Patient Questions
Keloid Questions
Keloid formation can be prevented through timely interventions in low, medium and high-risk cases. For high-risk patients, silicone gel or sheets should be applied for up to three months after the wound has epithelialized. Silicone gel sheets should be worn a minimum of 12-hour daily. Silicone gels have better compliance in humid environmental conditions and body areas with increased mobility. In more severe cases, intralesional corticosteroid injections may be indicated. Preventive measures in medium risk patients include silicone gel or sheets, hypoallergenic microporous tape, or twice daily application of onion extract creams. Standard hygiene practices are recommended for low-risk patients. Prevention of exposure of scars to sunlight during their healing phase plays an important role in reducing the risk of occurrence of keloids or hypertrophic scars
Hypertrophic scars are raised scars that remain within the boundaries of the original lesion, often regress spontaneously and rarely recur after surgical excision. Hypertrophic scars commonly arise where scars cross joints . Keloid is a raised scar that spreads beyond the margin of the original wound, continues to grow over time, does not regress spontaneously and commonly recurs after excision. Keloids have a tendency to occur on the ear lobe, sternal notch, shoulders, upper back, and nape of the neck.
Genetic and environmental factors play a role in keloid development. A positive family history increases the risk for the development of keloids although no specific gene has been identified. Dark-skinned individuals of African, Asian, and Hispanic descent have higher rates of keloid development compared to Caucasians, but that does not mean that Caucasians cannot form keloids. Environmental factors such as those causing skin trauma including surgery, piercings, acne, chicken pox, folliculitis, tattooing, insect bites, burns, lacerations, and vaccinations, can all be predisposing factors for keloid formation. Keloid incidence is also higher during pregnancy and puberty. Wound infection leading to delayed healing and hypertension are also triggers for keloid development.
Numerous management strategies are available for ear keloids, but satisfactory results are obtained only after using various combinations of the existing therapies. Surgical removal of the lesion alone is usually followed by recurrence. Triamcinolone acetonide 40mg/ml injection monthly for up to 6 months is combined with keloid excision. Corticosteroid injection in association with 5-fluorouracil, pulsed dye laser, and cryotherapy has been reported to be more efficient than corticosteroid alone. Cryotherapy produces tissue necrosis and substantial flattening of the keloid scars. Laser assisted drug delivery, commonly with CO2 fractional laser, is being used to modulate scars post excision and prevent recurrence. Surgery with postoperative radiation therapy has been suggested to more effectively treat keloids than radiation monotherapy. Silicone gel sheets worn 12 hours a day are effective in prevention of recurrence post-surgery. The ear is easily amenable to pressure therapy. Various devices like magnets, ear clips and methyl methacrylate stents have been conceived to provide pressure-induced localized hypoxia resulting in keloid flattening.
Keloids can cause significant discomfort to those suffering from it. Most keloids are red raised, firm, itchy and painful.
Acne Scar Questions
Lasers in scars are based predominantly on the fractional technology which works on the principle of fractional photo thermolysis. Fractional lasers create microscopic thermal zones of controlled depth and density around which normal skin acts as a reservoir of tissue repair full stop. Fractional lasers are ablative and non-ablative. Commonly used ablative fractional lasers are 10,600 nm CO2 laser and 2940 nm fractional erbium yag laser. The most crucial factors in the use of fractional ablative lasers are their energy and treatment density as post inflammatory hyperpigmentation (PIH) is a common adverse effect. Non ablative fractional lasers use laser sources like erbium or thulium in the mid infra-red wavelengths such as 1550nm, 1440nm, and 1927 nm to create coagulation zones at a depth of 200-500 um beneath the skin surface. Fractional 1540 erbium glass, Fractional 1,550nm Erbium-doped laser (EDL) have shown good results in acne scars. These lasers are safe in dark skin types but require multiple sessions for a good therapeutic outcome. Other lasers such as 1064-nm Nd: YAG, picosecond lasers, pulsed dye laser, and intense pulsed light are effectively used in treating pigmented and erythematous scars.
