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Why can silicone reduce keloid?

Why can silicone reduce keloid?


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I heard people use silicone sheet for reducing raised scars (i.e., keloids). I was wondering what is the rational behind it, and whether it actually works.


I cannot say the mechanism, but I can confirm it works, and can say that is generally accepted as working, not as some weird dubious treatment. I had surgery to install a rod in my leg after a broken bone. On the advice of my physical therapist, I purchased "Scar Away" brand silicone oil with roller applicator. Placing a thin layer and massaging with the applicator twice a day for four weeks turned my giant cheloids into small sections of skin which were distinguishable only by their smoothness and lack of hair, not color. He said he used to work for some basketball team and it was common practice to be used in professional basketball.


According to several papers (Sawada and Sone, 1992; Wong et al., 1996), increased hydration appears to be the main mechanism by which silicone oil acts on raised scars. Combined with an occlusive dressing, this preparation would increase hydration of the scar site. Sawada and Sone (1992) compared silicone oil treatment to vaseline treatment and found significantly improved healing with silicone oil, concluding that it was the hydrating action of silicone oil that led to improvement.

Sawada Y, Sone K. 1992. Hydration and occlusion treatment for hypertrophic scars and keloids. Br J Plast Surg 45(8):599-603.

Wong TW, Chiu HC, Chang CH, Lin LJ, Liu CC, Chen JS. 1996. Silicone cream occlusive dressing--a novel noninvasive regimen in the treatment of keloid… Dermatology 192(4):329-33.


Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting

Background: Topical silicone gel sheeting has been used for more than 20 years to help reduce the size of hypertrophic scars and keloids. Its clinical efficacy and safety is well established.

Objective: To determine whether topical silicone gel sheeting can be used to prevent hypertrophic scars and keloids from forming following dermatologic skin surgery.

Methods: Patients undergoing skin surgery were stratified into two groups: those with no history of abnormal scarring (low-risk group) and those with a history of abnormal scarring (high-risk group). Following the procedure, patients within each group were randomized to receive either routine postoperative care or topical silicone gel sheeting (48 hours after surgery). Patients were followed for 6 months.

Results: In the low-risk group, there were no statistical differences between individuals using routine postoperative care or using topical silicone gel sheets. In the high-risk group, there was a statistical difference (39% versus 71%) between patients who did not develop abnormal scars and used topical silicone gel sheeting and patients who developed abnormal scars after routine postoperative treatment. Those individuals having a scar revision procedure also showed a statistical difference if topical silicone gel sheeting was used following surgery.

Conclusion: Topical silicone gel sheeting, with a 20-year history of satisfaction in dermatology, now appears to be useful in the prevention of hypertrophic scars and keloids in patients undergoing scar revision.


How does topical silicone work?

Skin hydration and homeostasis
Doctors agree that silicone, when applied topically to a scar, mimics the occlusion properties of the stratum corneum. The stratum corneum is the outermost layer of the skin that helps maintain skin hydration and flexibility. When a person sustains a wound, the skin’s hydration mechanism can be disrupted and the oxygen and moisture balance in the skin becomes volatile. The ideal oxygen and moisture balance is called homeostasis. To induce hydration and maintain homeostasis of the skin after trauma, silicone can be applied to facilitate a healthy wound-repair response. Topical silicone is semi-permeable, so it allows the user to maintain the perfect balance of oxygen and moisture retention at the scar site.

Collagen regulation
Collagen is the most abundant structural protein in the bodies of most mammals, and plenty of it is present in our skin. When a person sustains a wound, fibroblasts and keratinocytes in the dermis signal collagen production to promote the growth factor and repair the damaged tissue. The skin is constantly producing new collagen, but trauma causes skin cells to go into overdrive and produce excessive amounts of it. This is what causes raised and discolored scarring. Topical silicone regulates collagen production by inhibiting the growth factor and preventing the overgrowth of scar tissue.

Two types of scars most characterized by the overproduction of collagen are keloid and hypertrophic scar formations. Keloids appear as ropey growths on the skin that branch out past the initial wound site. Hypertrophic scars are raised and bumpy, but don’t expand beyond the limits of the wound. Both scar types can be red or purple in appearance and are typically itchy and painful. Topical silicone is an effective treatment option to prevent or reduce the appearance of these scars by hydrating the skin and controlling collagen production.


