Principles of Scar reduction - (Not Peyronies Disease Specific)

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Hawk

This is a very interesting if somewhat long document on principles of scar formation, prevention, and reduction that could be a piece of the Peyronies Disease puzzel.  It is posted with full permission of all parties with copyright claims.  Careforscars.com  was especially helpful.  I had a long chat with the Executive staff who seemed well informed on Peyronie's Disease.  They promised to send me additional non commercial information on this topic.


TITLE: Method to reduce or prevent scar tissue formation (HSS-0047)

DESCRIPTION: During a normal wound healing process, fibroblasts replace tissues (e.g. collagen and proteoglycan matrix) which have been damaged or destroyed. Scar tissue and surgical adhesions occur when the balance between matrix synthesis and degradation is disturbed resulting from increased fibroblast metabolism and proliferation.  
APPLICATION: The anti-fibrotic activity of this technology encompasses treatments for preventing or reducing the formation of scar tissue and similar conditions that are manifested by the action of fibroblast cells. Thus, this invention treats or prevents fibrosis, keloidosis, fibrocystic conditions, adhesive capsulitis, and capsular contracture (and therefore prevents joint stiffness), as well as depressed scars from inflammatory responses including acne, wrinkling, cellulite formation, all which involve fibroblast proliferation in a localized area of the body.

ADVANTAGES: Fluoroquinolones are well known anti-infectives. While many of them are considered safe and well tolerated potential side effects, when they occur, are mild. They are relatively stable and inexpensive. Systemic administration of fluoroquinolones permits a less invasive means for treating a patient susceptible to scar tissue formation or related pathologies. In addition, systemic administration permits a physician to have greater control over drug administration, including frequency and dosage, without concern as to whether, for example, a locally administered drug is effectively releasing active ingredient or whether the contents of an injection remain at the desired site.

STAGE OF DEVELOPMENT: Anti-fibrotic activity of specific fluoroquinolones, ciprofloxacin and ofloxacin, have been substantiated through extensive in vitro testing on mammalian fibroblast cell lines. Optimization is ongoing.

The prevention of adhesion (scar) formation should be a primary goal of all fertility surgery. Efforts can (and should) be undertaken to reduce postoperative adhesion formation by using principles collectively referred to as "microsurgical techniques." When the infertility surgeon recreates a pelvic organ, opens a previously blocked fallopian tube, removes abnormal structures from within the uterine cavity, ablates endometriosis, or lyses existing pelvic adhesions the restoration of normal anatomy and function often depends on minimizing scar tissue secondary to surgery.
The microsurgical techniques that should be employed include:

(1) Very gentle tissue handling (pulling, rubbing and poking the delicate reproductive tissues can result in trauma and adhesion formation),

(2) Meticulous control of bleeding = hemostasis (whole blood within the pelvis is highly irritating to the peritoneal lining and the inflammation that results can lead to adhesion formation),

(3) Use of magnification if necessary (for establishing proper tissue planes during dissection and for determining the degree of reapproximation accomplished when tissues are placed together),

(4) Careful avoidance of infection (administration of antibiotics to prevent reactivation of a dormant infection within say the fallopian tubes, sterile technique in handling the operating instruments),

(5) Maintaining tissue moisture (irrigation is generally better than sponging, preventing desiccation or drying is important since either leads to adhesion formation),
(6) Minimal effective coagulation of bleeding sites (over cauterizing results in ischemia and this may enhance adhesion formation),

(7) Reducing foreign material that is placed intraoperatively (use of small caliber suture material reduces overall bulk, rinsing sterile gloves or similar objects placed intraabdominally removes talc), and (  Reducing lateral thermal damage of tissue (lasers, especially ultrapulse [or XJ pulse] and superpulse CO2 lasers, allow application of very high power densities to tissues to accomplish ablation by vaporization with little lateral thermal damage. This is theoretically of great significance)

