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Biofilms and Impaired Wound Healing … 227
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024.
Update on Technology
and Evidence-Based Management
of Scars
Luc Téot, Hester Colboc, and Sylvie Meaume
Abstract
Scars form a medical problem still considered as a cosmetic issue by most of the
societies and poorly covered except for burns and trauma. The classification
established in 2002 (Mustoe et al. 2002) separates 6 classes of scars, from
immature scar to large spreading keloidas. POSAS scale is now considered as
one of the most valuable tool concerning objective assessment, taking in account
the perception and the psychological consequences observed by the patient him
(her)self and the surrounding actors. Amo ng the 30 Millions of surgical
procedures realized every year in Europe, 1–6% lead to postoperative
complications like surgical site infection, largely impacting the scar quality.
The development of hypertrophic scars depends on the age, the anatomical
location and its specific mechanical properties (the face is not submitted to the
same mechanical forces than the back), the origin of the lesion (burns, post-op
local infection,…) and the compliance of the patient to the proposed treatments.
Scar management drastically changed during the last decade. Thanks to a large
transdisciplinary approach, new technologies emerged. These technologies are
mainly based on early mechanotherapy, antiproliferative drugs and lasers.
Keywords
Pathological scarringMechanotherapyLasersPrevention
L. Téot (&) H. Colboc S. Meaume
Montpellier University Hospital, Montpellier, France
e-mail: l-teot@chu-montpellier.fr
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. Mani (ed.), Chronic Wound Management,
https://doi.org/10.1007/978-3-031-26110-7_11
229
230 L. Téot et al.
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Introduction
Scars form a medical problem still considered as a cosmetic issue by most of the
societies and poorly c overed except for burns and trauma. The classification
established in 2002 (Mustoe et al. 2002) separates 6 classes of scars (Table 1), from
immature scar to large spreading keloids. POSAS scale is now considered as one of
the most valuable tool concerning objective assessment, taking in account the
perception and the psychological consequences observed by the patient him(her)self and the surrounding actors. More than 30 Millions of surgical procedures are
realized every year in Europe, leading to a variable rate of postoperative complications (between 1 and 6%) impacting the scar quality. the development of
hypertrophic scars is variable, depending on the age, the anatomical location and
the compliance of the patient to the proposed treatments. Scar management drastically changed during the last decade. Thanks to a large transdisciplinary approach,
some important principles are now confirmed and new technologies emerged. These
Table 1 Classification of
scars (Mustoe et al. 2002)
A Normal scar is flat and pale without itching and not enlarged
An Immature scar, frequently observed in children is a mild
transitory rise in height of the scar, becoming red, sometimes
itching, presenting a slight augmentation of the density. This
scar will normalize after a variable period of time, reaching
18 months–2 years in some patients
Atrophic scars can develop by a combined separation of the
dermal edge with preservation of epidermis continuity. These
scars are often observed in adolescents after skin resection for
benign tumors on the back
An Hypertrophic scar is a scar proliferation staying into the
limits of the edges of the initial scar, with a progression starting
one month after the complete healing, growing for five to six
months and presenting a plateau with a slow decrease of the
inflammatory signs, issuing after one year (sometimes more) to
a stable scar having lost its inflammatory signs. It may be linear
after a surgical suture or wide spreading after burns. They are
usually red, itching and raised in height
Keloids are characterized by a pseudo-tumor proliferation
extending over the edges of the initial wound and keep growing
along time, some of them reaching high volumes. They are
more observed over the thorax, on the ear lobes and the neck
Skin contractures are frequent in burns, with bands of
hypertrophic retractile scars limitating the joint movement.
Their mechanical force is strong enough, when not correctly
managed, to impact the growth plates of diaphyseal bones,
issuing to permanent deformities of limbs along the children
growth
Self inflicted scars are usually linear and located on the anterior
part of the forearms. These situations are observed in
psychologically affected adolescent patients
Update on Technology and Evidence-Based Management of Scars 231
technologies are mainly based on mecanotherapy, antiproliferative drugs and lasers.
