1. MANAGEMENT AND PREVENTION
OF ABNORMAL SCARS

2. LATEST FIGURES
A scar is a mark left in the skin by the healing of injured tissue.
In the developed world, 100 million patients develop scars each year, some of which cause considerable physical and psychological problems. (Bayat et al 2003).
11 million of these scars are keloid, and 70% of scars are due to burns injuries.

3. SKIN STRUCTURE AND FUNCTION
Skin consists of two main layaers, the outer epidermis and the underlying dermis.
The epidermis consists of five layers. Cells of the basal cell layer divide continually. Older cells are displaced towards the surface and shed as dead cells. This regeneration of multiplying and migrating basal cells in damage, leaves no visible scar.(Nursing standard 19; )

4. SKIN FUNCTION AND STRUCTURE
The dermis consists of collagen and elastin fibres in a matrix, supplied by a rich capillary network. The dermis supports the epidermis. Elastin provides the elasticity and the collagen provides the tensile strength.
Dermal damage is repaired by a process of granulation. The proportion of the constituents and the mechanism of repair differ from that of normal dermis, resulting in the formation of a visible scar. (Bayat et al 2003).

5. STRUCTURE OF THE SKIN Epidermis Oil gland Papillary dermis Muscle
Sweat gland
Reticular dermis
Hair
Fat tissue
Blood vessels
Nerve

6. PARTIAL AND FULL THICKNESS INJURIES
Blister
Fluid
Epidermis
Epidermis
Dermis
Dermis
Layer of fatty tissue
Layer of fatty tissue

7. WOUND HEALING AND SCAR FORMATION
Scar formation is a natural part of the wound healing process, and occurs after almost every dermal injury.
Some scars are considered trivial, but some are psychologically damaging, itchy, painful, cause sleep disturbance, anxiety, depression, and distruption of life. (Rumsey and White 2003).

8. WOUND HEALING AND SCAR FORMATION
Age
General condition
Size and location of the wound
Predisposing diseases: Arthritis, diabetes, infection, leukaemia or other cancers.
Calvin 1998, separates the wound healing process into phases that we have already learnt from the pathophysiology presentation.
Wound healing can be influenced by many different factors:

9. SCARS
Almost always arise from some sort of trauma
Scar tissue consists mainly of newly synthesised collagen, produced by fibroblasts in response to injury
Scars lack pigmentation, hair and sweat glands

10. HYPERTROPHIC / KELOID SCARS
Raised scars that remain within the boundaries of the original legion
Often red, inflamed, itchy and painful
KELOID
Raised scars that spread beyond the margins of the original wound, invading normal skin
Does not regress and will invariably recur after surgical excision

11. HYPERTROPHIC / KELOID SCARS
Usually develop six to eight weeks post epithelialisation.
They are a consequence of the rapid proliferation of collagen in healing skin-4 times as much as in normal skin
Maturation is from months.
KELOID
Can occur spontaneously, or from a trauma as little as an insect bite or ear piercing.
A lot more common on the asian, black, oriental population due to the number of melanocytes.
There has been no cases in Albino people.

12. KELOID SCARS

13. KELOID SCARS

14. HYPERTROPHIC SCARS

15. TREATMENT OPTIONS
SURGERY
Surgical incision is the most long standing, simplest way of removing keloid tissue.
It’s effectiveness as a single mode of treatment is limited. Reoccurrence rates are known to be more than 80% within two years (Mustoe et al 2002).

16. TREATMENT OPTIONS
CORTICOSTEROIDS
Injections being a first line therapy for keloids and a second line for hypertrophics
Corticosteroids are seen to decrease fibroblast proliferation, collagen synthesis and suppress inflammatory mediators.
Response rates are good, % with 9% recurrence.
Injections carried out monthly for up to six months
Pain on injection and skin atrophy can be side effects.

17. TREATMENT OPTIONS
PRESSURE
Pressure speeds up the formation of collagen, flattens the scar and reduces the number of cells in a given area.
It needs to be started early and kept on 24 hours a day for a year or so and have poor results on six month + scars.
It can be used in conjunction with other treatments.

18. TREATMENT OPTIONS
SILICONE
Silicone gel sheeting has been used since the early 1980’s to manage keloid and hypertrophic scars.
It is painless, and used regularly for burns, surgical procedures and traumatic events.
Hydration from the silicone gel, modulates the effects of keratinocytes on fibroblasts in the scar tissue.

19. TREATMENT OPTIONS
SILICONE
Randomised controlled trials have demonstrated that silicone gel sheeting is a safe and effective management option for both types of scar. (Mustoe et al 2002).
Scars that are treated with silicone less than three months old do not become hypertrophic!! (English and Shenefelt 1999).
Silicone improves the itching, pain,colour.
It has been proved to flatten hypertrophic scars quicker than pressure.

20. TREATMENT OPTIONS
Radiotherapy
Cryotherapy
Laser therapy

21. ANY QUESTIONS??