Treatments for keloids and hypertrophic scars

So in talking about scars, there are three basic things which lead to keloids and hypertrophic scars:

• Genetics
• Tension
• Inflammation

Most of the treatments out there are aimed at these.  Bad scars are not seen immediately.  It would be unusual to see a scar elevating and looking bad until a month or more out of surgery.  I see all my patients back at 3 months (don’t miss that visit!) and the primary reason? To see if I see any inklings of poor scarring.  The initial signs are subtle, but there.

The best treatment for scars is prevention.  At my recent meeting with many who are doing research on scarring (so I would consider them quite the experts) they recommended doing what I already do. 

• Tape the scars. 
• At 3-4 weeks you can change to silicone gel or silicone sheets.   Sheets can sometimes be hard to keep on, particularly if it is hot (sweat makes it fall off), so I also recommend Kelocote. 

Even when you do this, you can still form bad scars.  What do you do then?  None of these are ideal.  A lot of times it may be best to cut out the scar and retry, particularly if the first time the injury was traumatic (skinned knee), infected, or under a lot of tension to close. 

• Surgeries:  Z plasty, W plasty.  These involve cutting out the scar and actually making the scar longer, but breaking it up.  This reduces the tension on the scar.
• Pressure.  This is difficult for most scars, but very effective for the earlobe keloids.  When doing burn scars on the arm we use silicone sheets and an arm pressure dressing.
• Steroid injection.  This is to decrease inflammation.  There are different strengths of steroid.  It will not cause the scar to narrow.  Issues with steroid? It can cause skin discoloration, can thin the skin, the scar can widen, and can cause an increase in the capillaries. 
• Radiation.  This is used to decrease inflammation.  Sometimes is done immediately after the scar was cut out and sewn again.  I saw a talk by Dr. Ogawa, a published expert on scars.  He has found “customizing” the amount and doing it over the course of a few days has lowered the recurrence rate.  (when he did one time at 15 gray he found a 30% recurrence rate of the keloid)
• Laser.  He uses the NDYag laser, doing a few passes in 1-2 sessions a month.  He has found the thickness of the scar important- the thinner the scar, the more effective the laser.