elastomer's mechanism of action on scars, the clinical trials regarding its efficacy, a description of some controversial points and contradicting evidence, and possible adverse effects of this treatment method.
Topical silicone therapy probably will continue to be the preferred first-line treatment for hypertrophic scars due to its availability, price, ease of application, lack of serious adverse effects, and relative efficacy. Hopefully, future RCTs will help to clarify its exact clinical efficacy and appropriate treatment protocols to optimize treatment results. In a single-center placebo-controlled double-blind trial, Stoffels et al examined the impact of silicone spray on scar formation.
These investigators reported that after 3 months of treatment the Patient Scar Assessment Scale demonstrated that patient satisfaction with the silicone application was significantly higher compared to placebo. However, when treatment was stopped after 3 months, the topical silicone spray did not exhibit any lasting long-term impact on the objective results of scar formation.
In a review on "Prevention and management of keloid scars", Lutgendorf et al noted that "[a]lthough silicone gel sheeting is a well-accepted treatment modality, the studies to date provide level IV evidence, with a lack of controls and increased susceptibility to bias. A recent Cochrane systematic review on the use of silicone gel sheeting for preventing and treating hypertrophic and keloid scars found that any effects were obscured by the poor quality of research".
Several clinical trials have demonstrated the effectiveness of intralesional 5-fluorouracil in the treatment of keloid scarring Asilian et al, ; Nanda and Reddy, ; and Manuskiatti and Fitzpatrick, Asilian and colleagues examined the effectiveness of a combination of intralesional steroid, 5-fluorouracil 5-FU , and pulsed-dye laser in the treatment of hypertrophic scars and keloids. A total fo 69 patients were randomly assigned to treatment with intralesional triamcinolone acetonide TA , intralesional TA plus intralesional 5-FU, and TA, 5-FU and pulse-dye laser treatment.
Tosa et al stated that because intralesional injection of TA, a widely used for the treatment of keloid, is painful, many patients discontinue treatment. The subjects were 42 patients with keloid who had been treated with intralesional injection of TA but had discontinued treatment owing to intolerable pain. Patients assessed pain with a mm visual analog scale VAS with 0 mm for "no pain" and mm for "worst possible pain".
Finally, the patients assessed the tolerability of this treatment. The mean VAS score during intralesional TA injection therapy without pre-treatment with lidocaine tape was In contrast, the mean VAS score during intralesional TA injection therapy in the same patients after pre-treatment with lidocaine tape was This approach increases patient comfort and should enable patients to continue the treatment.
Pai and Cummings examined if surgical excision with or without adjuvant treatment beneficial in reducing the size of the scar in patients with hypertrophic and keloid scarring of the sternotomy wound. More than 15 papers were found using the reported search, of which 9 represented the best evidence to address this clinical issue. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated.
One of the studies showed no difference between surgery and adjunctive TA or colchicine. One study showed that incomplete excision resulted in higher recurrence rates. Post-operative radiation was found to be useful in 2 of the studies, although 1 study showed that it was not useful. One RCT showed improvement after laser compared to no treatment; 2 other trials showed no difference between laser, silicone gel, intralesional steroid or 5-FU.
One trial showed that peri-operative systemic steroid application gave rise to no improvement but in fact worsened scar formation. Large and multiple keloids are difficult to treat radically and are currently only treatable by multi-modal therapies that aim to relieve symptoms. An UpToDate review on "Keloids" Goldstein and Goldstein, states that "[i]ntralesional corticosteroids are first-line therapy for most keloids. A systematic review found that up to 70 percent of patients respond to intralesional corticosteroid injection with flattening of keloids, although the recurrence rate is high in some studies up to 50 percent at five years ".
Meshkinpour et al examined the safety and effectiveness of the ThermaCool TC radiofrequency system for treatment of hypertrophic and keloid scars and assessed treatment associated collagen changes. Scars were graded before and then 12 and 24 weeks after treatment on symptoms, pigmentation, vascularity, pliability, and height. No adverse treatment effects occurred.
Differences in collagen morphology were detected in some subjects. The authors concluded that use of the thermage radiofrequency device on hypertrophic scars resulted in collagen fibril morphology and production changes. ThermaCool alone did not achieve clinical hypertrophic scar or keloid improvement. They noted that the collagen effects of this device should be studied further to optimize its therapeutic potential for all indications.
Davison et al ascertained the effectiveness of interferon alpha-2b in keloid management. These investigators prospectively assessed the effects of interferon alpha-2b as post-excisional adjuvant therapy for keloids. A total of 39 keloids in 34 patients were photographed, measured, and surgically excised. The patients were followed- up in the plastic surgery clinic.
The trial protocol was terminated at mid-trial surveillance. Recurrence in either group did not correlate with location of the keloid or race. The authors concluded that interferon does not appear to be effective in the clinical management of keloids. This finding is consistent with an earlier controlled trial which also found a lack of effectiveness of intralesional interferon alpha in the treatment of keloids al-Khawajah, Al-Attar et al reviewed the major concepts of keloid pathogenesis and the treatment options stemming from them.
They noted that mechanisms for keloid formation include alterations in growth factors, collagen turnover, tension alignment, and genetic and immunologic contributions. Treatment strategies for keloids include established e. The authors concluded that combination therapy, using surgical excision followed by intra-dermal steroid or other adjuvant therapy, currently appears to be the most effective and safe current regimen for keloid management.
The statistical analysis showed synergistic action of cryosurgery and corticosteroids may offer promise in the treatment. Karrer noted that keloids are a therapeutic challenge for dermatologists. Although multiple therapeutic options are available, a reliably effective approach with few side effects remains elusive. High quality research in evaluating the effectiveness of keloid therapy is also lacking.
