Hypertrophic Scar (HTS) PDF

HYPERTROPHIC SCAR (HTS) BY Reham Elkalla lecturer of physical therapy for burn and surgery, BUC Objectives By the end of this lecture the student should be able to: Define hypertrophic scar and its causes Summarize the mechanism of hypertrophic scar formation. Differentiate between hypertrophic and...

HYPERTROPHIC SCAR (HTS) BY Reham Elkalla lecturer of physical therapy for burn and surgery, BUC Objectives By the end of this lecture the student should be able to: Define hypertrophic scar and its causes Summarize the mechanism of hypertrophic scar formation. Differentiate between hypertrophic and scars keloids Utilize different assessment tools for hypertrophic scars. Understand the underlying mechanism for each treatment approach used for hypertrophic scars. Design a proper treatment program for hypertrophic scars Hypertrophic scar Definition ▪ A raised, red, rigid, inflexible cell-like. ▪ Over production of collagen or dermal content within the boundaries of wound. ▪ Precipitated due to multiple underlying dermal injuries such as burn, surgery, and trauma causing functional and cosmetic problems. Excessive scar formation after wound closure Incidence of hypertrophic scar Occurs in more than 50% of patients with deep second to third degree burns (dermis involved) Higher incidence in children and dark skinned population More prevalent in chest, neck, lower face burns and near joints, where tension on skin is greater. Mechanism of hypertrophic scar formation Excessive deposition of fibroblast-derived extracellular matrix (ECM) proteins and especially collagen, over long periods and by persistent inflammation and fibrosis Difference between normal skin & HTS: Normal skin orientation Type of collagen Parallel that gives a good tensile strength. HTS 1. 2. 1. Balance between collagen production and 1. collagen breakdown. 1. Type 1&2 collagen are more than type3 collagen. 2. Random orientation. More cross bridge between cells that give more tensile strength. Collagen production is more than collagen breakdown. Type 3 collagen is more than type 1&2 1) Chronic inflammation leads to hypertrophic scar. The presence of persistent inflammation (NO, histamine, Ang-1, prostacyclin and vascular endothelial growth factor) leads to activation of granulation and tissue repair process, angiogenesis, and then scar formation; if this process is relatively slow, then continuous hyperplasia will result in a hypertrophic scar. 1) Delayed wound healing more than 2-3 weeks due to: a) DM & autoimmune disease. Causes b) Smoking & malnutrition. c) Infection & failure of skin graft. d) Old age due to peripheral vascular disease. 2) Genetic factors: Imbalance between breakdown and production between collagen & elastin. 5) Repeated harvesting of donor sites. 6) Mast cell degranulation. 7) Trapped foreign material. Factors affecting the severity of HTS Age Children are more liable to form HTS due to: 1) Type 3 collagen fiber is more than type1&2. 2) High skin tension and child is a hyperactive Geriatrics is less liable to form HTS as elastin is more than collagen but still may occur. Burn depth The more the depth of the burn wound the more the HTS formation Skin tension The areas of high skin tension more liable to HTS formations are eg: upper back, sternum, deltoid, buttocks and thighs. TBSA High TBSA is more liable to form HTS. Characteristics of HTS According to stage (maturation), The character of HTS differs as following: Acute (immature) HTS: 3R chronic (mature) HTS: 3P Red ( due to increase of vascularity). Pale (decreased blood supply). Raised (due to increase collagen production than breakdown). Planner (because collagen breakdown is more than production). Rigid (due to the imbalance between collagen and elastin, as collagen is more). Pliable (balance between collagen and elastin level). Scar maturation 4-8 weeks to full scar maturation with non hypertrophic healing ( first degree, superficial second degree) Hypertrophic scars begin to appear 6 weeks – 3 months post-burn. Peak between 3-6 months post-burn. Partially resolve between 12-18 months: became softer, flatter, and pale. May take up to 2 years to completely mature Associated problems with H.S Hypertrophic scar after a burn trauma may lead to many physical and psychological impairments, as. Increased pain levels Contracture formation Loss of ROM. Elevated anxiety levels Poor cosmoses Decreased health-related quality of life What is keloid? ▪ Over production of collagen or dermal content but exceed the boundaries of wound. ▪ The Orientation of collagen is more randomly than HTS. ▪ The size of interstitial space and water content is less than that of HTS. Hypertrophic scar keliods ▪ Over production of collagen or dermal content within the boundaries of wound. ▪ Over production of collagen or dermal content but exceed the boundaries of wound. ▪ More prevalent in chest, neck, lower face burns and near joints, where tension on skin is greater ▪ Common around the anterior portion of the chest, upper back, shoulders, and earlobes ▪ Occurs in 4–5 weeks after injury ▪ Occurs in a year after surgery ▪ It may last for about 6 month to 1 year. ▪ It may last for 2 years. ▪ It is wavy-like structure ▪ It is larger than hypertrophic scar ▪ Less vascularized dermis ▪ Highly vascularized dermis ▪ It is caused by trauma and burns injuries ▪ It is caused by minor injuries ▪ Increased collagen type III. ▪ Increased collagen type I. ▪ HTS express high levels of low-density dermatan sulfate proteoglycans only. ▪ They are composed of large amounts of both lowdensity chondroitin sulfate proteoglycans (PGs) and low-density dermatan sulfate proteoglycan Management of hypertrophic scar A- Inspection Its mainly to determine maturity of the scar so look for: 1.Color: red, pale or in-between. 