You can also opt for an oral over-the-counter antihistamine to help with the itching. According to health professionals, oral antihistamines usually work better than antihistamine creams. Over-the-counter medicines such as diphenhydramine and hydroxyzine can cause drowsiness, so be wary of them. Instead, try cetirizine or loratadine, as they do not have these side effects.

One of the most common home remedies for keloid itching is our trusty apple cider vinegar. It helps relieve the itching while at the same time minimizing the redness and the size of the keloid. Apply the vinegar directly to the affected area and massage it in gently. Allow it to dry and repeat the process several times a day for best results.


Surgical Remove

Skin experts often suggest a surgery to remove keloid from your ear via a scalpel. This method is likely to create a new wound, which develops a keloid later as well.

Radiation

Radiation treatment seems effective when it comes to reducing the size of a keloid. Dermatologists opt for it following a surgery.

Pressure Earrings

If you go for surgery to have the keloid removed, your dermatologist may suggest wearing a pressure earring after the surgery. You can wear these earrings to create moderate pressure on your ear to prevent the reoccurrence of keloid after the surgical treatment.


Risk Factors and Etiology

The primary risk factor for keloids is darkly pigmented skin, which carries a 15- to 20-fold increased risk, perhaps because of melanocyte-stimulating hormone anomalies.4 Familial predisposition, with autosomal dominant and recessive genetic variants is recognized.5 Black, Hispanic, and Asian persons are far more likely to develop keloids than white persons.6 , 7 Hypertrophic scars, however, are less likely to be associated with skin pigmentation.

Keloids are more common in persons younger than 30 years, with risk peaking between 10 to 20 years of age, and in patients with elevated hormone levels (e.g., during puberty or pregnancy).8 Sternal skin, shoulders and upper arms, earlobes, and cheeks are most susceptible to developing keloids9 ( Figure 1 ). Certain types of trauma and delayed healing (longer than three weeks) heighten keloid incidence even more, with burns carrying the highest risk. Acne, ear piercing, chickenpox, vaccinations (particularly bacille Calmette-Guérin vaccination), biopsy procedures, and lacerations may cause abnormal scarring ( Figure 2 ). Acne keloids are particularly common. Keloids are more than just cosmetically unacceptable many are also pruritic and painful. They often result in severe emotional distress.

Cheeks are a common location for keloids, often secondary to acne.

Copyright © Logical Images, Inc .

Cheeks are a common location for keloids, often secondary to acne.

Copyright © Logical Images, Inc .

Mild trauma, often from shaving, can result in formation of a keloid, such as this one along the hairline.

Copyright © Logical Images, Inc .

Mild trauma, often from shaving, can result in formation of a keloid, such as this one along the hairline.

Copyright © Logical Images, Inc .


2. Classical treatment and preventive options for keloids and hypertrophic scars

2.1. Massage therapy

Massage therapy, manual or mechanical (i.e., compressed air, threadlike showers, vacuotherapy, etc.), is standard therapy in rehabilitation centers specializing in the treatment of scars and burns [15].

Although there is no scientific evidence, it has been shown that massage therapy not only reduces scar-related pain and itching [16], but also increases range of motion, reveals patients’ anxiety and improves their mood and mental status [17].

A recent meta-analysis including 144 patients from 10 different publications who received scar massage concluded that although scar massage is anecdotically effective, its evidence is weak, regimens used are heterogeneous, and outcomes measurements are subjective and not standardized [18]. There is currently an ongoing interventional randomized clinical trial (clinical trials.gov identifier: <"type":"clinical-trial","attrs":<"text":"NCT00175344","term_id":"NCT00175344">> NCT00175344) by University of British Columbia studying postoperative scar massage in women with breast cancer [19]. Further well-designed and large-sample clinical trials are warranted.

2.2. Pressure garments

Another treatment strategy that also alleviates itching and pain associated with abnormal scars but also with no scientific evidence is the use of pressure garments [20]. However, pressure garments still represent the current standard first-line prophylactic therapy for hypertrophic burn scars [21].

Mechanical compression is shown to reduce collagen synthesis by several mechanisms. These include decreased blood, oxygen and nutrients delivery to the scar, MMP-28 (matrix metalloprotease-28) downregulation and increase of PGE2 (prostaglandin-E2), which activates collagenase [22].

