ASSIGNMENT MODULE 1

NAME: DR DIANA VEROSHINI A/P GENGATHARAN

CCWC COHORT 15

TOPIC: PATHOPHYSIOLOGY AND MANAGEMENT OF HYPERTROPHIC SCAR AND KELOID

NUMBER OF WORDS: 955 words

Hypertrophic scars and keloids are two common types of abnormal deposition of collagen in the
skin that often develop as a result of insult to the deep dermis including burn injury, lacerations,
abrasions, surgery, piercings and vaccinations. By causing thickened scars that can be painful and itchy,
contractures and excessive scarring significantly affects patients’ quality of life both physically and
psychologically. However, there are distinct differences in the histopathology and pathogenesis of these
two pathologies.

Hypertrophic scar and keloid are both the results of the wound healing process. Hypertrophic
scars and keloids are characterized by the excessive formation of collagen in response to a wound,
leading to raised, thickened and discolored scars. Hypertrophic scars are confined to the site of injury,
and are typically characterized by an excess of type III collagen, with a normal ratio of type I to type III
collagen. In contrast keloid extend beyond site of injury and are characterized by an excess of both type
I and type III collagen, leading to disordered deposition of collagen and irregular structure.

The pathophysiology of hypertrophic scar and keloid formation is complex and involves complex
interactions between genetics, environmental, and cellular factors. Genetic predisposition may play a
crucial role in susceptibility to these conditions. Multiple cellular and molecular mechanisms can be
broadly classified into three phases: inflammation, proliferation and tissue remodeling.

In the inflammation phase, immune cells and platelets are recruited to the site of injury,
releasing various cytokines and growth factors, including transforming growth factor-beta (TGF-
B),platelet-derived growth factor (PDGF), and interleukin-1(IL-1). These factors stimulate the migration
of fibroblasts, the primary cell type responsible for producing and maintaining the extracellular matrix
(ECM).

In the proliferative phase, fibroblasts differentiate into myofibroblasts, which are contractile
cells that play a key role in wound closure. Myofibroblasts are characterized by the expression of alpha-
smooth muscle actin (a-SMA) and are stimulated by TGF-B and PDGF. They produce and deposit large
amounts of collagen, particularly type III collagen which serves as a framework for new tissue formation.
In hypertrophic scars, the overproduction of collagen leads to the formation od dense, disorganized
bundles, while in keloids, the collagen bundles are arranged in a whorled pattern.

In the tissue remodeling phase, the newly formed tissue undergoes maturation and remodeling
leading to scar contraction and tissue stabilization. This process is regulated by a balance between ECM
synthesis and degradation. In hypertrophic scars and keloids, the balance is tilted towards ECM
synthesis, resulting in excessive tissue growth and fibrosis.
 The management strategies for hypertrophic scars and keloids, including both non invasive and
invasive techniques.

Non invasive management:

Compression therapy involves applying pressure to the scar site to flatten it and prevent
excessive collagen production. This can be done using specialized pressure dressings, silicone gel sheets
or custom-made compression garments. This technique is relatively safe and non-invasive but requires
consistent and long-term use to achieve optimal results.

Topical agents such as silicone therapy involves applying silicone-based products such as gels or
sheets to the scar site, to reduce redness, itchiness and thickness. These agents provide hydration and
oxygenation to the wound this improving its texture and elasticity. The sheet should be worn for at least
12 hours a day for several months to see results.

Cryotherapy involves the use of extreme cold to destroy cells in affected area. The procedure
involves applying liquid nitrogen to the scar tissue, which freezes and then thaws the cells. The patient
may need multiple sessions to achieve optimal results.

Laser therapy uses light energy to remove scar tissue. The laser works by vaporizing the scar
tissue leaving behind healthy skin. Laser therapy is effective for small scars. However, multiple
treatments may be needed to achieve significant results and the procedure can be costly.

Invasive management:

Surgical excision refers to the removal of the hypertrophic scar or keloid from the skin. The
procedure involves cutting out the scar tissue and stitching the wound back together. It is an effective
method of treatment especially when the scar is large and cannot be treated with other methods.
However, the procedure comes with a risk of recurrence, bleeding and infection.

Intralesional injections involve injecting corticosteroids directly into the scar tissue. The
injections are usually given once a month over a period of several months. Corticosteroids work by
inhibiting the production of collagen, reduce inflammation, and preventing further scarring. However,
they have risk of side effects such as skin discoloration, thinning of the skin and occasional pain at the
injection site.

In conclusion hypertrophic scars and keloid formation is a complex process involving genetic,
environmental and cellular factors. Effective management of these conditions require a multidisciplinary
approach aimed at prevention, early intervention and tailored treatment options. Patients should be
educated about the different treatment options available to them and the potential risks and benefits of
each. Ongoing research into the pathophysiology and management of hypertrophic scars and keloids is
necessary to identify new and improved treatments for these challenging conditions.

References:

Kumar V., Abbas A. K., Fausto N., In Robbins and Cotran, Pathologic Basis of Disease, 7th Edition (Eds:
Kumar V., Abbas A. K., Fausto N.), Elsevier Saunders, Philadelphia, PA: 2004
Ghazawi F. M., Zargham R., Gilardino M. S., Sasseville D., Jafarian F., Adv. Skin. Wound Care 2018, 31,
582. - PubMed

Gauglitz, G.G., Korting, H. C., Pavicic, T., Ruzicka, T., & Jeschke, M.G. (2011) Hypertrophic scarring and
keloids: pathomechanisms and current and emerging treatment strategies. Molecular medicine.

Lee, B. B., Kwon, Y.S., & Kim, Y. J. (2017). Current understanding of hypertrophic scars, keloids, and
keloid scar contractures: the molecular and cellular basis for treatment.