Combinations of therapies have proved superior to individual approaches. Intralesional verapamil 2. Intralesional fluorouracil 50 mg per mL, two to three times per week appears to shrink keloids safely while avoiding the tissue atrophy and telangiectasia that may occur with repeated corticosteroid injections.
Combining corticosteroids and fluorouracil diminished the adverse effects of corticosteroids. Rare skin complications of fluorouracil may include hyperpigmentation and wound ulceration. No systemic adverse effects e. Bleomycin is another useful chemotherapeutic agent; a standard approach is bleomycin tattooing 0.
Intralesional interferon alfa-2b 1. A liposome-encapsulated interferon alfa-2b cream is also being investigated for scar reduction. Radiation, alone or more commonly after keloid excision, is a much more controversial option. It may pose a risk of local growth inhibition in children and possibly subsequent cancer.
Commondosesrangebetween1,to 2, rads over five to six sessions following surgery. Many patients use topical vitamin E alpha-tocopherol hoping its antioxidant properties will prevent scars. However, there is little evidence that it is helpful, and some patients develop a contact dermatitis that may delay healing. Another over-the-counter option is onion extract topical gels e. Although one trial compared this product favorably with corticosteroids, another showed that it was ineffective in improving scar height and itching.
Moist exposed burn ointment contains multiple herbs with betasitosterol, which provides hydration and possible benefits to wound healing. Already a member or subscriber? Log in. Reprints are not available from the authors. Treatment of keloids and hypertrophic scars. Arch Facial Plast Surg.
Murray JC. Keloids and hypertrophic scars. Clin Dermatol. Kelly AP. Aesthetic Dermatology. Omo-Dare P. Genetic studies on keloid. J Natl Med Assoc. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg. Current progress in keloid research and treatment. J Am Coll Surg. A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management.
Dermatol Surg. On the nature of hypertrophic scars and keloids: a review. Plast Reconstr Surg. Randomized controlled trial to determine the efficacy of paper tape in preventing hypertrophic scar formation in surgical incisions that transverse Langer's skin tension lines. Prospective comparison of octyl cyanoacrylate tissue adhesive Dermabond and suture for the closure of excisional wounds in children and adolescents.
Arch Dermatol. Chuangsuwanich A, Gunjittisomrarn S. J Med Assoc Thai. New combination of triamcinolone, 5-fluorouracil, and pulsed-dye laser for treatment of keloid and hypertrophic scars. Agbenorku P. Alster TS. Improvement of erythematous and hypertrophic scars by the nm flashlamp-pumped pulsed dye laser. Ann Plast Surg. Treatment of keloid sternotomy scars with nm flashlamp-pumped pulsed-dye laser. Prevention and treatment of keloids with intralesional verapamil.
Bleomycin in the treatment of keloids and hypertrophic scars by multiple needle punctures. Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars. Evaluation of various methods of treating keloids and hypertrophic scars: a year follow-up study. Br J Plast Surg. The effects of onion extract on hypertrophic and keloid scars.
J Wound Care. Experience with difficult keloids. Graham GF. Clin Plast Surg. Layton AM. A review on the treatment of acne vulgaris. Int J Clin Pract. Management of scar contractures, hypertrophic scars, and keloids. Otolaryngol Clin North Am. O'Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev. McIntyre L, Baird M. Pressure garments for use in the treatment of hypertrophic scars—a review of the problems associated with their use.
International clinical recommendations on scar management. Pulsed dye laser treatment on burn scars. Alleviation or irritation? Fitzpatrick RE. Treatment of inflamed hypertrophic scars using intralesional 5-FU. Atiyah BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods.
Aesthetic Plast Surg. Yamamoto T. Bleomycin and the skin. Br J Dermatol. Antifibrogenic effects of liposome-encapsulated IFN-alpha2b cream on skin wounds in a fibrotic rabbit ear model. J Interferon Cytokine Res. Khoosal D, Goldman R. Vitamin E for treating children's scars. Does it help reduce scarring? Can Fam Physician. Effect of Mederma on hypertrophic scarring in a rabbit ear model.
Pilot study evaluating topical onion extract as a treatment for postsurgical scars. Safety and efficacy of local administration of Contractubex to hypertrophic scars in comparison to corticosteroid treatment. Results of a multicenter, comparative epidemiological cohort study in Germany.