This is in agreement with the findings of Durani and Bayat who reported that the level of evidence LOE of cryosurgery in the treatment of keloids is 4 LOE-1 denotes highest quality while LOE-5 denotes lowest quality. Berman et al evaluated the tolerability and efficacy of etanercept as compared to TA for the treatment of keloids.
A total of 20 subjects were randomly assigned to receive monthly intralesional injections of either 25 mg of etanercept or 20 mg of TA for 2 months. Keloids were evaluated at baseline, week 4, and week 8 by subjects and investigators in a blinded fashion using physical, clinical, and cosmetic parameters. Photographs were taken and adverse events were noted during each evaluation. There was no significant difference between the 2 treatment groups. The authors concluded that etanercept was safe, well-tolerated, improved several keloid parameters, and reduced pruritus to a greater degree than TA therapy.
However, they noted that further studies are needed before it can be recommended for the treatment of keloids. Berman stated that the potential of various biological agents to reduce or prevent excessive scar formation has now been evaluated in numerous in-vitro studies, experimental animal models and preliminary clinical trials, in some cases with particularly promising results. Perhaps prominent among this group of biological agents, and, to some degree, possibly representing marketed compounds already being used "off label" to manage excessive scarring, are the tumor necrosis factor alpha antagonist, etanercept, and immune-response modifiers such as interferon-alpha2b and imiquimod.
The author noted that additional assessment of these novel agents is now justified with a view to reducing or preventing hypertrophic scars, keloid scars and the recurrence of post-excision keloid lesions. In a meta-analysis, Anzarut et al evaluated the effectiveness of pressure garment therapy PGT for the prevention of abnormal scarring after burn injury.
Primary authors and pressure garment manufacturers were contacted to identify eligible trials. Bibliographies from included studies and reviews were searched. The review incorporated 6 unique trials involving patients. Original data from 1 unpublished trial were included. Overall, studies were considered to be of high methodological quality. The meta-analysis was unable to demonstrate a difference between global assessments of PGT-treated scars and control scars [weighted mean differences WMD : The meta-analysis for scar height showed a small, but statistically significant, decrease in height for the PGT-treated group standardized mean differences SMD : Results of meta-analyses of secondary outcome measures of scar vascularity, pliability and colour failed to demonstrate a difference between groups.
The authors concluded that PGT does not appear to alter global scar scores. It does appear to improve scar height, although this difference is small and of questionable clinical importance. The beneficial effects of PGT remain unproven, while the potential morbidity and cost are not insignificant.
Given current evidence, additional research is needed to examine the effectiveness, risks and costs of PGT. In a prospective, randomized, clinical trial, Xiao et al examined the effectiveness of intralesional botulinum toxin type A BTX-A injections in the treatment of hypertrophic scars. A total of 19 patients were enrolled in this study. At 1-month intervals, BTX-A 2. All the patients were followed-up for at least half a year. Therapeutic satisfaction was recorded, and the lesions were assessed for erythema, itching sensation, and pliability.
At the half-year follow-up visits, all the patients showed acceptable improvement, and the rate of therapeutic satisfaction was very high. The erythema score, itching sensation score, and pliability score after the BTX-A injection all were significantly lower than before the BTX-A injection. The authors concluded that for the treatment of hypertrophic scars, doctors and patients both found BTX-A acceptable because of its better therapeutic results.
Its effect of eliminating or decreasing hypertrophic scars was promising. The findings of this preliminary report need to be validated by further investigation. In a randomized, double-blind, placebo-controlled trial using the reduction mammoplasty wound-healing model, van der Veer et al assessed the effectiveness of topical application of calcipotriol a synthetic derivative of calcitriol or vitamin D to healing wounds in preventing or reducing hypertrophic scar formation and investigated the biochemical properties of the epidermis associated with hypertrophic scar formation.
A total of 30 women who underwent bilateral reduction mammoplasty were included in this study. For 3 months, scar segments were treated with either topical calcipotriol or placebo. Three weeks, 3 months, and 12 months post-operatively, the scars were evaluated and punch biopsy samples were collected for immuno-histochemical analysis. No significant difference in the prevalence of hypertrophic scars was observed between the placebo-treated and calcipotriol-treated scars.
The authors concluded that topical application of calcipotriol during the first 3 months of wound healing does not affect the incidence of hypertrophic scar formation. Hayashida and Akita stated that pediatric burn wounds present unique challenges.
Second-degree burns may increase in size and depth, raising concerns about healing and long-term scarring. Results of a clinical study in adults with second-degree burn wounds suggested that application of basic fibroblast growth factor may reduce time to second-intention healing and result in a more cosmetically acceptable scar.
Wounds, which still exudative not healed after 21 days, were covered with a split-thickness skin graft. All wounds were clinically assessed until healed and after 1 year. A moisture meter was used to assess scars of wounds healing by secondary intention.
A color meter was used to evaluate grafted wounds. Five wounds in each group required grafting. Wounds not requiring grafting were no longer exudative after The authors concluded that both the short- and long-term results of this treatment in pediatric burn patients are encouraging and warrant further research.
Verhaeghe et al noted that non-ablative fractional laser NAFL therapy is a non-invasive procedure that has been suggested as a treatment option for hypertrophic scars. These researchers evaluated the safety and effectiveness of 1,nm NAFL therapy in the treatment of hypertrophic scars. An intra-individual RCT with split lesion design and single-blinded outcome evaluations was performed. Patients received 4 NAFL treatments at monthly intervals.