In theory (although not proven in the existing literature) laparoscopy has an advantage over laparotomy in terms of adhesion formation. With laparoscopy, small abdominal incisions are made and ports maintain access while occluding the holes when no instruments are actively being used. When compared to laparotomy, this should result in less infection (since the sites are not open for the duration of the case), less tissue drying (especially for longer duration cases since tissue drying can be tremendous during open cases), and less tissue trauma secondary to rubbing or moving intraabdominal structures with surgical gloves. Additionally, the laparoscope is able to be placed immediately adjacent to the operative site to enhance visualization of structures that are buried in the pelvis and the laparoscope can magnify tissues slightly. The magnification achieved with the laparoscope is proportional to the distance of the lens from the tissue viewed, such that at a distance of 1 cm from tissue the laparoscope typically magnifies the tissue about 6 fold, at 2 cm about 4 fold, at 3 cm about 2 fold, at 4 cm there is no magnification and at distances greater than 4 cm there is a reduction in size of the viewed tissue.
Adjuvants are materials that can be used to help prevent adhesion formation. The two primary classes of adjuvants include mechanical barriers and surgical adjuvants.
Mechanical barriers include Gore-Tex surgical membranes (that must be sewn into position), Interceed TC-7 (a material placed over raw surfaces), and 32% Dextran 70 (a highly concentrated sugar like solution made up of high molecular weight glucose polymers that draws in water to act as a mechanical barrier between structures).
Of these barriers, Interceed seems to be the most commonly used. Literature from several clinical reports support a role for Interceed in adhesion prevention.  32% Dextran 70 (Hyskon) has been popular in the past and is still in use in some centers. Mechanical separation of raw surfaces is associated with the water drawn into the concentrated solution (hydroflotation) and a siliconizing effect (the solution is slick). When 200 cc of 32% Dextran is placed intraperitioneally there is usually some ascites for up to a week, and patients occasionally complain of fluid leaking from the incision sites, labial swelling, bloating and weight gain.

Surgical adjuvants include antiinflammatory drugs, anticoagulants, prophylactic antibiotics, calcium channel blockers and plasminogen activators.

The antiinflammatory drugs include corticosteroids (intended to decrease vascular permeability and enhance lysosomal stabilization, each of which should limit adhesion formation), antihistamines (intended to decrease vascular permeability and decrease fibroblast proliferation, each of which should limit adhesion formation), and nonsteroidal antiinflammatory agents like motrin (reduces prostaglandin formation to limit adhesion formation). None of these agents has been shown to be beneficial in terms of adhesion formation in large clinical trials but they are often used by physicians whose personal experience with the medications has been favorable. I do not (currently) use these agents.
Anticoagulants include low dose heparin (about 1-5 units/mL) within irrigation solutions. High doses of heparin should not be used because there is an increased chance of hemorrhagic surgical complications. Low dose heparin has not been shown to be of benefit in terms of adhesion formation in clinical trials.

Antibiotics may reduce the incidence of infection when given prophylactically. The goal is to achieve adequate doses at the tissue sites during the surgery. Vibramycin is often used for tubal surgery since it effectively treats Chlamydia. Many of the higher generation cephalosporins also work well for gynecological pelvic surgery. I typically use cefotetan or mefoxin (depending on availability).

Calcium channel blockers have been used in hamsters with good results, but human studies are lacking. In theory, these agents decrease tissue ischemia, limit prostaglandins, reduce platelet aggregation, and limit vasoconstriction. The use of these agents is awaiting appropriate human trials.

Plasminogen activators accelerate fibrinolysis to reduce the bulk of fibrin clots. Use of these agents is also awaiting appropriate human clinical trials.

Scar Prevention and Treatment
by James Beckman, M.D.
All scars consist of collagen, which forms in response to an injury to the structural soft tissues of the body. Although injury to the epidermal cell layer may cause pigment changes, there should be no change in the skin collagen content. Another article will discuss the problems related to "hypo" or "hyper" pigmentation resulting from injury to the epidermis. This article will deal simply with the mechanics of true scar formations. Collagen resides in the deeper dermal layer. The skin care professional should understand the evolution of scars, as prevention and treatment are necessary in the plastic surgical setting.