The number of treatments performed with lasers for scars depends on several factors like the skin type of the patient, the severity of scar, patient s occupation, willingness for prolonged downtime and the type of laser device used for treatment. Ablative fractional lasers require 4-6 sessions while non ablative lasers may need 6-8 sessions for satisfactory improvement of acne scars. Newer treatment options including radiofrequency microneedling with pins or needles has become popular and is used frequently in treating acne scars. Again, several sessions with these devices are needed, anywhere from 3-6.
Laser Treatment Questions
Lasers in scars are based predominantly on the fractional technology which works on the principle of fractional photo thermolysis. Fractional lasers create microscopic thermal zones of controlled depth and density around which normal skin acts as a reservoir of tissue repair Fractional lasers are ablative and non-ablative. Commonly used ablative fractional lasers are 10,600 nm CO2 laser and 2940 nm fractional erbium yag laser. The most crucial factors in the use of fractional ablative lasers are their energy and treatment density as post inflammatory hyperpigmentation (PIH) is a common adverse effect. Non ablative fractional lasers use laser sources like erbium or thulium in the mid infra-red wavelengths such as 1550nm, 1440nm, and 1927 nm to create coagulation zones at a depth of 200-500 um beneath the skin surface. Fractional 1540 erbium glass, Fractional 1,550nm Erbium-doped laser (EDL) have shown good results in acne scars. These lasers are safe in dark skin types but require multiple sessions for a good therapeutic outcome. Other lasers such as 1064-nm Nd: YAG, picosecond lasers, pulsed dye laser, and intense pulsed light are effectively used in treating pigmented and erythematous scars.
The number of treatments performed with lasers for scars depends on several factors like the skin type of the patient, the severity of scar, patient s occupation, willingness for prolonged downtime and the type of laser device used for treatment. Ablative fractional lasers require 4-6 sessions while non ablative lasers may need 6-8 sessions for satisfactory improvement of acne scars. Newer treatment options including radiofrequency microneedling with pins or needles has become popular and is used frequently in treating acne scars. Again, several sessions with these devices are needed, anywhere from 3-6.
Fractional ablative lasers such 10600 nm fractional CO2 and Er: YAG 2940 nm lasers are effective in treating severe atrophic scars and have longer downtime between 7-10 days depending upon skin type. Nonablative lasers, such as 1550 nm, 1540 nm fractional laser and picosecond pulse duration lasers, may be considered in patients with mild/moderate scars and have shorter downtimes between 2-5 days maximum . Treatment downtime is dependent on the energy, density settings and number of passes given on the treatment area with the laser.
After laser treatments for scars, the skin becomes red, swollen and may feel sunburned. Redness typically lasts for 1 to 2 weeks. If there is significant edema, patients are encouraged to sleep on an extra pillow at night to help reduce the swelling. A cool compress or an ice pack can be used frequently during the first 24 to 48 hours. A thin layer of petroleum jelly / moisturizer or an antibiotic cream may be applied twice daily. For uninterrupted healing of the skin, it is important to avoid any face treatments for 2- 3 weeks after procedure and topical medications till the redness and peeling of skin has settled completely. Non ablative lasers generally cause mild and transient redness on face that resolves in 24 hours. If blistering or erosions develop post treatment, it is important to seek treatment at the earliest to avoid complications. Regular broad spectrum sunscreen application is necessary to protect the newly laser-resurfaced skin.
Other Questions
Hidradenitis suppurativa also known as acne inversa is a chronic, inflammatory, recurrent, skin disease of the hair follicle that presents with painful inflammatory nodules, abscesses, comedones, scarring, and sinus tracts affecting the axillae, groin, and anogenital regions. Medical management is initiated with topical applications like clindamycin, benzoyl peroxide washes and combined with oral antibiotics such as oral tetracycline, combinations of oral rifampicin and tetracycline, oral clindamycin, dapsone, anti-androgens, oral retinoids, cyclosporine, metronidazole and biological immunomodulators. In the US, the first biologic injectable medication is now FDA approved and more are slated for approval in the next several years. Some patients may require surgical interventions that include deroofing or excision of lesions.