It has been reported that pressure garments should be worn at least 23 h a day, at 20� mm Hg (better around the low range), starting as soon as possible after wound re-epithelialization, for 6� months [21]. Pressures below 10 mm Hg have been shown to produce no beneficial effects, whereas pressures exceeding 40 mm Hg may lead to maceration and paresthesias [23]. Pressure and radius are inversely correlated. Indeed, effectiveness of pressure therapy depends mainly on the anatomic area where it is applied [24]. Concave and flexion areas are the least effective ones, whereas trunk and limbs are the most suitable anatomic locations to apply pressure therapy. A meta-analysis concluded that the potential morbidity and costs of pressure therapy currently appear to outweigh its still unproved efficacy [25]. The main disadvantage of pressure therapy is the low patient-adherence to the treatment (less than 40%) mostly due to the significant discomfort associated with this therapy [21]. Other risks include skin rash and erosion (specially in humid and hot climates, or if too much pressure is applied), pruritus, swelling and even skeletal and dental deformities [26�].

Given current lack of evidence, well-designed clinical trials are required to examine the effectiveness, risks and costs of pressure garment therapy [25].

2.3. Adhesive tape support/silicone gel sheeting

Hydration and occlusion have been suggested in the literature to be the main mechanisms of action of topical adhesive tape (plastic or paper) and silicone materials (sheets, strips, gels, creams, sprays and foams available over the counter or custom-made). Accordingly, it seems that silicone in particular is not always required. In fact, silicone and non-silicone gel dressings may be equally effective in the treatment of hypertrophic scars [29] however, studies have shown that silicone gel and silicone gel sheeting (SGS) appear to provide an appropriate occlusion level to treat abnormal scars, in contrast to other materials, such as vaseline [30]. Among the different available silicone formats, although silicone gel and SGS have equivalent efficacy in the management of excessive scarring after an operation, silicone gel currently appears to be the preferred silicone therapy, due mainly to ease of use, as Mustoe and colleagues advocate [30].

On the other hand, application of microporous hypoallergenic paper tape with an appropriate adhesive to fresh surgical incisions, beginning at 2 weeks and used for a minimum of 3 months after surgery, has been reported to be effective in controlling scar tension, eliminating stretching forces, and preventing hypertrophic scarring [31]. It may become more cost effective and theoretically can be worn for 4𠄷 days continuously, even during bathing.

Silicone sheets are recommended to be worn for 12� h a day for at least 2 months, beginning 2 weeks after wound healing. Silicone gel should be applied twice daily and has the advantage of additionally be used in areas where the sheets will not conform [32]. Folliculitis is a possible adverse effect, specially for silicone sheets [33].

Although topical silicone materials (silastic or elastomers and gel sheets) may not have any effects on mature hypertrophic scars [34], they appear to flatten, soften and increase pliability of fresh scars [35]. However, a randomized controlled trial with intraindividual comparison showed no added beneficial effect when applying silicone underneath the pressure garment in burn hypertrophic scars [36]. Silicone gel sheeting in pathological scars has been reported to have at best a class 3 scientific evidence [37]. Indeed, a recent Cochrane meta-analysis including 20 clinical trials found that although silicone gel sheeting decreased scar thickness and improved scar color with statistical significance, the analyzed studies had poor quality and were highly susceptible to bias, with weak evidence of the efficacy of silicone gel sheeting to prevent abnormal scarring in high risk patients [38]. Once again, one of the most popular anti-scarring strategies in the clinics lacks enough scientific evidence and well designed research studies are warranted prior to set appropriate high-quality professional recommendations or protocols.

2.4. Intralesional corticosteroid injections

Intralesional corticosteroid injections improve scar pliability, diminish its volume and height and reduce scar-related itching and pain [20]. The most used current protocol involves insoluble triamcinolone acetonide (TAC) (10� mg/ml), alone or better in combination with lidocaine, weekly, biweekly or monthly.

Despite relatively few randomized, prospective studies, there is a broad consensus that injected triamcinolone is efficacious. It is first-line therapy for the treatment of keloids, and second-line therapy for the treatment of hypertrophic scars, if other less invasive treatments have not been efficacious [1,39�]. The main milestone of this treatment is the high frequency of side effects, up to 63% [1], such as hypopigmentation, skin atrophy, telangiectasias, rebound effects, ineffectiveness and injection pain. These side effects seem to be diminished when using corticosteroids concomitantly with 5-FU [5].