Most of these therapies are used with a lack of firm randomized controlled clinical
trials to support their efficacy, and there has been often a lack of appropriate
labelling or classification of scars to allow optimal evaluation of existing literature.
Scars change over time so that improvements may not necessarily be due to the
treatment intervention but simply to scar maturation.
Biological Resume of Events Occurring After a Skin Injury
After injury the sequence of events associate platelet aggregation, provisional fibrin
matrix followed by influx of inflammatory cells, and subsequent cell proliferation
including fibroplasia and angiogenesis. After the third day, matrix collagen deposition begins. Maximal collagen deposition occurs in the first few weeks with a
combination of Type 1 and Type 3, followed by many months of collagen
breakdown and synthesis with increasing type 1 collagen with increased organization and scar strength. Once the wound is covered by keratinocytes a cellular
apoptosis occurs , with a resolution of inflammation. These phases of inflammation,
cell proliferation, and collagen remodeling results, for a surgical incision, to a fine
line scar or “normal” scar, and in case of broader injury a flat scar. Hypertrophic
scars may be a consequence of bad transmission of signaling between keratinotcytes and the underlying layer of proliferating fibroblasts (Andrews et al. 2016).
Keloids occur with a genetic predisposition, and are formed of anarchic layers of
collagen deposition.
Factors Impacting Scars
Several factors may impact on the scar occurrence and evolution, the age of onset
the extent on the body and the anatomical location.
The Young Age
Scarring will follow the hormonal sequences accompanying the child growth, with
peaks occurring between 3 and 7 years, and a second period of intense activity
around the puberty. Scars will stay inflammatory for long periods of time, more
than 2 years, imposing long periods of care to prevent hypertrophic scarring.
Between 70 and 85% of burns scars become hypertrophic in children. In the first
years of life the psychological consequences are more on the surrounding parents,
and during puberty the consequences may be devastating, especially if visible areas
are concerned, like the face or the upper limbs.
232 L. Téot et al.
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Technologies should be adapted to the child with less painful treatments and
more delayed surgical scar revisions when possible.
The Elderly
Traumatic and surgical acute wounds healing is rather good even in very old
patients and hypertrophic or keloid scars are rare, at least in the Caucasian population (Monarca et al. 2012).
The poor quality of the scar is usually not a major problem (appearance, color,
shape) (Brands-Appeldoorn et al. 2018) except in exposed regions (face) or when
impacting the function (heel, eyelid and peri-orificial areas).
Pruritus and/or pain may appear very lately after the trauma/surgery and occur
after 20 or 30 years. They are linked to dermatological problems (dry skin) or
neurogenic disorders. These situations may be treated symptomatically with
appropriate cosmetics (Humbert et al. 2016). A few of them need surgery, but war,
post-traumatic post surgical scars are not usually reasons to go to see a doctor.
Atrophic and adherent cars can be improved by injecting fat under the scar, a
recent technique presenting the advantage of being minimally invasive when
anticoagulation is not needed or should be stopped.
The Reappearance of a Wound on a Scar
The recurrence of a tumor may be at the origin of the scar. A biopsy or the
recurrence of a chronic ulcer (arterial or venous, pressure, or diabetic foot ulcers) is
needed to diagnose a malignant transformation.
It can also lead to the reassessment of the patient and indication of preventive
treatment of compression or discharge (cushion, shoe, soles). Unstable scars may
appear because of their location, sometimes due to a poor quality of the dermal
component (absent or fibrotic) or insufficient preventive measures taken against
aggressive external agents (shoes, stockings, bandages, prosthesis ...) (Figs. 1 and 2).
Post irradiation scars in cancer treatments (breasts for example) poses the
problem of radiodermatitis and radionecros is which evolves and worsens over time,
in particular in the elderly who were irradiated at a time when the administered
doses were high.
