I. Overview of scarring
Scarring is the inevitable result of tissue repair when skin injury reaches the dermal reticular layer. Trauma repair is an extremely complex biological process that contains many cytochemical, immunological and molecular biological processes involving many factors such as multiple repair cells and cytokines. Broadly speaking, there is no scar formation and no wound healing, so it is not scientific to define keloid lightly.
The main effects of keloid scars on the human body: bulging on the skin surface or accompanied by abnormal pigment metabolism, affecting the appearance; itching, pain and discomfort and other conscious symptoms; occurrence of contracture causing organ deformity and affecting the function of the body; can be followed by ulceration or even cancer.
The purpose of prevention of scar: to prevent further deformation and functional disorders caused by scar, and to reduce the impact of scar on the body surface.
II. Prevention before scar formation
(a) Foreseeing the scar caused by primary injury
Primary injury scarring mainly refers to scarring caused by trauma and burns, which are often heavy and accompanied by different degrees of infection. Therefore, the focus is to prevent and control the infection, to create good conditions for wound healing, and to close the wound as early as possible. In the case of infection control, drugs such as growth factors can also be used to promote early wound healing, shorten the healing time and reduce scar growth. During the period of wound healing and repair (within 3 to 4 months), try to eat less spicy and stimulating food to avoid stimulating the capillaries of the wound and the increase of collagen metabolism to produce scarring. In addition, applying steroid ointment at the early stage of scarring has some effect, but it is not effective for old scarring.
(B) Reduce scar formation factors during treatment
The principle of treatment: love the tissue and reduce trauma.
(C) Treatment of body surface wounds is the key to prevent scar formation
For early fresh wounds, blood clots, foreign bodies and necrotic tissues should be removed thoroughly. Close the wounds as early as possible. For late contaminated wounds, the wounds should be thoroughly cleared, and drainage strips can be placed when closing the wounds, along with local or systemic application of antibiotics. For wounds with large tissue defects, tissue mobilization (flaps) should be adopted as early as possible to cover the wound and reduce granulation and scar tissue formation. In principle, the simplest surgical method should be used and unnecessary additional incisions should be avoided as much as possible, especially for patients with a tendency to keloid scarring. The scar formation period can be controlled by pressure method and medication method.
Prevention of scar formation
Although the scar has been formed, some measures will still have some inhibiting effect on the growth of the scar at this time, which can reduce the degree of scar formation and the harm caused by the scar to the organism. The prevention of scar formation period is to take effective measures to slow down the growth of the scar before the scar matures after the wound is healed, and to pass through the proliferation period to enter the maturation period and turn into a mature scar. The main methods are: compression therapy, drug therapy, radiotherapy and functional rehabilitation.
At present, there are various methods to prevent keloid hyperplasia, but the effect is not the same. Most of them choose 2 to 3 methods with less side effects and easy to use to carry out comprehensive prevention and treatment, and their effect is better than single methods.
(A) Compression therapy
The method of preventing and treating scar growth by applying continuous pressure to the wound healing site with elastic fabric is called compression therapy. Since the 1970s, many medical centers have been using this method as the treatment of choice for the prevention of proliferative scarring after burns. Currently, the method is widely accepted as a routine method of preventing scar growth. It is one of the most definitive treatment options available. The principles of compression therapy: one early (after the wound heals), two tight (pressure of 2,0 to 2,4 kPa), and three long-lasting (pressure 24 hours a day except for bathing for 6 to 12 months). Compression therapy is mainly applied to hyperplastic keloid scars, especially those with large areas throughout the body, and can also be used as an adjunctive treatment measure after keloid surgery or radiotherapy.
After the trauma surface is healed, compression bandages such as elastic bandage and elastic mesh sleeve should be used as early as possible, for example, splinting should be used to keep the joint in functional position, which can effectively reduce scar hyperplasia and scar contracture. Burn patients need to use elastic banding and other measures to apply pressure therapy to the skin graft area, deep II° wound healing area, and medium-thickness skin donor area. If the treatment is strictly adhered to, in general, after 2 weeks of compression therapy, the itchy and painful scar symptoms will be gradually reduced, the scar will become flat in 1 month, and it will be softened in about 1 year.
(II) Drug therapy
Drug-assisted therapy should be used early in all cases where compression is not suitable or scar hyperplasia is obvious. It can inhibit the synthesis of collagen by fibroblasts, promote the degradation of collagen and the transformation between type I and type III collagen, alleviate the symptoms and prevent or reduce the scar hyperplasia.
1. Topical medication
The more commonly used ones are silicone gel product patches and immunosuppressive topical rubs.