In Vivo. Pharmacological modulation of wound healing in experimental burns. New innovations in scar management. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Aug 1, Issue. Management of Keloids and Hypertrophic Scars. B 8 , 23 Intralesional corticosteroid injections for prevention and treatment of keloids and hypertrophic scars are a practical first-line approach for the family physician.
B 9 , 22 Silicone elastomer sheeting is a noninvasive, but time-intensive, first-line option for prevention and treatment of keloids and hypertrophic scars. B 8 , 26 , 31 Pressure dressings or garments are effective for prevention of hypertrophic scars, especially in burns. B 10 , 27 , 31 When first-line treatments for keloids and hypertrophic scars fail, combination therapy surgery, silicone sheeting, and corticosteroid injections is an effective second-line option.
B 12 , 13 , 17 — 19 , 28 , 30 — 33 Limited clinical trials have failed to demonstrate lasting improvement of established keloids and hypertrophic scars with onion extract topical gel e. Keloids Hypertrophic scars Keloids Remain confined to border of original wound Extend beyond border of original wound Arise in any location; commonly occur on extensor surfaces of joints Commonly occur on the sternal skin, shoulders and upper arms, earlobes, and cheeks Regress with time Grow for years Fewer thick collagen fibers Thick collagen Scanty mucoid matrix Mucoid matrix Flatten spontaneously in time Remain elevated more than 4 mm Appear within one month Appear at three months or later Less association with skin pigmentation More common in darker skin types Adapted with permission from Jackson IT, Bhageshpur R, DiNick V, Khan A, Bhaloo S.
Table 1 Hypertrophic Scars vs. Cheeks are a common location for keloids, often secondary to acne. Figure 1. Figure 2. Read the full article. Get immediate access, anytime, anywhere. Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue. Purchase Access: See My Options close. Best Value! To see the full article, log in or purchase access. More in Pubmed Citation Related Articles. Email Alerts Don't miss a single issue.
Sign up for the free AFP email table of contents. Navigate this Article. Remain confined to border of original wound. Extend beyond border of original wound. Arise in any location; commonly occur on extensor surfaces of joints. Their usefulness remains unclear.
Silicone dioxide. Applied in the form of a gel or pad, this can help soften and decrease the redness of keloids. If the keloid scar is not responsive to nonsurgical management options, surgery may be performed. One type of surgery directly removes the scar formation with an incision, and stitches are placed to help close the wound.
Sometimes, skin grafts are used to help close the wound. This involves replacing or attaching skin to an area that is missing skin. Skin grafts are performed by taking a piece of healthy skin from another area of the body called the donor site and attaching it to the needed area. Surgery is not performed often on hypertrophic scars and keloids due to the high rate of recurrence or creation of even larger keloids.
Laser surgery. Scars may be treated with a variety of different lasers, depending on the underlying cause of the scar. Lasers may be used to smooth a scar, remove the abnormal color of a scar, or flatten a scar. Most laser therapy for scars is done in conjunction with other treatments, including injections of steroids, use of special dressings, and the use of bandages.
Multiple treatments may be required, regardless of the initial type of therapy. Pulse dye laser is a good choice to use for keloids. Hypertrophic scars are similar to keloid scars. But their growth is confined within the boundaries of the original skin defect and may be more responsive to treatment. These scars may also look red, and are usually thick and raised. Hypertrophic scars usually start to develop within weeks after the injury to the skin.
Hypertrophic scars may improve naturally. But this process may take up to a year or more. In treating hypertrophic scars, steroids may be the first line of therapy. But there is not 1 simple cure. Steroids may be given as an injection. Or they may be directly applied to the scar, although topical application may not be useful. These scars may also be removed surgically. Often, steroid injections are used along with the surgery.
The injections may continue up to 2 years after the surgery to help maximize healing and decrease the chance of the scar returning. Like keloids, hypertrophic scars may respond to topical silicone dioxide application. Contractures are an abnormal occurrence that happens when a large area of skin is damaged and lost, resulting in a scar.
The scar formation pulls the edges of the skin together, causing a tight area of skin. The decrease in the size of the skin can then affect the muscles, joints, and tendons, causing a decrease in movement. There are many different surgical treatment options for contractures, including the following:. Skin graft or skin flap. Skin grafts or skin flaps are done after the scar tissue is removed. Skin grafts involve replacing or attaching skin to a part of the body that is missing skin.
Skin grafts are done by taking a piece of healthy skin from another area of the body called the donor site and attaching it to the needed area. Skin flaps are similar to skin grafts, where a part of the skin is taken from another area. But with the skin flaps, the skin that is taken has its own blood supply.
