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Updated: Dec 17 2021

Hypertrophic & Keloid Scars

Images scars.jpg scar.jpg scar.jpg,_post_surgical.jpg
  • Snapshot
    • A 50-year-old Caucasian man presents to his dermatologist for a scar that is hindering mobility in his right knee. A few weeks ago, he tripped and fell on a sharp rock, resulting in a 6 cm cut over his knee. Since then, his cut has healed and a raised pink scar has grown over the wound. On physical exam, it is exactly 6 cm without growing beyond the original wound and is pink and shiny. His right knee does not fully extend due to the scar. To prevent further contractures, the physician discuss the possibility of surgical excision. (Hypertrophic scar)
  • Introduction
    • Clinical definition
      • abnormal and excessive scarring in response to dermal injury, resulting in hypertrophic scars or keloids
  • Epidemiology
    • Incidence
      • keloid
        • 6-16% of African population
    • Demographics
      • most commonly in ages 10-30
    • Risk factors
      • keloid
        • ↑ in groups with darker skin
        • patients of African, Hispanic, or Asian descent
        • family history
        • wounds on chest, shoulders, upper arms, earlobes, or cheeks
      • hypertrophic scar
        • wounds on areas of high skin tension
          • shoulders, neck, knees, ankles
      • both
        • dermal injury caused by burns
        • wounds that take > 3 weeks to heal
  • Etiology
    • Pathogenesis
      • dysregulation of wound healing
        • recall normal wound healing stages
          • inflammation, proliferation, and remodeling/maturation
      • keloid
        • ↑↑ type I and type III collagen
          • disorganized and extends beyond the original wound
          • abnormalities in melanocyte stimulating hormone may contribute
      • hypertrophic scar
        • ↑ type III collagen
          • organized as parallel and confined to the original wound
          • increased activation of myofibroblasts may contribute
    • Keloid
      • previous trauma
      • spontaneous
    • Hypertrophic scar
      • previous trauma
  • Presentation
    • Symptoms
      • abnormal scarring occurs after trauma or injury
      • often itchy or painful (keloids > hypertrophic scar)
      • keloid
        • may take months to years to develop
      • hypertrophic scar
        • usually appears within 1 month
    • Physical exam
      • scarring along previous site of wound
      • well-defined, firm, and shiny
      • pink, purple, or hyperpigmented
      • irregular borders
  • Studies
    • Biopsy
      • indication
        • only if clinical diagnosis is uncertain
    • Histology
      • keloid
        • thick collagen fibers with abundant mucoid matrix
        • disorganized type I and III collagen
      • hypertrophic scar
        • thin collagen fibers with minimal mucoid matrix
        • myofibroblasts
        • parallel type III collagen
  • Differential
    • Dermatofibroma protuberans
      • slowly growing, asymptomatic, skin-colored or hyperpigmented plaque with irregular nodularity
      • locally invasive, malignant sarcoma
    • Dermatofibroma
      • benign, fibroblast proliferation
      • appears as firm, skin-colored or hyperpigmented nodule that may be asymptomatic or pruritic
      • may dimple when pinched
      • does not substantially grow in size
    • Basal cell carcinoma
  • Treatment
    • Medical
      • intralesional corticosteroid injections
        • indication
          • first-line for treatment that is often used with silicone sheeting
      • silicone sheeting
        • indications
          • first-line for treatment that is often used with intralesional corticosteroid injections
    • Non-operative
      • laser therapy or cryotherapy
        • indication
          • when first-line therapies fail
          • for larger lesions (> 0.5 cm in height)
    • Operative
      • surgical excision
        • indication
          • for scars that are associated with contractures
  • Complications
    • Contractures limiting mobility associated with hypertrophic scars
  • Prognosis
    • Keloid
      • recurrence is frequent
      • will not regress over time
    • Hypertrophic scar
      • recurrence is rare
      • may regress over time
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