Filippova Olga, Baindurashvili Alexey, Krasnogorskiy Ivan, Afonichev Konstatnin

1. CAUSES OF HYPERTROPHIC SCARS IN CHILDREN WITH
EFFECTS OF BURNS
AND WAYS TO PREVENT THEIR DEVELOPMENT
Filippova O.V., Baindurashvili А.G.,Krasnogorskiy I.N., Afonichev К.А.
FSBI «Scientific and Research Institute for Children’s Orthopedics n.a.
G.I.Turner»
under the Ministry of Health of the Russian Federation
Saint-Petersburg
 Significance:
 extensive planar scarring is not
always possible to remove
completely with surgery;
 obvious clinical presentation
that causes considerable
discomfort in the child
indicates the need for
systematizing of conservative
treatment based on
morphological features of
scarring at each stage of their
maturation;
 prolonged excessive activity of
scarring process impairs
functional and aesthetic
outlook and the possibility of
reconstructive surgery in the
future.
 Objective: to identify the
leading mechanisms of
hypertrophy of postburn scars
at different stages of their
maturation, to develope
regimen of conservative
treatment.

2. Clinical material and methods
 Patients: 217 children aged from 4 to 15 y/o, with extensive
scarring requiring multistage reconstructive treatment
 Methods:
 Clinical: assessment of anamnesis, complaints, external
characteristics of scarring
 Histological method: evaluation of morphometric parameters of
scar layers and microvascular bed, cells, and their number
 Immunohistochemical method:
~ detection enzymes of mast cells, which play an important role in
the development of inflammation and remodeling of connective
tissue matrix (Mast cell Tryptase);
~ detection of identifier of macrophagal activity CD 68;
~ detection of markers of cellular apoptosis - p53 and its inhibitor
- Protein bcl-2
Histological and immunohistochemical studies were
performed using the equipment:
~ preparation of slices: Microm STP 120, Microm EC350, Microm
HM 430 (Carl Zeiss, Thermo Scientific, Germany);
~ microscopic examination of histological preparations and
photographs were taken using a light microscope Axio Scope А1
(Carl Zeiss, Germany);
~ morphometric measurements were carried out in the studied
tissues using light microscopy Leitz (Wetzlar, Germany);
~ the study of processes in the scar tissue was performed with
monoclonal antibodies to various antigens Novocastra, Leica
Microsystems (United Kingdom), Sigma-Aldrich (Israel)

3. Lymphocytes, macrophages and mast cells are a source of
fibrogenic cytokines. Excessive activity of lymphocytes,
macrophages (CD 68) and mast cells (Mast cell Tryptase)
enhances fibrosis and scar hyperplasia
0
500
1000
1500
2000
2500
1-6
mon.
7-12
mon.
1-2 y. 2-6 y.
Intact skin
Scar
Number of
lymphocytes
at 1 мм2
Lymphocytic infiltration
in the scar
Intact skin
0
20
40
60
80
100
120
140
160
180
200
1-6
months
1-2 y.
Intact skin
Scar
0
50
100
150
200
250
300
1-6 m. 7-12 m. 1-2 y. 2-5 y.
Intact skin
Scar
+ CD 68
at 1 мм2
+ Mast cell Tryptase
at 1 мм2
 Increased activity of
macrophages CD 68 is
observed for a further year
after epithelialization
of burn wound
 During the first 6 months
after the burn wound
epithelialization, enzyme
(Mast cell Tryptase) increase
is noted, indicating the
activity of mast cells.
(hematoxylin-eosin, × 300)

4. Prolonged macrophage-lymphocyte activity in the
scar creates a cytokine pattern that contributes to
disorder of cell apoptosis and long synthetic activity
of fibroblasts
4 - 12 months after epithelialization: strong decrease in the ability of
cells to apoptosis p53, accompanied by increased apoptosis
inhibitor bcl-2 in the first half-year.
12 months - 2 years: the maximum level of cell apoptosis, the
minimum values ​​of the inhibitor apoptosis..
2 - 5 years: normalization of inhibitor of apoptosis. The ability of
cells to apoptosis in mature scars remained low.
0
50
100
150
200
250
300
350
400
450
4-6
m
onths
7-12
m
.
1-2
y.
2-5
y.
+р53
+bcl-2
+р53 intact
skin
+bcl-2 intact
skin
number of
cells
at 1 мм2 р53 -marker of apoptosis
bcl-2 -inhibitor of apoptosis
time from the moment the wound epithelialization
Dynamics of expression of apoptosis inhibitor
bcl-2 in different periods after epithelialization
After 4 months After 8 months After 1.5 years After 3 yaers
Intact skin
(magnification x 300)
*
*
*
*
*- p<0,05

5. scar in 3-4 months after
epithelialization:
multiple expansion due
to compression of the
lumen of venules, their
collagen bundles at the
mesh layer, impaired
venous drainage
scar in 5-12
months
after
epithelialization:
reducing the lumen
of arterioles and
venules due to the
ongoing synthesis
of collagen
scar in 2 years
after
epithelialization:
uniform
vasoconstriction
scar in 2 years after
epithelialization:
trophic erosion of
functionally active
areas on the
background of
worsening
circulatory
Excessive collagen synthesis leads to an irreversible
change in the conditions of circulation in scar
(hematoxylin-eosin, × 300)

6. Conclusions
In the first 4-6
months after
epithelialization:
increased activity of
lymphocytes and
macrophages,
cytokine synthesis
and stimulation of
fibroblasts
From 5-6 months
after
epithelialization -
compression of
venules with
collagen bundles,
impaired venous
drainage
From 8 months to
1, 5 years -
compression of
arterioles with
collagen bundles,
impaired arterial
inflow
Uniform narrowing
of the vascular bed
The most significant prognostic period is a period of
scar development from 1 to 6 months:
adequate conservative therapy in this period can
significantly improve the functional and cosmetic
characteristics of the scar
Cytokine
phase
of scar
development
Collagen-
venous phase
of scar
development
Collagen-
arterial phase
of scar
development
Аdaptation
phase
compression,
antihistamine
and anti-
inflammatory
therapy
compression,
collagenolytic,
antihistaminic
therapy
compression,
collagenolytic,
antihistaminic
therapy,
silicone
preparations
collagenolytic
therapy,
silicone
preparations,
polishing