Adverse event registration and pain evaluation were used to evaluate safety. Patient global assessment PGA was a secondary endpoint to additionally evaluate effectiveness. Patients experienced moderate pain during treatment and mild adverse events. The authors concluded that in this trial, blinded PhGA could not confirm the clinical effectiveness of 1,nm non-ablative fractional laser in the treatment of hypertrophic scars, but the treatment is safe, and patients judged that the treated part had a better global appearance.
Waibel et al stated that hypertrophic scars and contractures are common following various types of trauma and procedures despite skilled surgical and wound care. Following ample time for healing and scar maturation, many millions of patients are burdened with persistent symptoms and functional impairments. Cutaneous scars can be complex and thus the approach to therapy is often multi-modal.
Intralesional corticosteroids have long been a staple in the treatment of hypertrophic and restrictive scars. Recent advances in laser technology and applications now provide additional options for improvements in function, symptoms, and cosmesis. Fractional ablative lasers create zones of ablation at variable depths of the skin with the subsequent induction of a wound healing and collagen remodeling response.
Recent reports suggested these ablative zones may also be used in the immediate post-operative period to enhance delivery of drugs and other substances. These researchers presented a case series evaluating the effectiveness of a novel combination therapy that incorporates the use of an ablative fractional laser with topically applied triamcinolone acetonide suspension in the immediate post-operative period. This was a prospective case series including 15 consecutive subjects with hypertrophic scars resulting from burns, surgery or traumatic injuries.
Three blinded observers evaluated photographs taken at baseline and 6 months after the final treatment session. Scores were assigned using a modified Manchester quartile score to evaluate enhancements in dyschromia, hypertrophy, texture, and overall improvement. Combination same session laser therapy and immediate post-operative corticosteroid delivery resulted in average overall improvement of 2.
Dyschromia showed the least amount of improvement while texture showed the most improvement. The authors concluded that combination same-session therapy with ablative fractional laser-assisted delivery of triamcinolone acetonide potentially offers an efficient, safe and effective combination therapy for challenging hypertrophic and restrictive cutaneous scars. The main drawbacks of this study were its small sample size and the lack of a control arm.
These preliminary findings need to be validated by well-designed studies. Jin and colleagues performed a meta-analysis to evaluate the effectiveness of various laser therapies for prevention and treatment of pathologic excessive scars. The pooled response rate, pooled standardized mean difference of Vancouver Scar Scale scores, scar height, erythema, and pliability were reported.
A total of 28 well-designed clinical trials with patients were included in the meta-analysis. The pooled estimates of hypertrophic scar studies also showed that laser therapy reduced total Vancouver Scar Scale scores, scar height, and scar erythema of hypertrophic scars. Regression analyses of pulsed-dye laser therapy suggested that the optimal treatment interval is 5 to 6 weeks.
In addition, the therapeutic effect of pulsed-dye laser therapy is better on patients with lower Fitzpatrick skin type scores. The authors concluded that this study presented the first meta-analysis to confirm the safety and effectiveness of laser therapy in hypertrophic scar management.
The level of evidence for laser therapy as a keloid treatment is low. Moreover, they stated that further research is needed to determine the mechanism of action for different laser systems and to examine the effectiveness in quantifiable parameters, such as scar erythema, scar texture, degrees of symptom relief, recurrence rates, and adverse effects.
In all the treated keloids, the defect healed in 6 to 8 weeks, and no recurrence was seen while on imiquimod application; however, all keloids completely recurred within 4 weeks of stopping imiquimod. Side effects were mild and acceptable in the form of burning and pain. The authors concluded that imiquimod did exert an anti-fibrotic action but it was short-lived. Pain, tenderness, pruritus and keloid recurrence were evaluated at baseline, week 2, week 6 and 6 months.
Pruritus did not attain statistical difference between the groups. At 6 months, keloid recurrence rates were The authors concluded that imiquimod was well-tolerated. However, there was not enough statistical power to detect a significant difference in 6-month keloid recurrence rates between the imiquimod-treated group and the vehicle-treated group.
A total of 9 patients with a keloid lesion on the trunk were treated with surgical excision and primary closure. The patients were evaluated 2, 4, 8, 12, and 20 weeks after. Keloid recurrence occurred in 8 patients, 7 of them 12 weeks after surgery. These researchers lost track of 1 patient.
Viera et al stated that there is very limited evidence on the best wound management for minimizing scarring. Multiple available therapeutic modalities have been used for the treatment of keloids; however, high-recurrence rates continue to be reported. Currently, there are biological and anti-neoplastic agents that can potentially treat and prevent excessive scar formation. Some of them have been used as "off-label" therapies, and others are still in the experimental phase e.
The authors concluded that latest discoveries in the use of novel agents suggested therapeutic alternatives for the prevention of recurrences of hypertrophic scars and post-excision keloid lesions. Gold et al reviewed available data on methods for preventing and treating cutaneous scarring. Additional data and published studies were submitted for consideration by members of the International Advisory Panel on Scar Management.
One of the most significant advances in scar management over the past 10 years has been the broader application of laser therapy, resulting in a shift in status from an emerging technology to the forefront of treatment. Accumulated clinical evidence also supports a greater role for 5-FU in the treatment of hypertrophic scars and keloids, particularly in combination with intralesional corticosteroids. The authors stated that encouraging data have been reported for newer therapies, including bleomycin, onion extract-containing preparations, imiquimod, and mitomycin C, although methodological limitations in available studies merit consideration.
