2013 Wound Care People Ltd - Journal of Community Nursing
Transcription
2013 Wound Care People Ltd - Journal of Community Nursing
W ound H eAling Abnormal scarring: an overview d Lt A first used in an attempt to illustrate the way the lesions expand laterally from the original scar into normal tissue. Keloids are dermal fibrotic lesions that are raised, reddish-purple, nodular scars that are firmer than hypertrophic scars (Figure 2). They have a prolonged proliferative phase due to an inherited metabolic alteration in collagen. Keloids continue to grow indefinitely and may become uncomfortable and restricting, itchy or painful. Formation may occur weeks or years following the initial trauma. Keloids arise due to trauma or injury to the skin such as scratches, injections, insect bites, ear piercing and tattoos3. Young people with darker skin are more prone to this type of scarring; keloids are between five and 15 times more common in black people than white people6, suggesting a genetic basis. Additionally, they are more common on certain parts of the body for example ears, chest, shoulders and back. Both keloid and hypertrophic scars have many features in common, they are both raised; initially pink to purple lesions that are often painful, pruritic or both3. Table 1 outlines the clinical features of each. Hypertrophic scars and keloids usually form7: in body areas that exhibit slow wound healing; in pressure dependent or movement-dependent areas; in areas of tension that are particularly prone to abnormal scar formation. Hypertrophic scars have a good le scar is an essential part of the natural healing process subsequent to an injury to the dermis or the epidermis1. Scars are thick mounds of scar tissue, characterised by excessive amounts of collagen deposition2. The type of scar that forms can depend on a variety of factors3: the nature of the injury; part of body injured; size and depth of the wound. Scar classification is therefore important as subtle differences in clinical characteristics can indicate the diagnosis and treatment protocol required3. op An estimated 23 million adults in the UK have some sort of scar. Normal scars are preceded by injury, immediate in onset, flat and asymptomatic. These are the most common type of scar and are a result of the body’s natural healing process. Hypertrophic and keloid scars occur when the healing process is deranged. This article, abridged and amended from an article previously published in JCN, outlines the differences between these latter types. Normal scars Pe Normal scars, the most common, are immediate in onset, flat and asymptomatic. They form when a skin defect heals without excessive quantities of newly synthesised collagen. Initially the scar may be red or dark and raised, but will become pale and flat over time; this may take up to two years4. Abnormal scar formation is unique to humans; the range of suggested aetiologies and treatments for abnormal wound healing indicate that our understanding of these processes is incomplete. nd C ar e Key words: Hypertrophic scar Keloid scar Scar management © 20 13 W ou Hypertrophic scars To view original article please visit: http://www.jcn.co.uk/journal/03-2011/ wound-management/1416-scar-therapies/ ?s=scarring Hypertrophic scars are caused by overzealous collagen synthesis coupled with limited collagen degradation during the remodelling phase of wound healing. These scars occur within weeks of the initial trauma and have a tendency to remain stable or regress with time; while they remain confined to the boundary of the original injury, they may continue to thicken for up to six months5. Hypertrophic scars are pink, raised, firm erythematous scars characterised by a decrease expression of collagenase (Figure 1). Hypertrophic scars are more common in young people and people with very pale or very dark skin. Despite numerous studies, however, there is no uniformly accepted theory or explanation which indicates which factor initiates hypertrophic scar formation. Almost all hypertrophic scars are associated with an assault or injury to the skin, in addition factors such as skin tension, wound infection, and prolonged inflammatory response, have all been implicated5. Figure 1: A hypertrophic scar. Keloid scars The term keloid, meaning “crab claw” was Journal of Community Nursing May/June 2013, volume 27, issue 3 Figure 2: Keloid scarring. 25 W ound H ealing Hypertrophic Inheritance Significant familial Less familial incidence predilection Racial Blacks more than Caucasians Less race related Sex Females more than males Equal sex ratio Age Most common in 10 to 30 year Any age but more common in olds younger age groups (under 20yrs) Borders Overgrows wound border Natural History Develops months after injury Develops soon after injury and and rarely subsides subsides with time Location High predilection for the face, Across flexor surfaces earlobes, pre-sternal area and deltoid region Aetiology Possible auto-immune phenomenon © 20 13 W 26 le op Conclusion The prevention of scar formation is important for physical and mental wellbeing; teaching patients to massage their scars will have a significant effect in preventing the scar to form. Appropriate management of the scar will ensure that the wound remains healed and that the patient is happy with the outcome. Pe ar e ou No scar can ever be removed completely, although they may improve naturally over time. Their appearance can be improved by surgical