It has been reported that corticosteroids suppress healing and pathological scarring by three mechanisms: anti-inflammatory and immunosuppressive effect, vasoconstriction, and inhibition of fibroblast and keratinocyte proliferation due to an antimitotic effect [20].

The rates of response to intralesional corticosteroid injections vary from 50% to 100%, with a recurrence rate of 9% to 50% [29]. Results may be improved when corticosteroids are combined with other therapies such as surgery, pulsed-dye laser (PDL), irradiation, 5-fluorouracil and cryotherapy [1,5,42,43]. Surgical excision with intraoperative local injection of triamcinolone acetonide followed by repeated injection at weekly intervals for 2𠄵 weeks, and then monthly injections for 4𠄶 months, may yield a good result [20].

2.5. Laser and light-based therapy

Many different lasers have been studied and utilized in the treatment of hypertrophic scars and keloids including CO2, Er:YAG and PDL, among others [44].

The vascular PDL (pulsed dye laser) 585� nm is a nonablative non-fractional laser that has been recognized as an excellent first-line treatment, and specially preventive strategy for hypertrophic scars [45]. Indeed, the primary indication for PDL is to reduce erythema [46]. The conventional short-pulsed dye laser (585 nm PDL) has been described as the most appropriate and effective system for the treatment of scars, with improvement in scar texture, color, and pliability, as well as minimal side effects [47,48]. Indeed, this type of laser improves the appearance of hypertrophic scars, keloids, erythematous scars and striae, and diminishes pruritus [47,49,50]. Thick keloids or thick (ϡ cm) hypertrophic burn scars do show minimal improvement with 585-nm PDL treatments though, but it seems that enhanced clinical results are achieved when PDL is combined with intralesional corticosteroids or 5-fluorouracil injections [44,51], or when other lasers are used, like the fractional CO2 laser. Fractional laser therapy may indeed aid to deliver TAC into the scar and maximize its anti-scarring effects when injected immediately after the laser treatment [52]. The main side effect of PDL 585 nm is prolonged purpura [20,44,51], so a newer laser, the first known LPDL (long-pulsed dye laser) or PDL 595 nm, with a cryogen-spray cooling device, was developed and it currently appears to be a good alternative [49] and it has gained much popularity. Similarly, another less-invasive method, IPL (intense pulsed light), seems to be as effective as LPDL in improving the appearance of hypertrophic surgical scars, minimizing even more the risk of purpura [49]. With similar results to PDL, it has been reported that the Q-switched, 532 nm, frequency-doubled Nd:YAG laser appears also to be promising to manage hypertrophic scars and keloids [48].

One of the most recent developments introduced into laser technology in clinics is the nonablative fractional laser (NAFL). Nonablative fractional lasers have shown significant improvement in the pigmentation and the thickness of surgical scars and have shown early promise in the treatment of atrophic scars, hypertrophic and hypopigmented scars [53]. NAFL offers a new option for the treatment of surgical scars and may outperform the PDL [54]. Recently, nonablative fractional lasers (1540/1550 nm) with a 15 mm handpiece have also been successfully used for the treatment of keloids [44]. However, data regarding recurrence rates in a long-term follow-up is still lacking. The traditional non-fractional continuous wave-CO2 laser and Nd:YAG 1064 nm had high scar recurrence rates and therefore were abandoned [51].

One of the recommended laser protocol regimens for both keloids and hypertrophic scars described in the literature involves 585� nm PDL with non-overlapping laser pulses ranging from 6.0 to 7.5 J/cm 2 (7 mm spot) or 4.5 to 5.5 J/cm 2 (10 mm spot), 1.5𠄳 ms, applied over the entire surface of the scar, with up to 7 days purpura as the most common side effect after the 585-nm PDL, 2𠄶 sessions every 6𠄸 weeks [5,44]. Generally, first results are seen after the second treatment. Darker pigmented patients or patients with scars in sensitive areas (i.e. chest) should have the energy densities decreased by 10% [55], and may require longer treatment intervals, to avoid post-inflammatory hyperpigmentation.

