Analysis of Risk Factors to Predict Occurrence and Prognosis of Postsurgical Hypertrophic Scar Development: A Review of 4238 Cases

PURPOSE

This study aimed to identify the risk factors associated with the occurrence and prognosis of hypertrophic scarring following thyroidectomy.

MATERIALS AND METHODS

A total of 4238 patients who underwent thyroidectomy were included in this study. A multivariable logistic regression model was developed to identify the risk factors for hypertrophic scar development and its prognosis.

RESULTS

Our analysis revealed that hypertrophic scar development was associated with younger age [odds ratio (OR)=0.949, p<0.0001], male sex (OR=0.562, p<0.0001), higher body mass index (OR=1.137, p<0.0001), prominent sternocleidomastoid muscles (OR=2.522, p<0.0001), scarring located within 1 cm of the sternal notch (OR=4.345, p<0.0001), and a history of keloid development (OR=2.789, p=0.0031). Additionally, scar location within 1 cm of the sternal notch (beta=4.326, p=0.0429) and a history of keloid development (beta=23.082, p<0.0001) were found to be associated with the prognosis of hypertrophic scarring.

CONCLUSION

The findings of this study provide valuable insights into the risk factors associated with hypertrophic scarring following thyroidectomy. Clinicians can use this information to predict the occurrence of hypertrophic scarring and its prognosis, and take preventative measures accordingly.

Comorbidities of Keloid and Hypertrophic Scars Among Participants in UK Biobank

Importance

Keloids and hypertrophic scars (excessive scarring) are relatively understudied disfiguring chronic skin conditions with high treatment resistance.

Objective

To evaluate established comorbidities of excessive scarring in European individuals, with comparisons across ethnic groups, and to identify novel comorbidities via a phenome-wide association study (PheWAS).

Design, Setting, and Participants

This multicenter cross-sectional population-based cohort study used UK Biobank (UKB) data and fitted logistic regression models for testing associations between excessive scarring and a variety of outcomes, including previously studied comorbidities and 1518 systematically defined disease categories. Additional modeling was performed within subgroups of participants defined by self-reported ethnicity (as defined in UK Biobank). Of 502 701 UKB participants, analyses were restricted to 230078 individuals with linked primary care records.

Exposures

Keloid or hypertrophic scar diagnoses.

Main Outcomes and Measures

Previously studied disease associations (hypertension, uterine leiomyoma, vitamin D deficiency, atopic eczema) and phenotypes defined in the PheWAS Catalog.

Results

Of the 972 people with excessive scarring, there was a higher proportion of female participants compared with the 229 106 controls (65% vs 55%) and a lower proportion of White ethnicity (86% vs 95%); mean (SD) age of the total cohort was 64 (8) years. Associations were identified with hypertension and atopic eczema in models accounting for age, sex, and ethnicity, and the association with atopic eczema (odds ratio [OR], 1.68; 95% CI, 1.36-2.07; P < .001) remained statistically significant after accounting for additional potential confounders. Fully adjusted analyses within ethnic groups revealed associations with hypertension in Black participants (OR, 2.05; 95% CI, 1.13-3.72; P = .02) and with vitamin D deficiency in Asian participants (OR, 2.24; 95% CI, 1.26-3.97; P = .006). The association with uterine leiomyoma was borderline significant in Black women (OR, 1.93; 95% CI, 1.00-3.71; P = .05), whereas the association with atopic eczema was significant in White participants (OR, 1.68; 95% CI, 1.34-2.12; P < .001) and showed a similar trend in Asian (OR, 2.17; 95% CI, 1.01-4.67; P = .048) and Black participants (OR, 1.89; 95% CI, 0.83-4.28; P = .13). The PheWAS identified 110 significant associations across disease systems; of the nondermatological, musculoskeletal disease and pain symptoms were prominent.

Conclusions and Relevance

This cross-sectional study validated comorbidities of excessive scarring in UKB with comprehensive coverage of health outcomes. It also documented additional phenome-wide associations that will serve as a reference for future studies to investigate common underlying pathophysiologic mechanisms.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago

BACKGROUND

In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.

METHODS

All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.

RESULTS

Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.

CONCLUSIONS

Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.

A Neglected Acne Scar Type: Papular Acne Scars and Their Correlations With Keloid Scars

BACKGROUND

Acne scarring can be divided into 2 types: atrophic and hypertrophic scars. Papular acne scars are commonly encountered, skin-colored papules on the chin and back.

OBJECTIVE

This study aimed to estimate the prevalence of each acne scar type and to investigate the clinical manifestations of papular acne scars.

METHODS

This retrospective study included 416 patients with acne scars. Dermatologists classified the scars into 3 types (atrophic, papular, and keloid type) based on clinical photographs and analyzed the clinical and histologic features of papular acne scars.