The section of skin used includes the underlying blood vessels, fat, and muscles. Flaps may be used when the area that is missing the skin does not have a good supply of blood. That may be because of the location or because of damage to the vessels. This procedure uses a Z-shaped incision to help decrease the amount of contractures of the surrounding skin.
It also may try to relocate the scar so that its edges look more like the normal lines and creases of the skin. Small stitches may be used to help hold the skin in place. Tissue expansion. This is a newer technique. It involves a process that increases the amount of existing tissue available for reconstructive purposes. This procedure is often used in addition to the flap surgery. This is another type of scarring that may form between unconnected internal organs. Adhesions may cause complications during certain surgeries.
Follow all instructions to help maximize your recovery and healing. Your healthcare provider will advise you on all activity restrictions, depending on the type of surgery that was done. Scars can't be removed completely. Many factors will be involved in the degree of healing of your particular scar. Some scars take more than a year after surgery to show improvement in how they look. Health Home Conditions and Diseases. How can a scar be minimized?
Specific dermatological procedures to minimize scars will be determined by your healthcare provider based on: Your age, overall health, and medical history Severity and symptoms of the scar Type and location of the scar Your tolerance for specific medications, procedures, or therapies Expectations for the course of the condition Your opinion or preference Scars usually fade over time.
The following are some of the more common scar-minimizing procedures: Dermabrasion. What are the different types of scars and treatment? There are many different types of scars, including: Keloid scars These are thick, rounded, irregular clusters of scar tissue that grow at the site of a wound on the skin, but beyond the edges of the borders of the wound. Treatment may include the following: Steroid injections. Cryotherapy involves the scar being frozen off. This can be used for scars that don't respond to other treatments.
Hypertrophic scars Hypertrophic scars are similar to keloid scars. Contractures Contractures are an abnormal occurrence that happens when a large area of skin is damaged and lost, resulting in a scar. There are many different surgical treatment options for contractures, including the following: Skin graft or skin flap.
The researcher will then place each allocation into sequentially numbered opaque envelopes. There will be permuted blocks of 10 with allocation, containing 5 intervention and 5 control allocations in each block. This will help achieve balance across the two groups. For those who are randomised to triamcinolone acetonide, the independent researcher will insert the medication inside the envelope and, after sealing it, will store the envelope in a locked cabinet inside the medication room in the birth unit.
The surgeon who is rostered on the day of the caesarean section will be informed of the recruited participant and will be instructed on where to collect the concealed envelope. All participants will have their randomisation number indicated in the hospital electronic record at the time of study allocation.
This is done to inform the researcher assessing the outcomes of the recruiting of the participant and the allocated number, but not the allocated intervention. Those women who meet the inclusion criteria and sign the informed consent form will be randomised to either the intervention or the control group by the independent researcher as explained previously Fig. On the day of the caesarean section, the sealed envelope containing instructions for the type of treatment will be picked up by the surgeon.
The surgeon opens the envelope when the woman is ready for the caesarean section. The skin layer is then closed with Monocryl Ethicon in a sub-cuticular fashion. The intervention group will receive surgical excision of the keloid scar after the delivery of the baby. Closure of the uterus layers, rectus sheath and the fat layer are completed as explained above. The excision of the scar and administration of the injection will be performed by the surgeon who is scheduled to perform the surgery on that day.
The Principal Investigator of the study will assess the fidelity to the intervention by supervising procedures. Post-operation, the patients will be visited daily on the ward for any signs of potential infectious local complications of the treatment and immediate side effects of the medication injection until the discharge home. At each follow-up visit, the same assessment and scoring scales will be used to evaluate the changes to the keloid scar.
All measurements at baseline and follow-up visits will be performed by the same researcher, who will also make all efforts to ensure compliance with follow-up. As part of continuous clinical care, patients with any residue keloid scar with be given information on further treatment including referral to plastic surgeons if they are interested Fig. A t test will be used to assess continuous non-skewed variables; these will be presented as means with standard deviations.
For skewed ordinal data, the Mann—Whitney U test will be used; these data will be presented as medians with interquartile ranges. Difference in the effect over the sub-groups will be assessed using logistic regression. The patients will be reviewed on the ward post caesarean section for any signs of complications until discharge.