Regarding burn scar management protocols with lasers and lights, Hultman et al. have suggested the use of PDL, fractional resurfacing CO2 laser and IPL in a timely manner: 6� months after burn, one year after burn or several years after burn, respectively. The primary aims are to minimize hyperemia and prevent hypertrophic scarring with the PDL, to soften, release and flatten the scar with the CO2 laser, and to correct residual color cosmetic sequelae and chronic folliculitis with the IPL [56]. The aforementioned group reported the successful use during the almost 5 months of mean follow-up of a prospective before-after cohort study of one or more of the following therapeutic strategies in a total population of almost 150 burn patients: PDL 595 nm (the Candela V-beam Wayland, MA, USA) at 5� J/cm 2 – selection depending on the Fitzpatrick skin type – with none or less than 30% overlap and 1𠄲 passes, with a 7 mm spot size and pulses of 1.5 ms �lative” fractional CO2 laser resurfacing (the Lumenis UltraPulse Santa Clara, CA, USA the deep dermal DeepFX™ better combined with the microablative ActiveFX™, constituting the TotalFX™, at 15 mJ or 70� mJ per micropulse and frequency of 600 Hz or 150 Hz, respectively), and the IPL [57]. Of all 3 types of laser/light modalities, PDL was the most used. As laser therapy may easily counteract abnormal scarring associated dysfunctions or contractures in burn patients and therefore avoid reconstructive surgeries of burn sequelae, an earlier use of PDL to prevent hypertrophic scars and alleviate pruritus may be postulated. Furthermore, it has been suggested that the PDL should be offered as standard management of patients with facial hypertrophic burn scars, where it has been shown to be able to completely resolve persistent scar erythema even as long as 17 years post-burn [51].

Despite the increasing popularity and optimism regarding laser in scar management after burn or other injuries, laser therapy remains an emerging technology with limited follow-up study and lack of multicentric controlled studies [1,20]. More research is needed to evaluate the efficiency, safety, dosage regimens, appropriate type and timing, and scar recurrence rates of all the otherwise promising wide array of laser and light-based therapeutic techniques [44].

2.6. Cryotherapy

Cryotherapy is a very effective method to treat small scars, such as severe acne scars [58]. Cryotherapy combined with intralesional triamcinolone has been described as the most common traditional therapy for hypertrophic scars and keloids [20]. Its main handicap is permanent hypopigmentation as a common side effect [1]. Monthly-sessions are recommended (not more often, to favor postoperative healing), and success rates after 2 sessions using contact or spray cryosurgery with liquid nitrogen vary between 30 and 75%, being higher in hypertrophic scars than keloids [1,59]. From the three most used methods to apply cryotherapy, the new intralesional cryoneedle has shown increased efficacy compared with that obtained using either contact or spray probes [7].

2.7. Radiotherapy

There is a consensus that ionizing irradiation is an effective way to treat keloids [60]. Superficial X-rays, electron-beam therapy and brachytherapy have been used with good results in scar reduction protocols, primarily as adjuncts to surgical removal of keloids [61].

Best results can be achieved with 1500� rads (15� Gy) over five or six sessions in the early postoperative period (24– 48 h after keloid surgical excision) [1,20], although recent keloid reports advocate for higher doses, 25� Gy [62]. Radiotherapy (brachytherapy as first line followed by electron-beam therapy [62]) is the most efficacious treatment available in severe cases of keloids, combined with surgical excision [6,35]. Its main disadvantage is the malignancy risk as possible but rare side effect [1,20,46,60,63].

2.8. Fluorouracil (5-FU)

5-FU is a chemotherapy drug, a pyrimidine analog with antimetabolite activity [64], effective in the treatment of keloid scars [65], especially during the first 5 years of appearance. Wound ulceration, hyperpigmentation and pain are potential complications of the treatment [5,20]. Weekly intralesional 5-FU injections (50 mg/ml) for 12 weeks resulted in reduction in scar size of at least 50% with no recurrence in 24 months [66].

The triple combination of 5-FU, corticosteroids and PDL is a successful multifaceted approach for the treatment of hypertrophic scars and keloids [67] and it currently appears to be the most promising therapy for keloids [42].

2.9. Interferon

Interferon (IFN) subdermal injections are reported to be more efficient than triamcinolone acetonide injections in preventing postsurgical recurrence of keloids. However, these painful injections may require regional anesthesia [1,20,68] and flu-like adverse effects are also common [2].

