Tratamento da cicatriz hipertrófica

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Tratamento da cicatriz hipertrófica

Mensagem  Lucas Silva em Qua Jan 30, 2013 3:13 pm

Os textos não definem tratamentos específicos para a cicatriz hipertrófica. A maioria deles são os mesmos usados para o quelóide. Portanto, colocarei os principais tratamentos para quelóide

Hypertrophic scars may initially appear similar to keloids, but in contrast to the latter, hypertrophic scars do not extend beyond the margins of the wound. While the treatment strategies are similar for both lesions , hypertrophic scars are far less likely to recur once treated. Most of the literature on keloids suggests that a high recurrence rate (50%) is expected, regardless of treatment.

Hypertrophic scars are associated with adverse wound healing factors, such as infection, excessive tension, foreign bodies, and repetitive trauma;

If located in an amenable anatomic location, hypertrophic scars can generally be treated with simple excision, providing wound closure can occur without undue tension. Steroid injections may be appropriate, depending on the particular wound and the patient. Although an injection of intralesional triamcinolone acetate usually flattens the raised scar and decreases pruritus, the discolored or atrophic appearance of the widened portion of the scar remains. Limitations of steroid treatment must be recognized by the surgeon and the patient to optimize satisfaction with the results. Steroid injections must be administered cautiously to avoid overtreatment, which may result in skin atrophy, telangiectasias, and a depressed scar.

DIAGNOSIS — The diagnosis is based upon the clinical appearance of excessive scar tissue. Patients may be asymptomatic, but frequently have lesions that are pruritic, tender to palpation, or occasionally are the source of sharp, shooting pains. Most commonly keloids occur on the ears, neck, jaw, presternal chest, shoulders, and upper back (picture 1A-B). Acne keloidalis nuchae refers to inflamed pustules and papules on the posterior neck that often heal with keloid formation (picture 2).

Hypertrophic scars may initially appear similar to keloids, but in contrast to the latter, hypertrophic scars do not extend beyond the margins of the wound (picture 3). While the treatment strategies are similar for both lesions [20], hypertrophic scars are far less likely to recur once treated.

TREATMENT — The best treatment is prevention in patients with a known predisposition. This includes preventing unnecessary trauma or surgery (including ear piercing, elective mole removal), whenever possible. Any skin problems in predisposed individuals (eg, acne, infections) should be treated as early as possible to minimize areas of inflammation. Patients who have acne keloidalis nuchae should avoid shaving in the neck region, and the posterior hair should only be trimmed with scissors and trimmed no shorter than one-eighth of an inch.

A number of treatment options are available for painful or cosmetically disfiguring keloids:

Intralesional corticosteroids
Excision
Silicone gel sheeting
Cryosurgery
Pressure earrings
Radiation therapy
Interferon alfa
Intralesional fluorouracil
Intralesional verapamil
Laser therapy
Imiquimod

Combinations of these therapies are also effective. Patients should be advised, however, that recurrences are possible despite therapy. The earlier keloids are treated, the more likely it is that they will respond to therapy.

lntralesional corticosteroids — Intralesional corticosteroids are first-line therapy for most keloids. A systematic review found that up to 70 percent of patients respond to intralesional corticosteroid injection with flattening of keloids, although the recurrence rate is high in some studies (up to 50 percent at five years).

Excision — Scalpel excision may be indicated if injection therapy alone is unsuccessful or unlikely to result in significant improvement. Excision should be combined with preoperative, intraoperative, or postoperative triamcinolone or interferon injections . Recurrence rates from 45 to 100 percent have been reported in patients treated with excision alone; this falls to below 50 percent in patients treated with combination therapy . Postoperative use of imiquimod every other day may reduce the rate of recurrence . Referral to a dermatologist or plastic surgeon is indicated for excision because of the high rate of recurrence.

Silicone gel sheeting — Silicone gel sheeting has been used for the treatment of symptoms (eg, pain and itching) in patients with established keloids as well as for the management of evolving keloids and the prevention of keloids at the sites of new injuries .
Silicone sheeting is used to decrease the irritation and pruritus associated with keloids. The proposed mechanism of action involves maintenance of scar hydration and inducement of a subsequent decrease in cytokine release, resulting in less collagen deposition. Certain authors report great success in keloid regression with this modality. Unfortunately, the general opinion on silicone sheeting does not support significant reduction in the dimensions or pigment characteristics of keloids, although silicone sheeting can be very effective in decreasing pruritus.

A systematic review of controlled trials found some evidence that silicone gel sheeting may reduce the incidence of abnormal scarring, but concluded that any estimate of effect was uncertain because the underlying trials were of poor quality and highly susceptible to bias . Treatment with silicone gel sheeting appeared in some studies to improve elasticity of established abnormal scars, but the evidence was again of poor quality and susceptible to bias.