Formation
A series of complex reactions leads to the development of scar tissue. Within 48 hours of injury, the body recognizes a wound manifested by swelling, redness, tenderness and pain and begins the restoration process. Special white blood cells accumulate around the wound, while a "glue-like" substance called Fibrin coats the wound edges. Three days following injury, production of collagen is begun. The collagen produced is simply developed and exists in a random, haphazard fashion. This new collagen is produced for several months. Though the collagen fibers are structurally sound, this disorganized array makes a raised, firm, and relatively non-pliable mass.
Over the ensuing six weeks, the scar tissue begins to be transformed by enzyme action in a remodeling process that both aligns collagen fibers and provides flexibility. The final maturation of the scar occurs over a one- to two-year period of time for most skin areas, but remodeling continues for up to 18 years.

Types of Scars
A scar may be classified by both its appearance and dimensions. There are various scar types including those that appear flat, raised, wide, and those that are thick and reach deeper levels. The simplest form of scarring, and often the most easily repaired or treated, occurs when only the dermis just under the epithelium has been injured. More often than not, these would occur with procedures (or injuries) involving surface area such as medium depth peels, dermabrasion, deeper peels, or laser resurfacing for example.
Skin has an enormous capacity to stretch and then to regain its shape later. Partial tears in the collagen matrix occur and form stretch marks if the collagen fiber content is massively stretched and partially torn over a short period of time. Seen most commonly during the last trimester of pregnancy when rapid growth in abdomen size occurs, this type of scar is called a strain. Strains may cause some thinning of the dermal layer, but the most noticeable effect is that of a lack of pigmentation within the stretch mark.
Slightly deeper scars may appear flat, although these may involve mid-dermal skin layers as well. For instance, some acne scars are saucer-shaped but have wide dimensions. Other scar types occur in relation to full thickness injury or wound, including surgical incisions. A traumatic wound incurring tissue loss will heal by a granulation mechanism, and the scar will contract toward the center to create healing by secondary intention. (Imagine a drawstring used to close a purse.) This will cause surface irregularities with a depressed central area and loss of pigmentation. Scars from sutured surgical incisions can be minimized if deeper layers of the sub-dermis are sutured prior to skin closure to alleviate tension on the skin. When surgical incisions are placed optimally (along or parallel to normal skin creases or skin wrinkle lines), there will be minimal tension or pulling on the closed wound during the collagen formation period, resulting in imperceptible scars.
The last form of scarring is related to an overgrowth of collagen and scar tissue as seen in hyper-tropic scars or in true keloid scars. The hypertropied scar is indicative of excessive amounts of collagen build-up usually in response to tension or pulling on the wound edges during the early wound-healing phase. Keloids involve excessive amounts of collagen scar tissue in response to the immune system stimulating the wound to create an even larger defect involving destruction of previously "normal" or uninjured skin.

Appearance Factors
Understanding the factors of scar formation can help to ensure proper treatment and wound care and thus avoid scarring. Resurfacing procedures can affect scarring as these procedures are designed to create controlled damage by removing epidermal cells and/or portions of the dermis. Any event that causes a removal of epithelial cells stimulates the production of new collagen, which imparts a more youthful texture and firmness to skin and more uniform pigmentation. Laser resurfacing, dermabrasion, micro-dermabrasion, deep chemical peels and superficial peels are designed to elicit this cosmetic improvement. Impaired or delayed healing, however, may allow scar formation to occur.

In treating these wounds, blood supply, capillary flow and the availability of nutritional substances for the healing wound are mandatory for optimum healing and minimal scarring. Causes for delayed healing include improper dressing, improper cleansing, and repeated trauma to the area that will impair the cosmetic appearance. Likewise, infection causes a delay in wound healing and even a destruction of other soft tissue structures, such as fat, collagen, or even normal dermis.

If an open wound is denuded of epithelium, it is important to consider the type of dressing. A dry, open wound is much more prone to scarring and infection and will take several days longer for healing, thereby increasing the potential severity of the scar. Closed dressings, which help to retain moisture, markedly decrease healing time, whether the dressing is flexan, silicone sheeting, petroleum jelly or other material.