RESULTS

Among 416 patients with acne scars, 410 patients (98.56%) had atrophic scars, 53 patients (12.74%) had keloid scars, and 46 patients (11.06%) had papular acne scars. Twenty patients (4.81%) had both papular and keloid acne scars. Histologic analysis showed fibrotic tissue in both keloid and papular acne scars. Fibrosis of the papular scar was limited to the upper dermis.

CONCLUSION

Papular acne scars were significantly more prevalent in patients with keloid scars than in those without keloid scars. These results provide a basis for understanding papular acne scars, which have been under-recognized. The association between papular and keloid acne scars can suggest the decision for scar treatment.

Can proliferative hypertrophic scars of the median sternotomy incision predict the occurrence and characteristics of urethral stricture?

Objectives:

To investigate the correlation between the characteristics of urethral stricture and incision scars in patients with urethral stricture and median sternotomy incision.

Methods:

We identified 368 patients who had undergone internal urethrotomy between January 2014 and December 2017. A total of 49 male patients with a median sternotomy scar and diagnosed with urethral stricture were retrospectively evaluated. The median sternotomy incision scars were assessed using the Vancouver Scar Scale (VSS) and the patients were divided into 2 groups. Group I consisted of patients with a VSS score of <4 points, and those with ≥4 points constituted group II. The groups were compared in terms of age, smoking habit, body mass index, diabetes mellitus, hypertension, urethral stricture etiology, length and localization, and stricture relapse after intervention.

Results:

The mean total VSS score was 2.0 points in group I and 7.46 points in group II. There was a significant correlation between the VSS total score and the urethral stricture length among the whole study population (correlation coefficient value=0.481; p<0.001). The urethral stricture was longer as the VSS score increased.

Conclusion:

A poorly healed median sternotomy incision scar can predict a poor wound healing in the urethra tissue. Further large scale, multi-center and prospective studies are needed to clarify this relationship.

Intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars

OBJECTIVE

To compare the use of intralesional triamcinolone acetonide and its combination with 5 flourouracil in the treatment of keloid and hypertrophic scars in terms of reduction in initial height of the scar.

METHODS

The randomised controlled trial was conducted at the Department of Plastic Surgery, King Edward Medical University, Lahore, from March 2011 to December 2012. It comprised patients of both genders having keloids or hypertrophic scars (1 cm to 5 cm in size) having no history of treatment for the scars in preceding 6 months. Those who were pregnant, planning pregnancy or lactating were excluded. The subjects were divided into two groups: Group A received intralesional triamcinolone acetonide alone; and Group B received triamcinolone acetonide + 5 flourouracil. Eight injections were given at weekly interval. Scars were assessed 4 weeks after the completion of treatment on a five-point scale. SPSS 16 was used for statistical analysis.

RESULTS

The 150 subjects in the study were divided into two equal groups of 75 (50%) each. Good to excellent results were seen in 51 (68%) cases in Group A compared to 63 (84%) in Group B. Frequency of complications was 18 (24%) and 6 (8%) in Group A and Group B respectively.

CONCLUSION

Combination of triamcinolone acetonide and 5 flourouracil is superior to triamcinolone acetonide therapy in the treatment of keloids and hypertrophic scars.

Saphenous vein harvesting site dermatoses in eastern India

Coronary artery bypass grafting (CABG) has become a common surgical procedure. During this procedure, the greater saphenous vein is most often used as the conduit and the side effects of the leg vein harvesting include a variety of cutaneous changes. We report the cutaneous effects at the saphenous vein harvesting sites in 21 patients who underwent CABG.

The use of Hyalomatrix PA in the treatment of deep partial-thickness burns

Since 2001, Hyalomatrix PA (Fidia Advanced Biopolymers, Abano Terme, Italy) has been used in our center on pediatric burned patients as a temporary dermal substitute to cover deep partial-thickness burns after dermabrasion. This "bridge" treatment was adopted to remove necrotic debris (dermabrasion) and to stimulate regeneration in a humid and protected environment (Hyalomatrix PA). We present results obtained with this approach. On the third to fifth day after admission, dermabrasion was practiced on deep burned areas, which were covered with Hyalomatrix PA. Change of dressings was performed every 7 days. On day 21, those areas still without signs of recovery were removed with classic escharectomy and covered with thin skin grafts. We treated 300 patients. Sixty-one percent needed only one dermabrasion treatment, 22.3% (67 patients) more than one, and 16.7% (50 patients) the classic escharectomy. A total of 83% of patients healed within 21 days. Our study suggests that the combination of dermabrasion with a temporary dermal substitute could be a good and feasible approach for treatment of deep partial-thickness burns. Prospective randomized studies are now necessary to compare our protocol with the gold standard treatment of topical dressings.

