Review Eur J Dermatol 2014; 24(4): 435-43

Sylvie MEAUME1 Management of scars: updated practical

Anne LE PILLOUER-PROST2
Bertrand RICHERT3 guidelines and use of silicones
Diane ROSEEUW4
Javid VADOUD5
Hypertrophic scars and keloids resulting from surgery, burns, trauma
1 APHP, Hôpital Rothschild, and infection can be associated with substantial physical and psycho-
Service de Gériatrie – Plaies et Cicatrisation, logical distress. Various non-invasive and invasive options are currently
75012 Paris,
France available for the prevention and treatment of these scars. Recently, an
2 Dermatology Department, international multidisciplinary group of 24 experts on scar management
Private Hospital Clairval, (dermatologists; plastic and reconstructive surgeons; general surgeons;
13009 Marseille,
France physical medicine, rehabilitation and burns specialists; psychosocial
3 Dermatology Department, and behavioural researchers; epidemiologists; beauticians) convened to
University Hospitals Brugmann - Saint update a set of practical guidelines for the prevention and treatment of
Pierre - Queen Fabiola Children’s Hospitals
Université Libre de Bruxelles hypertrophic and keloid scars on the basis of the latest published clinical
1020 Brussels, evidence on existing scar management options. Silicone-based products
Belgium such as sheets and gels are recommended as the gold standard, first-
4 Dermatology Department,
UZ Brussel, Vrije Universiteit Brussel, line, non-invasive option for both the prevention and treatment of scars.
1090 Brussels, Other general scar preventative measures include avoiding sun exposure,
Belgium
5 Dermatology Department,
compression therapy, taping and the use of moisturisers. Invasive treat-
Clinique du Parc Léopold,
ment options include intralesional injections of corticosteroids and/or
Rue Froissart 38, 5-fluorouracil, cryotherapy, radiotherapy, laser therapy and surgical exci-
1040 Brussels, sion. All of these options may be used alone or as part of combination
Belgium
therapy. Of utmost importance is the regular re-evaluation of patients
Reprints: J. Vadoud every four to eight weeks to evaluate whether additional treatment is
<drvadoud@[Link]> warranted. The amount of scar management measures that are applied
to each wound depends on the patient’s risk of developing a scar and
their level of concern about the scar’s appearance. The practical advice
presented in the current guidelines should be combined with clinical
judgement when deciding on the most appropriate scar management
measures for an individual patient.
Key words: Guidelines, Prevention, Scar, Silicone gel, Silicone sheet,
Article accepted on 2/14/2014 Treatment

S
cars are an undesirable, yet normal outcome of treatments such as intralesional corticosteroid injections, 5-
wound healing [1]. Hypertrophic scars usually fluorouracil injections, cryotherapy, radiotherapy and laser
remain within the border of the original wound and therapy. These treatments can be used alone or as part of
may spontaneously regress over time, whereas keloid scars combination therapies. Patients often present to dermatol-
extend further beyond the wound’s margins and remain ogists once they have a maturing or matured hypertrophic
elevated [1, 2]. Scars are especially likely to occur after scar or keloid. In many cases, earlier consultation with a
a deep wound which extends through the dermis into the dermatologist may be more effective, since scars are often
subdermal tissue [3]. They occur with equal frequency easier to prevent than to treat.
in men and women, although injuries in adolescents and To assist physicians such as dermatologists who are
young adults generally produce worse scarring compared involved in scar management to select the most appropriate
with those in elderly people [2, 4]. Hypertrophic scars and treatment for their patients, a set of practical guidelines
keloids frequently occur in areas of the body that are subject for the prevention and treatment of hypertrophic scars
to stretching tension, such as the deltoid, sternal and supra- and keloids was recently developed by a multidisciplinary
pubic regions and the lower abdomen. Furthermore, people group of 24 experts (including dermatologists; plastic
with pigmented skin are more likely to develop keloids com- and reconstructive surgeons; general surgeons; physical
pared to those with white skin [2]. Hypertrophic scars and medicine, rehabilitation and burns specialists; psychosocial
keloids are not only physically disfiguring and psycholog- and behavioural researchers; epidemiologists; and beau-
doi:10.1684/ejd.2014.2356

ically distressing, but they also can cause significant pain ticians) from seven countries [5]. These guidelines were
and itching [1, 2]. developed using the latest clinical evidence on scar manage-
Dermatologists now have many different treatment options ment measures that has been reported since the publication
for the prevention and treatment of scars. These include of a previous set of scar management guidelines in 2002
non-invasive treatments such as silicone sheets or gels, tape, [6]. The aims of the current article are to discuss the key
compression therapy and physiotherapy, as well as invasive aspects of the current guidelines that are of relevance to

