hyper trohpic scar MANAGEMENT FOR --pdf.pdf

MANAGEMENT OF HYPERTROPHIC SCAR

1. DR/MOSTAFA AHMED
LECTURER AT FACULTY OF
PHYSICAL THERAPY

2. ▪Ahypertrophicscar(HSC)isdefinedasaskinscarthatrises
abovetheskinlevelbutstaysinsidethebordersoftheoriginal
lesion.
▪Akeloidscar,ontheotherhand,isdefinedasascarthatgrows
outsidethemarginsoftheoriginalwound.
▪AlthoughtherearefundamentaldifferencesbetweenHSCand
keloidsintheirpathogenesisandnaturalhistory,bothresultin
increasedfibroblastsandextracellularmatrixformation.
▪HSCusuallydevelopduringthefirstthreemonthsaftertheinitial
injuryoroperation,whereaskeloidscarsappearwithinorover
12monthsaftertheinjuryandmayreappearevenseveralyears
aftertreatment.

3. PROCESSOFSCAR
FORMATION
▪Normalscarringoccursafteranytypeofinjurytotheskin,with
theexceptionofthemostsuperficialscratches.Thereisacritical
depthinaskinwoundafterwhichscarformationbegins,and
woundsthataremoresuperficialhavethepotentialtoheal
withoutscarring.Thisdepthisshowntobeapproximatelyone
thirdofthetotalskinthickness.
▪Thisisdemonstratedindermalburninjuries,wheresuperficial
dermalburnshealwithoutscarring,butdeeperdermalburns
oftendevelopmarkedlyhypertrophicscars,especiallywhen
treatedconservatively.

4. PROCESSOFSCAR
FORMATION
▪Whenalinearsurgicalwoundishealing,thereisusuallylittle
needforthescartocontract.Inalargerplanarwound,suchasa
burnwound,contractionoccursasaphysiologicalresponseto
decreasethewoundsurface.InaHSC,myofibroblastsoften
persistlongafterwoundclosureasaresultoftension,among
otherpossiblecauses.

5. CAUSESOFHERTROPHIC
SCAR
▪Prolongedhealingtime.
▪Genetic
▪Poorgranulationtissueformation
▪Unhealthygranulationtissue
▪Increasedmyofibroblastactivation
▪Chronicinflammatoryprocess
▪Infection

6. CALSSIFICATIONOFSCAR
Scartype Description
Maturescar Alight-colored,flatscar.
Immaturescar itchyorpainful,andslightly
elevatedscarintheprocessof
remodeling.Manyofthesewill
maturenormallyovertimeand
becomeflat.

7. CALSSIFICATIONOFSCAR
Linearhypertrophic A red, raised,
sometimesitchyscar
confinedtotheborder
oftheoriginalsurgical
incision.Thisusually
occurswithin2weeks
aftersurgery.
Widespreadhypertrophic
(e.g.,burn)scar
Awidespread red,
raised,sometimesitchy
scarthatremainswithin
thebordersoftheburn
injury.

8. CALSSIFICATIONOFSCAR
Minorkeloid Afocallyraised,itchyscar
extending overnormal
tissue.Thismaydevelopup
to1yearafterinjuryand
doesnotregressonitsown.
Simplesurgicalexcisionis
often followed by
recurrence.
Majorkeloid
Alarge,raised(>0.5cm)
scar,possiblypainfulor
pruriticandextending
overnormaltissue.

9. FACTORSAFFECTINGSCARFORMATION
▪RACE
Atwotimesgreaterincidenceofhypertrophicscaringhasbeennotedin
blackpopulationswhencomparedtoCaucasians.Thisphenomenonwas
attributedtopossibleabnormalityintheproductionofmelanocyte–
stimulatinghormone.
▪AGE
Ithasbeennotedthatapproximately88%ofhypertrophicscarsoccurred
inpeoplelessthan30years.Thehighincidenceofscaringinthisgroupwas
duetothatyoungerpeoplewithmoresusceptibletotrauma,havegreater
slinkrateofcollagensynthesis.Theelderlymayhavelessscaringdueto
decreasedcollagenmetabolism,lesselasticityandmoreskinredundancy.

