Treatment Options to Reduce Scarring in Wound Healing

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Presentation given at the 11th annual Symposium on Wound Care 2011 sponsored by the Baptist Health System San Antonio, Texas.

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  • Treatment Options to Reduce Scarring in Wound Healing

    1. 1. Treatment Options to Reduce Scarring in Wound Healing Suresh Koneru, MD
    2. 2. Contact Info• 423 Treeline Park, #300, SAT 78209• 210-499-5900• doctorkoneru@yahoo.com• www.twitter.com/drkoneru• www.DrKoneru.com• www.linkedin.com/in/sureshkonerumd
    3. 3. Scarring• Prevention• Treatment
    4. 4. Stages of Wound Healing• Inflammatory • Platelet aggregation and release of growth factors• Proliferative • Granulation tissue formation, collagen deposition, and epithelialization• Remodeling • Collagen III to I, contraction of scar
    5. 5. Animal Models• None for Hypertrophic or Keloid scar• Red Duac Pig• Rabbit Ear• Fetal Mice and Pigs
    6. 6. Snake Oil
    7. 7. Prevention - Inflammatory Phase• Fetal Wound healing has decreased inflammatory Phase • Increase in TGF-β3 and decrease in TGF-β1 and TGF-β2• Increases in Epinephrine causes increase Neutrophil proliferation and decrease keratinocyte, stem cell, and collagen migration • Stress causes increase in Epinephrine, Timolol blocks
    8. 8. Fetal Wound Healing
    9. 9. Reference
    10. 10. Promise of TGF-β3
    11. 11. Promise of TGF-β3
    12. 12. Phase 3 Trial• Renovo a U.K. Based Biopharmaceutical company product JUVISTA• REVISE Trial failed to meet primary or secondary efficacy endpoints (Feb 2011)• Same company has other products: • Prevascar - IL-10 • Juvidex - Mannose - 6 - Phosphate
    13. 13. Stress and Inflammatory Modulation• Beta blockers like Timolol have been shown to block epinephrine inhibition of wound healing• Ref: Slowing of Wound Healing by Psychological Stress by Klecolt-Glaser, et al; The Lancet, 1995 Vol 346, pp 1194-1196
    14. 14. Prevention - Proliferative Phase• Minimize Collagen build-up• Topicals applied after epithelialization
    15. 15. Vitamin E• Antioxidant and Membrane Stabilizing Agent• Would take the average American 4 years to become depleted• May have an effect similar to steroids on inhibiting collagen formation but this is counteracted by Vitamin A• Prospective double blinded randomized trial on burn patients showed no effect on scar thickness, range of motion, or cosmetic appearance. Almost 20% suffered skin irritation • Jenkins, M., Alexander, J. W., MacMillan, B. G., Waymack, J. P., Kopcha, R. Failure of topical steroids and vitamin E to reduce post-operative scar formation following reconstructive surgery. J. Burn Care Rehabil. 7: 309, 1986
    16. 16. Mederma• Derivative quercetin is a bioflavinoid has antiproliferative effects and antihistamine effects.• Rabbit Ear Model - Improvement in dermal collagen, but no difference in scar thickness, erythema, dermal vascularity, or inflammation • Effect of Mederma on Hypertrophic Scarring in the Rabbit Ear Model, Mustoe, T et al, Plast. Reconstr. Surg. 110: 177, 2002
    17. 17. Massage• Topical to aid in hydration of the scar• Massage applies pressure to the scar
    18. 18. Surgical Prevention• Tension free approximation of skin edges• Incisions along Langer’s lines• Minimize suture and reaction• Everting skin edges• Full Thickness grafts or flaps to prevent contraction
    19. 19. Treatment• Steroid Injections • In the office • Kenalog (triamcinolone acetonide) • Can cause increase in BS in DM
    20. 20. Treatment• Compression • Garments to exert constant pressure on scar and remodel collagen • Massage is a form of pressure • Orthoplastic devices
    21. 21. Compression Basic Science
    22. 22. Treatment• Silicone • Available commonly as a sheet or as a gel • May have some effect on electrostatic forces • Benefit of hydration of stratum corneum • Recommend at least 12 hours/day of coverage
    23. 23. Silicone References
    24. 24. Treatment• Occlusion • Tape may have a mechanical stress relieving effect in addition to occlusive benefit • Paper tape simple to place on incisions • Recent occlusive dressing with silicone (Neodynebio.com) holds some promise
    25. 25. Occlusion References
    26. 26. Reference for References
    27. 27. Treatment• Laser • 585 nm Pulsed Dye laser improves redness, pliability, bulk, and dysesthesia • CO2 and Er:YAG may improve atrophic scars
    28. 28. Treatment• Radiation Therapy • Reserved for keloid scar • Probably most effective when used postop excision of keloid immediately following surgery (same day) • Dose adjusted based on location, ethnicity, and character of the keloid (10 to 20 Gy daily divided anywhere from 2 to 4 days)
    29. 29. Treatment• Fat Grafting • The promise of Stem Cells • Grafted fat maintains the characteristics of the donor fat, but also takes on some of the characteristics of the recipient tissue. • Recipient characteristics are likely due to stem cells
    30. 30. Fat Grafting Reference
    31. 31. Summary• Prevention • Good Surgical Technique • Minimize tension, Eversion, Identical tissue • Minimize Inflammatory Phase
    32. 32. Summary• Treatment • Steroid Injections • Massage • Compression • Taping • Silicone • Laser • Radiation • Sun Avoidance
    33. 33. Treatment Options to Reduce Scarring in Wound Healing Suresh Koneru, MD

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