Interferon-α, β, and γ have been shown to increase collagen breakdown [1]. Furthermore, IFN-𻄫 has been suggested to have antiproliferative properties [5]. IFN-γ inhibits TGF-β and therefore fibrosis, via initial activation of Jak1, which in turn stimulates the negative regulator of collagen YB-1 (Y-box protein-1), which activates Smad7, eventually leading to TGF-㬡 suppression [69]. However, there is a study where IFN-γ failed to antagonize TGF-β-mediated fibrotic response in keloid-derived dermal fibroblasts [70].

In vivo, intralesional IFN-γ has been shown to be effective in improving the appearance of keloids and hypertrophic scars, and in reducing keloid recurrence after excision [71], with variable treatment regimens. For instance, 0.01𠄰.1 mg, 3 times a week for 3 weeks [72], or a unique weekly maximal dose of 0.05 mg for 10 weeks [73]. IFN-𻄫 intralesional injection is usually used at 1.5 million IU twice daily over 4 days in keloids or three times weekly for hypertrophic scars [1,74].

Although IFN is an expensive form of therapy, it remains a promising therapeutic approach for excessive scarring [5].

2.10. Bleomycin

Bleomycin induces apoptosis, inhibits collagen synthesis via decreased stimulation by TGF-㬡 [75], and is frequently used as an antitumor agent. It has also antibacterial and antiviral activity [76]. Intralesional multiple jet injections of bleomycin 0.1 ml (1.5 IU/ml) at a maximum dose of 6 ml to avoid toxicity (cutaneous and less frequent pulmonary), 2𠄶 sessions within a month, may currently be indicated as a therapy for keloids and hypertrophic scars unresponsive to intralesional steroid injection [77,78], such as patients with old scars [1] however, its use is still uncommon.

2.11. Imiquimod 5% cream

Imiquimod is a immune-response modifier and Toll-like receptor (TLR) agonist [79], approved for the treatment of genital warts, basal cell carcinoma and actinic keratoses [5].

Imiquimod stimulates interferon and TNF-α, which increases collagen breakdown and reduces fibroblast-mediated collagen production, respectively [80]. The cream is applied on alternate nights for 8 weeks after surgery. Adverse effects include irritation and hyperpigmentation [81]. Although many clinical studies suggest the beneficial effect of imiquimod in the prevention of postsurgical keloid recurrence [82�], it still remains questionable [79].

2.12. Tranilast

Tranilast (N-(3,4-dimethoxycinnamoyl) anthranilic acid) is an anti-allergic drug that inhibits the release of histamine and prostaglandins from mast cells, a H1 receptor antagonist [85]. It also suppresses collagen synthesis of keloids and hypertrophic scar-derived-fibroblasts by downregulating TGF-㬡 [86]. This drug is approved in Japan and Korea for the treatment of hypertrophic scarring [87].

2.13. Botulinum toxin A

Botulinum toxin A (Botox ® , Allergan, Irvine, CA, USA) is a potent neurotoxin that produces a temporary flaccid paralysis (chemoimmobilization) of striated muscle for a period of 2𠄶 months [88]. For more than 30 years, its application has proven safe and efficient in the treatment of a variety of disorders, including hyperfunctional facial lines [89]. Using a primate model, local botulinum toxin A-induced paralysis of the musculature subjacent to a cutaneous defect minimizes the repetitive tensile forces on the wound edges, improving scar cosmesis [88].

Botulinum toxin A has been used for the treatment of keloids by intralesional injection in a prospective, uncontrolled study [90]. Intralesional botulinum toxin was given at a concentration of 35 U/ml, with the total dose varying from 70 to 140 U per session, at 3-month intervals for a maximum of 9 months. At 1 year follow-up, the therapeutic outcomes were good (n = 5), fair (n = 4) and excellent (n = 3), with no patients failing therapy or showing signs of recurrence [90].

Xiao and colleagues studied 19 patients suffering from hypertrophic scars who received intralesional injections of botulinum toxin (2.5 U/cm 3 per lesion at 1-month intervals) for 3 months. At 6-month follow-up, all of the patients showed acceptable improvement of the scars and therapeutic satisfaction was very high [91].

Some reports suggest that using intramuscular BTA in conjunction with scar revision on the face helps to reduce the development of a widened scar [92]. However, controversy is served [93,94], and larger, randomized, controlled studies need to be conducted to test the effect of chemoimmobilization in scarring [95].

