Hypertrophic Scarring


Article Author:
Shawn Schmieder


Article Editor:
Sarah Ferrer-Bruker


Editors In Chief:
Amanda Oakley
Jules Lipoff
Shyam Verma


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
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Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/18/2019 10:31:53 PM

Introduction

Hypertrophic scarring represents an undesirable variant in the wound healing process. Another variant of wound healing, the keloid scar, is often used interchangeably with hypertrophic scarring, but this is incorrect. The excess connective tissue deposited in hypertrophic scarring is restricted to the area within the original wound. The excess connective tissue deposited in the keloid, however, extends beyond the area of the original wound. This article will review both of these entities in detail.[1][2][3][4]

Etiology

A variety of risk factors are linked to both hypertrophic scars and keloids. A very important, common risk factor in clinical practice is tension on the wound. Hypertrophic scars and keloid scars often develop on areas of the body that undergo the most skin tension. These include the back, chest, and upper arms. In contrast, hypertrophic scars rarely develop in areas with little skin tension such as the upper eyelids.[5][6][7][8]

Certain, systemic factors can increase the risk of hypertrophic scars. One study showed that hypertension is associated with increased keloid severity. Another systemic risk factor is inflammation. Systemic inflammation is seen after burn injuries further increasing the risk of developing hypertrophic scars and keloids for up to 1 year.

Multiple episodes of trauma to the same area are also a risk factor for hypertrophic scarring and keloid scars. One example is the use of earrings. Each time a person puts on or takes off the earing there can be some amount of trauma to the area. The site of ear piercings is a common area for the development of keloids. Burn wounds are prone to hypertrophic scaring especially if they affect the deeper dermis. One study found that hypertrophic scarring was much more likely in burn wounds that took 3 weeks or more to heal. Infection is another risk factor for hypertrophic and keloid scars. In addition, genetics can play a role in hypertrophic scars or keloids. Certain single-nucleotide polymorphisms are associated with keloid scars in persons of Japanese descent.

Epidemiology

Adolescents and pregnant women may be more likely to form hypertrophic and keloid scars. People with darker skin complexions are about 15% more likely to develop keloid scars, and the lowest incidence of hypertrophic scars is in persons with albinism. It is estimated that 70% of deep (full thickness), burn injuries result in hypertrophic scars.

Pathophysiology

Although there is a defined clinical distinction between hypertrophic scars and keloid scars these two disorders may lie within a spectrum of the same pathophysiologic process. Wound healing is divided up into three phases (inflammatory, proliferative, remodeling). The scar is formed in the last phase (remodeling phase).

There are increased numbers of myofibroblasts in hypertrophic scars. Transforming growth factor beta stimulates differentiation of both local and bone fibroblasts into myofibroblasts, which then creates tension on the wound. Certain pro-inflammatory mediators are unregulated in keloid scars. These include tumor necrosis factor-alpha, interleukin-1 alpha, interleukin-1 beta, and interleukin-6. Some experts believe that these mediators are more sensitive to being released in response to trauma in patients predisposed to hypertrophic and keloid scarring.

Burn wounds can be divided into superficial (partial thickness) and deep (full thickness). The majority of partial thickness burn wounds heal without hypertrophic scarring. Deep wounds stimulate dermal fibroblasts to produce collagen and inflammatory mediators like transforming growth factor-beta 1 (TGF-beta1). TGF-beta1 further stimulates fibroblasts to deposit elastin and collagen.

Histopathology

The distinction between hypertrophic scars and keloid scars can sometimes be seen histologically. Both hypertrophic scars and keloids show thick bundles of collagen on histopathology. Hypertrophic scars show deposition of collagen type-3 fibers that are arranged parallel to the epidermis. Keloid scars show haphazard sheets of type-1 and type-2 collagen with random directional orientation. This is sometimes termed “keloid collagen.” There also tend to be more blood vessels seen histologically in keloid scars than in hypertrophic scars.

