a brief summary of scars, their pathology and management

1. SCAR
DR. PRASANNA SOMVANSHI
SR-1,PLASTIC SURGERY.
GGMC AND SIR JJ GROUP OF HOSPITALS

2. Defination-
“Mark remaining after the healing of a wound or other morbid process”

3. EVALUATION
 FIRST STEP IN EVALUATION IS
FOCUSSED HISTORY AND
THOROUGH PHYSICAL
EXAMINATION

4. IDEAL SCAR
 FLAT
 NARROW
 GOOD COLOUR MATCH
 PARALLEL OF WITHIN THE SKIN CREASE

5. SCAR ASSESSMENT
 NEEDED TO IMPROVE THE
OUTCOME
IDEAL SCALE SHOULD
DEMONSTRATE –
 VALIDITY
 INTEROBSERVER RELIABILITY
 CLINICAL APPLICABIITY

6. SCAR GRADING
 MOST FREQUENTLY USED
MEASURE IS THE BURN SCAR
INDEX OR THE VSS.
 LESS USEFUL AS IT WAS
CREATED PRIMARILY FOR BURN
SCAR .

7.  OTHER SCALES
1. VISUAL ANALOG SCALE (VAS)- CAN BE USED FOR BURNS AND
SURGICAL SCAR.INCLUDES COLOUR,CONTOUR,TEXTURE,PHOTOGRAPHS
AND HISTOLOGY.
2. PATIENT AND OBSERVER SCAR ASSESSMENT (POSAS)-
CAN BE USED FOR BURNS AND LINEAR SCARS. PATIENT OPINION IS
INCLUDED – SYMPTOMS,PAIN ,ITCHING
3. STONY BROOK SCAR EVALUATION SCALE – TOOL FOR
EMERGENCY PHYSICIAN TO EVALUATE WOUND AT THE TIME OF SUTURE
REMOVAL,NOW IT CAN BE USED FOR SCARS AS WELL.
4. MCFONTZL – DEVELOPED SPECIFICALLY FOR FACIAL TRAUMA.

8. MCFONTZL SCALE

9. SCAR BIOLOGY

10. SCAR CLASSIFICATION

11.  IN HEALING , ONCE THE DERMAL DEFECT IS CLOSED AND
EPITHELIZATION IS COMPLETE, THE PROCESS OF SCARRING SLOWS
DOWN. WHEN THESE SIGNALS ARE ABSENT IT LEADS TO EXCESSIVE
SCAR.
 HTS AND KELOID – FIBROPROLIFERATIVE DISORDER
 CAUSES FOR EXCESSIVE SCARRING
1. TGF-BETA 1
2. LACK OF APOPTOSIS OF ACTIVATED FIBROBLAST SECRETING ECM
COMPONENTS

12. HTS V/S KELOID
 HTS –
1. HIGHER LEVELS OF
NEUROPEPTIDE SUBSTANCE P
2. EXCESSIVE TENSILE FORCES
ACROSS WOUNDS.
 KELOID
1. ABSENCE OF APPROPRIATE STOP
SIGNALS
2. EXCESSIVE STIMULATION
3. DEFECTIVE REPAIR PROCESS
4. HISTOLOGY – ACELLULAR IN
THE CENTER, FIBROBLAST AT
THE GROWING EDGES.

13. PREVENTION OF SCARRING
 SURGICAL TECHNIQUE
1. ATRAUMATIC TECHNIQUE
2. MINIMIZING TENSION
3. SKIN EVERSION
4. PERFECT APPOSITION
5. USE OF NATURAL SKIN TENSION
 PATIENT FACTORS
1. POOR NUTRITION
2. DIABETES
3. OBESITY
4. RADIATION EXPOSURE
5. STEROIDS AND ISOTRETINOIN
6. GENETICS

14. PREVENTION OF SCARRING
 WOUND INFECTION AND
FOREIGN BODY REACTION
1. LEAD TO POOR SCARRING
2. LEAVING THE INITIAL DRESSING
FOR 48-72 HOURS,THE TIME
NEEDED FOR EPIDERMAL
CLOSURE,TO MAINTAIN WOUND
STERILITY
3. DEBRIDEMENT OF ANY
DEVITALIZED TISSUE AND
PERIOPERATIVE AB’S
 ADJUNCTIVE THERAPY
1. TAPING
2. SILICON GEL SHEETING – 1ST
LINE PROPHYLAXIS, SHOULD
BEGIN AFTER EPITHELIZATION,
BE WORN FOR 12-24 HOURS PER
DAY FOR UPTO 1 MONTH
3. EXTERNAL SPLINTS

15. TREATMENT OF SCAR

17. TREATMENT OF SCARS
 HTS
1. PRESSURE GARMENTS – IMPROVED
SCAR THICKNESS WHEN PRESSURE
IS ABOVE 15mm Hg.
2. SILICON SHEETS – IMPROVED
HYDRATION AND OCCLUSION,
INCREASED TEMPERATURE
ELEVATION BY 1 DEGREE C OR LESS
AFFECTING COLLAGENASE
ACTIVITY
3. STEROIDS – 2ND LINE TREATMENT.
FOCAL SUPRESSION OF
INFLAMMATORY CYTOKINES AND
INHIBITION OF FIBROBLAST
ACTIVITY.
4. LASER – PULSED DYE LASER (CO2
AND ER-YAG). ABSORPTION BY Hb
WITH CAPILLARY ABLATION AND
REDUCED PERFUSION
5. RE-EXCISION
 KELOIDS –
MULTIMODAL APPROACH
ONLY THERAPY AVAILABLE FOR MATURE
KELOID
1. MONITOR AND DO NOTHING
2. EXCISE AND ADJUNCTIVE THERAPY
 ADJUNCTIVE THERAPY
1. STEROIDS
2. RADIATION
3. CRYOTHERAPY
4. LASER
5. IMMUNOSUPPRESSION

18.  TREATMENT OF KELOIDS
1. INTRALESIONAL STEROIDS – 1ST LINE, EARLY RAPIDLY PROLIFERATING
LESION RESPOND BEST.
2. SHORT COURSE LOW DOSE (20 Gy) RT AT KELOID EXCISION WOUND
3. CRYOTHERAPY – LOW COST AND EFFECTIVE METHOD, EARLY LESION < 1-
2 YEARS HAVE MORE FAVOURABLE RESPONSE.
 TO SUMMARISE –
1. SMALL KELOIDS – IL STEROIDS,SILICON SHEETS AND PRESSURE
GARMENTS
2. LARGE RECALCITRANT KELOIDS – SURGERY,STEROIDS.RADIATION

19. EMERGING TREATMENT
1. TGF-BETA
2. IFN’S
3. 5-FU
4. BLEOMYCIN

20. THANK YOU