10. FACTORSAFFECTINGSCARFORMATION
▪LOCATION
Hypertrophicscarsrarelyoccuroftheeyelids,genitals,palms,orsoles,whereskinin
relaxedorsplintedbyitsattachmenttounderlying.Certainareasofthebodyappearmore
predisposedtotheformationofhypertrophicscarssuchasthesternum,upperback,
shoulderdeltoid,Thebuttocksanddorsalaspectofthefoot.
▪DEPTH
Deeperburnswhichinvolvethereticulardermishavescarmorethansuperficialburns
thatinvolvesonlytheepidermisorthepapillarydermis.Thus,increasescaringisdueto
formationofagranulationtissueandprolongedhealingtime.
▪GANDER
Genderdoesnotappeartobeapredictorofscaring,withmalefemaleratiobeing
approximatelyequal.

11. PHYSICALTHERAPYMANAGEMENT OF
SCAR
1.SCARASSESSMENT
2.PHYSICALTHERAPYTREATMENT FOR
HEPERTROPHICSCARANDKELOID

12. SCARASSESSMENT
A.SUBJECTIVEASSESSMENT
▪ModifiedVancouverscarscale
▪Manchesterscarscale
B.OBJECTIVEASSESSMENT
▪Ultrasonicscanning
▪Laserdoppler

13. SCARASSESSMENT
A.SUBJECTIVEASSESSMENT
▪Modified Vancouver scar scale The
firstvalidatedandstillwidelyusedscar
assessmentscaleistheVancouverBurn
ScarAssessmentScaleorVancouverScar
Scale(VSS)developedby Sullivanetet al.
Theyscoredpigmentation,vascularity,
pliability,andscarheight/thickness,leading
toatotalscorebetween0and13points.

14. SCARASSESSMENT
A.SUBJECTIVEASSESSMENT
▪Manchesterscarscale
TheManchesterScarScalewasintroduced
byBeausangetal.in1998.Ithasfour
parameters(colour,contour,distorsionand
texture)

15. SCARASSESSMENT
B.OBJECTIVEASSESSMENT
▪Ultrasonicscanning
Suchasthetissueultrasoundpalpationsystem(TUPS),havebeenusedtoquantifyscar
thickness.
▪LaserDoppler
Usedforforthemeasurementofburnscarperfusion.

16. PHYSICALTHERAPY TREATMENT FOR
HEPERTROPHIC SCARANDKELOID
▪Scarmanagementforpost-burninjuryisalongandoftenpainfulprocess;itisnot
somethingthatcanbecarriedoutforafewweeksandthenabandoned,itis
somethingwhichmustcontinueformanymonthstominimizepost-burn
complicationsfromoccurring.
▪Keloidscarsareadifficultclinicalentity.Thereisnosingleeffectivetreatment
againstkeloids,andacombinationoftherapiesisusuallycommenced,including
cortisoneinjections,pressuregarmenttherapy,siliconegelsheetingand,in
severeandrecurrentcasesirradiationtherapyhavebeensuggested.Ifsimple
excisionisattemptedwithoutothertreatmentmodalities,therecurrencerateis
high,andinsomecasesthesituationcanbeworsenedwithsurgery.

17. PHYSICAL THERAPYTREATMENT FOR
HEPERTROPHICSCARANDKELOID
▪POSITIONIG
▪SPLINTING
▪STRETCHINGEXERCISES
▪MASSAGE
▪PRESSURETHERAPY
▪SILICONEGEL
▪LOWLEVELLASERTHERAPY
▪PRESSUREEARRINGS

18. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHICSCARANDKELOID
▪POSITIONIG
Anti-contracture positioningshouldcontinuetobeencouraged formanymonthspost-injury
▪SPLINTING
oSplintsprescribedarenotonlyessentialforpositioningbutalsoforstretchingandlengthening
thecontractedscartissue.Continuedearlysplintingremovedonlyforexerciseandspecific
functionalactivitiescanmaximizelong-termoutcomeandcanbecontinuedfor6monthspost-
healingto2yearsinchildren.
oThesplintingregimeshouldbereducedgraduallytoovernightsplintingonceROMisbeing
maintained.

19. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHICSCARANDKELOID
▪STRETCHING EXERCISES
oIftheburnisclosetooroverajoint,itmustbestretchedtoavoidlossofROM
andtopreventapost-burncontracturedeveloping.
oStretchingofaffectedjointsseveraltimesadaytotheirmaximumfunctional
range,inconjunctionwithasplintingregimeappearstohelpelongatethescar
tissuemaintainingROM.
oWhenthescartissuedoesnotrespondtorepeatedtreatmentsorthe
contractionincreases,thetissueswillrequiresurgicalreleasetoregainthe
rangeofmovement.