Some scars from childhood link to operated orthopedic malformations are
associated with joint deformations of osteoarthritis because of mechanical forces
pressure or friction exerted on those scars or because of underlying medical
problems in the region: arterial disease or neuropathy.
r
Update on Technology and Evidence-Based Management of Scars 233
Fig. 1 Pressure ulcer
Fig. 2 Post surgical wound
• Consequence of poo
quality of dermal
component (fibrotic)
• Succession of closure
and reoppening
phase
• More and more
complicated to treat
and to obtain total
wound closure
• Should be biopsied if
persistance
Location : On the back beetween the two shoulders
• Melanoma excision
• Excessive tension
• Poor quality of dermal
component
• Poor preventive
measure taken against
external agressive
agent (taxi driver)
• Succession of healed
and evolutive stage
(biopsy to detect
melanoma recurrence)
Degenerescence/Marjolin’s Ulcer
A rare and aggressive skin cancer, develops late on scars from burns, or from
delayed wound healing problems: chronic osteitis, burns, pressure ulcers, lupus
scar, skin graft, radiodermatitis. Squamous cell carcinoma are more frequently
observed than basal cell carcinoma, melanoma or sarcoma. The occurrence of a
wound on a scar aged of more than 20 years always requires a biopsy (Cruickshank
and Gaskele 1963; Yu et al. 2013 ).
Hyperkeratosis
Hyperkeratosis is common especially on scars on plantar aspect of the foot, the
heel, next to the Achilles tendon or on the toes and the lateral aspects of the foot.
Due to a thickening of the stratum corneum reaction to friction or to mechanical
conflict, especially in case of loss of the sensibility (diabetes, nerve damage). The
cracks ca n appear and constitute entry doors exposing to the risk of deep infection.
These wounds finally closed after a succession of closure and multiple
re-openings, source of discomfort and risk of cancer transformation. The treatment of
these unstable scars become more and more complex due to underlying diseases and
comorbidities. Biopsies often need to be done to rule out a malignant degenerescence.
234 L. Téot et al.
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Adherence to the depth is a problem that worsens with age. A long term
healing occurring on a wound with a loss of deep substance (dermis, fat, gliding
capacities) and not correctly repaired thanks to negative pressure therapy, skin
substitute or flap may lead to an atrophic scar adherent to the deep plans, creating of
a fixed point, disrupting normal skin movements, in particular at the junction
between the edges of the skin flap and normal skin. These adherences expose to
skin reopening due to the loss of elasticity of age-related skin.
Generic principles of scar management depending on the time of onset after
healing:
• At one month local signs are minor and formed by a scar redness, itching and a
mild elevation.
These signs should be better defined and included in the training program of any
nurse and doctor, especi ally surgeons (any kind) for a precise assessment of the scar
during their first post op clinic after suturing or skin grafting.
Silicone can be applied locally either as a sheet to be maintained locally by
clothes or bandages, or using gels to regularly apply over exposed scars or even
sprays easier to use and reapplied during the day. Some authors recommend a
systematic use of silicone sprays after trauma or surgery. Starting early the silicone
application may limit redness and mild elevation. The mechanism of action of
silicone therapy on scar maturation has not been completely elucidated but a
growing body of evidence indicates that the beneficial effects of silicone gel is
decreased water evaporation of skin and therefore increased hydration of the stratum corneum. After application of silicone gel or cream in combination with an
occlusive dressing, a silicone film forms which may explain a comparable effect on
water loss and hydration of the upper layers of the epidermis (Mustoe 2008). Limit
or suppress sun exposure should be the rule, even anti UV creams cannot prevent
the local inflammation induced by sun exposure. The use of hydrocolloid dressings
has been proposed by some Burns teams, their self adhesion capacity and suppleness during movements making them comfortable and easy to wear for the child.
They prevent sun exposure and maintain a local adapted level of humidity, prone to
decrease local inflammation.
• At three months the scar is red, itching and mildlyelevated silicone application
is recommended and, depending on the extent of the scar and the degree of
inflammation, complementary techniques can be proposed.