History and Physical

Hypertrophic scarring presents as an area of increased induration and often dyspigmentation over the site of a wound. Keloids present as marked hypertrophy of dermal tissue and they too often feature dyspigmentation. As mentioned above, keloid scars extend beyond the margin of the original wound. Hypertrophic scars and keloid scars also differ in the time it takes for them to develop, especially after burn injury. Hypertrophic scars develop in 1 to 2 months after injury, whereas, keloids develop months to years after the initial injury.

Hypertrophic scars and keloids often cause irritation, pruritus, and even neuropathic pain. Severe hypertrophic scars or keloids over a large area can cause contractures that may be disabling.

Evaluation

Diagnosis is usually made clinically. However, if a hypertrophic scar or keloid continues to worsen or change a biopsy may be necessary. Hypertrophic scars remain within the boundaries defined by the original defect/wound. Keloid scars extend beyond the original wound.

Treatment / Management

Reducing tension on the wound with good surgical technique is an important aspect of prevention of hypertrophic scars during surgery. Patients who are known to form hypertrophic scars or keloids should avoid elective surgical procedures.[9][10][11]

Once the hypertrophic scar or keloid scar has formed there are a variety of treatment modalities that may be used. Corticosteroid injection is a mainstay of therapy for hypertrophic scars. Surgical excision may be used to treat hypertrophic scars or keloid scars. However, in the case of keloid scars, surgical excision should not be used alone but rather in combination with another modality such as corticosteroid injection or radiotherapy. Radiotherapy has been shown to treat and prevent keloid scars. Laser therapy including long-pulsed Nd:YAG laser or pulsed dye laser have proven benefit in treating hypertrophic scars. These lasers target blood vessels and therefore are very helpful in reducing the color changes seen in hypertrophic scars. Cryotherapy may be used to treat hypertrophic or keloid scars. Although one would assume that a destructive treatment such as cryotherapy would induce scars, experts believe that a different collection of inflammatory mediators are released in response to cold injury compared to other types of injury such as burn injury. 5-Fluorouracil has successfully treated and prevented keloids.

The treatment of burn wounds and the prevention of hypertrophic and keloid scars after burn injury represents a daunting challenge for clinicians. As mentioned above, burn wounds can be divided into superficial (partial thickness) and deep (full thickness). The majority of partial-thickness burn wounds heal without hypertrophic scarring. Most experts opt to manage deep wounds by excising the burned area and placing a split-thickness autograft. Laser therapy is often used to treat hypertrophic scars caused by burns. Laser therapy not only improves the color of the hypertrophic scar but can reduce the height of the scar and tension on the scar. Laser therapy can also relieve symptoms such as pain and pruritus. Traditionally, compression therapy was used in the management of burn wounds, but a meta-analysis found that compression therapy did not show efficacy in altering the progression of hypertrophic scars. In addition, good nutrition and vitamin supplementation are recommended for burn patients or those with chronic wounds. Like many other disorders in dermatology and medicine, the future of burn wound management may lie in targeting specific molecular pathways. These include therapies directed at WNT/beta-catenin pathway, the TGF-beta pathway, the Notch pathway, the Sonic hedgehog pathway and the RAS/MEK/ERK pathway.

Differential Diagnosis

Although most hypertrophic and keloids scars are diagnosed clinically, a biopsy may be necessary, especially if one of these lesions continues to grow or change. There are a few entities to keep in mind that may mimic a hypertrophic scar or keloid clinically and/or histologically. These include, but are not limited to, dermatofibrosarcoma protuberans, dermatofibroma, nodular scleroderma, and infectious processes such as a lobomycosis.

Enhancing Healthcare Team Outcomes

The actual treatment of hypertrophic scarring is done by a plastic surgeon and a dermatologist. However, the followup of patients is done by the nurse practitioner and primary care provider.  Once the hypertrophic scar or keloid scar has formed there are a variety of treatment modalities that may be used. Corticosteroid injection is a mainstay of therapy for hypertrophic scars. Surgical excision may be used to treat hypertrophic scars or keloid scars. In addition, both cryotherapy and Laser therapy including long-pulsed Nd:YAG laser or pulsed dye laser have proven benefit in treating hypertrophic scars. These lasers target blood vessels and therefore are very helpful in reducing the color changes seen in hypertrophic scars.  Despite the plethora of treatments, the results of most treatments are not satisfactory. [12][13] (Level V)There is no one treatment better than the other and all of them have the potential to worsen the scar. Like many other disorders in dermatology and medicine, the future of hypertrophic scars treatment may lie in targeting specific molecular pathways. These include therapies directed at WNT/beta-catenin pathway, the TGF-beta pathway, the Notch pathway, the Sonic hedgehog pathway, and the RAS/MEK/ERK pathway.


