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Abstract: An 18-year-old Xiao Yan presented with a red scar on her chest that was above the skin surface and irregular in shape, with a hard texture and a slight itching sensation, which was a clinical manifestation of a keloid. Xiao Yan reported that her chest was broken due to trauma and gradually crusted over time, but she did not take local care of it later, resulting in scarring.
Basic information】Female, 18 years old
Disease Type】Keloid
Hospital】Wuhan University Central South Hospital
Date of Consultation】August 2019
Treatment plan】Medication (Trinostat capsule, Tretinoin injection) + physical therapy (fractional laser)
Treatment period】4 months of combined treatment, regular follow-ups
【Treatment effect】The patient’s scar was significantly improved after treatment
I. Initial consultation
Xiao Yan reported that her chest was hard with a red scar caused by the healing of trauma. On examination, it was clear that the patient had a 3×0.5cm scar on her chest, which was higher than the skin surface, oval in shape and smooth on the surface.
II. Treatment history
After clarifying the patient’s health condition and the absence of drug allergy history, the patient’s scar site was injected with tretinoin injection to inhibit the extension of the scar to the surrounding area and also to promote the reduction of the scar, which also helps to avoid the re-formation of the whip scar, for 2 months of injection treatment. The patient also requires a large application of trinostat capsules to inhibit the action of fibroblasts. After drug treatment, the patient has some poorly absorbed scar tissue, which is treated with fractional laser, using ultra-pulse and laser scanning output to promote drug absorption to induce recovery of scar symptoms.
III. Treatment Effect
The patient’s keloid symptoms improved significantly after medication and fractional laser treatment. At 1 month of medication, the color of the keloid became lighter and the size of the keloid was reduced by half, and at 2 months of medication, the size of the keloid continued to decrease. After fractional laser treatment, the color of the keloid gradually returns to normal skin color, and the symptoms have improved significantly and the prognosis is good.
IV. Notes
I was very happy to see the improvement of the patient’s symptoms. Patients should reduce the consumption of spicy and greasy stimulating foods as much as possible, and eat more fresh vegetables and fruits to help promote skin metabolism and help the lesions recover quickly. In addition, patients are advised to pay attention to protecting themselves from further skin damage and keloid scars, so as not to affect the aesthetic appearance of the skin.
V. Personal Insights
Keloid scars are mostly seen in people with keloid body, which is related to genetic factors. Since keloid scars can affect the aesthetics, such people are usually more anxious, especially those with facial keloid scars, and may even develop social fear. Through the treatment plan of 18-year-old Xiao Yan in this case, people with keloid scars are urged not to be overly worried and anxious, but to actively seek medical help to improve their symptoms through systematic treatment, and the prognosis is relatively good.