EJD, vol. 24, n◦ 4, July-August 2014 435

To cite this article: Meaume S, Le Pillouer-Prost A, Richert B, Roseeuw D, Vadoud J. Management of scars: updated practical guidelines and use of silicones. Eur J
Dermatol 2014; 24(4): 435-43 doi:10.1684/ejd.2014.2356
dermatologists involved in scar management and to thor- used as monotherapy, until the scar is flattened [5]. Patients
oughly evaluate the latest clinical evidence for the use with widespread hypertrophic scars may be treated with
of silicone therapy on which the recommendations in the corticosteroids at an earlier stage in the maturation of their
guidelines are based. scar. Intralesional corticosteroids may be supplemented
with 5-fluorouracil in those with refractory scars. Simi-
larly, patients with growing keloids may be treated with
Scar management practical guidelines intralesional corticosteroids with or without other agents
such as 5-fluorouracil, bleomycin or verapamil, in addi-
tion to first-line treatment with silicones and compression
Practical guidelines for the prevention and treatment of therapy.
hypertrophic scars and keloids developed by an inter- Surgical scar revision or resurfacing may be offered to
national, multidisciplinary group of experts are shown in patients with hypertrophic scars after 12 months of treat-
figure 1. Most scar management measures can be used ment. Surgery must also be considered earlier for those with
for both prevention and treatment. The treating physician functional impairment, e.g., by contracture release. Keloids
should always re-evaluate the patient every four to eight that have not responded to 12 months of treatment may be
weeks to determine whether or not additional therapeutic surgically excised, but this should be combined with radio-
options need to be considered [5]. therapy or intralesional cryotherapy to reduce the high rate
of recurrence of these scars [2, 5].
Preventive measures The specific treatment options recommended in these
guidelines are discussed in more detail in the following
Immediate priorities for scar prevention include rapid sections.
wound closure, early debridement of dead tissue, measures
to prevent or treat inflammation and infection, and pro-
vision of adequate wound dressings to establish a moist
wound healing environment [5]. The amount of preventive Non-invasive management options
measures that should be applied to a newly formed wound
depends on the individual patient’s risk factors for scar for- The two principal non-invasive management options rec-
mation (e.g., type and location of wound, age and skin type) ommended in the guidelines for scar prevention and
and the level of aesthetic concern the patient has about scar treatment are silicone products and compression therapy.
formation. Medical ointments and creams may be useful for reducing
General preventive measures, as recommended in the latest scar pruritus and physical therapies may also be valuable
guidelines include: sun protection, the use of moisturising as part of overall scar management.
creams and the use of moisture retentive dressings such
as silicone gel [5]. Transepidermal water loss is increased
in hypertrophic scars and keloids [7]. The subsequent Silicone sheets and gels
dehydration of keratinocytes may stimulate the production Silicone-based products for scar management have been
of cytokines, leading to excessive collagen deposition by available for the past 30 years and are recommended in
fibroblasts, which results in scar formation [8]. Moisturisers the current guidelines as the “gold standard” option for
increase the water (or moisture) content of the skin, whereas the prevention and treatment of hypertrophic scars and
silicone-based dressings help to decrease the evaporation of keloids [5, 10]. Silicones have been manufactured in vari-
water through the skin and to restore the barrier function of ous forms such as silicone sheets and more recently silicone
the skin, which can help to reduce scar formation [9]. Other gels [11].
preventive measures include taping, splinting or stretching, Silicone sheets have to be worn over the scar for 12–24
and physical treatments such as manual massage, ender- hours each day for three to six months [5]. The sheets can be
mology and physiotherapy [5]. used until they begin to disintegrate but need to be washed
daily with mild soap and water to prevent side effects such as
rashes and infections. The composition of different silicone
Treatment of hypertrophic scars and keloids sheets varies widely, with some only containing medical
As shown in figure 1, first-line non-invasive treatment grade silicone whereas others contain a combination of
options for linear and widespread hypertrophic scars and silicone and polytetra-fluoroethylene, which provides an
keloids include silicone-based products such as sheets and internal reinforcement to create thin, durable sheeting and
gels and compression therapy [5]. Both treatments should to increase flexibility and breathability. Silicone sheets have
be applied only once the wound has closed. Early treatment variable adhesion properties, with some being self-adhesive
is essential, particularly for those with widespread hypertro- whilst others require taping to fix them to the skin. Silicone
phy from burns, trauma or infection. These patients should sheets are not suitable for use on large areas of skin and
be referred to a dermatologist as soon as possible and treated on mobile body parts such as the joints. Patients may be
with custom-made pressure garments with silicone inlays reluctant to use the sheets on visible areas such as the face
[5]. and compliance with this treatment is often an issue [10].
Patients with linear scars and continuing hypertrophy after Silicone gel is applied to the skin as a thin layer where
six months should continue their first-line therapy and it dries to form an adherent, transparent, flexible silicone
should initiate second-line therapy with intralesional corti- sheet that is impermeable to fluids. Such gels are suitable
costeroids. Triamcinolone acetonide is the most commonly for use on visible areas such as the face and hands, and
used corticosteroid with the current guidelines recommend- their ease of application (twice a day) is associated with
ing a dose of 40 mg/mL every two to four weeks when increased patient preference and compliance [12].