However, other studies have provided conflicting results …. Other therapies that have been used for keloids include intralesional bleomycin, mitomycin C, and topical imiquimod cream. Ledon et al provided a comprehensive review of current intralesional treatment modalities for keloids and hypertrophic scars. These researchers performed a PubMed search for literature pertaining to intralesional treatment modalities for keloids and hypertrophic scars.
References from retrieved articles were also considered for review. These investigators noted that many intralesional therapies for keloids and hypertrophic scars are currently available to physicians and patients. Mechanisms of action and side effect profiles vary between these agents, and new approaches to keloids and hypertrophic scars are frequently being explored.
The authors concluded that RCTs are needed to evaluate these new and promising modalities fully. Song noted that hypertrophic scars and keloids remain a challenge in surgery. Although the bench to bedside conundrum remains, the science of translational research calls for an even higher level of cooperation between the scientist and the clinician for the impetus to succeed. All of the above presupposed a stimulus that would result in an uncontrolled up-regulation of collagen and extracellular matrix expression in the pathogenesis of the keloid.
This bedside to bench initiative, as in true science, realized more ponderables than possibilities. By the same token, research into the epidermal-mesenchymal signaling, molecular biology, genomics, and stem cell research holds much promise in the bench top arena. To assess efficacy, many scar assessment scores exist in the literature. The clinical measurement of scar maturity can aid in determining end-points for therapeutics.
Tissue oxygen tension and color assessment of scars by standardized photography proved to be useful. In surgery, the use of dermal substitutes holds some promise as these researchers surmised that quality scars that arise from dermal elements, molecular and enzyme behavior, and balance. Although a systematic review showed some benefit for earlier closure and healing of wounds, no such review exists at this point in time for the use of dermal substitutes in scars.
Adipose-derived stem cell, as it pertains to scars, will hopefully realize the potential of skin regeneration rather than by repair in which the researchers were familiar with as well as the undesirable scarring as a result of healing through the inflammatory response. The author concluded that translational research will bear the fruit of coordinating bench to bedside and vice-versa in the interest of progress into the field of regenerative healing that will benefit the patient who otherwise suffers the myriad of scar complications.
Wat and associates provided evidence-based recommendations to guide physicians in the application of intense pulsed light IPL devices for the treatment of dermatologic disease. Studies that examined the role of IPL in primary dermatologic disease were identified, and multiple independent investigators extracted and synthesized data.
Recommendations were based on the highest level of evidence available. These researchers found Level 1 evidence for the use of IPL for the treatment of melasma, acne vulgaris, and telangiectasia; Level 2 evidence for the treatment of lentiginous disease, rosacea, capillary malformations, actinic keratoses, and sebaceous gland hyperplasia; and Level 3 or lower evidence for the treatment of poikiloderma of Civatte, venous malformations, infantile hemangioma, hypertrophic scars, superficial basal cell carcinoma, and Bowen's disease.
The authors concluded that IPL is an effective treatment modality for a growing range of dermatologic disease and in some cases may represent a treatment of choice. It is typically well-tolerated. Moreover, they stated that further high-quality studies are needed. Goyal and Gold noted that keloids and hypertrophic scars remain one of the more difficult treatment concerns for clinicians. A variety of therapies have been used in the past with moderate success.
On occasion, combination therapy has been used to treat these lesions, in an attempt to lessen the symptoms of pain and pruritus that often accompanies keloids and hypertrophic scars, as well as treating the actual lesions themselves.
These researchers introduced a novel triple combination injection process in an attempt to further reduce the signs and symptoms of these lesions. The combination includes 5-FU, triamcinolone acetonide, and hyaluronidase.
All 3 agents supposedly work in concert to treat keloids and hypertrophic scars, and this was the first work at looking at these medicines given together, at the same time, in a series of recalcitrant keloids and hypertrophic scars. The authors concluded that the positive results warrant further investigation and hope for those with keloids and hypertrophic scars. In a systematic review, Prodromidou and colleagues examined available evidence that support the use of botulinum toxin injections for the treatment or prevention of hypertrophic scars in current clinical practice.
A total of 10 studies patients were included. Of these, patients were injected with botulinum toxin type A, 9 patients were offered botulinum toxin type B and the remaining patients represented the control groups. Significantly improved cosmetic outcomes were observed among certain studies using the VAS experimental group: median score 8. However, the methodological heterogeneity of the included studies, the lack of control group in the majority of them, the use of subjective scales of measurement and the frequent use of patient self-assessment precluded unbiased results.
The authors concluded that current evidence does not support the usage of botulinum toxin; future RCTs are needed in the field to reach firm conclusions regarding its place in current clinical practice. In a meta-analysis, Zhang and colleagues evaluated the effectiveness of therapeutic BTX-A in the prevention of maxillofacial and neck scars.
All languages were included as long as they met the inclusion criteria. A total of 9 RCTs patients were included. Moreover, they stated that because there were only a few studies, further clinical practice should be performed and larger databases should be consulted to better determine the effectiveness of BTX-A. Hypertrophic scars were harvested from the ears of 18 young adult New Zealand big-eared rabbits and treated with BTX-A or triamcinolone acetonide TAC in-vivo experiment.
The hypertrophic index HI was measured by histological examination. Collagen fibrils were checked by sirius red straining, and the cell nucleuses of fibroblasts were checked by Ki The authors concluded that these findings showed that BTX-A effectively improved the appearance HS and inhibited the formation of collagen fibrils and fibroblasts in-vivo. Austin and associates noted that keloids and hypertrophic scars are conditions of pathologic scarring characterized by fibroblast hyper-proliferation and excess collagen deposition.
These conditions significantly impact patients by causing psychosocial, functional, and aesthetic distress. Current treatment modalities have limitations. Clinical evidence indicated that botulinum toxin A BoNT-A may prevent and treat keloids and hypertrophic scars.