Safety and efficacy of local administration of contractubex to hypertrophic scars in comparison to corticosteroid treatment. Results of a multicenter, comparative epidemiological cohort study in Germany

OBJECTIVES

To investigate the safety and efficacy of Contractubex administration to hypertrophic scars in routine out-patient practice and to compare it to corticosteroid treatment.

PATIENTS AND METHODS

This was a multicenter, retrospective cohort study, based on 38 randomly selected practices representatively distributed in Germany, including dermatologists and general practitioners. Data from 859 patients fulfilling the inclusion criteria were assessed and analyzed. Of these, 771 patients were eligible for the per protocol treatment with Contractubex (n=555) and corticosteroid (n=216). The safety and efficacy of local administration of Contractubex to hypertrophic scars was compared to corticosteroid treatment.

RESULTS

At the end of defined treatment periods (minimum 28 days for local therapy with 1 intralesional corticosteroid application), normalization of the pre-treatment pathological parameters (erythema, pruritus, consistency) of hypertrophic scars was more frequent (42.5%) after Contractubex per protocol treatment as compared to corticosteroid per protocol treatment (22.2%). After adjusting imbalances of baseline characterisics between the treatment groups by the propensity score, the odds ratio was 2.274, demonstrating a significant superiority (p<0.001) of Contractubex treatment as compared to corticosteroid treatment. The time to normalization of erythema, pruritus and consistency was significantly (p=0.034) shorter with Contractubex treatment (median 344 days) than with corticosteroids (median 507 days). No unexpected or severe adverse events occurred in the Contractubex-treated patients. Apart from moderate pruritus (10% Contractubex vs. 1% corticosteroids), adverse events were significantly (p<0.001) more frequent in corticosteroid-treated patients (teleangiectasias 15% vs. 7% Contractubex; cutaneous atrophy of scars 10% vs. 2% Contractubex; cutaneous atrophy of scar surrounding skin tissue 11% vs. 1% Contractubex).

CONCLUSION

For the primary aim of this study (assessment of normalization of erythema, pruritus, and consistency of hypertrophic scars) and for time to normalization, local administration of Contractubex was significantly more effective than corticosteroid treatment. Concerning safety, Contractubex treatment was associated with significantly less adverse events (e.g. teleangiectasias, cutaneous atrophy of scars and surrounding skin tissue) than topical corticosteroid application.

Epidemiology, aetiology and management of abnormal scarring: a review of the literature

Keloid and hypertrophic scars are the result of abnormal processes in scar formation. This paper reviews the literature and the many debates concerning the processes that cause abnormal scarring.

Incidence of hypertrophic scars among African Americans linked to vitamin D-3 metabolism?

The pathogenesis and progression of wound-healing involve intricate pathways and numerous chemical mediators. This remains an area of intense study as undesirable results of this process, such as hypertrophic scars and keloids, can result in significant morbidity. These lesions are distinct in their characteristics, although they are similar in their distribution in patients with darker skin colors. There is a robust inflammatory mechanism behind the formation of hypertrophic scars and keloids. Furthermore, their development may be intimately related to vitamin D-3, which has been shown to be a powerful anti-inflammatory agent. This chemical is made in the skin, whose production is influenced by various factors of which the amount of melanin is a crucial one. More specifically, an increase in pigmentation has been shown to decrease the amount of vitamin D-3 synthesis in the skin. Thus, this paper proposes the hypothesis linking the propensity of inflammation and subsequent scarring in darker-skinned individuals to the reduced levels of vitamin D-3 production in their skin.

A Comparison of Complication Rates in Large and Small Inferior Pedicle Reduction Mammaplasty

The main objective of this retrospective study was to determine whether the rates of complications are higher in large reductions (> or =1000 g per breast) as compared with smaller reductions (< or =999 g per breast) using the inferior pedicle technique. A retrospective chart review of 133 consecutive patients operated on between October of 2000 and March of 2002 was undertaken. Complication data were recorded and analyzed on a per-breast basis. Two hundred sixteen breasts had reductions of 999 g or less, whereas 50 breasts had reductions of 1000 g or more. The overall mean follow-up period was 152 days (range, 20 to 522 days). There were no statistically significant differences in the rates of nipple necrosis, hematoma formation, seroma, delayed healing, culture-positive wound infection, fat necrosis, cyst formation, nipple sensation, or hypertrophic scarring between the large and small reductions. However, the rate of wound dehiscence was significantly lower in the smaller reduction group. The rates of wound dehiscence and hypertrophic scarring were also significantly lower in patients who had received at least 5 days of postoperative antibiotics. A statistically significant difference was also reported for clinical wound infection (p < 0.0005). Body mass index had no statistically significant effect on the rate of nipple necrosis, hematoma formation, fat necrosis, cyst formation, nipple sensation, or hypertrophic scarring. However, body mass index had a statistically significant effect on delayed healing, wound dehiscence, and culture-positive wound infection. A higher mean body mass index predicted a delayed healing, wound dehiscence, and infection. The inferior pedicle technique is a safe method of breast reduction regardless of degree of parenchymal resection. However, the use of postoperative antibiotics for at least 5 days is recommended to reduce rates of wound dehiscence and improve postoperative scarring.