The mechanism by which silicone gel sheeting might exert an anti-scarring effect is unknown, but may be related to hydration, generation of static electricity, or reduction of mast cells.

Silicone gel sheeting and silicone gel are available by prescription and over-the-counter. The sheeting is clear and sticky and should be cut to fit the size of the keloid. The sheeting is placed on top of the keloid, taped into place, and left on for 12 to 24 hours per day. The sheet is washed daily and replaced every 10 to 14 days. Effectiveness is judged after two to six months of therapy.


Cryosurgery — Cryosurgery is most useful in combination with other treatments for keloids , although up to 50 percent of patients may respond to cryotherapy alone . The major side effect is permanent hypopigmentation, limiting its use in patients with darker skin.

A 10- to 30-second freeze-thaw cycle is used and can be repeated up to three times per treatment session. Therapy is repeated once per month until response occurs.

Pressure earrings — Uncontrolled studies have reported that pressure therapy is an effective treatment for keloids of the ear following piercing . The earrings, also called Zimmer splints, are splints that are inexpensive and molded to the appropriate size, cosmetically altered to appear as earrings. One online source for these is Delasco (www.delasco.com).

Radiation therapy — Most studies , but not all , have found radiation therapy to be highly effective in reducing keloid recurrence, with improvement rates of 70 to 90 percent when administered after surgical excision. A small randomized trial of treatments after surgery found recurrences in 2 of 16 earlobe keloids (13 percent) treated with radiation therapy and in 4 of 12 earlobe keloids (33 percent) treated with steroid injections .

However, concern regarding the potential long-term risks (eg, malignancy) associated with using radiation for an essentially benign disorder limits its utility in most patients. Only a few cases of malignancy that may have been associated with radiation therapy for keloids have been reported . Although causation cannot be confirmed in these cases, caution should still be used when prescribing radiation therapy for keloids, particularly when treating younger patients . Radiation therapy may occasionally be appropriate as treatment for keloids that are resistant to other therapies. In addition, radiation therapy may be indicated for lesions that are not amenable to resection .

Keloid characteristics may play a role in predicting the response to therapy. A study in which patients were treated with Sr-90 brachytherapy after surgical excision of keloids found that the location (thorax), size (large), and etiology (result of a burn injury) are factors that may predict a less favorable response .

Interferon alfa — Interferon alfa injections may reduce recurrence rates postoperatively. However, all currently available studies of interferon therapy suffer from methodologic problems, making an evidence-based recommendation regarding its use difficult .

Intralesional fluorouracil — Intralesional fluorouracil (5-FU) may be of benefit for keloids. In a case series, 28 patients were treated with intralesional 5-FU 50 mg/mL with a volume of 0.5 to 2.0 mL per session for up to 12 weekly sessions . Greater than 50 percent response to treatment reportedly occurred in the majority of patients after 12 weeks. Ulceration occurred in 21 percent of patients.

In a second case series of 20 patients, 17 patients had at least 50 percent improvement and only one showed no improvement . Among the 19 patients with any improvement, nine patients had a recurrence within one year.

Intralesional 5-FU can be used in combination with intralesional corticosteroids.

Pulsed dye laser — Pulsed dye laser treatment can be beneficial for keloids , and appears to induce keloid regression through suppression of keloid fibroblast proliferation, and induction of apoptosis and enzyme activity.

Combination treatment with pulsed dye laser plus intralesional therapy with corticosteroids and/or fluorouracil may be superior to either approach alone.

Other — Other therapies that have been used for keloids include intralesional verapamil and topical imiquimod cream. There is currently insufficient evidence to make definitive recommendations about these therapies when used alone; as discussed above, imiquimod may provide benefit when used after surgical excision.

The high recurrence rate of keloids has initiated a wide variety of different treatment approaches. Thus far, convincing evidence does not exist to recommend any therapy over surgical excision followed by sequential intralesional steroid injections; however, well-controlled studies on the treatment of keloids are rare.

The favored treatment regimen for hypertrophic scars is surgical excision. The response is generally more favorable than that with keloids, as long as the initial negative influences on healing are not reproduced. The use of intralesional steroid injections in hypertrophic scarring remains questionable. The risks and benefits must be weighed and clearly explained to the patient.

Bibliografia:

Hypertrophic Scarring and Keloids - Medscape - http://emedicine.medscape.com/article/876214-overview#a11
Keloids - Uptodate

Lucas Silva

Mensagens : 12
Data de inscrição : 27/11/2012

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