These researchers investigated cellular pathways involved in BoNT-A therapeutic modulation of keloids and hypertrophic scars. They searched PubMed, Embase, and Web of Science for basic science articles related to botulinum toxin therapy, scarring, fibroblasts, keloids, and hypertrophic scars. A total of 11 basic science articles involving keloids and hypertrophic scars were reviewed. BoNT-A may modulate collagen deposition, but there is a paucity of evidence regarding specific mechanisms of action.
The authors concluded that BoNT-A has the potential to prevent or treat pathologic scars in patients with a known personal or family history of keloids and hypertrophic scars, which may improve patient psychosocial distress and reduce clinic visits and health care costs. Variability in keloid and hypertrophic scar response to BoNT-A may be due to inter-experiment differences in dosing, tissue donors, and assay sensitivity. Guida and colleagues noted that recent studies have highlighted new botulinum neurotoxin BoNT applications in the field of dermatology.
These investigators reviewed current knowledge of BoNT use in dermatology; the literature of the past 5 years was reviewed. These researchers described interesting protocols of BoNT treatment for hyperhidrosis HH , hypertrophic scars and keloids, Raynaud phenomenon, facial flushing, oily skin, psoriasis, Hailey-Hailey disease, and cutaneous lesions like painful lesions and peri-orbital syringomas.
The authors concluded that several skin conditions eligible for BoNT treatment have been described. After the wide application for HH treatment, scars as well as vascular and inflammatory skin disorders, oily skin and cutaneous lesions represent fields of application of BoNT. Moreover, these researchers stated that further studies are needed to improve the knowledge of the connection between BoNT and the cutaneous neuro-immune system and to better define standard protocols of treatment.
Hao and co-workers stated that clinical observations indicate that botulinum toxin type A BTXA can inhibit the growth and improve the eventual appearance of hypertrophic scarring. However, the molecular mechanism remains unclear. These researchers used human keloid fibroblasts to examine the molecular mechanism of BTXA on hypertrophic scarring. Different concentrations of BTXA 0. Changes in cellular morphology, viability, proliferation, cell cycle, and apoptosis were observed by immuno-fluorescence, MTT assay, and flow cytometry.
In addition, real-time quantitative polymerase chain reaction qPCR and Western blotting were used to explore the potential molecular mechanisms. Keloid fibroblast viability decreased with increasing BTXA dose. After BTXA treatment, the volume of keloid fibroblasts cells increased, but the nucleus of cells shrunk. Long thin dendrites were formed as the concentration of BTXA increased. They stated that the findings of this study provided theoretical support for the clinical application of BTXA to control hypertrophic scarring.
Wang et al evaluated the effectiveness of verapamil in preventing and treating keloid and hypertrophic scars. The selection of articles was limited to human subjects. A total of 5 RCTs or cluster-randomized trials or controlled clinical trials CCTs comparing the effectiveness of verapamil with conventional treatments were identified. The results showed that verapamil could improve keloid and hypertrophic scars, and was not significantly different from conventional corticosteroid injections.
Few adverse effects were observed. However, this result should be considered carefully, as most of the included studies have a high risk of bias because of issues with randomization, allocation concealment, blinding, incomplete outcomes and selective reporting.
The authors concluded that verapamil could act as an effective alternative modality in the prevention and treatment of keloid and hypertrophic scars; however, they stated that more high-quality, multiple-center, large-sample RCTs are needed to define the role of verapamil in preventing and treating keloid and hypertrophic scars. In a double-blind RCT with a paired split-scar design, Danielsen et al compared verapamil and triamcinolone for prevention of keloid recurrence after excision.
Calcium channel blocking activity of verapamil in keloid cells was explored. Interim analysis was performed after 14 subjects were recruited. The authors concluded that verapamil is safe but not as effective as triamcinolone in preventing keloid recurrence after excision. They stated that further study is needed to determine if clinical response to verapamil is linked to modulation of intracellular calcium.
Li and Jin stated that keloids and hypertrophic scars are the most common types of pathological scarring. Traditionally, keloids have been considered as a result of aberrant wound healing, involving excessive fibroblast participation that is characterized by hyalinized collagen bundles. However, the usefulness of this characterization has been questioned.
In recent years, studies have reported the appropriate use of verapamil for keloids and hypertrophic scars. Treatment groups were divided into verapamil and non-verapamil group. Non-verapamil group included steroids and intense pulsed light IPL therapy.
Total effective rates included cure rate and effective rate. Cure: skin lesions were completely flattened, became soft and symptoms disappeared. Efficacy: skin lesions subsided, patient significantly reduced symptoms. Inefficient definition of skin was progression free or became worse. Random-effects model was used for the meta-analysis. A total of 6 studies that included patients with keloids and hypertrophic scars were analyzed.
Analysis of the total effective rate of skin healing was performed. The total effective rates in the 2 groups were The meta-analysis showed that there was no difference between the 2 groups. These researchers also compared the adverse reactions between the verapamil treatment group and the steroids treatment group in 2 studies, and the result indicated that the verapamil group showed less adverse reactions. The authors concluded that there were no differences between the application of verapamil and non-verapamil group in keloids and hypertrophic scars treatment.
These investigators stated that verapamil could act as an effective alternative modality in the prevention and treatment of keloid and hypertrophic scars; a larger number of studies are needed to confirm their conclusion. Kwak and colleagues noted that hypertrophic scarring is a pathological condition that occurs after trauma or surgery. Angiogenesis occurs more often with hypertrophic scarring than with normotrophic scarring. The regulation of angiogenesis is one of the key factors in hypertrophic scar management.
