Injection options for treating hypertrophic scars

Kristina Novak (Mushikhina) , otorhinolaryngologist, plastic surgeon, specialist in contour plastic surgery, graduate student of the Department of Otorhinolaryngology of NMU named after. O.O. Bogomolets

There are several ways to treat hypertrophic scar . Unfortunately, they tend to recur after surgical removal; they can also appear as a result of surgical correction of atrophic and normotrophic scars. Today's medical options include surgery, compression therapy to remove scars, as well as topical treatments such as injections or medical devices.

Recent studies show that effective treatment results can be obtained using infiltrated unstable hyaluronic acid and glucocorticosteroids. Let us analyze the clinical experience of such therapy.

Brief description of a clinical case

History: A 29-year-old patient came to us for the removal of a type II hypertrophic scar located in the area of the external nose, on the dorsum. Read more about the types and clinical features of hypertrophic scars in the previous article . The scar appeared 2 years ago after surgery due to a boil on the external nose.

Treatment: Association therapy using unstable hyaluronic acid and cortisone has been proposed.

Conclusion: The treatment made it possible to completely eliminate the hypertrophic scar, without relapse and deterioration in aesthetic appearance several months later.

Disease history

The patient noticed the presence of a hypertrophic scar located in the area of the left wing of the external nose. The scar appeared 2 years ago after surgery due to a nasal boil. Postoperative evolution included normal wound healing during the first 3 days, but localized wound infection occurred on day 5. The patient underwent systemic antibiotic therapy and removal. Lruxol ointment was added to the treatment. No relapses were observed. 35 days after the last examination, a hypertrophic scar (about 1-5 cm) again developed in the wound healing area.

Sixty days later, after a detailed examination, the patient was offered surgical excision of the scar, which was refused.

After 2 years, the patient contacted us with a request to correct the scar. According to her, she refused laser treatment.

Treatment regimen

We offered therapeutic hydrocortisone injections and unstable hyaluronic acid injections (Lacerta®; Diprospan).

Having received consent, before the above treatment, a course of betamethasone dipropionate 6.43 mg was administered (1 ml administered using a 30-gauge needle), infiltration of the scar and surrounding area was done using a 30-gauge needle, after which the steroid was released in a retrograde manner.

After each injection, the patient used topical Dermatix® therapy with daily use (once daily) for the first 30 days of therapy. No compression treatment was used.

Thirty days after the last hormone infiltration, treatment was stopped to monitor the development of the affected area. 35 days after the end of the course, the hypertrophic scar acquired a soft consistency, decreased by 40%, and the skin adhesions became smaller.

We performed two intercellular infiltration procedures with 0.8 ml of unstable hyaluronic acid (Lacerta®) between Diprospan therapy sessions, even during the second hormone treatment session.

The adhesion disappeared and the scar was reabsorbed 15 days after the last cortisone infiltration. No recurrence of the lesion was observed at follow-up visits at 6 and 12 months.

Treatment results: A - before photo; B - photo after

conclusions

Combined treatment with hyaluronic acid and glucocorticosteroids is often used in various fields of medicine to treat inflammatory tendon diseases. Recent in vivo and in vitro studies have elucidated the mechanism of action of this therapy: steroids are able to reduce fibroblast proliferation in a dose-dependent manner, while hyaluronic acid can reduce inflammation by affecting prostaglandin secretion.

The ability of unstable hyaluronic acid to strengthen the extracellular matrix of the dermis is also widely known when used regularly for a minimum of three consecutive sessions with a maximum period of 30 days between injections. Hypertrophic scars are rich in fibrocytes and rough connective tufts, which increase the texture and formation of the scar, making it more like a “tendon” structure. Based on the structural similarity between the two tissues, we predict that the combination of Diprospan and Lacerta® will cause scar regression.

Treatment sessions alternated between steroids and hyaluronic acid every 15 days throughout the treatment period. The course can balance the turnover of fibroblasts, inducing a wound healing mechanism without pathological activity and determining scar involution. The precision of the injection method, especially when injecting hyaluronic acid directly into the dermis, was definitely an important aspect of this therapy.

Various treatments are now available to prevent hypertrophic lesions, such as topical silicone therapy, collagen cream, or cortisone. These methods, unfortunately, can only be used at the remodeling stage of wound healing (in the first year after injury).

Possible treatment algorithms for patients with hypertrophic scarring

Pharmacological treatment using cortisone injections directly into the dermis to reduce inflammation is carried out during the first 6 months after surgery to avoid and prevent the formation of a hypertrophic scar or keloid. If the scar recurs, laser therapy may be effective. Alternatively, surgical resection with careful postoperative monitoring of wound healing throughout recovery may be effective. Cryotherapy can be used as a stand-alone treatment or in combination with surgery/radiation therapy. The latest generation of treatments, which are still in the experimental stage, are the interferon bleomycin or 5-fluorouracil injections.

In the case described above, we used a combination of glucocorticosteroid (Diprospan) and Lacerta®, since the patient refused additional surgical treatment or laser therapy. Even if the scar was developed several years ago, repeated treatments carried out with different doses of hormone associated with non-cross-linked hyaluronic acid injections achieve complete resolution of the lesion. The precision of the dissection method, extended infiltration, dose adjustment according to lesion responses and constant repetition of therapy showed satisfactory results after 6 months.

Analysis of the treatment performed

In conclusion, I would like to dwell on the disadvantages and advantages of the methodology used.

Probably the most important disadvantage relates to the price of the unstable hyaluronic acid used for treatment, which may not be affordable for all patients. Less important disadvantages relate to the repeated infiltrations required to obtain results. A similar problem also arises when using laser treatment methods.

The advantages of the method used are primarily the physiological restoration of cell balance due to the dual effect of anti-inflammatory and stimulating effects. Although multiple infiltrations are necessary, we used a 25-gauge needle for hormone injections and a 30-gauge needle for hyaluronic acid injections, which resulted in less trauma and less inflammation. This is, for example, the opposite of surgical treatment, where there is always a subsequent inflammatory process. The retrograde infiltration technique can destroy the internal structure of the scar and, by releasing unstable hyaluronic acid after passage of the needle, change the nature of the cells to restore normal skin histology. Other methods, such as cryotherapy or radiation therapy, are able to destroy only the keloid structure and identify fibrotic changes in skin cells without actual tissue regeneration.

Finally, the technique used is able to increase the cellularity of the lesion and improve the quality of vascularization in the treated area due to the regenerative ability of unstable hyaluronic acid without the risk of tissue necrosis that can occur when using compression devices.

I would like to emphasize as the conclusion of the case considered that, in addition to the dosage of medications, the number of treatments, and the long duration of time, the area being treated is also important. Pharmacological research to develop more viscous substances and the relationship between glucocorticosteroid and injectable hyaluronic acid may open new horizons in the development of innovative scar treatments.

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Read more about hypertrophic scars in the previous article from the author .