436 EJD, vol. 24, n◦ 4, July-August 2014

 A

Figure 1. Practical guidelines for the management of hypertrophic and keloid scars [5].

EJD, vol. 24, n◦ 4, July-August 2014 437

 C

Figure 1. (Continued)

Mechanism of action Re-evaluation of silicone products: latest clinical

Many explanations for the mechanism of action of silicone evidence
products have been proposed. For example, silicones may Previous and current guidelines recommend silicone prod-
raise the surface temperature of the skin, which can increase ucts as safe and effective first-line non-invasive options
collagenase activity leading to collagen breakdown [13]. for the prevention and treatment of hypertrophic scars and
Furthermore, a negative static electric field between the keloids [5, 6]. The earlier recommendations were based
silicone product and the skin may cause realignment of on the results of clinical studies that were published at that
collagen, resulting in shrinkage of scars [14, 15]. time [22-33]. The latest guidelines also take into account the
However, occlusion and hydration of the stratum corneum results of many recently published studies, some of which
are now universally accepted as the major mechanisms are considered here in more detail.
responsible for the action of silicones [10]. Transepidermal Several recent studies have confirmed the safety and effi-
water loss is increased following a full thickness wound cacy of silicone sheeting for scar prevention and treatment
and may take over one year to return to pre-wound levels [34-36]. For example, Sakuraba et al. showed that silicone
[7]. A high loss of water from the epidermis may lead to sheets placed over wounds two weeks after median ster-
dehydration of keratinocytes. These cells may then release notomy effectively prevented the formation of keloids over
cytokines to activate dermal fibroblasts to increase collagen 24 weeks in nine patients [34]. Li-Tsang et al. conducted a
production which can lead to excessive scarring [10]. randomised clinical trial which showed that silicone sheet-
Studies have demonstrated that silicone sheets decrease ing significantly reduced the thickness and improved the
evaporation of water from the skin and increase hydration of pliability (p<0.001) of severe post-traumatic hypertrophic
the stratum corneum [16-18]. The reduction in transepider- scars in 45 Chinese patients after six months of treatment
mal water loss will reduce the stimulation of keratinocytes, with non-significant improvements in pain and itchiness
which in turn will stop producing cytokines and so der- [35]. In addition, a recent meta-analysis of 15 studies
mal fibroblasts will not be activated. Occlusion is also an involving 615 people showed that silicone sheeting reduced
important component of the mechanism of action of silicone the incidence of hypertrophic scarring in high-risk individ-
products, with a study showing a greater improvement in uals compared with no treatment (response rate: 0.46; 95%
scars treated with silicone cream containing 20% silicone confidence interval 0.21–0.98) [37].
oil and occlusive dressing compared with those treated with Compliance with silicone sheets can be improved through
silicone cream covered with gauze [19]. patient education programmes. A study of 25 patients with
In vitro research has shown that the production of basic hypertrophic burn scars showed that patients who received
fibroblast growth factor (bFGF) can be increased by silicone detailed education on the use of silicone sheets had sig-
products [20]. An increase in bFGF levels in fibrob- nificantly better compliance with their treatment compared
lasts leads to a reduction in collagen production. Another with those who received conventional education (p<0.001)
investigation indicated that silicone sheeting may act by and this translated into significantly improved scar out-
down-regulating the production of the fibrogenic cytokine, comes at six months (e.g., pigmentation (p = 0.02), height
transforming growth factor ␤2, by fibroblasts [21]. (p = 0.03) and pliability (p = 0.02)) [38].