Vascular endothelial growth factor VEGF is an essential factor in the angiogenetic response. These researchers examined if decreasing the level of VEGF is effective for treating hypertrophic scarring. A total of 10 8-week-old female New Zealand white rabbits were included; 4 defects were created on each ear by using a 6-mm punch.
Bevacizumab was administered in 1 ear and normal saline was administered in the other ear. Treatment was administered starting on day 2, every 2 days, until day The levels of VEGF were measured using enzyme-linked immunosorbent assay on day 10 and histologic results were analyzed on day Bevacizumab induced-defects showed less hypertrophic scarring when compared with the control group as measured by the scar elevation index SEI and loose collagen arrangement. The SEI in the experimental group was 1.
Additionally, the VEGF level was lower The authors concluded that preventing excessive angiogenesis is effective for preventing scar formation, especially with hypertrophic scarring. Moreover, they stated that although bevacizumab reduces scar formation, it does have adverse effects. No research on the effect of local injection or topical application of bevacizumab to scars has been published.
They stated that further research should be performed in-vivo to ensure the use of bevacizumab without adverse effects and to reveal the mechanisms underlying its effect. Silva and colleagues noted that since the s, the use of autologous fat grafting has been growing in plastic surgery. Recently, this procedure has come to be used as a treatment for keloids and hypertrophic scars mainly due to the lack of satisfactory results with other techniques.
So far, however, it lacks more consistent scientific evidence to recommend its use. These investigators reviewed the evidence of autologous fat grafting for the treatment of keloids and hypertrophic scars. They performed a review in the PubMed database using the keywords "fat grafting and scar", "fat grafting and keloid scar" and "fat grafting and hypertrophic scar".
Inclusion criteria were articles written in English and published in the last 10 years, resulting in 15 studies. These articles indicated that autologous fat grafting performed at sites with pathological scars led to a reduction of the fibrosis and pain, an increased range of movement in areas of scar contraction, an increase in their flexibility, resulting in a better quality of scars. The authors concluded that current evidence suggested that autologous fat grafting for the treatment of keloids and hypertrophic scars is associated with a better quality of scars, leading to esthetic and functional benefits.
However, they noted that this review has limitations and these findings should be treated with reservations, since they mostly came from studies with low levels of evidence 9 of the 15 articles were classified as cases series evidence level: IV. They stated that new studies with the strongest level of evidence randomized and controlled clinical trials, prospective cohort studies, and comparative studies with control groups are needed to elucidate some of the gaps in our knowledge concerning the role of autologous fat grafting in pathological scars e.
Ai and colleagues stated that although pressure therapy PT represents the standard care for prevention and treatment of HS from burns, its practice is largely based on empirical evidence and its effectiveness remains controversial.
These researchers examined the effect of PT for HS; they performed a systematic review and meta-analysis. Several electronic databases were screened to identify related RCTs; 12 RCTs involving patients with HS resulting from burn injuries were included. However, due to limitations, more large and well-designed studies are needed to confirm these findings and the side-effects of the PT may also need to be evaluated.
They stated that future investigations should ensure adequate randomization, concealment of allocation, blinding of patients and outcome assessors and descriptions of withdrawals and losing. Scar characteristics wrinkles, texture, diameter, area, volume of elevation, hemoglobin and melanin were assessed using the Antera 3D system. These results demonstrated that rESWT with 0. Down-regulation of Smad3 expression may underlie this inhibitory effect.
However, the mechanism underlying the observed beneficial effects is not well understood. These researchers examined the mechanism underlying changes in cellular and molecular biology that is induced by ESWT of fibroblasts derived from scar tissue HTSFs. They cultured primary dermal fibroblasts derived from human HTS and exposed these cells to 1, impulses of 0.
At 24 hours and 72 hours after treatment, real-time PCR and Western blotting were used to detect mRNA and protein expression, respectively, and cell viability and mobility were assessed. Expression of E-cadherin was increased, while that of N-cadherin was reduced. Expression of inhibitor of DNA binding 1 and 2 was increased. The authors concluded that suppressed epithelial-mesenchymal transition might be responsible for the anti-scarring effect of ESWT, and has potential as a therapeutic target in the management of post-burn scars.
Fernandez-Mayola and associates stated that HTS and keloids are forms of aberrant cutaneous healing with excessive extracellular matrix ECM deposition. Current therapies still fall short and cause undesired effects. These investigators evaluated the ability of growth hormone releasing peptide 6 GHRP6 to both prevent and reverse cutaneous fibrosis and to acquire the earliest proteome data supporting GHRP6's acute impact on aesthetic wound healing.
Two independent sets of experiments addressing prevention and reversion effects were conducted on the classic HTS model in rabbits. The incidence and appearance of HTS were systematically monitored. The authors concluded that the findings of these preliminary proteomic study suggested that the anti-fibrotic preventing effect exerted by GHRP6 depended on different pathways involved in lipid metabolism, cytoskeleton arrangements, epidermal cells' differentiation, and ECM dynamics.
Ren and colleagues examined the influence of hyperbaric oxygen HBO on scar formation in rabbit ears. A total of 20 New Zealand rabbits were selected to establish the hypertrophic scar model on the ears. The rabbits were randomly divided into control group and experimental group 7d, 14d, 21d, and 28d group according to different HBO treatment days , each experimental group received HBO treatment after the operation at the same time every day for 1 hour.
