Classification and methods of correction of keloid scars

Natalia Sachuk, chief physician and co-owner of the Farmosa MC, doctor of the highest category, dermatovenerologist, trichologist, dermato-oncologist, cosmetologist, member of the All-Ukrainian Academy of Dermatovenerology, Association of Psoriasis, Association of Preventive and Anti-Aging Medicine, Society of Trichologists of Ukraine, All-Ukrainian Association of Dermatovenerologists and Cosmetologists (Ukraine)

Trauma to the skin below the level of the basement membrane and the lower third of the hair sheath, covered with epidermis, leads to the formation of scar tissue. Depending on the depth and area of ​​the injury, the time of its healing, endocrinological and immune status, scars can be of a different nature, and the approach to their treatment will be completely different.

Scar classification

All scars are divided into two large groups: normal and pathological.

Normal scars:

• normotrophic (level with the skin, without atrophy of the underlying tissues);
• atrophic (level with the skin, with tissue atrophy);
• hypotrophic (retracted, with the presence of minus tissue).

Pathological scars:

• hypertrophic (protruding above the skin due to hyperproduction of collagen);
• keloids (occur as a result of pathological proliferation of coarse fibrous connective tissue).

Pathological scars present certain difficulties in treatment and diagnosis, and therefore arouse interest and caution among specialists in aesthetic medicine. Their formation is based on pathomechanisms that have a great influence on the appearance of the scar:

• pathological scars arise as a result of a long-term inflammatory process at the site of skin damage as a result of the addition of a secondary infection;
• excessive formation of inflammatory mediators leads to disruption of microcirculation in connective tissue and increased synthesis of collagen and glycosaminoglycans by fibroblasts , induction of chemotaxis and proliferation of certain populations of fibroblasts, which are characterized by high metabolism and collagen synthesis;
• swelling and inflammation of tissues lead to hypoxia, accumulation of free radicals in tissues, NO, which also stimulate fibroblast metabolism;
• the accumulation of functionally active fibroblasts at the site of the pathological process determines the nature of further tissue changes.

An important point in influencing the formation of scars is the correct alignment of the edges of the wound when suturing it, especially when the skin bordering the wound is too stretched.

Stages of scarring

After the triggering mechanisms for scar formation occur, it goes through three stages of physiological scarring:

1. Fibroblastic stage:

• lasts up to 30 days
• characterized by the proliferation of young fibroblasts, an abundance of blood vessels, epithelization by the 18th day, the formation of a large amount of amorphous substance in the scar tissue and the production of reticular fibers;

2. Fibrous stage:

• formed by the 33rd day from the moment of injury
• Characterized by the presence of mature fibroblasts and the accumulation of fibrous structures, primarily collagen fibers, in scar tissue;

3. Hyaline stage:

• is formed by the 42nd day;
• It is characterized by hyalinosis of collagen fibers of scar tissue, a decrease in the number of cells and vessels.

An important fact is that up to 26 days, physiological (normotrophic) and pathological (keloidogenesis) scarring occurs in a similar way, and then everything depends on the course of the processes described above: they can stimulate keloidogenesis.

The main differences between the stages of formation of a pathological scar:

• in stage I (fibroblastic), against the background of a large number of young fibroblasts, their clusters appear - nodules. The fibroblastic stage in keloid scars lasts up to 1 year; over time, maturation is observed only in the deep layers;
• in stage II (fibrous), young fibroblasts continue to dominate quantitatively and form large nodular clusters;
• in stage III (hyaline), the number of young fibroblasts also does not change, but the synthesis of immature components of the intercellular substance is activated, and subsequently the tissue does not tend to normal maturation processes.

Features of keloid scars

Visually, the formation of a keloid scar begins 2⎼3 weeks after the wound has healed slightly. Then, areas of highly compacted tissue appear in the area of ​​damage, pain, increased sensitivity, burning and itching occur, and hard, glossy skin seals form at the site of the scar.

When a keloid just begins to form, the skin becomes red or, conversely, turns pale. The contour of a keloid scar is always located outside the main damage (wound or cut) and often exceeds it by 1.5⎼2 times. In some cases, a keloid scar does not stop growing even after several years. An autoimmune process is assumed with the formation of antibodies to fibroblasts, enhancing their ability to synthesize collagen. The importance of the mechanical properties of the skin is also pointed out, in particular increased tension, which is different under normal conditions in different zones, which explains the predominant localization in certain parts of the body, such as the anterior surface of the sternum, neck, chin, perioral region, earlobes, shoulder girdle, area around the joints.

People with dark skin are more likely to develop keloid scars. Both men and women are equally susceptible to their occurrence. Most often observed in patients aged 10 to 40 years. They appear less frequently in children and the elderly. Hormonal, endocrine status, stress influence the formation of a disturbed immune process.

Types of keloids

Spontaneous and secondary keloids

Spontaneous ones are dense tumor-like formations of pink, red or bluish color and of various shapes: spherical, tick-shaped. The seals are located more in the central part, which rises above the skin, has a shiny and smooth surface with many telangiectasias. The skin in the keloid area is tense, often inflamed, ulcerated with the formation of difficult-to-heal erosions.

Secondary keloids, unlike hypertrophic scars, extend beyond the initial injury and often have a spherical or linear shape. Spontaneous keloids often have an irregular stellate outline. Characteristic is the presence of claw-shaped strands that penetrate healthy skin.

Young and mature keloids

Young keloids include scars that appeared on the body less than five years ago. The skin in such areas can continue to grow and is smooth. The scar has a reddish-bluish tint.