438 EJD, vol. 24, n◦ 4, July-August 2014

Since the publication of a previous set of scar management guidelines recommend compression therapy for the treat-
guidelines in 2002 [6], several clinical studies of new sili- ment of hypertrophic scars and keloids, in particular after
cone gels have been published which have shown that these burn injuries. Pressure garments should also be consid-
gels have at least equivalent efficacy to silicone sheets for ered as a prophylactic measure in wounds that take more
scar management and that patients may find the gel formu- than 14 days to heal spontaneously [5]. Pressure therapy
lations easier to use [12, 39]. Chernoff et al. conducted should only be applied once the wound has closed and the
a study in which 30 patients with bilateral scars result- patient is able to tolerate the pressure. Additional benefits
ing from laser exfoliation each had one scar treated for of pressure therapy include relief of oedema, itchiness and
90 days with either silicone gel, silicone gel sheeting or pain [5]. Disadvantages of pressure therapy are the cost
a combination of these products, and the other scar was of treatment, since pressure garments are usually custom
untreated [12]. The results showed that the silicone gel and made, and poor patient compliance, since the garments are
combination treatment were associated with improved res- often uncomfortable and have to be worn for most of the
olution of scars compared with silicone gel sheeting alone. day [44].
In addition, the patients rated the silicone gel as being Several, but not all, recently published clinical studies
significantly easier to use than the silicone gel sheeting on the use of pressure garments for scar treatment have
(p<0.001) [12]. In another study, Karagoz et al. showed reported beneficial effects. Engrav et al. showed that pres-
that silicone gel was as effective as silicone sheeting at sure therapy improved clinical outcomes in 54 patients with
improving scars as assessed with the Vancouver scar scale moderate to severe scarring. Patients with forearm injuries
in a six-month study of 45 post-burn hypertrophic scars. received normal and low compression on their wounds. The
Both of these silicone products were significantly more results showed that normal versus low compression resulted
effective at improving these scars than Contractubex, a topi- in wounds which were significantly softer (difference: -1.7
cal onion extract containing heparin and allantoin (p<0.05) durometer units; 95% confidence interval -2.8 – -0.6), thin-
[39]. ner (difference: -0.65 mm (95% confidence interval -1.2 –
Several other recently conducted studies have confirmed -0.13) and had improved clinical appearance [45]. A study
the beneficial effects of silicone gels in the prevention conducted by Van den Kerchove et al. showed that garments
and treatment of scars. Chan et al. conducted a ran- which deliver a mean pressure of 15 mmHg were associated
domised, placebo-controlled, double-blind clinical trial with significant improvements in scar thickness (p = 0.027)
which showed that silicone gel was effective in preventing but not erythema (p = 0.64) compared with garments that
the development of hypertrophic scars after median ster- delivered lower pressures in 60 patients with 76 burn scars