After the day 29, the scars were collected. Histo-morphological change in scars was observed by hematoxylin-eosin staining, Masson staining, and transmission electrical microscope. The expression of bax, bcl-2, and the cell apoptosis rate was detected by immuno-histochemical method. Both number of fibroblast and amount of collagen fibrils in experimental group were significantly reduced compared with those in control group. In Masson staining, arrangement of collagen fibrils in experimental group was much more irregular and coarse than control groups.
Fan and associates noted that Cesarean delivery has already become a very common method of delivery around the world, especially in low-income countries. Hypertrophic scars and wound infections have affected younger mothers and frustrated obstetricians for a long time.
Mesenchymal stem cells MSCs have strong potential for self-renewal and differentiation to multi-lineage cells. Previous studies have demonstrated that MSCs are involved in enhancing diabetic wound healing. Thus, this study is designed to examine the safety and efficacy of MSCs in the treatment of Cesarean section skin scars. This trial is a prospective, randomized, double-blind, placebo-controlled, single-center trial with 3 parallel groups. Study duration will last for 6 months, comprising a 1 week run-in period and 24 weeks of follow-up.
The primary aim of this trial is to compare the difference in Vancouver Scar Scale rating among the 3 groups at 6th month. Adverse events AEs , including severe and slight signs or symptoms, will be documented in case report forms. The authors concluded that this trial is the first investigation of the potential for therapeutic use of MSCs for the management of women's skin scar after Cesarean delivery.
The authors concluded that although encouraging results of molecular- or cytokine-targeting therapies are being continuously reported, current prophylaxis and treatment strategies still mainly focus on decreasing inflammatory processes. They stated that further understanding of the mechanisms underlying excessive scarring is needed to develop more effective prophylaxis and treatment strategies.
Dogra and colleagues evaluated the safety and effectiveness of micro-needling treatment for atrophic facial acne scars. A total of 36 patients 26 females, 10 males with post-acne atrophic facial scars underwent 5 sittings of derma-roller under topical anesthesia at monthly intervals. Objective evaluation of improvement was performed by recording the acne scar assessment score at baseline and thereafter at every visit.
Pre- and post-treatment photographs were compared, and improvement was graded on quartile score. Final assessment was performed 1 month after the last sitting. Patients were asked to grade the improvement in acne scars on VAS 0 to 10 point scale at the end of study. Of 36 patients, 30 completed the study.
The age group ranged from 18 to 40 years, and all patients had skin phototype IV or V. There was a statistically significant decrease in mean acne scar assessment score from The results on VAS analysis showed "good response" in 22 patients and "excellent response" in 4 patients, at the end of study.
The procedure was well-tolerated by most of the patients, and chief complications noted were post-inflammatory hyperpigmentation in 5 patients and tram-trek scarring in 2 patients. The authors concluded that micro-needling with derma-roller is a simple and cheap, means of treatment modality for acne scars re-modulation with little downtime, satisfactory results and peculiar side effects in Asian skin type.
In a retrospective study, Chandrashekar et al assessed the safety and effectiveness of micro-needling fractional radiofrequency in the treatment of acne scars. A total of 31 patients of skin types III to V with moderate and severe facial acne scarring received 4 sequential fractional RF treatments over a period of 6 months with an interval of 6 weeks between each session.
Estimation of improvement with Goodman and Baron's Global Acne Scarring System showed that by qualitative assessment of 31 patients with grade 3 and grade 4 acne scars, Adverse effects were limited to transient pain, erythema, edema and hyperpigmentation. The authors concluded that micro-needling fractional RF is effective for the treatment of moderate and severe acne scars. Ramult and colleagues noted that patients who suffer from scars or wrinkles have several therapeutic options to improve the appearance of their skin.
The available treatment modalities that provide desirable results are often overtly invasive and entail a risk of undesirable adverse effects. Micro-needling has recently emerged as a non-ablative alternative for treating patients who are concerned with the aesthetic changes that result from injury, disease or ageing. In a systematic review, these investigators evaluated the current evidence in the literature on micro-needling.
A systematic literature review was performed by searching the electronic databases PubMed and Google Scholar. The reviewed articles were analyzed and compared on study design, therapeutic protocol, outcome parameters, efficacy measurement and results to evaluate the strength of the current evidence. Micro-needling was examined in experimental settings for its effects on atrophic acne scars, skin rejuvenation, hypertrophic scars, keloids, striae distensae, androgenetic alopecia, melasma and acne vulgaris.
Several clinical trials used randomization and single-blind design to strengthen the validity of the study outcome. Micro-needling showed noteworthy results when used on its own and when combined with topical products or RF. When compared with other treatments, it showed similar results but was preferred due to minimal AEs and shorter down-time.
The authors concluded that this systematic review positioned micro-needling as a safe and effective therapeutic option for the treatment of scars and wrinkles. These researchers stated that the current literature show some methodological shortcomings, and further research is needed to truly establish micro-needling as an evidence-based therapeutic option for treating scars, wrinkles and other skin conditions.
Sheridan et al stated that hypertrophic scarring is a major source of morbidity in patients with burns. The physiologic characteristics are poorly understood, but increased neo-vascularity is typically seen in those wounds destined to become hypertrophic. These investigators theorized that ablation of the developing neo-vasculature may favorably influence the development of the hypertrophic scar. In a pilot study, these researchers established the practicality and safety of tunable dye laser neo-vessel ablation at nm; 10 sites of evolving hypertrophic scar in 9 children were treated with a series of msec 6.
Although all children had the expected transient post-treatment purpura, no pain, ulceration, pruritus, or worsening of the lesions was seen. The authors concluded that this technique appeared safe and was worthy of continuing investigation.
