Scar correction: principles for choosing a treatment plan

Svetlana Korkunda , Ph.D., Associate Professor of the Department of Combustiology, Reconstructive and Plastic Surgery, Kharkov Medical Academy of Postgraduate Education (Kharkiv)

Topical methods

Topical methods for correcting scar tissue include the direct use of various cosmeceuticals and physical factors that affect the quality or color of scar tissue. Anti-scar creams are most often used - on the recommendation of a doctor, patients independently apply them to the scar tissue. As a rule, the earlier such treatment is started on an active scar, the better the result (except in cases of keloid scar).

Also, patients are recommended to wear elastic pressure bandages or special compression garments from the moment the scar forms. This method is used for hypertrophic and keloid scars (that is, scars with “plus tissue”) in order to compress the vessels in the scar tissue and inhibit its development. Such an effect should be implemented for at least 23 hours a day (that is, the patient can remove the bandages only for hygienic or therapeutic procedures), for a total period of at least 4-6 months - depending on the type, location and type of scar.

In combination with pressure bandages, patients are recommended to use silicone plates - they are applied to scars for several hours a day (up to 12 hours in total), they have practically no shelf life and are individual means of treatment.

However, the specialist needs to remember that all these methods are used only for active scar tissue and are completely ineffective for old scars!

Correction of dyschromia

Often, scar tissue has a different color from unchanged tissue - such dyschromia can have manifestations of both hyperpigmentation and depigmentation. Depigmented areas of scar areas react very poorly to any impact, so the use of decorative cosmetics is recommended for such patients.

To correct hyperpigmentation, as well as to even out the microrelief, courses of superficial peeling or 1-3 mid-peeling procedures are carried out. Naturally, such procedures assume that the patient will be in strict photoprotection mode during treatment and subsequently, which is especially important in the summer.

Depigmenting cosmeceutical systems (Obagi), containing tretinoin in high concentrations, have not only the effect of correcting hyperpigmentation, but also a pronounced anti-scar effect.

Physiotherapeutic methods

Physiotherapy in the correction of scar pathology is used in various protocols.

In the presence of active scars with severe itching and pain, a course of electrophoresis with chlorpromazine can be prescribed. For hypertrophic and keloid scars during the period of active development, the following complex of simultaneous treatment is used: magnetic therapy on the entire surface of the scars, phonophoresis with steroid ointments and electrophoresis with enzyme preparations or potassium iodide immediately after magnetic therapy on different areas, alternating each day the procedure on different areas of the scars. Phonophoresis can also be carried out with low-dose drugs in combination with special gels (Guna Gel Therapy) - “Traumel S” and Made for active scars; Placenta compositum, Made, "Collagen D6", Coenzyme compositum for atrophic or old scars. Atrophic scars are an indication for vacuum roller massage.

Italian and American laser therapists have experience in phototherapy of scars. Laser units with a specific wavelength are used to target various types of scar tissue. Photoenergy causes biophysical changes in scar tissue, which is clinically manifested by a decrease in the volume and vegetative activity of hypertrophic scars and, conversely, replenishment of the volume of atrophic ones.

Balneotherapy in the treatment of patients with scars can be implemented in sanatoriums with natural sources of radon and hydrogen sulfide or in physiotherapy departments. Courses of radon and hydrogen sulfide baths or applications and irrigations are quite effective in patients with active scars, in eliminating scar contractures. Mature scar tissue is not an indication for balneotherapy - in this case, balneotherapy can only act as a component of the treatment of concomitant pathology. In addition, this method has age restrictions: children and patients of the older age group receive treatment in lower doses or it may be contraindicated for them.

Cryotherapy for pathological scars is indicated in the presence of active hypertrophic or keloid scars. It is carried out in cryomassage mode (course every other day or daily) or cryodestruction. The danger is recurrence of the pathological scar.

Microdermabrasion can only be used for inactive or atrophic scars, since mechanical trauma to active scar tissue will provoke either scar recurrence or hyperpigmentation.