2.Injectable drugs
The more commonly used intra-scar injectable drugs are corticosteroids, such as de-inflammatory suxamethasone, tretinoin, compound betamethasone, etc., and some use colchicine and tumor necrosis factor (TNF), etc.
(iii) Radiotherapy
There are 90Sr, 32P and other isotope dressing, X-ray and electronic ray irradiation methods, among which electronic ray irradiation with stable, controllable and safe dose is the best. At present, it is mostly used for the prevention of recurrence after keloid surgery and advocates early postoperative application, usually given within 2 weeks at 1200-1500rads.
(iv) Integrated functional rehabilitation therapy
It is important to improve the quality of life of patients, including physical functional rehabilitation and psychological rehabilitation. Early sports therapy, maintaining functional position with proper fixation and psychological guidance are mainly used. When the patient’s general condition improves, the wound begins to heal or completely heal, and there is a tendency of scar proliferation (especially when the scar location involves joint movement), slow active and passive activities such as joint flexion, extension, abduction, internal retraction, external and internal rotation should be started 2 to 3 times a day. Various plastic splints, devices, massage and other therapies can also be used to keep the joints in a functional position and to counteract scar contracture, prevent limb dysfunction and promote the recovery of the patient’s physical and mental health.
It should be emphasized that this measure is often overlooked during this period, as patients tend to treat themselves at home. Doctors should carefully introduce the importance of these measures to patients or their families for the prevention of scar growth, and supervise and implement their effective implementation.
(V) Physiotherapy
The timely and effective application of various physical factors to treat the trauma at the early stage of trauma can effectively prevent or reduce the proliferation of scar, and the application of physical factors after the trauma is healed and the scar is proliferated also has better effect, so the physical therapy of scar does not start after the trauma is healed, but should start after the trauma and run through the whole treatment process until the patient recovers. Hot compress, ion introduction, ultraviolet radiation and electromagnetic therapy can be used to relieve scar symptoms and prevent further proliferation of scar.
4. Prevention of scar proliferation
The prevention of scar proliferation is to remove all the factors that accelerate scar proliferation, reduce the growth of scar, and prevent the deformity and dysfunction caused by scar to the body. If the scar has become a mature mass, it falls under the scope of treatment. The basic methods are the same as above. Compression therapy, pharmacotherapy, radiotherapy, functional rehabilitation, physical therapy, and avoidance of chronic stimulation (avoiding chronic stimulation such as friction and prolonged sunlight exposure can help reduce the proliferation of scar).
V. Prevention after scar treatment
Keloid scars are sure to recur after surgical excision alone, just like without surgery, and therefore cannot be treated with surgical excision alone. The preventive measures are largely the same as above.
Scar surgery should be strictly selected for indications, and the surgical operation should comply with the treatment principles of scar surgery: tension-free, lumen-free, minimally invasive incision, no residual blood clots, foreign bodies (including sutures), and early radiation therapy (it is currently proposed that early radiation therapy should be given after scar surgery because fibroblasts in the granulation tissue become fibroblasts within 24 hours, and theoretically cannot wait until the stitches are removed before radiation therapy, but clinical In the work, it is found that some patients delay the healing of the wound after radiation therapy, and in serious cases, it even leads to skin ulceration. There are different opinions on the time of starting postoperative radiotherapy, and now there is no prospective analysis stating the best treatment time), etc. The focus is that after the stitches are removed from the surgery, the wound should be treated with radiation and other adjuvant treatments in time, and local pressure or medication should be carried out in time when there are signs of recurrence, etc.
Scar prevention for patients with skin diseases
When skin diseases such as folliculitis, acne, boils, etc. occur on the body surface, the local skin should be protected and not squeezed or scratched to avoid leaving depressions or proliferative scars. If the scar is continuously stimulated, it may lead to cancer.
Prevention of scar cancer
The prevention of scar cancer includes: pay attention to protect the scar, avoid chronic stimulation and repeated injury; treat the ulcerated wound as early as possible to control chronic infection; remove unstable scar and chronic sinus infection by surgery as early as possible.
In conclusion, prevention of scarring requires a professional technical team, scientific theoretical guidance, advanced treatment equipment, comprehensive treatment measures and persistent faith, because prevention and treatment of scarring is a systematic, long-term, complex process that takes about 3 to 10 years, which requires sufficient patience, perseverance and adequate communication between doctors and patients. In addition, we should all be fully aware of the limitations of scar treatment, and it is difficult to obtain very satisfactory results in a short period of time. Scar revision can also only achieve some improvement because with each surgery, there is a new trauma. Therefore, taking measures to maximize the prevention of scar formation is of equal importance to the treatment of scarring.