Mature keloids exist for more than five years. Usually by this time keloid scars stop growing and become pale. Visually, the surface of the damaged area looks wrinkled.

True and false keloids

True keloid forms spontaneously, most often on the skin of the chest and upper third of the shoulder.

False - can develop anywhere after a skin injury.

Stages of development of a keloid scar

The formation of rough tissue occurs gradually, so doctors divide the process of development of keloid damage into four stages:

Stage 1 – epithelization:

• The wound or cut is overgrown with thin epithelial tissue.
• After a week, the resulting epithelium becomes denser, acquiring a pale color.
• 2–3 weeks after the injury, the injury site swells and a skin bulge appears.
• When you touch the area, painful sensations occur.

Stage 2 – swelling:

• Compaction occurs within 3⎼4 weeks.
• After about a month, the pain at the wound site disappears, the area covered by the connective tissue turns red.

Stage 3 – compaction:

• The site of injury is heavily overgrown with connective tissue, which is why dense formations are felt upon palpation.
• The scar resembles a tubercle rising above the healthy area.

Stage 4 – softening:

• The scar gradually loses its red tint and becomes pale.
• The neoplasm turns from dense to soft and mobile.
• On palpation, patients complain of pain.

A keloid scar that has passed through all four stages does not affect human health, but is a cosmetic defect that affects the psychological state. Sometimes, occupying large areas of the skin, keloids can even limit physical activity. Keloids never disappear on their own, nor do they decrease in size over time. Only with the help of medical, cosmetic and surgical procedures can damage be corrected or removed.

Treatment of keloid scars

When treating keloid scars, combined therapy methods are used, which must be individual, taking into account the type of scar, location, and size.

Surgical methods of treatment

It is used mainly for old scars; the following types of skin grafting are most often used: free, combined, with a skin flap on a feeding pedicle, stalked and others.

Drug therapy

Mainly used for flatter, softer, fresher scars. Corticosteroids are injected into the keloid tissue at intervals of 2⎼4 weeks. "Diprospan" or "Kenalog" is used. Practice shows that it is better to dilute these drugs with saline solution in order to avoid pronounced atrophy in the injection area, as well as the development of telangiectasia in adjacent areas of the skin. Therefore, injections should be carried out strictly in the central, densest part of the scar. The number of procedures, as a rule, does not exceed 3⎼5. This method is aimed at controlling the production of collagen by fibroblasts.

It is also relevant to use enzymes aimed at stopping the development of connective tissue, such as Longidase, Lidaza, Hyaluronidase - 250 IU in 0.5 ml of solution. To do this, take a bottle with 3,000 IU and dissolve it in 6 ml of saline solution. Such drugs break down hyaluronic acid, the building material of the keloid scar. The course includes from 5 to 10 injections. This therapy can be repeated after a year, but this is usually not necessary.

Physiotherapy in the treatment of keloids

1. Squeezing
   As soon as the scar begins to form (no older than 1 year), a compressive silicone plate is applied to it, due to the external pressure of which the growth of the keloid is stopped. The plate should be worn around the clock for 9⎼12 months.
   If there is a predisposition to the formation of keloid scars, then such a gel silicone patch is applied to the wound immediately after primary healing; it should also cover part of the healthy skin to stop the development of new vessels in the adjacent areas. It is advisable to use the patch 24 hours a day for from three months to one and a half years.
   There is silicone in the form of a gel that forms a film (for example, Sodermix, Dermatix), but it is used only at the stage of hypertrophy formation and is no longer effective for formed keloid.
   
2. Ultrasound therapy
   The procedures are performed locally: ointments or gels are applied to the scar, in which the active ingredients are the enzymes listed above. For better and faster effects, electrophoresis and phonophoresis are used.
   
3. Laser resurfacing of keloids
   The action of the laser can be aimed at several points: telangiectasia and destruction of scar tissue. The nutrition of the neoplasm is disrupted due to the gluing of capillaries by Q-switched laser radiation. At our Farmosa medical center, the method most often used is laser non-ablative fractional erbium scar resurfacing. To achieve maximum effect and prevent relapses, which are still possible, in addition, local corticosteroid therapy is used.
   Non-ablative resurfacing is used in a course of up to 5–6 procedures, once every 3–4 weeks, locally, only on the scar. In this case, dry crusts form on the 4th day, which last up to a week. When using ablative lasers, the percentage of keloid return is too high, so this technique is undesirable.
   The timing of the post-destructive rehabilitation period is important, since the post-inflammatory reaction can cause a relapse. For this purpose, soft regenerants are used, for example, “Bepanten Plus”, “Vulnostimulin”, and only for a short period - up to two weeks.
   
4. Cryodestruction – intralesional and local external
   The use of liquid nitrogen intralesional using a cryodestructor "Krion" with a special intralesional nozzle causes destruction of the keloid. The duration of the procedure is 5–15 seconds, this is enough for the necrosis of scar tissue cells to occur. Effective on young keloids. Due to the high temperature, application cryodestruction is used extremely rarely and gives poor results.
   
5. UV protection.
   If keloid scars are located on exposed areas of the body, then sunscreen with SPF 100 should be used in addition to other treatment methods to prevent hyperpigmentation from occurring.

Unfortunately, patients often turn to qualified doctors late, self-medicating and using traditional methods, which can sometimes lead to a worsening of the situation. It must be explained that the sooner treatment begins, the more effective the result will be. This is especially important to consider when prescribing local corticosteroid therapy.

There is no ideal method for treating keloid scars - only a comprehensive professional approach will help make them less noticeable and minimize the possibility of relapses and complications.

First published in ​"Les Nouvelles Esthétiques Ukraine" No. 1 2017