removal, silicone gels, and laser therapy. Generally, conservative non-surgical methods are applicable as a primary treatment option. Choice of treatment will depend upon anatomical location of the scar and patient lifestyle. Massage and creaming Massage can help prevent abnormal scar formation; it breaks up the collagen fibres to soften, flatten and fade scars. While evidence is unsubstantial, it correlates with the evidence for the use of pressure therapy8. Any type of emollient cream can be used, but not oil or petroleum based if having pressure therapy. Massage should be started as soon as the wound heals. Silicone gels Silicone gels have been used for management of scars since the early 1980s. Poston9 argues that it is a safe and effective management option; the gels adhere and mould to any body contour and are safely and painlessly applied and removed. Their mechanism of action remains unknown, but the moisture vapourisation rate has been found to be half of that of exposed scar tissue10. The softening and flattening effect of gel sheeting may be due to hydration of the stratum corneum and/or release of a low molecular weight silicone fluid. Poston9 suggests that application of silicone gel improves the redness, itching, texture and thickness of hypertrophic and keloid scars in 60-100 per cent of cases. Results from randomised, controlled trials suggest that silicone gel sheeting is a safe and effective management option for both hypertrophic and keloid scars11. In addition the International Clinical Recommendations on Scar Management state that the only treatments for which there is sufficient evidence to make evidence based recommendation are silicone gel sheeting and intra-lesional corticosteroids11. The gels are self-adhesive or can be held in place by bandages, tape, tubular bandages or pressure garments. Patients are advised to build up wear time until patients can tolerate eight hours or more, and ensure good hygiene of the product12. Pressure therapy Pressure therapy promotes: restoration of function; relief of symptoms; prevention of recurrence; optimum aesthetic appearance. Pressure garments are most useful when the scar is still immature, either as prophylaxis in individuals who are at risk of developing abnormal scars, or when there are early signs of abnormal scarring. They are 85 per cent successful in compliant patients, but the garments are tight, often only available in one colour and must be worn for 23 hours a day for up to two years, so compliance is often an issue5. Pressures should be 24mmHg or above and must be maintained for a minimum of 12 months. They can be used in conjunction with silicone gels, adding efficacy in areas that are difficult to apply pressure such as the sternum and joints11. C Management Related to tension and timing of wound closure nd response to treatment, whilst keloids seldom resolve spontaneously and have a poor response to treatment3. Treatment options outlined below refer therefore to hypertrophic scars. Remains within wound borders d Keloid Pharmacology Intra-lesional cortico-steroid injections of triamcinolone are thought to be effective; steroids restrict the blood flow locally in the scar and inhibit protein synthesis5. Corticosteroid treatment appears to diminish tissue deposition and to soften and flatten keloid scars; injections are more effective in preventing hypertrophic scars than resolving them, and are frequently administered in combination with surgery and pressure therapy to prevent recurrences3. Laser therapy Current laser technology permits successful treatment of various types of scars. Alster12 demonstrated clinical and textural improvements in erythematous and hypertrophic scars and keloids. Lt Table 1: Clinical features of keloid and hypertrophied scar tissue References 1. Ladak A, Tredget EE. (2009) Pathophysiology and Management of the Burn Scar. 2. Clinical Plastic Surgery. 36: 661-674 3. Munro KJG. (1995) Hypertrophic and Keloid Scars. Journal of Wound Care. 4; 3: 143-148 4. Juckett G, Hartman-Adams H. (2009) Management of Keloids and Hypertrophic Scars. American Family Physician. 80; 3: 253 – 260 5. Pape SA. (1993) The Management of Scars. Journal of Wound Care. 2; 6: 354 – 360 6. Bloemen MCT, Van de Veer WM, Ulrich MMW, et al. (2009) “Prevention and curative management of hypertrophic scar formation”. Burns. 35: 463-475. 7. Butler PD, Longaker MT, Yang GP. (2008) Current Progress in keloid research and treatment. Journal of American College of Surgeons. 206; 4: 263-272 8. Niessen F, Spauwen P, Schalkwijk J, et al. (1999) On the nature of hypertrophic scars. Plastic & Reconstructive Surgery. 104; 5: 1435 – 1458 9. Patino O, Novick C, Merlo A, et al. (1998) Massage in Hypertrophic Scars. Journal of Burn Care and Rehabilitation. 20; 3: 268-271 10. Poston J. (2000) The use of silicone gel sheeting in the management of hypertrophic and keloid scars. Journal of Wound Care. 9; 1: 10-16 11. Momeni M, Hafezi F, Rahbar H, et al. (2009) Effects of silicone gel on burn scars. Burns. 35: 70-74 12. Mustoe TA, Cooter RD, Gold MH. (2002) International clinical recommendations on scar management. Plastic & Reconstructive Surgery. 110; 2: 560-571 13. Fette A. (2006) Influence of silicone on abnormal scarring. Plastic Surgery Nursing, 26; 2: 87-92 14. Alster T. (1997) Laser Treatment of Hypertrophic Scars, Keloids and Striae. Dermatologic Clinics. 15; 3: 419-429 Journal of Community Nursing May/June 2013, volume 27, issue 3