They stated that investigations with higher fluences and multiple treatments were in progress. Parrett and Donelan noted that hypertrophic scarring after partial-thickness burns is common, resulting in raised, erythematous, pruritic, and contracted scars. Treatment of hypertrophic scars, especially on the face, is challenging and has high failure rates.
Excisional treatment has morbidity and can create iatrogenic deformities. After an extensive experience over 10 years with laser therapy for the treatment of difficult scars, the pulsed dye laser PDL has emerged as a successful alternative to excision in patients with hypertrophic burn scars.
Multiple studies have shown its ability to decrease scar erythema and thickness while significantly decreasing pruritus and improving the cosmetic appearance of the scar. The authors concluded that PDL should become an integral part of the management of burn scarring and would significantly decrease the need for excisional surgery. This was a review; it did not provide clinical data to support its claim.
Hultman et al presented the largest study to-date that examined long-term impact of laser therapies, a potentially transformative technology, on scar remodeling. These investigators conducted a prospective, before-after cohort study in burn patients with hypertrophic scars; PDL was used for pruritus and erythema; fractional CO2 laser was used for stiffness and abnormal texture. A total of burn patients mean age of Laser treatments produced rapid, significant, and lasting improvements in hypertrophic scar.
Provider-rated VSS dropped from Patient-reported UNC4P fell from 5. The authors concluded that for the first time, ever, in a large prospective study, laser therapies have been shown to dramatically improve both the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instruments.
They stated that laser treatment of burn scars represented a disruptive innovation that could yield results not previously possible and may displace traditional methods of operative intervention. Blome-Eberwein et al conducted a prospective study of fractional CO2 laser treatment of mature burn scars, comparing objective and subjective scar measurements evaluating at least 1 treatment and 1 control scar on the same patient pre- and post-treatments.
After institutional review board approval, burn survivors with mature blatant burn scars were invited to enter the study. A series of 3 fractional CO2 laser treatments was performed in an office-setting, using topical anesthetic cream, at 40 to 90 mJ, to spots per cm. Subjective and objective measurements of scar physiology and appearance were performed before and at least 1 month after the treatment series on both the treated and the control scar.
A total of 80 scars, 48 treatment and 32 control scars, were included in the study. Treatment pain score averaged at 4. All treated scars showed improvement. Elasticity improved, but without statistical significance; VSS assessments by an independent observer improved from 8 to 6; patient self-reported pain and pruritus remained unchanged in both groups.
The authors concluded that fractional CO2 laser treatment is a promising entity in the treatment of burn scars; these findings showed significant differences in objective measurements between the treated scars and the untreated control scars over the same time period. Tao et al stated that burn scars cause cosmetic disfigurement and psychosocial distress. Treated burn scars improved significantly in thickness, texture and color.
The patient received 2 treatments with nm PDL 5 mm, 7. The burn scars became thinner, smoother and more normal in pigmentation and appearance. The PDL targets scar hyper-vascularity, the 15,50 nm erbium:glass stimulates collagen re-modelling and the 1, nm thulium targets epidermal processes, particularly hyper-pigmentation. They stated that this combination addressed scar thickness, texture and color with a low side effect profile and was particularly advantageous in patients at higher risk of post-procedure hyperpigmentation.
The thulium laser specifically addressed hyper-pigmentation, which was advantageous in patients with skin of color who were more prone to developing PIH. Moreover, they stated that further studies are needed to optimize settings and establish treatment guidelines. Zuccaro et al noted that treatment with laser therapy has the potential to greatly improve hypertrophic scarring in individuals who have sustained burn injuries. More specifically, recent research has shown the success of using PDL therapy to help reduce redness and post-burn pruritus and using ablative fractional CO2 laser therapy to improve scar texture and thickness.
Before-after VSS scores decreased from 7. The authors concluded that the results obtained from this study supported the use of laser therapy to improve hypertrophic burn scars in the pediatric population. Moreover, they stated that rigorous randomized controlled trials RCTs are needed to confirm the effectiveness of this therapy.
Rodriguez-Menocal et al stated that hypertrophic scarring is a fibro-proliferative process that occurs following a 3rd-degree dermal burn injury, producing significant morbidity due to persistent pain, itching, cosmetic disfigurement, and loss of function due to contractures. Ablative fractional lasers have emerged clinically as a fundamental or standard therapeutic modality for hypertrophic burn scars.
Yet the examination of their histopathological and biochemical mechanisms of tissue remodeling and comparison among different laser types has been lacking. In addition, deficiency of a relevant animal model limits the ability to gain a better understanding of hypertrophic scar pathophysiology.
To evaluate the effect of ablative fractional lasers on hypertrophic 3rd-degree burn scars, these researchers have developed an in-vivo red Duroc porcine model; 3rd-degree burn wounds were created on the backs of animals, and burn scars were allowed to develop for 70 days before treatment.
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A certain number of weeks each year.. Movies or tunes cd YouTube has everything in its checklist. In an evidence review of plantar fasciitis treatments published in the New England Journal of Medicine, Buchbinder concluded that "the available data do not provide substantive support for [the] use" of ESWT for plantar fasciitis.
Commenting on the results of the study by Buchbinder and colleagues, Ham and Strayer stated that "[e]xtracorporeal shock wave therapy cannot be recommended to improve pain and function in patients with plantar fasciitis based on the results of this study.
Although previous studies do report a benefit from ESWT, this study appears to represent a higher level of evidence than was previously available for evaluating the efficacy of this therapy. An updated meta-analysis combining all the studies on ESWT will be useful". ICDCM codes are used in medical billing and coding to describe diseases, injuries, symptoms and conditions. Can't find a code? Podiatry Management is the national practice management and business magazine, reaching over 18, subscribers.
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