Prevention
The most effective technique for minimizing unfavorable scarring begins long before the treatment modality. Pre-op skin conditioning can have a marked effect on shortening the re-epithelialization time by significantly increasing capillary blood supply, nutritional elements, enzymes and removal of wastes. A healthy wound with good blood supply is less likely to develop infection and post-traumatic hyperpigmentation or scar formation.
Pre-op conditioning is recommended six weeks prior to resurfacing procedures, including laser, medium to deep chemical peels and dermabrasion. Weekly 70% Lactic Acid peels thin the epidermis, stimulate increased capillary production, and promote a healthy melanin production.

Two weeks prior to resurfacing procedures, some form of melanin suppressant should be applied twice daily. Theraderm Enlighten is a good choice as it contains 2% hydroquinone and 3% kojic acid - effective in blocking key enzymes responsible for melanin production.
Topical antioxidants are also very useful in pre-op conditioning and post-op treatment. Although vitamin C in higher concentrations and vitamin E applied topically do have an antioxidant effect and provide some protection from UV light, oligomeric proanthocyanidins (OPCs) are unsurpassed in efficiency. Theraderm RS-OPC Reparative Gel is 20 times more effective than vitamin C and 50 times more effective than vitamin E in preventing free radical damage. This oil-free gel is water soluble allowing for efficient absorption and delivery, while hyaluronic acid and Aloe Vera hydrate and soothe the skin to aid the healing process.

Postoperative care is also essential in preventing scarring that might occur from unforeseen factors. It is well known that moist skin heals much more rapidly than dry skin, reducing the chances for post-op scarring. Closed dressings have been shown to promote more rapid healing than open techniques.
When the epithelium has healed and the skin surface is dry, I recommend the Fruit Acid Exfoliant with 10% lactic acid as a daily maintenance product. Post-laser treatment is the exception, however. Instead of daily application of lactic acid, I recommend a 70% Lactic Acid peel for a short duration (15 seconds) as soon as complete re-epithilialization has occurred. Begin subsequent Fruit Acid Exfoliant use 4-6 weeks later.
It is helpful to restore essential oils for barrier function and protection of skin at the earliest possible time. Super-fine lanolin products, such as the Theraderm Enriched Facial Moisturizer and Soft & Smooth Body Moisturizer, are ideally suited to restore the intercellular lipid barrier.

Treatment
Despite prevention practices, unavoidable complications during the healing phase can often lead to scars. When a delay in healing occurs that may preclude a pigment defect, I start early use of Temovate or Diprolene (0.05% of either) cream. These extremely strong, rapid-acting and effective steroids will quiet inflammation, reducing the chances of hyperpigmentation.

In the event of bacterial infection, antibiotics are necessary. In the case of viral herpes infections, it is mandatory to implement Zovirax, Acyclovir or similar anti-viral medications designed for herpes. One indication of herpes infection is failure to epethelialize within the expected healing period. These lesions should be cultured, and the patient should begin anti-viral medication immediately.

Hypertrophic scars should be aggressively treated with topical steroids as above, along with the use of super-fine lanolin moisturizer and daily scar massages in the longitudinal direction of the scar rather than against the grain of the scar. Soft & Smooth Body Moisturizer is an excellent choice for scar massages as it contains lanolin and 7% Lactic Acid for cell renewal and restoration.

Post-acne or similar depressed scars may need more aggressive treatment with laser or TCA peels around the perimeter of the scar to blunt the sharp edge of the crater. After scars have healed, collagen or autologous fat injections under the depressed portion of the crater may be helpful.

Nearly any scar may be improved if a proper treatment plan is implemented with a willing and compliant patient. However, prevention is key in maintaining patient satisfaction and ensuring beautiful results.

Dr. Beckman is board certified in plastic surgery and was in private practice for 24 years. He is a life member of the American Society of Plastic Surgery, The Southeastern Society of Plastic Surgery, and is the founder and CEO of Therapon, Inc. With a lifetime special interest in skin care and a degree in chemistry, he has presented papers, been an invited speaker, and served on skin care/resurfacing panels at national and regional plastic surgery meetings. He welcomes further questions at jbeckman@therapon.com.