notomy wounds [40]. The study included 50 Asian patients [46]. A recent meta-analysis of six studies of pressure gar-
and their wounds were divided into two halves with one ments involving 316 patients also found that this therapy is
half being treated with silicone gel and the other half being associated with a significant reduction in scar height (stan-
treated with a placebo gel for three months. The silicone dardised mean difference -0.31; 95% confidence interval
gel was associated with a significant reduction in scores for -0.63 – 0.0), but did not find any other benefits in terms of
scar pigmentation, vascularity, pliability, height, pain and composite assessment scores and measures of scar vascular-
itchiness (p≤0.02) [40]. ity and colour [47]. Furthermore, a prospective randomised
Signorini et al. showed that the application of silicone gels study of 122 patients with burns found that pressure ther-
to recent post-surgical scars was associated with signif- apy versus no therapy did not affect the median time to
icant improvements in clinical outcomes compared with wound maturation (266 vs 273 days, respectively; p = 0.51)
placebo (e.g., scar quality, p<0.001 between the treatment or decrease the mean length of hospital stay (27 vs 25 days,
groups) [41]. A total of 160 patients were included in this respectively; p>0.05) [48].
study and only 7% of the silicone gel-treated patients had Compression therapy may be used as part of combination
hypertrophic scars or keloids after four months of treat- therapy with silicones. A study conducted by Li-Tsang et
ment, compared with 26% of the placebo-treated patients. al. showed that this combination therapy was associated
All of the patients considered the gel was easy to apply with a significant reduction in scar thickness compared
and none reported any side effects [41]. In a randomised, with a control group (massage therapy) after only two
double-blind, placebo-controlled study of silicone gel in months of treatment (p<0.001) [49]. In contrast, the sil-
23 patients with burn scars, van der Wal et al. showed that icone monotherapy was shown to reduce scar pain and
the silicone gel significantly improved the roughness of the pruritus, but not scar thickness. This study included 104
scars (p = 0.012) and that patients experienced significantly patients with hypertrophic scars, mainly due to burning and
less itching (p = 0.013) during six months of treatment scalding injuries [49].
[42]. Another small non-comparative study indicated that
silicone gel is effective in reducing scar pigmentation and
elevation. In this study of six patients with mature scars, Medical ointments and creams
eight weeks of treatment with silicone gel was also associ-
ated with a 7.2% decrease in scar collagen and a 3% increase Several medical ointments and creams, such as menthol
in blood flow in the scar [43]. creams, topical anti-histamines (e.g., doxepin) and topical
calcineurin inhibitors, may be useful in the treatment of
scar pruritus, despite a lack of supporting evidence from
published clinical studies [5, 50]. In addition, some, but not
Compression therapy all studies have shown that topically applied imiquimod 5%
A growing body of evidence supports the use of compres- may reduce the recurrence rate of keloids following surgical
sion therapy as a scar management measure. The current excision [51-53].