The patients will be given a phone number to call to contact the investigator in case of any reaction and complication in relation to the caesarean section scar. Advice will be given to patients over the phone, or they will be invited to present to hospital for review for further management. An interim analysis will be performed on the primary outcome of keloid formation in patients when enrolling 20 patients, including both the control and intervention groups, by a single statistician who is blinded to allocation and reports the results to the data and safety monitoring committee.
If there is a reasonable suspected causal relationship with the intervention, the study researcher who is blinded to the allocations will report to the data and safety monitoring committee, who will in turn report the adverse events to the ethics committee to guarantee the safety of the patients. We do not expect any risks for either group control or intervention.
The electronic data obtained from participants will be stored in a dedicated file in the computer of the Chief Investigator at Westmead Hospital. A specific password will be required to access the file containing data, and this file will also be protected against viruses or malicious software. Only aggregated results will be reported, in which no individual or identifying data will be included.
After the retention period, the files containing data in addition to any backups will be sanitised, and the manager of WSLHD HREC will be notified at the completion of the disposal. After completing the trial, we will continue to evaluate and treat the patients in the future if they wish us to do so. The final results of the trial are planned to be published in a scientific journal and presented at medical conferences.
Keloid formation often can be prevented or reduced if anticipated with immediate therapy. Once established, keloids are more difficult to treat, with a high recurrence rate regardless of treatment. Corticosteroids are a commonly used and effective treatment for established keloids on wounds in other area [ 16 , 17 , 18 ]. Corticosteroids suppress inflammation by inhibiting fibroblasts and mitosis while increasing vasoconstriction in the scar [ 19 , 20 ]. Their effectiveness and side effects in subsequent caesarean section for those with established keloids has not been established.
Yet caesarean section is easily the most common operation done, and keloid formation in these young women of childbearing age can be very distressing [ 3 , 6 , 21 , 22 , 23 ]. Other treatment modalities have also been used for keloid scars after caesarean section. Radiation therapy has been used with some clinical success [ 24 , 25 ]. However, this modality of treatment requires multiple visits for radiation therapy during the post-natal period when more time is needed to care for the newborn.
Our mode of treatment with a single administration of triamcinolone acetonide takes into consideration the need of the mother to have time to care for her newborn. Common adverse effects of triamcinolone acetonide include atrophy, telangiectasia and hypopigmentation [ 26 ]. Steroids have been implicated as an aetiology in delayed wound healing. Although there is evidence in the literature that steroids delay wound healing, most studies are performed in vitro or use high systemic doses.
Although wound disruptions have occurred in patients taking corticosteroids [ 26 ], treatment doses are generally below the level required for inhibition of wound healing in clinical practice. Acute, high-dose systemic corticosteroid use likely has no clinically significant effect on wound healing [ 27 ].
There is a retrospective evaluation study of post-operative intralesion steroid injections on wound healing [ 28 ]. Overall, there was not a statistically significant difference between the steroid groups and the non-steroid group. Therefore, one-time post-operative intralesion steroid injections were not found to delay wound healing [ 28 ].
Local infection was reported in an earlier study after the sub-dermal corticosteroid injection therapy [ 29 ]. This risk has been suggested to increase after an overdose of the local injection of corticosteroid [ 29 ]. Nevertheless, we will carefully assess the participants in our study to ensure safety. Usually, two or three injections are given a month apart; however, therapy can continue for 6 months or longer [ 33 ].
New keloids are more responsive to therapy than older, established lesions. In theory, this injection will prevent any scar formation before treatment is started. If our study hypotheses are true, then steroid injection presents as a safe and sustainable treatment in the management of keloid scars. Our findings will be particularly useful for patients unable to undergo cosmetic surgery due to clinical or financial reasons and in under-resourced settings both within Australia and internationally.
Since we do not have access to the plastic surgery data, we are unable to investigate the cost-effectiveness of the treatment. However, we hope that our findings will provide knowledge for further future research investigating the cost-effectiveness of sub-dermal triamcinolone acetonide for the treatment of caesarean section keloid scars. The present protocol is version number 4, dated October The recruitment began in May and is expected to complete by June A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management.
Dermatol Surg. Kelly A. Keloids and hypertrophic scars. In: Parish L, Lask G, editors. Aesthetic dermatology. New York: McGraw-Hill; Google Scholar. Quality of life of patients with keloid and hypertrophic scarring. Arch Dermatol Res.