Scarred, but Not for Life: New and Old Therapies for Old and New Scars
by: Raphael Lee, MD, PhD
Professor of Surgery, Medicine, and Anatomy (Biomechanics)

People of all ethnic backgrounds can form problem scars. But among highly pigmented ethnic groups, such as those of African descent, certain types of these raised, hard, irregularly shaped scars are 15 times more common. About one out of seven African-Americans inherits a familial predisposition to swollen, unsightly scars.
Years ago there wasn't much that doctors could do for patients with problem scars. Now, better understanding of the normal process of wound healing and how it can go astray is leading to more effective treatments. Today, we expect a wound to heal without a prominent scar.

How Wounds Heal
There are three phases in the wound healing process: inflammation, transitional repair, and maturation.

The inflammation phase begins immediately after an injury and is one tool the body uses to prevent infection. Wounds do not become sterile until the outer layer of skin reforms. So, the length of time until the wound is closed determines how long this phase lasts.
The next phase is transitional repair. During this phase, a scar-tissue patch is quickly formed to hold the wound together. Under normal conditions, this stage begins a few days after an injury and lasts a few weeks. If the injury is severe, or the scar tissues are stressed and damaged, this phase can last longer.

The final phase of wound healing, called maturation, begins six to 12 weeks after a wound occurs. During this phase, the repair process is a mixture of creating new normal tissue and breaking down the scar-repair apparatus. When any of these processed is disturbed, it can result in problem scars.

Problem Scars

The terms doctors use to describe scars can be confusing. Generally, a hypertrophic scar is a thick, disfiguring scar that is raised above the skin surface and is usually triggered by disruption of the healing process. A keloid is a scar that forms in a person who has keloid disease--a genetic predisposition to over-react to a wound. Keloids are tumor-like scars that emerge as a wound heals. Although these two scar types behave differently, they are not easy to distinguish.

Hypertrophic Scars
Factors that increase or prolong wound inflammation or wound tension predispose an individual to hypertrophic scar formation. These factors include wound infection, delayed wound closure, or foreign materials in the wound. There are substantial increased risks for hypertrophic scarring in burn wounds, for example, that take longer than 21 days to heal.
Too much tension on the healing wound can also cause excess scarring. Therefore, scars located in certain areas of the body, such as the chest and upper back, are frequently hypertrophic.
Why do African, Asian, Mediterranean, and Hispanic people suffer from hypertrophic scars more often? Some evidence suggest that it may be related to differences in how much sunlight reaches the deeper layers of the skin where Vitamin D is activated. Hormones also contribute; these scars are more common at the start of puberty or during pregnancy. They tend to regress with time, leaving behind an unsightly gap of thinned dermis between wound edges.

Keloid Scars
Keloid scars do not regress. These scars are like benign tumors that invade surrounding tissue. Large disfiguring scars result. Keloids are a manifestation of a genetic anomaly and are associated with a strong family history. Age and sex hormones, however, also play a role, with younger people being more vulnerable.

Scar Care
Scar prevention in people predisposed to hypertrophic scarring requires more effort, but there is good news. Over the past two decades, we have developed several new prescription and non-prescription tools for scar management.  Scar treatment depends on whether the scar is old or new and whether it is a hypertrophic or a keloid scar.
New and growing scars are usually slightly tender and itchy. These symptoms occur because the scar is inflamed. Scars "mature" in six months to two years. Then they no longer itch, stop growing, and remain stable or decrease in size.

Keloids are more difficult and often require physician management. Unfortunately, medical insurance carriers often don't distinguish between keloid and hypertrophic scars and as a result limit access to treatment to people with disabling keloid disease.

Treatment for New Scars
Steroids: Injecting steroids to inhibit inflammation is one of the oldest and most established approaches to scar management. The adverse side effects of repeated injections as well as the frequent occurrence of skin depigmentation are drawbacks to this approach.

NSAIDS: Although, non-steroidal anti-inflammatory drugs (NSAIDS) have been used to prevent internal scarring in arthritis for decades, they have only recently been used for hypertrophic and keloid scar management. Our research team has found topical aspirin to be among the most effective agents for new scars. Topical aspirin should be used under a physician's guidance since some patients, particularly asthmatics, may develop hypersensitivity.