20. PHYSICALTHERAPYTREATMENTFORHEPERTROPHIC
SCARANDKELOID
▪MASSAGE
oBymassagetheupperlayerofthescarbecomessofterandmorepliableand
thereforemorecomfortable;thisalsohelpstoreduceitchingwhichcanalsobea
commonproblem.
oWhenscarsbecomethickandraised,theyholdadditionalfluid,Throughdeep
firmmassageofthescarusingthethumborfingertips,theeffectofthisexcess
fluidcanbereduced.
oMassagingwhileperformingstretcheshelpstoincreaseROMofalimbaffected
byaburnscar.
oBurnsscarscontainfourtimesmorecollagenthanotherscars.Deepmassageof
thescarinsmallcircularmovementsisthoughttohelpimprovewithalignmentof
thescartissueasitisformed.
oPsychologicalfactorsofindividualshavingdifficultyincomingtotermswith
having,whattheyfeelis,anunsightlyscarcanalsobereducedbytouchingthe
scarandlearningtoaccepthowitlooksandfeels.

21. PHYSICALTHERAPY TREATMENT FOR
HEPERTROPHIC SCARANDKELOID
▪PRESSURETHERAPY
oApplyingpressuretoaburnisthoughttoreducescarringandencouraging
reorientationofcollagenfibres.
ocreatelocalisedhypoxiatothescartissueandreducingbloodflowtohyper-
vascularscarsandthereforereducingtheinfluxofcollagenanddecreasing
scarformation.
oAssoonasthewoundsarefullyclosedandabletotoleratepressure,patients
arefittedwithpressuregarments.
oWhengarmentsarenotavailable,othermaterialscanbeusedaseffective
replacementssuchaselasticsupportbandages,'lycra'swimwearandcycling
shorts,sportsheadandwristbandscanbeused.
oPressuregarmentsmustbeappliedasearlyaspossibleformaximumeffect
andwornfor23hremovingonlyforwashingandcreamingofscars.

22. PHYSICALTHERAPY TREATMENT FOR
HEPERTROPHIC SCARANDKELOID
▪PRESSURETHERAPY
oIfapatienthasskingrafting,theyshouldbeprovidedwithapressuregarment
assoonaspossiblepost-healing.Iftheyhavehadanextensiveburnand
scatteredsmallunhealedareasremain,apressuregarmentcanbeapplied
withsmalltopicaldressingsappliedbeneathit.
oPressuregarmentsappear to help
•reducescarthickness/lumpiness
•reducescarredness
•reduceswelling
•relieveitching
•protectnewlyhealedskin/graft
•preventcontractures/maintaincontours

23. PHYSICALTHERAPY TREATMENT FOR
HEPERTROPHIC SCARANDKELOID
▪SILICONEGEL
oSiliconeisanothermodalityusedtotreathypertrophicscarring.The
exactmechanismofactionofsiliconeinthepreventionand
managementofhypertrophicscarsisunclear,althoughitislikelyto
influencethecollagenremodelingphaseofwoundhealing.Itappears
tosoftenandflattenscar,makingitcomfortableandimprovingits
appearance.
oHowtousethesiliconegelsheet:
1)Cutapiecelargeenoughtocoverthescarcompletely.
2)Thesheetshouldbeleftinplaceaslongastolerated—evenall
day.Thelongeritisinplace,thebetter.
3)Thepatientshouldremovethesheettowash.
4)Sheetsshouldbeusedforatleast2–3monthstomakean
appreciabledifference.

24. PHYSICALTHERAPY TREATMENT FOR
HEPERTROPHIC SCARANDKELOID
▪LOWLEVELLASERTHERAPY
Lowlevellasertherapywithcontinuouslaserpowerdiodeoutputof400mW,emittingredlaser
lightwithawavelengthof670nm,appliedenergydensity(dose)of4J/cm2andradiationtwice
aweek,withaminimumintervalof3days,over8weeksshowedinhibitoryeffectonpostburn
hypertrophicscarthroughitseffectinimprovingwoundhealing

25. PHYSICALTHERAPY TREATMENT FOR
HEPERTROPHIC SCARANDKELOID
▪PRESSUREEARRINGS
Somepatientsdevelopkeloidsafterearpiercing.Earrings
designedtoapplypressuretotheearlobearecommercially
available.Theyworkbestonsmallkeloids(<1cm).Pressure
earringsareespeciallyusefulwhencombinedwithexcisionof
thekeloid.Oncetheexcisionsutureshavebeenremoved,the
patientshouldweartheearringforatleast2or3months
(longerisbetter).Thisapproachmaypreventrecurrenceofthe
keloid.