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what is it?
-thickened, wided, raised scar, flesh tone colour,  occurs after skin injury
-abnormal response/imbalance of collagen to trauma or injury
-often seen at sites of body piercings, acne, cuts and burns
-may be itchy
- spontaneously regress

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- Silicones in combination with pressure therapy and intralesional injections of corticosteroids.

- If the keloid does not respond to 12 months of these treatments, then surgical excision should be considered always in combination with some form of adjuvant therapy.
- Silicone products may help to prevent excessive scar formation by restoring the water barrier through occlusion and hydration of the stratum corneum and need to be used as soon as the wound/suture is healed
- Silicone flattens the appearance

- Internal cryotherapy in which a metal rod is introduced into the keloid and the subsequent extreme cooling leads to tissue necrosis.

-  Laser CO2 and erbium:yttrium-aluminumgarnet lasers act to superficially ablate tissue with each pass. Their thermal energy, however, also results in collagen remodeling.

- Generate thinner, better-organized collagen.

- Improve scar pliability and contour

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collagen scars
LLLT

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LLLTs mechanism of action is through the use of photons to alter biological activity. The MOA is thought to be through the absorption of red and NIR light by mitochondria and perhaps cell receptors.
It can decrease IL6 mRNA, modulate PDGF, TGF-B, IL-13 and IL15 and MMPs associated with abnormal wound healing seen in hypertrophic scars.
LLLT can also relieve the pain and inflammation associated with hypertrophic scars.
Lasers and LED fall under this therapy type.

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Keloids are excessive scars that grow beyond the boundaries of the original wound.

- Can be differentiated into minor or major with the latter being large, raised (>0.5 cm) scars that may be painful, pruritic and protruding.

-  Keloids contain disorganized type I and III collagen bundles.
- Genetics play a role, from surgery, burn, chickenpox or scarring
- fibrous tissue form over the wound creating a elevated appearance

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Appear as an adherence of skin tissue and underlying tissue  (Especially in concave area). Often accompany with hypertrophic scarring. Have two type simple and complex contracted scaring depend on what kind of tissue involving during this tightening up remodeling phase of scarring. Can decrease the mobility movement of the skin, muscle, nerve, joint, etc.

Under microscopic view, the increasing in of skin tension in contracted scar relate increase the rigidity and tension in ECM lead to myofibroblast differentiation and link to lack of apoptosis => increase collagen production & increase scar contract

Highly result after burning

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Aetiology and physiology + modalities that can be used 

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Aetiology and physiology + modalities that can be used 

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hypertrophic scars - demonstrate abnormal fibroblast proliferation and excessive collagen production in response to a skin injury. There is insufficient collagen lysis during the remodelling phase.

Initially the pulse dye laser has been most efficient with the hypertrophic scars with the modalities of 585 and 595 nm. However now recent studies suggest hat the Nd:Yag laser (1064nm) can have better results for hypertrophic scars as it penetrates deeper into the skin and it acts by suppressing neovascularization in these pathological scars, which are characterised by vessel overgrowth that results in nerve fibers and collagen in the reticular layer of the dermis.

Hypoxia is created due to the destruction of blood vessels that leads to the decreased oxygen flow. changes occur in the tissues as a result of the hypoxia, with the production of new collagen, heating of collagen fibres, dissociation of disulphide bonds (which keep collagen fibres together), and collagen fibre realignment. hence laser therapy aligns reorganisation of collagen deposition.

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-taping e.g sterile tape - 3 months (directly after closure)
-Scar massage (ensures flexibility)
-bandage may weaken scar tissue and approve scar appearance e.g. silicone sheets (1st line of treatment 2-3 months daily)

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Keloids can form when the skin has been damaged, such as a cut, wound, acne etc. Why this happens is not well understood. Keloids will have growing and resting phases. In a growing phase, it tends to feel more itchy, painful and hot. Management in this stage is important to ensure overgrowth of tissue doesn't occur.
The Collagen produced is increased, expressing both collagen 1 and 3. Keratinocytes and fibroblasts secrete higher amounts of fibronection, pro collagen one, collagen one and collagen three. With the increased fibres it induces more contraction of the collagen lattice.

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Pathophysiology -
The pathogenesis of keloids is complex and involves both genetic and environmental factors. It is widely accepted that keloids develop subsequent to injury or inflammation of the skin, but the exact pathogenesis is still unknown.
When an imbalance occurs between the anabolic and catabolic phases of the healing process, more collagen is produced than is degraded, and the scar grows in all directions. The scar is elevated above the skin and remains hyperemic. Excessive fibrous tissue is classified as either a keloid or a hypertrophic scar.

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immature: LED/LLLT
mature: avoid sun exposure, start silicone sheets and compression along with skin care. 4wks-6mth combination of silicone dressings and cortico-steroid injections after 12months consider surgical excision, or other localised radiotherapy or cryotherapy.

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Silicone therapy is best used 12-24 hours a day for 3-6 months.