Anti-Histamines: These are commonly used to control symptoms of scar itching. However, they have other anti-scar properties. Anti-histamines inhibit the inflammatory response resulting in reduced scar formation and increased comfort. Patients taking antihistamines are less likely to scratch their scars, which reduces the scar growth rate. High-dose anti-histamines can inhibit collagen synthesis, which is excessive in scar formation.
Elastic wraps: Pressure garments have become a mainstay of scar prevention. Drawbacks are primarily related to their thermal insulation and movement restriction.
Gel Sheets: Hydrogel and silicone sheeting have been used to control scar formation. They can increase hydration of the skin over the scar and scar temperature. These products, available in some drug stores, can be used with anti-inflammatory creams and ointments to decrease scarring.

Radiation: Low dose radiation therapy in conjunction with surgical intervention is reserved as the method of last resort for the treatment of intractable keloid scars. Up to 80 percent of keloid can recur after surgery but combining surgery and radiation can reduce recurrence to 25 percent.

Treatment for Old Scars
Mechanical Tension Blockers: Several drugs commonly used to treat high blood pressure can be used to cause breakdown of older inactive scars. Calcium channel blockers, such as Verapamil, injected into the lesion, can induce scar degradation.
Surgical Removal: Surgical removal of scars is used for large scars that are unlikely to be substantially reduced by medical therapy within a practical timeframe. Surgery can also help scars that harbor infection and scars that hamper movement function. Gentle surgical technique is critically important. Additional measures to reduce inflammation, skin tension, and other factors are essential to reduce recurrence. Use of lasers and other burning techniques for scar removal is very controversial.
In conclusion, people with high-melanin content should be a little extra wary about scarring after a wound. But there is good news. We now know more about the basis for this process and are developing new therapies that can prevent new scars and even minimize the appearance and discomfort of old scars.

Practical Scar Care

The first consideration in scar treatment is prevention. Events that occur during the management of the open wound are influential. Providing a healthy environment for the wound to heal is most important.

Once the wound is closed, treatment can begin to prevent too much scarring. Over the past two decades, several new therapeutic approaches to scar management have been reported. These new approaches promise to add substantially to existing therapeutic approaches. We will attempt to briefly summarize most of these new concepts.

Anti-Inflammatory Agents
Limiting inflammation is paramount to scar reduction. Inhibition of inflammation using corticosteroid injections is one of the oldest and most established approaches to scar management. The broad effects include inhibition of protein synthesis, including collagen and other extracellular matrix proteins. However, the adverse side effects of repeated injections as well as the frequent occurrence of skin depigmentation are major drawbacks to this approach. Steroids are not effective for treatment of older, asymptomatic scars that are less metabolically active.

Although, non-steriodal anti-inflammatory drugs (NSAIDS) have been used to prevent internal scarring in arthritis for decades, they have only recently been used for hypertrophic and keloid scar management. Our experience suggests that the newer type-2 cyclooxygenase inhibitors are very effective in reducing symptoms of pruritus. They also seem to induce scar maturation and involution.

Salicylic acid and acetylsalicylic acid (aspirin) are powerful anti-inflammatory medications that are commonly used to treat skin inflammation related ailments. Salicylates (2-5%) are commonly used to control skin inflammation and are routinely used in acne treatment products. We have found topical salicylates to be among the most effective anti-scar agents. These agents should not be used on open wounds. Topical aspirin should be used under a physician's guidance since some patients, particularly asthmatics, may develop hypersensitivity.

Anti-histamines are commonly used to control symptoms of scar pruritus. However, they have other important anti-scar properties. Anti-histamines, particularly the H1 blockers, inhibit the inflammatory response resulting in reduced scar formation and increased comfort. Patients are less likely to scratch inflamed scars, which reduces the scar growth rate. Finally, anti-histamines in high doses are well known to inhibit collagen synthesis

Inhibitors of Gene Transcription
The anti-cancer drugs mitomycin-c and 5-fluorouracil inhibit population growth of cells by blocking DNA replication. A single application in the first few days after wound closure seems to be effective in scar reduction under laboratory conditions. Further investigation will be needed to determine how this approach can be used clinically.

Acceleration of Scar Degradation
While steroids and NSAIDs act to limit scar production, other strategies act to induce or accelerate scar degradation. This approach may be the best for management of older hypertrophic scars and older keloids. The rate of tissue breakdown can be increased by both pharmacologic and physicochemical means.