What is the prevalence of hypertrophic scarring following burns?

Hypertrophic scarring after burns remains a major problem and is considered to be "common". Pressure garments are commonly used as treatment even though there is little sound data that they reduce the prevalence or magnitude of the scarring. In 1999 we began a study of the efficacy of pressure garments on forearm burns. After studying 30 patients, mainly white adults, we found no hypertrophic scar in either those treated with pressure or without. This prompted us to review the literature on the prevalence of hypertrophic scarring after burns and found only four articles with a relatively small number of patients and only three geographical locations. It became clear that the prevalence of hypertrophic scarring is really unknown. We then did a retrospective study of 110 burn survivors and counted all hypertrophic scars of all sizes and locations in all races and found the prevalence hypertrophic scarring to be 67% which conflicts with the published reports and our prospective study and suggests that further research is necessary. We concluded that a worldwide, prospective survey is necessary to establish the prevalence of hypertrophic scarring after burns. In this article we are calling for and offering to organize this survey.

Hypertrophic and keloid scars

A comparison of the histological, epidemiological and aetiological characteristics of hypertrophic scars and keloids

Infections requiring hospital readmission following face lift surgery: incidence, treatment, and sequelae

This retrospective study evaluates 11 infections requiring hospital readmission following 6166 consecutive face lifts (0.18 percent). Seven patients had surgical drainage of an abscess, and four patients were treated for severe cellulitis, Staphylococcus was the predominant organism in all abscess cultures. Of three patients admitted 3 weeks after surgery, two cultured gram-negative organisms in addition to Staphylococcus. This suggests that all patients should be treated initially with Staphylococcus coverage. If a patient is readmitted more than 1 week postoperatively, gram-negative coverage should be considered, pending culture results. There was no consistent finding regarding past medical history, the use of perioperative antibiotics, surgical equipment used, complexity of the surgical dissection, drains, or hematoma formation. No patients demonstrated systemic signs or grossly abnormal laboratory results on readmission. Eight patients had no sequelae from the infection. Three patients developed scarring that was considered minor by the affected patients. These data support the conclusion that major infections following a face lift are rare occurrences. Standard medical and surgical care, given in a timely fashion, usually results in a satisfactory outcome with minimal morbidity.

[Palmar burns of the hand in children. 81 cases]

The authors reviewed 81 children between the ages of 5 months and 3 years suffering from palmar burns of hands from 1988 to 1992. Most burns were unilateral (53), superficial 2nd degree (48), due to contact (55), in boys (48) and only affecting the palm (69). The initial treatment consisted of directed healing followed by a split-skin graft in 8 cases. The initial scar was not retracted in 58 cases, retracted in 17 cases and hypertrophic in 8 cases. 79% of children had no sequelae at 12 months. At more than three years, 15% of children (12) had sequelae: 9 adhesions of the first commissure, 5 flexion deformities of long fingers, 3 clinodactylies, 1 syndactyly. All were operated by trident plasties, Colston flaps or full-thickness skin graft. A final functional assessment was performed. 90% of children had no sequelae. Four children still presented moderate functional discomfort (3 adhesions of the first commissure requiring reoperation, one case of decreased sensitivity). Palmar burns in children have a good prognosis. Factors of severity are: involvement of the 1st commissure, associated dorsal burn, deep 2nd degree, poor social conditions, delayed management.

Cosmetic result of lower midline laparotomy wounds: polybutester and nylon skin suture in a randomized clinical trial

OBJECTIVE

To compare the cosmetic outcome of lower midline laparotomy scars using either nylon or polybutester suture for skin closure.

METHODS

A randomized clinical trial compared polybutester skin suture with nylon for lower midline laparotomy wounds in 50 women undergoing gynecologic surgery. Scar hypertrophy, scar width, scar color, the presence of cross-hatching marks, and a total score were assessed in all patients at 18 months following surgery and compared by nonparametric statistical tests.

RESULTS

The wounds closed with polybutester suture were significantly less hypertrophic than those closed with nylon. Regardless of the suture material used, the lower part of the laparotomy scar showed an inferior cosmetic result compared with the upper part underneath the umbilicus for scar hypertrophy, scar width, and the total scar score.

CONCLUSIONS

Polybutester skin suture diminishes the risk of hypertrophic scarring because of its special properties allowing it to adapt to changing tensions in the wound. Increased closure tension of the skin in the midline region above the pubic bone may be caused by a relative immobility of the skin. Scar cosmetics in this area may be improved by extra subcuticular suture support.