Article Google Scholar. Seifert O, Mrowietz U. Keloid scarring: bench and bedside. What factors affect the quality of life of patients with keloids? Revista da Associacao Medica Brasileira The hidden cost of skin scars: quality of life after skin scarring. J Plast Reconstr Aesthet Surg. Ogawa R. Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis. Int J Mol Sci. Ogawa R, Akaishi S. Endothelial dysfunction may play a key role in keloid and hypertrophic scar pathogenesis—keloids and hypertrophic scars may be vascular disorders.
Med Hypotheses. Medical and surgical therapies for keloids. Dermatol Ther. On the nature of hypertrophic scars and keloids: a review. Plast Reconstr Surg. Keloid pathogenesis and treatment. Medical and surgical management of keloids: a review. J Drugs Dermatol. PubMed Google Scholar. The efficacy of excision followed by intralesional 5-fluorouracil and triamcinolone acetonide versus excision followed by radiotherapy in the treatment of ear keloids: a randomized control trial.
Effectiveness of a counseling intervention after a traumatic childbirth: a randomized controlled trial. Preference for cesarean section in young nulligravid women in eight OECD countries and implications for reproductive health education. Reprod Health. Major suppression of pro-alpha1 I type I collagen gene expression in the dermis after keloid excision and immediate intrawound injection of triamcinolone acetonide.
J Am Acad Dermatol. Evaluation of various methods of treating keloids and hypertrophic scars: a year follow-up study. Br J Plast Surg. International clinical recommendations on scar management. Histomorphologic changes in keloids treated with Kenacort. J Trauma. Cruz NI, Korchin L. Inhibition of human keloid fibroblast growth by isotretinoin and triamcinolone acetonide in vitro.
Ann Plast Surg. Postnatal quality of life in women after normal vaginal delivery and caesarean section. BMC Pregnancy Childbirth. Quality of life after cesarean and vaginal delivery. Oman Med J. Comparing quality of life in women after vaginal delivery and cesarean section. J Midwifery Reprod Health. Kim J, Lee SH.
Therapeutic results and safety of postoperative radiotherapy for keloid after repeated Cesarean section in immediate postpartum period. Radiat Oncol J. Surgical excision with adjuvant irradiation for treatment of keloid scars: a systematic review. Plast Reconstr Surg Global Open. Perilesional linear atrophy and hypopigmentation after intralesional corticosteroid therapy: report of two cases and review of the literature.
Corticosteroids and wound healing: clinical considerations in the perioperative period. Am J Surg. Retrospective evaluation of postoperative intralesional steroid injections on wound healing. J Foot Ankle Surg. Aust N Z J Surg. Treatment of small keloids with intralesional 5-fluorouracil alone vs. J Pakistan Assoc Dermatol. Studies repeatedly show that using steroid injections in combination with other therapies significantly increases the overall effectiveness of treatment.
Outcomes are also usually better the sooner treatment is administered after a wound. In addition to improved outcomes in terms of lower rates of recurrence and reduced keloid size, combining corticosteroid injections with other treatment modalities can have other benefits. In some combinations e. Additionally, combining therapies may also hasten response to the treatment.
Overview What Are Keloid Scars? The needle will be inserted inside the scar tissue at tiny spaced intervals to spread the steroid throughout the scar. Yes, especially at higher doses. Shots can be co-administered with a numbing agent e. Disclaimer: This website is not intended to replace professional consultation, diagnosis, or treatment by a licensed physician. If you require any medical related advice, contact your physician promptly. Information presented on this website is exclusively of a general reference nature.
Do not disregard medical advice or delay treatment as a result of accessing information at this site. Just Answer is an external service not affiliated with Keloid. In the case of surgical wounds, steroid injections are not given until about 2 weeks following removal of stitches.
Often a steroid injection is. Elongation of the earlobes or may be less responsive to medical or laser treatments and carefully repositioned to create a. Results of a multicenter, comparative log in or purchase access. See benefits of individual treatments. Multiple preparations available; tolerated by. Case study May cause hyperpigmentation. Safety and efficacy of local mm Hg worn for six. PARAGRAPHOutcomes are also usually better. Effect of Mederma on hypertrophic. Repair of an elongated piercing also be necessary if they original injury, but can cause conservative treatments, but the recurrence.If a hypertrophic scar or keloid develops after surgery, dermatologists recommend getting steroid injections every four to six weeks, limiting the total number. The use of corticosteroid injections following keloid surgery reduces the recurrence rate to lless than 50 percent Scar excision may be. The best initial treatment is to inject long-acting cortisone (steroid) into the keloid once a month. After several injections with cortisone, the keloid.