MANAGEMENT AND PREVENTION OF ABNORMAL SCARS

LATEST FIGURES A scar is a mark left in the skin by the healing of injured tissue. In the developed world, 100 million patients develop scars each year, some of which cause considerable physical and psychological problems. (Bayat et al 2003). 11 million of these scars are keloid, and 70% of scars are due to burns injuries.

SKIN STRUCTURE AND FUNCTION Skin consists of two main layaers, the outer epidermis and the underlying dermis. The epidermis consists of five layers. Cells of the basal cell layer divide continually. Older cells are displaced towards the surface and shed as dead cells. This regeneration of multiplying and migrating basal cells in damage, leaves no visible scar.(Nursing standard 19;28 2005)

SKIN FUNCTION AND STRUCTURE The dermis consists of collagen and elastin fibres in a matrix, supplied by a rich capillary network. The dermis supports the epidermis. Elastin provides the elasticity and the collagen provides the tensile strength. Dermal damage is repaired by a process of granulation. The proportion of the constituents and the mechanism of repair differ from that of normal dermis, resulting in the formation of a visible scar. (Bayat et al 2003).

STRUCTURE OF THE SKIN Epidermis Oil gland Papillary dermis Muscle Sweat gland Reticular dermis Hair Fat tissue Blood vessels Nerve

PARTIAL AND FULL THICKNESS INJURIES Blister Fluid Epidermis Epidermis Dermis Dermis Layer of fatty tissue Layer of fatty tissue

WOUND HEALING AND SCAR FORMATION Scar formation is a natural part of the wound healing process, and occurs after almost every dermal injury. Some scars are considered trivial, but some are psychologically damaging, itchy, painful, cause sleep disturbance, anxiety, depression, and distruption of life. (Rumsey and White 2003).

WOUND HEALING AND SCAR FORMATION Age General condition Size and location of the wound Predisposing diseases: Arthritis, diabetes, infection, leukaemia or other cancers. Calvin 1998, separates the wound healing process into phases that we have already learnt from the pathophysiology presentation. Wound healing can be influenced by many different factors:

SCARS Almost always arise from some sort of trauma Scar tissue consists mainly of newly synthesised collagen, produced by fibroblasts in response to injury Scars lack pigmentation, hair and sweat glands

HYPERTROPHIC / KELOID SCARS Raised scars that remain within the boundaries of the original legion Often red, inflamed, itchy and painful KELOID Raised scars that spread beyond the margins of the original wound, invading normal skin Does not regress and will invariably recur after surgical excision

HYPERTROPHIC / KELOID SCARS Usually develop six to eight weeks post epithelialisation. They are a consequence of the rapid proliferation of collagen in healing skin-4 times as much as in normal skin Maturation is from 12-18 months. KELOID Can occur spontaneously, or from a trauma as little as an insect bite or ear piercing. A lot more common on the asian, black, oriental population due to the number of melanocytes. There has been no cases in Albino people.

KELOID SCARS

KELOID SCARS

HYPERTROPHIC SCARS

TREATMENT OPTIONS SURGERY Surgical incision is the most long standing, simplest way of removing keloid tissue. It’s effectiveness as a single mode of treatment is limited. Reoccurrence rates are known to be more than 80% within two years (Mustoe et al 2002).

TREATMENT OPTIONS CORTICOSTEROIDS Injections being a first line therapy for keloids and a second line for hypertrophics Corticosteroids are seen to decrease fibroblast proliferation, collagen synthesis and suppress inflammatory mediators. Response rates are good, 50-100% with 9% recurrence. Injections carried out monthly for up to six months Pain on injection and skin atrophy can be side effects.

TREATMENT OPTIONS PRESSURE Pressure speeds up the formation of collagen, flattens the scar and reduces the number of cells in a given area. It needs to be started early and kept on 24 hours a day for a year or so and have poor results on six month + scars. It can be used in conjunction with other treatments.

TREATMENT OPTIONS SILICONE Silicone gel sheeting has been used since the early 1980’s to manage keloid and hypertrophic scars. It is painless, and used regularly for burns, surgical procedures and traumatic events. Hydration from the silicone gel, modulates the effects of keratinocytes on fibroblasts in the scar tissue.

TREATMENT OPTIONS SILICONE Randomised controlled trials have demonstrated that silicone gel sheeting is a safe and effective management option for both types of scar. (Mustoe et al 2002). Scars that are treated with silicone less than three months old do not become hypertrophic!! (English and Shenefelt 1999). Silicone improves the itching, pain,colour. It has been proved to flatten hypertrophic scars quicker than pressure.

TREATMENT OPTIONS Radiotherapy Cryotherapy Laser therapy

ANY QUESTIONS??