2.Height: raised or planer. Subjective Assessment of HTS: 3.Edema: it’s a sign of inflammation & thus immature phase. 4.Site of injury: see if the areas are of high skin tension & if they bypass a joint or not. B- Palpation Done to see the scar: 1. Is hot or not & the height of the scar. 2. Regularity of tissue as we know: If regular, it’s a mature scar & if irregular its immature scar c) Vancouver scar assessment scale ▪ A validated scar assessment tool. ▪ It is used to subjectively evaluate the degree of severity of the four clinical characteristics of scarring: Vascularity, Pigmentation, Pliability and Height Assess. ▪ Scoring system Of Vancouver Scar Scale is from 0 to 13 Scar characteristics Vascularity Normal Pink Red Purple Pigmentation Normal Hypopigmentation hyperpigmentation score 0 1 2 3 0 1 2 Pliability Normal Supple (flexible with minimal resistance). Yielding (giving way to pressure). Firm (inflexible, not easily moved and resistance to manual pressure). Banding (rope like tissue that blanches with extension of scar). Contracture (permanent shortening of the scar producing deformity). 0 1 2 3 4 5 height Flat Raised less than 2mm Raised 2-5mm Raised more than 5 mm 0 1 2 3 Total score 13 D)Modified Vancouver scar assessment scale Abbreviated form of Vancouver scale. It includes 3 items only (vascularity, pliability, height). E. Patient and Observer Scar Assessment Scale (POSAS): POSAS is a reliable and valid scar assessment scale that measures scar quality from two perspectives: the patient and the clinician POSAS includes subjective symptoms of pain and pruritus (itching). It consists of 2 numerical numeric scales: The Patient Scar Assessment Scale and the Observer Scar Assessment Scale. It assesses vascularity, pigmentation, thickness, relief, pliability, and surface area, and it also incorporates patient assessments of pain, itching, color, stiffness, thickness, and relief. Objective Assessment : 1. 2. 3. 4. Volume of scar Vascularity of scar Thickness of scar Rigidity of scar 1- Scar Volume It’s objective method used to assess scar volume Method 1- Using the dental Impression material for obtaining 3-dimensional copy of the scar as following * Apply the dental impression material on the scar * The material will form a positive scar mold. 2- Calculating the volume of the scar by syringe method as: * Have a syringe filled with a well-known amount of saline. * Take scar cast & fill it by saline from the syringe. *See the difference between the amount of the saline in the syringe before and after filling the cast. *The difference is the volume of the hypertrophic scar. 2- Laser Doppler device (Scar vascularity) ▪ Its objective method used to assess only one aspect of scar (vascularity). Blood flow measurement of microcirculation are used for the early clinical assessment of burn depth and prognostic evaluation of injuries that may require skin grafting As a quantitative indicator for scar assessment & healing. Disadvantages: 1. Expensive method of assessment 3-Ultrasonography for assessing height Its objective non-invasive method. It uses the reflection of high frequency sound waves to construct an image of body organ (a sonogram). High frequency ultrasonography higher than 20mhz scanners is well established for measuring the thickness. Assess only one aspect of scar (height). Disadvantages: Expensive method of assessment. 4. Three-dimensional topography ▪ Three-dimensional systems are attractive for their ability to capture scar surface characteristics. ▪ Used the 3-dimensional optical profiling system to generate a high-resolution topographic representation of the scar, finding it to be an effective objective tool to characterize scar. ▪ Used to measure scar volume and response to treatment. 5. Tonometer of assessing pliability Objective method used to measure pliability of the scar (elasticity of the scar) Non-invasive instrument. The device measure the amount of skin resistance to detect the elasticity. 6. Goniometer (indirect assessment): It's used to measure ROM of the joint bypassed with HTS causing limitation of its movement. The "degree" of joint ROM can be indicator for HTS maturation. Treatment of HTS Pressure therapy Laser Ultraviolet Deep friction massage Treatment Myofascial release Paraffin bath Exercise & stretching Home program 1. Pressure Therapy ❖Definition: is the application of mechanical pressure. It is the standard treatment used to minimize the effect of hypertrophic scar. Effect of pressure therapy ▪ ▪ ▪ ▪ ▪ Decrease blood flow & edema. Accelerate maturation of scar Realignment of collagen Remodelling of the skin Softening of the skin ❖ When to apply pressure therapy: Usually after wound closure by 2 weeks. ❖Amount of pressure therapy: As the intra capillary pressure is 25 mmHg so apply: 25 mmHg for prevention. 10-30 mmHg for remodelling of tissue. 