Local compression using compressive garments are used and realized at fashion.
Compression forces should not exceed 25 mm Hg, measurements of the body
segments (skull, upper arm, trunk, lower arms) being taken by specialists on special
paper sheets and sent to the fabric. Different companies may provide this service
around the world. These garm ents are coated with silicone. They should be redone
4 times a year during the child growth. They are considered as mandatory in all post
Update on Technology and Evidence-Based Management of Scars 235
burns extended scars in children and reimbursed in some countries (Anzarut et al.
2009). Plastic Orlen based may be needed in case of severe retraction, imposing
uncomfortable positions to the children.
Corticosteroid injections are not recommended in children, even if the cortisone
is injected and stays locally, the pain induced by successive picking being intolerable for most of the children even if nitrous oxide may be used in children over
the age.
The prolonged use of hydrocolloid dressings can be proposed for a long period
of time, even if some local allergic reactions were reported.
• At six months the scar evolution may be stabilised, or not.
Depending on the local signs of persisti ng inflammation, the local treatment is
maintained, more or less well accepted by the child. In adolescent burn patients,
wearing compressive garments is difficult. In some patients refusing any active
local treatment a psychological management may help to find a compromise
helping them to temporarily hide the scar zone.
• At one year, when local inflammation signs slowed down or completely dis-
appeared, a surgical treatment can be proposed. In children who do not accept
compressive garments or painful inje ctions, a surgical approach can be proposed,
either reducing the scar surface by serial excision or replacing the scarred area by
a flap. Other techniques like the use of dermal substitutes, or overgrafting has
been proposed (Kim et al. 2019; Hori et al. 2016).
Scar Assessment Scales
Several scar assessment scales were developed since the fi rst description called the
Vancouver scale in 1990 (Baryza and Baryza 1995). The POSAS scale (Draaijers
et al. 2004) introduced a new method of analysis taking care of the perception of the
patient, and other scales were further proposed (Lee et al. 2020; Busche et al. 2018;
Simons et al. 2019).
Non-surgical Technologies
Silicone
Compressive garments
Injectables
cortisone
5-FU and Bleomycin
236 L. Téot et al.
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Lasers
Led and photobiomodulation
Depigmentation lasers
Dye lasers
Non-surgical Technologies
Intra-Lesional Steroid Injections
Intra-lesional injection of corticosteroid (alone or with other agents) is one of the
commonest treatment methods for hypertrophic scars and keloids. They are injected
each four to six weeks as insoluble triamcinolone acetonide (0–40 mg/mL) until
pain, scar and pruritis subside. The response of patients to the treatment ranges from
50 to 100% while the recurrence rate ranges from 9 to 50%. However, 63% presents
with complications like localized ulceration, dermal atrophy and telangiectasia or
hypopigmentation. Noteworthy, pain might be managed through applying a local
anaesthetic. Corticosteroids alone represent the most efficient for young keloids,
while older keloids are further resistant (Oliveira and Gold 2020).
Silicone Gel/Sheet
Using silicone gel/sheets is assumed to diminish mobility and decrease the scar
tension. How silicone gel works is uncertain, however, it may serve as an impermeable membrane to preserve hydration of the skin.
De Oliveira and colleagues, (O’Brien 2006 ) found no statistically significant
difference in the symptoms or size of scar by taking any of the treat ments; however,
both scar types were combined in their analysis, and the follow up period was <six
months. These findings were in parallel with the results of Cochrane review (Ahn
et al. 1989) that was carried out among 13 trials including 559 subjects, observing
the efficacy of silicone gel in the management of abnormal scarring in vulnerable
groups. These studies collectively highlighted the demand for further controlled
trials to approve the safety and efficacy of silicone gel sheeting (O’Brien and Jones
2013).
Radiotherapy
Radiotherapy is preferred in elder adults who failed to respond to other treatments.
It is used only in the elderly patients due to the theoretical, yet small risk of
carcinogenesis, however, is effective. In resistant keloids, we could use ionizing
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