Occlusive Dressings
After elastic pressure wrap dressings applied to healing burn scars were observed to be effective in the reduction of scar formation, 20-24 mm Hg pressure garments have become the mainstay of scar prevention. The mechanism of action of pressure dressings is unknown because they remain effective even when they lose elasticity and pressure several weeks after daily use. Measurements show a decrease in wound metabolism with an increase in collagenase activity. Drawbacks to their use are primarily related to their thermal insulation and movement restriction.

Hydrogel and silicone sheeting have been used to control scar formation. Like elastic garments, the mechanism of action is not known, but hypotheses reported in the literature include induction of scar hypoxia, increased hydration of the epidermis covering the scar and increased scar temperature. Several reports have shown that hydrogel sheeting is equally effective as silicone and has fewer adverse side effects. Hydrogel sheeting has been approved by the FDA as substantially equivalent to silicone for treatment of hypertrophic scars. Hydrogels have the added advantage of dual use as a drug delivery vehicle as well as a higher heat capacity for buffering scar temperature.

Mechanical Tension Blockers
Calcium channel blockers and other calcium antagonists have been shown to induce changes in fibroblast gene expression resulting in decreased collagen synthesis and increased collagenase production. These effects appear to be mediated by interruption of the basic cellular communication pathways that are critical to regulation of scar fibroblast behavior. Verapamil, injected in the lesion, has been shown to induce scar degradation in the skin, fascia and periocular scars. These agents hold promise as treatment for established, non-inflamed scars that are no longer actively remodeling.

Tissue Heating
Both ultrasound and diathermy methods are commonly in use to soften scars in muscle and joints after injury. Although this approach is well established and effective, these devices are not widely used to treat skin scars, but the technology may be further developed.

Radiation
The density of fibroblasts in keloid and hypertrophic scars is higher than normal. In normal scars, fibroblasts are present in high numbers initially, but decrease as the wound enters the maturation stage. Ionizing radiation is another established method of therapy for hypertrophic scarring and keloids. Ionizing radiation activates several signaling pathways in the nucleus subsequent to the damage of DNA, as well as signalling pathways at the level of the cell membrane, which causes cell death. The primary mechanism of radiation induced scar control seems to be apoptosis of proliferating cells. Low dose ionizing radiation is most often reserved as the method of last resort for the treatment of intractable keloid scars. This therapy utilizes 15-20 Gy of ortho-voltage radiation fractionated in 5 to 6 treatments. Although radiation therapy alone is not adequate, if used in conjunction with surgical intervention, reduction in recurrence may reach 25% compared with a recurrence rate of up to 80% with surgery alone.

Surgical Removal
The most common indications for surgical removal of scars are the following: large scars that are unlikely to be substantially reduced using medical therapy within a practical timeframe; scars that harbor infection; and scar contractures that hamper movement function. Surgical revision of hypertrophic or keloid scars is associated with a high recurrence rate. Gentle surgical technique is critically important because inflamed scar tissue produces a tremendous scar response to trauma. Adjunctive measures to reduce inflammation, skin tension and other factors are essential to reduce recurrence. Use of lasers and other burning techniques for scar removal is very controversial.

In order to reduce the scar recurrence rate after surgery, effective scar control medications should be initiated pre-operatively and continued post-operatively. Our experience suggests that most patients with scars large enough to require surgical excision require both systemic COX-2 inhibitors and long-acting H1 anti-histamines to induce scar degradation and reduce recurrence. Increasingly, our experience suggests that topical application of NSAIDS to healing wounds will be the most practical approach. Trans-epidermal delivery of these agents is enhanced by the application of an occlusive barrier such as hydrogel sheeting.

Conclusion
Hypertrophic and keloid scarring can be essentially reduced to inflammation mediated dermal fibrosis, suggesting that there is much insight into effective management that can be gleaned from dermatological and rheumatologic conditions of similar pathophysiology. Patients today expect and require superior clinical outcomes compared to those acceptable in the past.

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Prostatectomy 2004, radiation 2009, currently 70 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums