6. Asian and Caucasian skin scar
• Asians exhibit a thicker dermis than
equivalently pigmented Caucasians.
• Tendency toward a more vigorous
fibroplastic response during wound
healing
– Results in hypertrophic scarring and
prolonged erythema during scar
maturation
– most scars take longer to mature
Sykes JM. Facial Plast Surg Clin North Am. 2007;15:353–360
7. Hyperpigmentation and scar formation
after skin injury in Asian skin
• Asian skin is thicker, has increased
melanin, and has a greater an skin is
number of sebaceous glands, leading to
increased sebum secretion.
• Darker skin types are prone to noticeable
scarring
• Acne is a particular problem for Asian skins
Chan IL et al. Int J Dermatol. 2019 Feb;58(2):131-143.
14. Atkinson JA , Plast Reconstr Surg. 2005
•Seventy patients who had undergone cesarean section
•paper tape versus control
15. Paper tape eliminate scar tension
• Tension acting on a scar is the trigger for hypertrophic scarring
Paper tape is likely to be an effective modality for the prevention of hypertrophic scarring
Atkinson JA , Plast Reconstr Surg. 2005
Tape (+)
Tape (-)
16. 矽膠 Silicone
• Silicone was first used in gel form
– for the treatment of burn scars at Australia’s
Adelaide Children’s Hospital in 1981
• Silicone has since been produced in various
forms
– Silicone cream compounds (Sawada 1990)
– Silicone oil or gel with additives such as vitamin E
(Palmieri 1995)
Perkins Burns, Including Thermal Injury 1982
Sawada Br J Plast Surg 1990
Palmieri Int J Dermatol, 1995
17. Silicone gel sheeting
• A soft, self adhesive and semi-occlusive sheet
• Made from medical-grade silicone (cross-linked
polydimethylsiloxane (PDMS) polymer) and reinforced with
a silicone membrane
Katz, et al. Cosmetic Dermatol;1992;
Williams, e al. British Journal of Nursing 1996.
18. 矽膠片Silicone therapy
• Alter the tissue oxygen level
• Produce pressure and
temperature changes
• The most likely hypothesis
– an occlusion and hydration effect
– environment diminishes
keratinocyte stimulation
• decrease in fibroblast activity
Mustoe TA, Aesthetic Plast Surg. 2008 ; Yagmur C, Plast Reconstr Surg 2010
20. Slicone gel: e.g. Dermatix® 舒痕凝膠
• Flattening and softening scars
• Contains
– Innovative CPX (cyclopentasiloxane)
technology
– Ingredient of Vitamin C ester to
penetrate deep into the skin layers and
lighten up your scar.
• Designed to be used on intact skin.
– It should not be used on open wounds
21. Silicone-Based Gel
(Self-Drying Silicone Gel)
• Silicone dressings (silicone elastomer)
– require minimal monitoring
– and lack the more serious adverse effects of other
treatment methods
• such as corticosteroids, radiation, and surgical excision,
which require a physician’s follow-up care
Berman B, et al Dermatol Surg. 2007;33:1291–1302
22. 2013 Cochrane
• Trials evaluating silicone gel sheeting as a treatment
for hypertrophic and keloid scarring showed
improvements in scar thickness and scar color but
are of poor quality and highly susceptible to bias
23. Hypertrophy scar:
Silicone-Based Therapies
• Silicone Gel
–Topical silicone therapy
– the preferred first-line treatment for hypertrophic scars
• due to its availability, price, ease of application,
• lack of serious adverse effects, and relative efficacy
Kim S et al. Plast. Reconstr. Surg. 2013: 132: 1580-89
24. Hypertrophy scar:
Silicone-Based Therapies
• Hypertrophic scars should be treated with either silicone
gel sheeting or silicone-based gel
– depending on the patient’s compliance and preference,
• Patients treated with soft silicone dressings showed more
rapid improvement in hypertrophic scar maturation than
untreated patients
26. 2013 Cochrane
• 20 trials , 873 people, age from 1.5 to 81 years
• In the prevention studies, compared with no treatment
– Silicone gel sheeting reduced the incidence of
hypertrophic scarring in people prone to scarring
• RR: 0.46, 95% CI: 0.21 ~ 0.98.
– Silicone gel sheeting produced a statistically
significant reduction in scar thickness
• mean difference (MD) -2.00, 95% CI -2.14 to -1.85
• color amelioration (RR 3.49, 95% CI 1.97 to 6.15)
29. Merderma: Onion extract (Allium cepa) contains several unique
bioflavenoids, such as quercitin, kaempferol, and cepalin;
metalloproteinases; and thiosulfates
31. Mederma (Onion-extract-based product)
• Active ingredient: Allium cepa
– Quercetin is a derivative of allium cepa
• Anti-inflamatory and anti-proliferative effect
• Minimize scar formation
• No clinical difference in scar hypertrophy
except better dermal collagen organization
• Onion extract gel did not improve scar
cosmesis or symptomatology
Chung VQ et al. Dermatologic Surgery, 2006
32. Combination of Onion Extract and
Silicone Derivative
• Achieve a satisfying decrease in scar height
• Post-burn hypertrophic scar
• Median sternotomy scar
•Hosnuter M, et al The effects of onion extract on hypertrophic and keloid scars. J Wound Care 2007;16:251–254.
•Karagoz H, et al. Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin
and allantoin for the treatment of post-burn hypertrophic scars. Burns 2009;35:1097–1103.
•Jeenwitheesuk K, et al. Role of silicone derivative plus onion gel extract in presternal hypertrophic scar protection: A
prospective randomized, double-blinded, controlled trial. Int Wound J. 2012;9:397–402.
Hosnuter M, et al 2007
Karagoz H, et al, 2009
Jeenwitheesuk K, et al. 2012
36. 1064 nm long pulsed (not Q-switched)
Nd:YAG Laser
• treated every 3–4 weeks using a 5-mm
spot size diameter,
• an energy density of 65–75 J/
cm2, an exposure time per pulse of 250 μs
(0.25 millisecond), and a repetition rate of 2
Hz.
41. • Complete a series of 3–4 treatments with the fractional CO2
laser (10600 nm)
Qu L et al. Lasers Surg Med. 2012:44;517-524
• Fractional CO2 lasers
improvement in the appearance of
mature burn scars
• Alteration of types I and III pro-collagen,
MMP-1, TGF-β2,- β3, bFGF, as well as
miRNAs miR-18a and miR-19a
expression may be responsible for the
clinical improvement after treatment.
42. • The small number of participants, varying schemes of laser therapy,
different types of lasers, and comparisons of different treatment
options, made it difficult to compare the results obtained.
• Currently, several types of lasers are available, such as 585 nm PDL,
Non-ablative fractional laser (NAFL), Fractional CO2 Laser, erbium,
neodymium- doped yttrium aluminium garnet (Nd:YAG), and helium-
neon (He- Ne) laser.
• The results of these studies suggest 585-nm PDL may reduce keloid
and hypertrophic scars severity compared with no treatment.
45. Surgery of hypertrophy scar
• Surgery: tension-releasing technique
– Z-plasty, W-plasty, and small wave incision
– nonabsorbable sutures for high-skin-tension sites
– FTSG
– Flap reconstruction
46. Keloid蟹足腫
• Definition:
– A dysregulated response to cutaneous wounding that
results in an excessive fibroblast and deposition of
extracellular matrix, especially collagen.
• Etiology:
– trauma, surgery, ear piercing, burn, vaccination,
tattoos, injection, etc.
47. • Age: most 10~30 years
• Sex: F:M 1:1
• Race: African, Asian, Hispanic descent
• Symptom: pain, pruritus, ulceration, bleeding,
cosmetic concern,
• Regional susceptibility: Anterior chest wall,
shoulder, earlobe, upper arm, perineum etc.
– Form in areas of high skin tension and
mechanical stress.
Keloid蟹足腫
50. 蟹足腫病理機轉Pathogenesis of keloid
• Abnormal growth factor regulation
– TGF- (especial TGF-1), FGF,VEGF etc.
• Altered collagen degradation:
– Collagen type III/ type I ratios,
• Increased extracellular matrix production:
– Fibronection, elastin, proteoglycans
– Matrix metalloproteinases (MMPs)
• Immune system:
– Mast cell (IgE), macrophage (TNF-a, IL-1)
Kuo YR, JID, 2006; Kelley AP, Semin Cutan Med Surg 2009; Ogawa R, PRS 2010
51. Various Treatment Strategies of Keloids
• Intra-lesional: Corticosteroid injection
• Topical:
– Corticosteroid
– Silicone gel sheeting
• Surgical excision
– Grafting, flap, intralesional excision
• Cryotherapy; Radiation
• Others
– Retinoid; Botulinum Toxin Type A
– Anti-neoplastic agents (5-FU,
Belomycin, Interferon-α2b)
Kuo YR, JID, 2006; Kelley AP, Semin Cutan Med Surg 2009; Ogawa R, PRS 2010
52. 蟹足腫治療
• Surgical Excision :
– Surgical excision alone is
rarely curative with high
recurrence rates ranging
between 45% and 100%
• Adjunctive therapies are
needed
54. • Intralesional triamcinolone acetonide (IL TAC) 10–40 mg/ml is most ubiquitous
dosage
• keloid regression through a variety of proposed mechanisms suppression of dermal
inflammation, reduction of oxygen delivery to the wound bed via vasoconstriction, and
antimitotic activity in keratinocytes and fibroblasts
Morelli Coppola M, et al . Clin Cosmet Investig Dermatol. 2018;11:387–96.
55. 類固醇抑制蟹足腫增生
Top 1 Journal of Dermatology (1/58, I.F.:7.216)
Kuo YR et al. Journal of Investigative Dermatology 126: 1264-1271; 2006
In situ hybridization
56. Kuo YR et al. Journal of Investigative Dermatology 126: 1264-1271; 2006
61. Botulinum toxin A (BTA)肉毒桿菌素
• Botulinum toxin type A (BTXA) can induce apoptosis in keloid fibroblasts.
• Its utility in keloid treatment may be related to reduction of muscular tension
at wound sites and direct fibroblast regulation.
62. Result: Compared with corticosteroid alone, corticosteroid combined with
botulinum toxin type A is more effective in the treatment of keloid and
hypertrophic scar
69. Shridharani SM, et al. Ann Plast Surg 2010;64: 355–361
• Intralesional injection and/or wound irrigation with
interferon-a2b, interferon-g, mitomycin-C, bleomycin, or
5-fluorouracil seems to have a positive effect on the
reduction of pathologic scars
• There is mounting evidence that these drugs used
alone or in combination therapy, have the potential to
be an integral part of the treatment paradigm for
hypertrophic scars and keloids
76. 依部位不同使用不同放射線劑量
Ann Plast Surg. 2022 Dec 1;89(6):626-630
• Lesion site might be a prognostic
factor for keloid recurrence.
• Adjuvant radiation dose
escalation for high-recurrence
risk areas (other than the head
and ear) are required.