30 mmHg for softening of skin. 1. Pressure Therapy N.B: More than 40 mmHg is contraindicated because it leads to necrotic ischemia, maceration and paraesthesia. ❖ Measurement of pressure: special air flow measuring manometer. Duration of application: For 14–23 h/day. It is removed only for exercise and hygiene. Easy to apply Reduce corrective surgery Swelling Available commercially disadvantages advantages Prevent and correct deformity Minimal disruption of function Blistering Types of application a) Bandaging: Disadvantages: ▪ Can’t determine amount of pressure of application. ▪ Can’t be used with children. b) Self adhesive elastic bandage: The only disadvantage you can’t determine the amount of pressure applied. Cohesive bandage; hand glove Types of application: c) Elastic tubular support: Used common for leg & forearm. Disadvantage Can’t determine amount of pressure. d) Pressure garment: It’s a splint of 2 types: 1. Ready- made. 2. Handmade which is better because its confirmed to patient size alignment but expensive. Ready-to-wear stocking Custom made face mask Types of application E) Silicone gel sheet ▪ Silicone gel is transparent, self-drying gel applied topically containing long-chain (polysiloxanes), silicone dioxide, and volatile components responsible for improving the appearance of HTS and prevent the scar formation. ▪ Most common treatments for hypertrophic scars. ▪ A typical treatment cycle recommended for optimal results is 8 to 12 weeks. ▪ Silicone gel sheeting can be applied to the scar as soon as the wound has healed, or the sutures have been removed from the incision Therapeutic effect. It increases hydration of stratum corneum and thereby facilitates the regulation of fibroblast production and reduction in collagen production. It protects the scarred tissue from bacterial invasion. It modulates the expression of growth factors, fibroblast growth factor β (FGF β) and tumor growth factor β (TGF β) Pressure garments should be worn at all times except showering or bathing, massage and moisturizing. This equates to approximately 23 hours per day. It is recommended that compression garments be worn whilst the scar remains active, approximately 12-18 months in adults. Children may require a pressure garment for a longer period. Procedures Young children grow rapidly and require regular assessment of fit e.g. Three monthly when compression garments would be remeasured due to growth and fabric fatigue. Two sets of garments are required for hygiene purposes i.e. one on, one in the wash. Education of the patients and carers is essential to ensure correct use of garments, including donning, doffing and daily laundering. Pressure garments will need to be re-tensioned or remeasured and replaced every 3-6 months based on wear and tear. Persistent swelling of areas distal to pressure garments may indicate uneven compression. it may be necessary to involve the distal area in the garment (e.g. add a glove to an arm-sleeve) to manage the swelling Care should be taken when donning and doffing compression garments to prevent shearing of the skin; aids are available to assist with donning Precautions Education of the patients and caregivers is essential. Skin must be checked daily as scars can have different sensation and the wearer may not be aware their skin has broken down. Young children and people with a cognitive impairment must have parents or carers monitoring use of the compression garments and skin integrity. Compression garments may need to be temporarily stopped based on skin deterioration, infection, deep venous thrombosis, excessive swelling and surgery or as advised Complication of pressure therapy: Ischemia & skin maceration. Hygiene problems. Pressure on bony prominence especially in children may lead to retardations of growth if epiphysis is affected. 2) Laser for treatment of HTS: Used up to 4 joules for bio inhibition effects to : Stimulation of the secretion of an inhibitory factor. Abnormal excessive collagen deposition during healing may be modulated by laser. The lasers is absorbed by hemoglobin, generating heat and leading to damage of the microvasculature. This results in hypoxia which leads to collagen fiber heating and subsequent alignment. Decrease fibroblast proliferation and collagen type III deposition. 3) Ultraviolet Several types of UV show a significant decrease in dermal thickness and collagen content in scars, exposure to HTS after epithelialization may lead to softening of the scar, thinning of the skin and decrease in collagen content. Ultraviolet light has been shown to exert an immunosuppressive, which may lead to a decrease in collagen synthesis. Leads to decreased procollagen synthesis by means of a TGF. 4) Deep friction massage: Used for localized points & small areas. Press by your finger with circular motion without displacement of your fingers. Use lubricants to decrease shearing force and avoid blistering or tearing. 5) Myofascial release With your palm apply 2 opposite forces without displacement of hands just maintain pressure. 6) Paraffin bath Effect: 1. Softening the scar tissue. 2. Prepare the patients for stretching exercise. Techniques of application: Dipping, Painting ,Wrapping , or pouring Used 5 parts of wax to 1 part of oil. Temperature: 45-50 c. Duration of treatment: 20 to 30 min. Keep your skin moist. 7- Exercise therapy Exercise program is based on patient's tolerance. It consists of active and passive movements of joints, manual massage over the scar area, flexibility and strengthening exercises. Hip extension stretch over exercise ball for burns to anterior hip region Exercises should be performed daily from 10 minutes to two hours, in 30-minute sessions at home and twice or three times a week at clinic. Neck stretch with assistance Neck stretch (mouth and teeth closed) Self stretching for Knee contractures 8) Home program: Avoid scratching. Administration of anti histamine drugs. Avoid exposure to sun rays as it leads to drying of skin so microtrauma is easy to occur. Keep your skin moist. Repeat exercise according to prescription. Maintain pressure garment (22-23 hours).