2.14. Surgery

Surgical treatment of keloids has been usually recommended to be used in mature scars with complementary conservative strategies, such as radiotherapy, interferon, bleomycin, cryotherapy or corticoids, to avoid recurrence [1] (decreasing the risk from 50% to 8% as a combined treatment [96]). It is important to note that laser and light-based therapies may eliminate the need of classical scar excision and reconstructive surgery in some cases [57]. Surgical treatment of excessive scars requires a careful personalized indication and patient selection on a case-by-case basis. For instance, surgery may be indicated to release a disabling immature or early-stage scar in a stable patient that suffers a hypertrophic scar that causes a severe contracture that impedes proper rehabilitation in the early period after burn. In this case, closure by local flaps like Z-plasties or others, dermal substitutes and skin grafts, or the use of tissue expanders or free flaps may be indicated. Indeed, most clinicians recommend surgical treatment of hypertrophic scars in general as first-line treatment if disabling scar contractures are present [97]. In the case of operative treatment of mature keloid scars, it is recommended to perform an intramarginal fusiform excision, so an incomplete resection, with a 308 angle with the cutaneous tension lines [98]. As a general rule, closure of the wound should be done with minimal tension and sutures, leaving everted wound borders. Z-plasties, W-plasties and advancement local flaps may indeed be indicated [99,100]. Stitches are recommended to be applied on few planes to eliminate tension and therefore prevent keloid recurrence, reabsorbable into the fascia or subcutaneous tissue (in the form of tensile reduction sutures applied on the deep and superficial fascia with few or no dermal sutures to prevent a high strange body reaction and a worse scar) [97], and usually simple non-reabsorbable mono-filament stitches for the skin. Undermining should not be encouraged [33]. Tangential shaving has also been described for raised scars, with optimal outcomes [99].


What are keloid scars anyway?

Any scar is the body’s normal, healthy attempt to repair a skin injury. But a keloid is an overgrowth of scar tissue. Keloids can develop after any surgery (including C-sections) or trauma to the skin, including injuries, tattoos, and piercings. They also may occur after bouts with acne, says Katy Burris, M.D, a dermatologist with the department of dermatology at Columbia University Medical Center. Occasionally keloids form with no clear cause, according to the American Academy of Dermatology (AAD).

They tend to be thick, pink or brown, and can resemble a barbell, Dr. Burris tells SELF. Keloids grow slowly over several months and, unlike other types of raised (hypertrophic) scars, keloids grow beyond the bounds of where the original skin trauma occurred, Jason M. Preissig, M.D., a dermatologist with Mercy Medical Center in Baltimore, tells SELF.

Experts don’t fully understand why keloids form, but it seems like there is a genetic component: If you have a first-degree relative who gets keloids, you are also more likely to get them, the AAD says. And those with African American, Asian, or Hispanic ethnicities are also more likely to develop keloids.

Normally there are biological mechanisms in place to regulate the processes of repairing and regenerating tissue in healing skin. But when a keloid forms, that’s a sign that something is off in that balance. Lab research suggests that abnormalities in the production of melanocyte that stimulates hormone and collagen in the skin as well as the effects of stress on hormones, and prolonged inflammation at the injury site, could contribute to the formation of keloids. But we’re still far off from really understanding exactly why and how they’re produced.

Even people who are prone to keloids don’t always get them after a skin injury. The factors that determine whether or not you develop a keloid or a "normal" scar aren't totally understood, but we know that keloids are more likely to develop on certain parts of the body (like the ears, shoulders, chest, neck, and back) and under certain conditions (if the injury had a prolonged healing time, for instance).

The good news is that keloids aren’t necessarily something you need to be worried about. “They’re not an infection, they’re not contagious, and they’re not related to cleanliness,” Dr. Preissig says. “They just occur randomly.” Although keloids aren’t harmful, sometimes they do come with some pain or itching. (The only time mine hurt was after my son was born and I’d hold him toward my chest. Naturally, he’d want to touch the keloid area.)

However, it’s a good idea to see a dermatologist if you have a keloid, Dr. Burris says. For one thing it’s important to make sure it’s actually a keloid and not another type of raised skin issue. And if you do decide you want to treat your keloid, the earlier you start addressing it, the better chance that the treatment will work.


Healing Your Scars: Understanding How Scar Tape and Silicone Sheets Work

How your scars heal after surgery is an important factor to many men and women. Most scars are itchy, painful, and make you feel self conscious. They may keep you from sleeping and cause worry or stress. Often after surgery your doctor may recommend scar tape or silicone gel sheet to help your scars heal effectively.