EJD, vol. 24, n◦ 4, July-August 2014 439

Physical treatments and was associated with a low recurrence rate of 14% [61].
In another study, bleomycin was shown to be particularly
Physical treatments for scars include massage therapy and effective for the treatment of keloids and hypertrophic scars
physiotherapy (e.g., splinting and taping) [5]. These treat-
ments should be combined with silicone and pressure larger than 100 mm2 in size [62]. Verapamil has also been
therapy when possible. shown to effectively treat keloids either as monotherapy, or
Although massage is anecdotally reported to be beneficial as adjuvant therapy after surgical excision with or without
for the treatment of scars, there is only very weak clinical silicone therapy [63-65].
evidence currently available to support its use [54]. Avail-
able data suggests that massage therapy may reduce pruritus Cryotherapy
and pain, and may improve the range of motion and appear-
ance of the scar [54]. In addition, the creams that are used as Cryotherapy may be used to treat recalcitrant keloids. In this
part of massage therapy may beneficially hydrate the skin. procedure, a metal rod is introduced into the keloid which
The latest guidelines recommend that the type of massage is then destroyed by extreme cooling [5, 66, 67]. A study
therapy should be adapted to the stage of scar maturation by Har-Shai et al. showed that intralesional cryotherapy is
[5]. associated with a significant 67% reduction in the volume of
Splinting may be applied to scars at an early stage of matura- recalcitrant keloid scars (p<0.005) as well as decreases in
tion in body areas that are prone to developing contractures scar hardness, elevation and erythema [66]. The main side
(e.g., neck, elbow, axilla) and may also be combined with effect associated with this treatment is hypopigmentation
silicone therapy to improve outcomes [5, 55]. Taping may [67].
reduce hypertrophic scar formation by decreasing tension
at the wound’s edges [56]. Radiotherapy
Adjuvant radiotherapy (e.g., brachytherapy with Iridium
192 or electron-beam irradiation) is advocated following
Invasive management options surgical excision of keloids to reduce their rate of recurrence
[5]. For example, post-excisional brachytherapy has been
Several invasive scar treatments may be used in der- associated with a low keloid recurrence rate of 5-24% [68-
matological practice, including intralesional injections of 70]. Disadvantages of this treatment are radiodermatitis,
corticosteroids with or without 5-fluorouracil, cryotherapy, atrophy and the theoretical possibility of carcinogenesis.
radiotherapy, laser therapy and botulinum toxin A.
Laser and light therapies
Corticosteroid injections Scar prevention
Corticosteroid injections (e.g., triamcinolone acetonide) Since 1983, clinical, histological and immunohisto-
can be used to treat hypertrophic scars and keloids as chemical studies have demonstrated that lasers have
monotherapy or in combination with other therapies. The “photo-biomodulation” capabilities, inducing tissue regen-
response rate to this treatment is between 50 and 100%, and eration which is similar to the scarless wound healing that
the recurrence rate is between nine and 50% [2, 57]. Local occurs in foetal tissue [71]. The pulsed dye laser, applied
side effects include skin and subcutaneous tissue atrophy, on the day of suture removal, with low fluences (about
capillary dilatation and hypopigmentation [2]. 4.5 J/cm2 ) and short pulse duration (about 1.5 to 2 ms)
remains the gold standard. This treatment has a transient
purpuric effect. Depending on patient risk factors and his-
Other intralesional injections tory, sessions can be repeated every three to four weeks.
5-Fluorouracil may be injected intralesionally, alone or with Recently, some new laser therapies have been shown to
corticosteroids, to treat widespread hypertrophic scars and provide good to excellent results in some clinical series,
keloids [5, 58]. A retrospective review of medical charts including diode laser EKKYO just after wound closure and
of patients with keloids (n = 102) showed that those who non-ablative or ablative fractional lasers just before wound
were treated with 5-fluorouracil together with steroids after closure or on the day of suture removal [72]. Sessions can
surgical excision had a numerically greater reduction in be repeated depending on the patient’s risk of developing a
lesion size compared with those who were treated with cor- scar and on the evolution of the scar itself. As is usual with
ticosteroids only after excision (92% vs 73%, respectively) laser therapy, indications, settings, post-operative care and
[59]. Another study by Wu et al. demonstrated that surgical follow-up must be adapted to the patient’s phototype to min-
removal of earlobe keloids followed by intralesional injec- imise complications such as scarring or depigmentation.
tion of 5-fluorouracil and corticosteroid prevented relapse
in all 83 (100%) patients over a mean of seven months of Scar management
follow-up [60]. The main side effects associated with 5- Except for ablative CO2 or Er:YAG lasers which are used
fluorouracil injections include pain, purpura formation and to remove major scars, lasers are most often used as a non-
a burning sensation. invasive option to improve scar texture, telangiectasia or
Other agents that may be injected into keloid scars include hyperpigmentation, or to prevent scar recurrence after a sur-
bleomycin and verapamil, although the clinical evidence to gical revision. Lasers must always be used in combination
support these options is currently more limited. Bleomycin with occlusion/compression therapy and are often immedi-
was shown to effectively flatten the majority of scars in ately followed by intralesional or laser-assisted delivery of
a study of 50 patients with keloids or hypertrophic scars corticosteroids. In a recent meta-analysis, pulsed-dye lasers