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Hypertrophic Scarring - Questions

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Which of the following will aid in the prevention and improvement of hypertrophic scarring from a burn wound?



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An 18-year-old African American female presents to your office with large nodules on her ear lobules bilaterally. The nodules are smooth on the surface and darker in color than the surrounding normal skin. She reports that these nodules appeared a few years after she started wearing earrings. These lesions clearly extend beyond the site of an ear piercing. She admits that they cause pain and irritation. She asks if anything can be done for the lesions. Which of the following is the best option for this patient?



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A 45-year-old male presents to the clinic with a raised scar on his back. He reports that he had a laceration in this area that was repaired approximately 5 months ago. He denies pain but admits to some mild pruritus associated with the lesion. On exam, there is a raised scar present on the patient’s right upper back. Despite being raised the scar seems to remain within the boundaries of the original wound. He asks if there is anything that can be done to reduce the height and “bumpiness” of the scar. Which of the following is the best option for this patient?



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A 51-year-old female presents for evaluation of a “bump” on her nose that bleeds from time to time. She explains to you that the bump will bleed and then “crust up” but never heals. On exam, there is a shiny, pearly papule with central ulceration on the tip of the patient’s nose. You explain to the patient that although biopsy is needed to confirm the diagnosis, this is likely a basal cell carcinoma and if so will need to be removed with surgical excision. The patient asks you what will cause a “bad” scar to form in this area after surgery? Which of the following is not a risk factor for developing a hypertrophic scar?



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A 51-year-old female presents to for a skin exam. On her upper back, there is a slightly depressed indurated white plaque that is approximately 2 cm in diameter. The patient has a history of hypertrophic scarring. When asked about the lesion the patient states that it may be a scar but does not distinctly remember trauma to the area. On dermoscopy, the lesion demonstrates arborizing vessels. Which of the following is not on the differential of hypertrophic scarring?



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Hypertrophic Scarring - References

References

Goverman J,He W,Martello G,Whalen A,Bittner E,Schulz J,Gibran N,Herndon D,Suman O,Kowalske K,Meyer WJ,Ryan C,Schneider J, The Presence of Scarring and Associated Morbidity in the Burn Model System National Database. Annals of plastic surgery. 2019 Mar;     [PubMed]
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Boehm KS,Al-Taha M,Morzycki A,Samargandi OA,Al-Youha S,LeBlanc MR, Donor Site Morbidities of Iliac Crest Bone Graft in Craniofacial Surgery: A Systematic Review. Annals of plastic surgery. 2018 Dec 18;     [PubMed]
Rodrigues M,Kosaric N,Bonham CA,Gurtner GC, Wound Healing: A Cellular Perspective. Physiological reviews. 2019 Jan 1;     [PubMed]
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Mokos ZB,Jović A,Grgurević L,Dumić-Čule I,Kostović K,Čeović R,Marinović B, Current Therapeutic Approach to Hypertrophic Scars. Frontiers in medicine. 2017;     [PubMed]
Poetschke J,Gauglitz GG, Current options for the treatment of pathological scarring. Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG. 2016 May;     [PubMed]
Weitemeyer MB,Bramsen P,Klausen TW,Hölmich LR,Gjorup CA, Patient-and observer-reported long-term scar quality of wide local excision scars in melanoma patients. Journal of plastic surgery and hand surgery. 2018 Oct 31;     [PubMed]
Jones LL,Calvert M,Moiemen N,Deeks JJ,Bishop J,Kinghorn P,Mathers J, Outcomes important to burns patients during scar management and how they compare to the concepts captured in burn-specific patient reported outcome measures. Burns : journal of the International Society for Burn Injuries. 2017 Dec;     [PubMed]

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