MANAGEMENT OF HYPERTROPHIC SCAR

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

2. ▪ A hypertrophic scar (HSC) is defined as a skin scar that rises
above the skin level but stays inside the borders of the original
lesion.
▪ A keloid scar, on the other hand, is defined as a scar that grows
outside the margins of the original wound.
▪ Although there are fundamental differences between HSC and
keloids in their pathogenesis and natural history, both result in
increased fibroblasts and extracellular matrix formation.
▪ HSC usually develop during the first three months after the initial
injury or operation, whereas keloid scars appear within or over
12 months after the injury and may reappear even several years
after treatment.

3. PROCESS OF SCAR
FORMATION
▪Normal scarring occurs after any type of injury to the skin, with
the exception of the most superficial scratches. There is a critical
depth in a skin wound after which scar formation begins, and
wounds that are more superficial have the potential to heal
without scarring. This depth is shown to be approximately one
third of the total skin thickness.
▪This is demonstrated in dermal burn injuries, where superficial
dermal burns heal without scarring, but deeper dermal burns
often develop markedly hypertrophic scars, especially when
treated conservatively.

4. PROCESS OF SCAR
FORMATION
▪When a linear surgical wound is healing, there is usually little
need for the scar to contract. In a larger planar wound, such as a
burn wound, contraction occurs as a physiological response to
decrease the wound surface. In a HSC, myofibroblasts often
persist long after wound closure as a result of tension, among
other possible causes.

5. CAUSES OF HERTROPHIC
SCAR
▪ Prolonged healing time.
▪ Genetic
▪ Poor granulation tissue formation
▪ Unhealthy granulation tissue
▪ Increased myofibroblast activation
▪ Chronic inflammatory process
▪Infection

6. CALSSIFICATION OF SCAR
Scar type Description
Mature scar A light-colored, flat scar.
Immature scar itchy or painful, and slightly
elevated scar in the process of
remodeling. Many of these will
mature normally over time and
become flat.

7. CALSSIFICATION OF SCAR
Linear hypertrophic A red, raised,
sometimes itchy scar
confined to the border
of the original surgical
incision. This usually
occurs within 2weeks
after surgery.
Widespread hypertrophic
(e.g., burn) scar
A widespread red,
raised, sometimes itchy
scar that remains within
the borders of the burn
injury.

8. CALSSIFICATION OF SCAR
Minor keloid A focally raised, itchy scar
extending over normal
tissue. This may develop up
to 1 year after injury and
does not regress on its own.
Simple surgical excision is
often followed by
recurrence.
Major keloid A large, raised (>0.5 cm)
scar, possibly painful or
pruritic and extending
over normal tissue.

9. FACTORS AFFECTING SCAR FORMATION
▪ RACE
A two times greater incidence of hypertrophic scaring has been noted in
black populations when compared to Caucasians. This phenomenon was
attributed to possible abnormality in the production of melanocyte –
stimulating hormone.
▪ AGE
It has been noted that approximately 88% of hypertrophic scars occurred
in people less than 30 years. The high incidence of scaring in this group was
due to that younger people with more susceptible to trauma, have greater
slink rate of collagen synthesis. The elderly may have less scaring due to
decreased collagen metabolism, less elasticity and more skin redundancy.

10. FACTORS AFFECTING SCAR FORMATION
▪ LOCATION
Hypertrophic scars rarely occur of the eyelids, genitals, palms, or soles, where skin in
relaxed or splinted by its attachment to underlying. Certain areas of the body appear more
predisposed to the formation of hypertrophic scars such as the sternum, upper back,
shoulder deltoid, The buttocks and dorsal aspect of the foot.
▪ DEPTH
Deeper burns which involve the reticular dermis have scar more than superficial burns
that involves only the epidermis or the papillary dermis. Thus, increase scaring is due to
formation of a granulation tissue and prolonged healing time.
▪ GANDER
Gender does not appear to be a predictor of scaring, with male female ratio being
approximately equal.

11. PHYSICAL THERAPY MANAGEMENT OF
SCAR
1. SCAR ASSESSMENT
2. PHYSICAL THERAPY TREA
TMENT FOR
HEPERTROPHIC SCARAND KELOID

12. SCAR ASSESSMENT
A. SUBJECTIVEASSESSMENT
▪ Modified Vancouver scar scale
▪ Manchester scar scale
B. OBJECTIVEASSESSMENT
▪ Ultrasonic scanning
▪ Laser doppler

13. SCAR ASSESSMENT
A. SUBJECTIVEASSESSMENT
▪Modified Vancouver scar scale The
first validated and still widely used scar
assessment scale is the Vancouver Burn
Scar Assessment Scale or Vancouver Scar
Scale (VSS) developed by Sullivanet et al.
They scoredpigmentation, vascularity,
pliability, and scar height/thickness, leading
to a total score between 0 and 13 points.

14. SCAR ASSESSMENT
A. SUBJECTIVEASSESSMENT
▪ Manchester scar scale
The Manchester Scar Scale was introduced
by Beausang et al. in 1998. It has four
parameters (colour, contour, distorsion and
texture)

15. SCAR ASSESSMENT
B. OBJECTIVEASSESSMENT
▪ Ultrasonic scanning
Such as the tissue ultrasound palpation system (TUPS), have been used to quantify scar
thickness.
▪ Laser Doppler
Used for for the measurement of burn scar perfusion.

16. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ Scar management for post-burn injury is a long and often painful process; it is not
something that can be carried out for a few weeks and then abandoned, it is
something which must continue for many months to minimize post-burn
complications from occurring.
▪ Keloid scars are a difficult clinical entity. There is no single effective treatment
against keloids, and a combination of therapies is usually commenced, including
cortisone injections, pressure garment therapy, silicone gel sheeting and, in
severe and recurrent cases irradiation therapy have been suggested. If simple
excision is attempted without other treatment modalities, the recurrence rate is
high, and in some cases the situation can be worsened with surgery.

17. PHYSICAL THERAPY TREA
TMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ POSITIONIG
▪ SPLINTING
▪ STRETCHING EXERCISES
▪ MASSAGE
▪ PRESSURE THERAPY
▪ SILICONE GEL
▪ LOW LEVELLASER THERAPY
▪ PRESSURE EAR RINGS

18. PHYSICAL THERAPY TREA
TMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ POSITIONIG
Anti-contracture positioning should continue to be encouraged for many months post-injury
▪ SPLINTING
o Splints prescribed are not only essential for positioning but also for stretching and lengthening
the contracted scar tissue. Continued early splinting removed only for exercise and specific
functional activities can maximize long-term outcome and can be continued for 6 months post-
healing to 2 years in children.
o The splinting regime should be reduced gradually to overnight splinting once ROM is being
maintained.

19. PHYSICAL THERAPY TREA
TMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ STRETCHING EXERCISES
o If the burn is close to or over a joint, it must be stretched to avoid loss of ROM
and to prevent a post-burn contracture developing.
o Stretching of affected joints several times a day to their maximum functional
range, in conjunction with a splinting regime appears to help elongate the scar
tissue maintaining ROM.
o When the scar tissue does not respond to repeated treatments or the
contraction increases, the tissues will require surgical release to regain the
range of movement.

20. PHYSICAL THERAPY TREA
TMENT FOR HEPERTROPHIC
SCARAND KELOID
▪ MASSAGE
oBy massage the upper layer of the scar becomes softer and more pliable and
therefore more comfortable; this also helps to reduce itching which can also be a
common problem.
oWhen scars become thick and raised, they hold additional fluid, Through deep
firm massage of the scar using the thumb or fingertips, the effect of this excess
fluid can be reduced.
oMassaging while performing stretches helps to increase ROM of a limb affected
by a burn scar.
oBurns scars contain four times more collagen than other scars. Deep massage of
the scar in small circular movements is thought to help improve with alignment of
the scar tissue as it is formed.
oPsychological factors of individuals having difficulty in coming to terms with
having, what they feel is, an unsightly scar can also be reduced by touching the
scar and learning to accept how it looks and feels.

21. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ PRESSURE THERAPY
oApplying pressure to a burn is thought to reduce scarring and encouraging
reorientation of collagen fibres.
o create localised hypoxia to the scar tissue and reducing blood flow to hyper-
vascular scars and therefore reducing the influx of collagen and decreasing
scar formation.
o As soon as the wounds are fully closed and able to tolerate pressure, patients
are fitted with pressure garments.
oWhen garments are not available, other materials can be used as effective
replacements such as elastic support bandages, 'lycra' swimwear and cycling
shorts, sports head and wrist bands can be used.
oPressure garments must be applied as early as possible for maximum effect
and worn for 23 h removing only for washing and creaming of scars.

22. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ PRESSURE THERAPY
oIf a patient has skin grafting, they should be provided with a pressure garment
as soon as possible post-healing. If they have had an extensive burn and
scattered small unhealed areas remain, a pressure garment can be applied
with small topical dressings applied beneath it.
oPressure garments appear to help
• reduce scar thickness/lumpiness
• reduce scar redness
• reduce swelling
• relieve itching
• protect newly healed skin/graft
• prevent contractures/ maintain contours

23. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ SILICONE GEL
o Silicone is another modality used to treat hypertrophic scarring. The
exact mechanism of action of silicone in the prevention and
management of hypertrophic scars is unclear, although it is likely to
influence the collagen remodeling phase of wound healing. It appears
to soften and flatten scar, making it comfortable and improving its
appearance.
oHow to use the silicone gel sheet:
1) Cut a piece large enough to cover the scar completely.
2) The sheet should be left in place as long as tolerated—even all
day. The longer it is in place, the better.
3) The patient should remove the sheet to wash.
4) Sheets should be used for at least 2–3 months to make an
appreciable difference.

24. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ LOW LEVEL LASER THERAPY
Low level laser therapy with continuous laser power diode output of 400mW, emitting red laser
light with a wavelength of 670 nm, applied energy density (dose) of 4 J/cm2 and radiation twice
a week, with a minimum interval of 3 days, over 8 weeks showed inhibitory effect on post burn
hyper trophic scar through its effect in improving wound healing

25. PHYSICAL THERAPY TREATMENT FOR
HEPERTROPHIC SCARAND KELOID
▪ PRESSURE EAR RINGS
Some patients develop keloids after ear piercing. Earrings
designed to apply pressure to the earlobe are commercially
available. They work best on small keloids (< 1 cm). Pressure
earrings are especially useful when combined with excision of
the keloid. Once the excision sutures have been removed, the
patient should wear the earring for at least 2 or 3 months
(longer is better). This approach may prevent recurrence of the
keloid.