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Ablative lasers:
Emit light at wavelengths targeting absorption of water molecules in skin, generation of heat and elimination of epithelium, papillary dermis. Re-epithelialisation, remodelling and collagen synthesis.
Fractional lasers:
Numerous discrete columns of thermal damage
Remodelling

More side effects; crusting, pigmentation

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aka depressive scars

May have hyperpigmentation or hypo-pigmentation

Often caused by cystic acne, surgery, burns and trauma

Occur most commonly on face and head and skin lying above tibia

Sunken appearance due to collagen damage or abnormalities in collagen production, injury, atrophy, deficit in underlying subcutaneous tissue

Drawing in of epithelium, exaggeratedly atrophic dermis, atrophy of underlying fat

Collagen bundles: atrophic

Elastin fibres: thin, disrupted and fragmented

Much lower MMP-2 levels (Matrix metalloproteinase)

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Non-invasive
Tissue tightening
High-frequency energy delivered to skin. Water in skin heats up stimulating wound healing response. Collagen remodelling to improve appearance.
Less side effects

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LLLT
-Mechanism of action- Selective photothermolysis were light energy is absorbed by haemoglobin that leads to coagulation
-Pulse dye laser will increase MMP-13 activity, reduce TGF beta expression, fibroblast proliferation, controlling amount of angiogenesis

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Silicone sheets
-soft, self-adhesive and semi-occlusive
-medical grade silicone- cross‐linked polydimethylsiloxane polymer
-reinforced with silicone membrane backing for durability and easier handling
Hypertrophic scars:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6580700/#:~:text=Silicone%20gel%20sheeting%20is%20one,been%20removed%20from%20the%20incision.

- Recommended tx cycle is 8-12 weeks
- Best time is when the scars are immature and younger than 12- 18 months, however can be used for mature scars as well
- "Sheets are worn for up to 24 hours and can be washed and reused"

Mechanism of action:
- Occlusion and hydration of the epidermis

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- Decreases blood flow to the scar

which causes collagenase-mediated collagen breakdown, hypoxia-induced fibroblast and collagen degradation, and decreased scar hydration (Tejiram et al., 2017)

- Decrease in collagen quantity
- Fades scar
- Softer scar tissue
- Provide pain relief
- Reduce thickness of scar
- Decreases erythema and height
- Reduction in itching
- Provides protection
- Done for about 6 months or up to 2 yeaars

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Risk factors associated with keloid formation include: being of Asian descent, being of Latino descent, being pregnant being younger than 30 years of age

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Risk factors associated with keloid formation include: being of Asian descent, being of Latino descent, being pregnant being younger than 30 years of age

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Keloids are the result of abnormal wound healing. Normally, there is a balance between the production and the breakdown of collagen, which is a protein that makes up the fibres in the skin. With keloidal scars, the cells in the skin called fibroblasts produce excessive amounts of collagen. The collagen fibres are also thicker and wavier. This leads to the thick, raised appearance that is characteristic of keloidal scars.

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Keloids are the result of abnormal wound healing. Normally, there is a balance between the production and the breakdown of collagen, which is a protein that makes up the fibres in the skin. With keloidal scars, the cells in the skin called fibroblasts produce excessive amounts of collagen. The collagen fibres are also thicker and wavier. This leads to the thick, raised appearance that is characteristic of keloidal scars.

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- icepick
- rolling
- boxcar

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Pulse dye laser
physical therapy measures and plastic surgical procedures but not eliminated completely

early skin graft at the burning site can have minimal the appearance of contracted scarring
silicon gel compression

Intralesional injections of triamcinolone, every 4 weeks, have been found to be effective for control of hypertrophic scar

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-Wearing pressure garments can minimize scarring and help pain relief.
-Avoiding to tight clothes in affected areas.
-Washing and keep pressure garments in hygiene.
- Vitamin E ointments and honey can help to maintain and reduce scarring from second-degree burns.

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Polydimethylsiloxane commonly used medical silicone, it’s an inert polymer that can be applied to scars. Application as soon as second week after surgery continuous for 3 months. Reduces the incidence of hypo trophic scars, helps improves pigmentation, vascularity, pliability, height, pain and pruritus.Silicon inhibits fibroblasts activity via hydration and occlusion, activates collagen via warming and polarization pd the scar tissue via the static negative charge or silicon  

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Polydimethylsiloxane commonly used medical silicone, it’s an inert polymer that can be applied to scars. Application as soon as second week after surgery continuous for 3 months. Reduces the incidence of hypo trophic scars, helps improves pigmentation, vascularity, pliability, height, pain and pruritus.Silicon inhibits fibroblasts activity via hydration and occlusion, activates collagen via warming and polarization pd the scar tissue via the static negative charge or silicon  

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Chronic wounds: Wounds that do not heal for at least 180 days (3months) and do not proceed through the normal reparative process

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Chronic wounds: Wounds that do not heal for at least 180 days (3months) and do not proceed through the normal reparative process

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The cause of a chronic wound must be identified before treatment can begin. This assessment includes an evaluation of the patient's general health, nutrition and medication and any contraindications that may deny the patient for specific treatments and management strategies. The cause of the wound dictates the management including the choice of dressing. Moist wound dressings are now preferred.