Injection methods

Intra-scar injections are carried out by several groups of drugs.

Hormone therapy

Steroid drugs have been used for several decades to be injected directly into scar tissue. The result of this effect is the destruction of scar tissue - the disintegration of existing tissue with preservation of fibrosis. A complication of the administration of hormonal drugs may be atrophy of the healthy dermis or subcutaneous fat when the drugs get into them and not into the scar. Courses of hormone therapy include no more than 4–5 procedures, carried out at intervals of 10–14 days; Not indicated for children and for use on the face.

Enzyme preparations can also be prescribed in the form of intraruminal injections - such courses, consisting of at least 20 procedures, are carried out 2-3 times a week. If the patient has large scar areas, treatment is carried out segmentally.

NB! Hormonal and enzyme preparations are effective only for active hypertrophic and keloid scars and are not indicated for atrophic and old scars!

Homeomesotherapy

It involves intraruminal administration of low-dose drugs in courses 2 times a week, lasting at least 8 weeks. Protocols for such treatment are presented in my article published in “Les Nouvelles Esthetiques Ukraine” No. 6 (76)/2012. In patients with active scars of any etiology and morphology, the drugs “Traumel S”, “Lymphomyosot”, Made, “Collagen D6” are used; for old or atrophic scars - Made and "Collagen D6", Placenta compositum, Coenzyme compositum, "Ubiquinone", as well as hyaluronic acid preparations - in particular, the Ukrainian-made drug Hyalual has been proven to be highly effective in the treatment of atrophic scars. The advantages of homeomesotherapy lie in the universality of its effect on scars (any scar tissue can be treated, regardless of age and morphology), safety and usefulness of the result (scar tissue is remodeled and transformed into a more normotrophic one).

An alternative for mesotherapy of atrophic scars is the use of dermarollers with the application of regenerating drugs (including low-dose ones) to the scars during the procedure. Microtrauma and penetration of therapeutic substances cause a remodeling effect on inactive or atrophic scar tissue.

Injection methods for treating scars also include options for general effects: pyrogenal therapy (a course of intramuscular injections of Pyrogenal according to a special scheme until the temperature rises, followed by a dose reduction); intramuscular injections of biogenic stimulants (aloe extract, FIBS, vitreous) - prescribed in a course of at least 30 procedures every other day. Currently, these drugs have very limited use.

Surgical excision

Surgical treatment is the option of choice for extensive hypertrophic scars and the only method that can help the patient as much as possible, although it may leave behind more or less noticeable postoperative scars. In this case, it is very important to carry out a differential diagnosis of keloid scars before excision.

If there are small scars, the operation can be performed simultaneously, with the application of cosmetic sutures. If suturing the wound after excision of scar tissue without tension is impossible, then stage-by-stage (with an interval of several months) excision of the scar is carried out until its area is minimally reduced, followed by excision and the application of cosmetic sutures. There are many types of local plastic methods for eliminating the wound defect that forms during excision of scars, as well as options for obtaining additional plastic material. For example, with endotissue dermatension, a special expander is implanted subcutaneously next to the scar tissue, which is subsequently filled with sterile liquid and thus stretches the skin above it. During the second stage of surgical treatment, the scar is excised, and a flap of the appropriate size with feeding vessels is cut out from the dermatension dome and moved to the wound defect. This method makes it possible to particularly effectively rehabilitate areas of a specific structure (scalp, face, perineum, joint area).

Modern surgical treatment protocols also involve the use of a number of the above treatment methods in the pre- and postoperative periods to prevent pathological scar formation during the formation of postoperative scars.

The presented options for influencing scar tissue can be combined and in any case are subject to individual prescription according to clinical indications. Also, patients with scars are recommended to use vitamin-mineral and protein complexes as sources of additional plastic material in order to create the most favorable conditions for the remodeling of scar tissue.

First published: Les Nouvelles Esthetiques Ukraine, No. 3 (79), 2013, pp. 74-79