Post-surgical scars may be depressed or elevated. Depressed scars can be corrected by laser resurfacing, filling the indentation or performing a scar revision. Microneedling, also known as collagen induction therapy, is of benefit in levelling depressed scars. Depressed scars can also be filled in with grafts such as fat, collagen, or synthetic materials. Subcision of a scar may be helpful before filler placement to release any fibrous bands between the scar and deep tissue. Scar revision involves excision of the area of the scar and is gold standard for repairing depressed post-surgical scars. The goal is to redo the closure with proper undermining and eversion of layers. Elevated post-surgical scars may be hypertrophic or keloidal. Steroid injections 5mg/ml to 40 mg/ml repeated monthly can be administered. Injections containing 5-FU or botulinum toxin type A have also been used in the treatment of keloids and hypertrophic scars. When hypertrophic scars and keloids are nonresponsive to injections, they can be revised through scar revision techniques using Z or W plasty.
Cosmetic camouflage plays an important role in improving the quality of life of people living with disfiguring scars. There are different ways to mask scars with cosmetics products, such as subtle coverage, pigment blending (color correcting), full concealment, and contouring.
Subtle coverage implies a light application that conceals only moderately. Pigment blending or color correcting involves selecting a cover cream that matches the pigment of the patient’s makeup and are used to disguise the yellowish shade of a bruise or the overall redness from a burn.
Full concealment refers to complete, masklike coverage, extending beyond the limits of the scar. Concealers are thicker creamy products more opaque than regular foundation makeup and effectively cover healed surgical scars, and bruises on the face or body. Contouring corrects the irregular surface contours. Powdered blush-type products are best suited for contouring. It is important to remove camouflage cosmetics every night. Hypopigmented areas also can be camouflaged with cosmetics. There are many companies that manufacture cosmetics designed for camouflaging purposes. Derma color, Cover mark, Keromask, Dermablend and NeoStrata are few having different shades. Both Dermacolor and Covermark are available in department stores in many areas around the world.
Scar contractures may cause a functional deficit hence early prevention and treatment is crucial. Contractures require surgical interventions that include plasties, skin grafting and flaps. Most commonly performed surgery is Z plasty. Linear contractures are best treated by multiple Z plasties. Skin grafts involve transferring skin form one site to another without any vascular connection. Large contractures have to be excised and replaced using different types of flaps. Skin needling using 3.0 to as much as 7 mm depth is another possibility and the advantage is that it may eliminate the need for larger operations
Scarring resulting from self-harm is a sensitive situation frequently associated with feelings of regret and body image disturbance. Self-harm scars are atrophic, depressed scars commonly seen in emotionally distressed teenagers and young adults. In most instances they turn hypopigmented in color. It is best to manage these individuals in a multidisciplinary setting involving assessment of mental health by a psychologist. The option of makeup and medical tattooing provides a suitable camouflage. More permanent treatments include needling, laser resurfacing, microneedle radiofrequency and surgical revision. Surgery may include removal of selected wide scars and primary closure or extensive removal of the scarred area and application of a skin graft. Skin needling using 1.0 to 3.0 mm is another way to treat these scars and does not carry the risk of pigmentary changes.
Permanent area of scarring on hairy regions of the body such as scalp, beard, eyebrows and eyelashes is difficult to hide with clothing and has a huge impact on the self-esteem and quality of life of patients. There are both non-surgical and surgical options for those suffering from scars causing hair loss. Non-surgical options for management include cosmetic camouflage with scalp dyes, coloured hairsprays, keratin microfibres, eyebrow make-up, semi-permanent micro-pigmentation tattooing, partial hair pieces, complete wigs, and false eyelashes. Surgical options for management include serial excision with or without tissue expansion, hair-bearing flaps with or without tissue expansion, and hair transplant surgery.