440 EJD, vol. 24, n◦ 4, July-August 2014

(low fluence, short pulse duration) were shown to be the Disclosure. Acknowledgements: We thank the following
only laser treatment to have evidence-based efficacy for the co-ordinating editors and authors of the Scar Management
treatment of scars [73]. In daily clinical practice, other “vas- Practical Guidelines book for their invaluable contri-
cular” lasers (e.g., KTP 532 nm; Nd-YAG LP 1064 nm) and butions to the development of these guidelines: Esther
intense pulsed lights are used with success. Non-ablative or Middelkoop (Association of Dutch Burn Centres, Bever-
ablative fractional lasers are increasingly being used for the wijk and Department of Plastic Reconstructive and Hand
treatment of scars, with a growing body of supporting evi- Surgery, Research Institute MOVE, VU University Medi-
dence from case reports and series, especially for post-burn cal Centre, Amsterdam, the Netherlands); Stan Monstrey
scars for which they provide good to excellent improve- (Plastic and Reconstructive Surgery Department, Burn
ments of texture, thickness, contracture, pruritus, pain and Centre, Ghent University Hospital, Ghent, Belgium); Luc
dyspigmentation [74]. The exact mechanism of action of Téot (Wound Healing Unit & Burns Surgery, Montpel-
lasers is not yet clearly understood. However, they seem to lier University Hospital, Montpellier, France); Jan-Jeroen
be able to induce a remodelling effect and also to induce Vranckx (Plastic and Reconstructive Surgery Department,
differentiation and migration of “niched” pilo-sebaceous KUL Leuven University Hospitals, Leuven, Belgium);
melanoblasts. Franco Bassetto (Plastic Surgery Institute, University of
In 2014, there is still uncertainty about which laser ther- Padova, Italy); Nele Brusselaers (Burn Centre and Depart-
apy is optimal for each type of scar and further studies are ment of General Internal Medicine, Infectious Diseases
needed to address this. However, laser therapy remains one and Psychosomatic Medicine, Ghent University Hospital,
of the key treatment options for scar management around Ghent, Belgium); Maarten Doornaert and Henk Hoek-
the world. sema (Department of Plastic and Reconstructive Surgery,
Ghent University Hospital, Ghent, Belgium); Anibal Jus-
tiniano (Institute of Health Sciences, Catholic University,
Botulinum toxin A Porto, Portugal); Benoît Lengelé (Anatomy Department,
The potential of botulinum toxin A to decrease tensile forces Catholic University of Louvain, Brussels, Belgium); Ali
on post-surgical or post-traumatic scars (especially on the Pirayesh (Amsterdam Plastic Surgery, Amsterdam, the
face and neck) and to minimise these scars is well-known, Netherlands and Department of Plastic and Reconstructive
and this treatment has been used by surgeons for about Surgery, Ghent University Hospital, Ghent, Belgium); Fab-
10 years [75]. More recently, in vitro and animal studies rice Rogge (Plastic and Reconstructive Surgery, Bruges,
have reported that botulinum toxin may act on the bio- Belgium); Claude Roques (CSRE Lamalou le Haut, Pedi-
logical behaviour of fibroblasts, although its mechanism atric Rehabilitation Centre, Lamalou-Les-Bains, France);
of action is still debated [76, 77]. Currently only a few Xavier Santos Heredero (Plastic and Reconstructive
reports have discussed the doses of botulinum toxin that Surgery Department, University Hospitals of Madrid Mon-
are required for scar prevention. Consequently we recom- teprincipe y Torrelodones, Madrid, Spain); Eric Van den
mend that botulinum toxin is given four to seven days before Kerckhove (Physical Medicine and Rehabilitation, Uni-
surgery perpendicular to the anticipated wound to reduce versity Hospital Gasthuisberg, KUL Leuven University
tensile forces with doses adjusted according to the muscles Hospitals, Leuven, Belgium); Helga Van De Velde (Insti-
involved and to avoid muscular imbalance. In hypertrophic tute Helga Van De Velde, Ghent, Belgium); Nancy Van
scars or minor keloids, a dose of 2.5 Speywood Units/cm2 Loey (Association of Dutch Burns Centres, Beverwijk, the
Netherlands); Antoine J van Trier (Department of Plas-
(or 1 Allergan Unit or DL 50/cm2 ) should be used. tic, Reconstructive and Handsurgery, Red Cross Hospital,
Beverwijk, the Netherlands); Ulrich E. Ziegler (Plastic
and Aesthetic Surgery, Stuttgart Sporerstrasse, Germany).
Conclusions Financial support: Editorial assistance in the prepara-
tion of this manuscript was provided by David Harrison,
Medscript Communications, funded by Meda Pharma SA.
There is a growing number of options for the prevention and Conflict of interest: none.
treatment of hypertrophic scars and keloids, although as yet
the published clinical evidence to support many of these is
rather limited. The scar management guidelines that are
presented in this article are based on the evidence available
to date. Silicone sheets and gels are recommended as the
current gold standard, first-line non-invasive option for the
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