Chronic Wound Scars

Scar Meeting, Montpellier April 2006
Chronic Wound Scars
Problems and Solutions
S. Meaume
Geriatrician - Dermatologist
Charles Foix Hospital - APHP Paris
[email protected]
Scar history
• stabilized after 3 months to several years
• quiescence or reactivation of the scar -> new
wound
–
–
–
–
mechanical forces
underlying pathology
trauma
neoplastic transformation
• vunerable for recurrence
Chronic wound scars
• No epidemiological
datas
• No clinical study
– Problem of methodology
: no tool kit to evaluate
– No EBM
• No potential market for
industry
• Frequent individual
reality
– for patient
– for medical team
Specific problem induced by
chronic wounds
• Chronic wounds
–
–
–
–
–
Pressure ulcers
Diabetic foot ulcers
Leg ulcers
Irradiated skin
Dermatological
diseases
– Burns
– ...
• « Standard »
clinical situations
–
–
–
–
–
Unstable scar
Hyperkeratosis
Scar folds
Recurrence
Neoplastic
transformation
– ...
« Normal » pressure ulcer scar
Achromic scar
Dry skin
Stage 2 pressure ulcer
Stage 2 pressure ulcer scar
Atrophic scar
Dry skin
Hyperkeratosis
Stage 3 pressure ulcer
Stage 4 pressure ulcer
Abnormal
keratinisation
• Hyperkeratosis
– On the lower extremities
• Lead to
– Permanent pain if normal sensory
endings
– Torpid progresive wound in
patient who have lost sensitivity
– Mecchanical conflict with the
shoes
– Recurrences : risk of compression
of the undelying structure
PU with surgical treatment : flaps
• Spinal cord injured young patient
• Absence or poor quality (fibrotic) of dermal
component
• Succession of active and healed stage of wound
• Each episode of reopening of the skin can reproduce
the preceding stage, or the wound can change
completely in shape size or depth
Post operative PU
• Adhesion to depth create a fixed point that perturb
normal skin movements
• Junction between flap edge and normal skin
– In 25% (up to 56%) after flap surgery
• Incisions submitted to tension (skin resection or
skin grafting)
Atrophic scar
• Scar fold on a border of a stage 4 PU in
spontaneous healing
– lack of dermal tissue
– difference in gliding between the 2 adjacent part
– shearing force create skin damage
Stage 4
Stage 2
Unstable scars on PU
• If permanent mechanical forces is applied (shear more
than pressure forces)
Pressure ulcers scar problems
: causes
• Lack of prevention
– Pressure (pressure relieving system -> low air low bed)
– Shear forces
• Lack of sensitivity (spinal cord injured, diabetic
patients)
• In stage 4 PU no depth tissues regeneration
• If surgery
– excessive or lack of « matelassage »
– folds
• Adhesion to depth, retraction, maceration, lack of
hygiene, lack of patient education, psychological
disorders
Diabetic foot ulcers : problems
• Problem of denervated
skin
• Hyperkeratosis +++
• Poor shoeing
– poor off-loading
– excessive pressure
• Instable scars
• Undetected fistulae skin
tears fissures
Cause of diabetic foot ulcers
pathologic scars :
• Alone or in combination
– Acquired bone deformation
(osteoarthropathy)
– Lack of sensitivity (neuropathy)
– Lack of vascularization (micro and macro
angiopathy)
– Mechanical stress on deformed areas
Hyperkeratosis
Necrosis
Pressure ulcer
DFU scars : solution
• Conservative treatment
– Enhanced prevention : education, proper hygiene, adapted shoes,
daily survey at risk areas
– prévention et traitement des hyperkératoses : chaussage adapté
• Surgical treatment
– Orthopedic management of foot deformations
– Revascularization
– Reconstructive surgery
• Modern « adjuvant » treatment
– Skin substitut (Dermagraft™) prevent recurence of wounds
– PDGF-bb (Regranex™) increase resistance of scar
Leg ulcers scars : problems
• Scar instability
– after skin grafting
– or spontaneous
wound healing
Malignant transformation
•
•
•
•
After 20 years
Malignant wound
Prognosis reserved
Conservative
treatment versus
amputation
Leg ulcers scars : problems
• Poor cosmetic skin
graft and donor site
aspect
• Recurrence +++
– Lack of compression
– Local trauma
Pinch skin greft
Basal cell carcinoma
Leg ulcer atrophic scar
• Increase the recurrence
Leg ulcers scars : causes
• Scar problems related
to
–
–
–
–
–
–
Edema et lymphoedema
Lipodermatosclerosis
Fibrosis
Dermatitis
« Atrophie blanche »
…
Leg ulcers scars : solution ?
• Surgical excision of fibrous bed ans ulcer follow by
graft (Smeller)
• Skin substitutes ? (Apligraf™, Epidex™…)
Irradiated skin : problem
• Scar transformation
• Biopsy
– Cancer recurrence
– Cancer
transformation
– Benign nodosity
Probelm of irradiated scars
• Bone exposition and
necrosis
• Adherence
• Rétraction
Conclusion
• Epidemiology
– not rare, but not evluated
• Problem essentialy in young people, with long
life expectancy
– Cosmetic
– But also functional
– And pb of cancer transformation
• No « potential » market and not a lot of
research on the topic for the moment