After surgery no one wants scars that last or become permanent. Check with your doctor to find the best type of silicone tape or sheet to use for healing your scars after surgery.

Silicone Gel Sheets

Gel sheets are thin self adhesive bandages that have been proven effective on scars or hypertrophic scars. It is an internationally recommended method to treat scars by the medical community. It has few side effects and is better than steroid injections and pressure applications. Surgical scars get thicker and then smaller as time passes and it heals.

The sheet reduces collagen production in scars. If you use them until you have no scab left it has many positive benefits. It prevents excessive growth of scar tissue. The scar is flattened and softened, the redness reduced, the sheets decrease the size of the scar, make the skin more flexible, and reduces itching and pain.

Silicone sheet are effective in reducing the size of the scar and improving scar appearance. It provides protection against clothing and bacteria. This is a form of scar healing tape because it sticks to your skin like a band aid. Gel sheets can be taped with silicone tape to keep them in place.

Silicone Tape to Make Scars Less Wide

When you want to make sure a scar does not get wider using silicone tape helps. Silicone tape placed on the length and width of the scar will keep it from getting longer and thicker. Because the tape has silicone gel on it has more healing power. It is easier to keep attached and is easy to remove from the skin.

The paper backing is easy to tear and breathes when applying to the skin. It has a tab that makes it easy to unwind when needed. When removed it does not rip and hurt skin. It is the choice by many nurses for use after surgery on wounds.

Silicone Gel

Silicone gel is a liquid that can be applied on the scar by squirting it into your hands and rubbing it onto the scar. After that you can apply silicone tape to cover the wound. It should be used twice a day. It is easy to use and affordable in cost. The tape protects the wound and can be removed when you clean and apply new gel.

Silicone Tapes, Sheets and Gels

All silicone products work to reduce the size and overall appearance of the scar. It will often help heal discoloration and the texture of the scar. They contain antioxidants that make the scar heal more effectively. They heal skin by adding moisture, oxygen, and hydration. Sheets work faster because you can leave them on all day under clothing. Sheets can be worn overnight too.

Silicone sheets reduce redness, and itchiness of the scar. They come in many sizes and can fit almost any size scar. It is the safest method around. Silicone sheets, tape, and gel are an effective say to heal scars after surgery. How to heal scars is easy with silicone gel products. This is one of the most effective scar treatments with the least side effects. Ask your doctor to recommend a brand like scarheal to aid with your recovery after surgery.


How to Prevent Keloid and Hypertrophic Scars

This article was co-authored by Adarsh Vijay Mudgil, MD. Dr. Adarsh Vijay Mudgil is a board certified Dermatologist, Dermatopathologist, and the Owner of Mudgil Dermatology, a state-of-the-art dermatology practice based in New York, New York. As one of the few dermatologists in the area to achieve board certification in both dermatology and dermatopathology, Dr. Mudgil specializes in all aspects of medical, surgical, and cosmetic dermatology. He received his Bachelor's degree with Phi Beta Kappa honors from Emory University and earned his Doctor of Medicine (MD) with Alpha Omega Alpha honors from the Stony Brook University School of Medicine. In medical school, Dr. Mudgil was among a handful of students nationwide to receive a coveted Howard Hughes Medical Institute Fellowship and Scholarship. He then completed his residency in dermatology at the Mount Sinai Medical Center in Manhattan, where he served as chief resident. Additionally, Dr. Mudgil went on to complete a fellowship at the prestigious Ackerman Academy of Dermatopathology. He is a fellow of the American Academy of Dermatology, the American Society for Dermatologic Surgery, and the American Society of Dermatopathology. Dr. Mudgil is also a member of the Mount Sinai School of Medicine teaching faculty.

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Nothing can leave you feeling more self-conscious than a nasty scar. While some scars are simply unavoidable after an abrasion, burn, or cut, there are proven techniques that can help you reduce the appearance of a scar. Two of the most common forms of scar tissue are keloid and hypertrophic. They normally form over a cut or wound to the skin. In general, keloid scars are more difficult to identify and treat than hypertrophic scars, but both can prevented, especially with the advice of a trained doctor. [1] X Trustworthy Source Cleveland Clinic Educational website from one of the world's leading hospitals Go to source