Both hypertrophic and keloid scars can be difficult to treat, though hypertrophic scars can improve somewhat over time. A number of different scar treatment options exist to help promote the scar's appearance improve, though many have manifested limited results. Indeed, some treatment options are associated with problems such as tissue atrophy and hypopigmentation.
Intralesional steroids have been used over the years to help get the symptoms and aesthetic issues associated with keloid scars under control. Intralesional steroids have also been used in tandem with other treatment options such as surgical excision, silicone, and pulse dye lasers. Intralesional steroid injections are made directly into the keloid scar.
Though pressure therapy can be hot and uncomfortable, it has been used with both hyptertrophic as well as keloid scars. It has often been applied in conjunction with other forms of therapy used simultaneously. Pressure therapy is applied using a compression garment that applies constant pressure to a scar at 15 to 45 mmHg. The pressure should be continuously applied, 24 hours a day for up to 6 months. Many patients see a reduction of redness as a result of pressure therapy, a good indication that the treatment is working. Pressure therapy combined with silicone gel sheets can sometimes prevent recurrences of keloid scars.
Silicon gel sheets are used to increase the pliability of scars and reduce elevation as well as pain and itching associated with the scar. They have been used as a preventative measure against the development of new scars with some success. Silicone gel sheets encourage scar occlusion and hydration, which has a positive impact on 70% to 90% of patients. The silicone gel sheets are applied to the scar tissue for 12 hours sometimes in conjunction with other treatment modalities. The treatment is often continued for 2 to 3 months or longer. The treatment is associated with few side effects.
Cryotherapy involves the use of liquid nitrogen to cause the death of scar tissues. It is not an appropriate treatment modality for darker skin colors because it disrupts skin pigmentation. Hypopigmentation can persist in lighter skin colors for 12 to 18 months or even become permanent. This treatment modality is best used on patients with light skin who have very small scars.
Excision of large, broad-based keloids is one of the only treatment methods that can diminish the size into a smaller, narrower, cosmetically acceptable scar. Unfortunately, however the trauma of excising the scar can lead to recurrence at a rate of 50% to 100%. Adjunct treatments such as intralesional steroids, topical imiquimod, or radiation can help reduce the recurrence rate. Radiation treatments and surgical excision have prevented recurrence of keloids in approximately 75% of patients.
Radiation therapy may be used by itself or in conjunction with surgical excision. This treatment protocol inhibits the development of fibroblasts as well as the vasculature of the skin. As a stand-alone treatment, radiation therapy has a recurrence rate of 50% to 100%, similar to surgical excision. However, for early keloids, radiation therapy can help prevent itching and burning associated with the scar.
Pulsed dye lasers, as well as ablative and non-ablative laser therapy is recommended for atrophic scars. Though ablative therapy has been associated with better results, patients also have to contend with greater downtime. Fractional ablative lasers target a smaller area, thereby achieving the same results without the same amount of recovery required. CO2 and erbium:YAG lasers have a skin tightening and vaporizing impact on atrophic scar tissue. Lasers tend to encourage the development of new, healthy collagen, contributing to the aesthetic value in treating atrophic scars.
The proper treatment of scars using laser therapy is contingent on the correct identification of the scar. Lasers are still be studied to determine their efficacy at treatment keloid scars, for example. Recurrence rates after using lasers has been rather high for keloid scars. The results of laser therapy using CO2 or Nd:YAG have been roughly equivalent to using surgical excision, though lasers have tended to reduce symptoms of burning and itching more readily than "cold steel".
The pulsed dye laser is the treatment method of choice for hypertrophic and keloid lesions because of its ability to improve the texture, size, pliability, and redness of the scars. Hypertrophic scars often improve by 50% to 80% after two laser treatments. Keloid scars, in contrast, may take several treatments and may need to be treated using surgical excision at the same time in order to produce desirable results.