This document discusses treatment options to reduce scarring in wound healing. It covers prevention strategies like minimizing tension and the inflammatory phase of healing. Treatment options discussed include steroid injections, massage, compression, taping, silicone, laser therapy, radiation therapy, and sun avoidance. Prevention focuses on good surgical technique and mimicking fetal wound healing processes. A variety of animal models are used to study scar formation.

1. Treatment Options to Reduce
Scarring in Wound Healing
Suresh Koneru, MD

2. Contact Info
• 423 Treeline Park, #300, SAT 78209
• 210-499-5900
• doctorkoneru@yahoo.com
• www.twitter.com/drkoneru
• www.DrKoneru.com
• www.linkedin.com/in/sureshkonerumd

3. Scarring
• Prevention
• Treatment

4. Stages of Wound Healing
• Inflammatory
• Platelet aggregation and release of growth factors
• Proliferative
• Granulation tissue formation, collagen deposition, and epithelialization
• Remodeling
• Collagen III to I, contraction of scar

5. Animal Models
• None for Hypertrophic or Keloid scar
• Red Duac Pig
• Rabbit Ear
• Fetal Mice and Pigs

6. Snake Oil

7. Prevention - Inflammatory Phase
• Fetal Wound healing has decreased inflammatory Phase
• Increase in TGF-β3 and decrease in TGF-β1 and TGF-β2
• Increases in Epinephrine causes increase Neutrophil
proliferation and decrease keratinocyte, stem cell, and
collagen migration
• Stress causes increase in Epinephrine, Timolol blocks

8. Fetal Wound Healing

9. Reference

10. Promise of TGF-β3

11. Promise of TGF-β3

12. Phase 3 Trial
• Renovo a U.K. Based Biopharmaceutical company product JUVISTA
• REVISE Trial failed to meet primary or secondary efficacy endpoints
(Feb 2011)
• Same company has other products:
• Prevascar - IL-10
• Juvidex - Mannose - 6 - Phosphate

13. Stress and Inflammatory
Modulation
• Beta blockers like Timolol have been shown to block epinephrine
inhibition of wound healing
• Ref: Slowing of Wound Healing by Psychological Stress by
Klecolt-Glaser, et al; The Lancet, 1995 Vol 346, pp 1194-1196

14. Prevention - Proliferative Phase
• Minimize Collagen build-up
• Topicals applied after epithelialization

15. Vitamin E
• Antioxidant and Membrane Stabilizing Agent
• Would take the average American 4 years to become depleted
• May have an effect similar to steroids on inhibiting collagen formation but this is
counteracted by Vitamin A
• Prospective double blinded randomized trial on burn patients showed no effect
on scar thickness, range of motion, or cosmetic appearance. Almost 20% suffered
skin irritation
• Jenkins, M., Alexander, J. W., MacMillan, B. G., Waymack, J. P., Kopcha, R. Failure of topical steroids and
vitamin E to reduce post-operative scar formation following reconstructive surgery. J. Burn Care Rehabil. 7: 309,
1986

16. Mederma
• Derivative quercetin is a bioflavinoid has antiproliferative effects and
antihistamine effects.
• Rabbit Ear Model - Improvement in dermal collagen, but no
difference in scar thickness, erythema, dermal vascularity, or
inflammation
• Effect of Mederma on Hypertrophic Scarring in the Rabbit Ear Model, Mustoe, T et al, Plast.
Reconstr. Surg. 110: 177, 2002

17. Massage
• Topical to aid in hydration of the scar
• Massage applies pressure to the scar

18. Surgical Prevention
• Tension free approximation of skin edges
• Incisions along Langer’s lines
• Minimize suture and reaction
• Everting skin edges
• Full Thickness grafts or flaps to prevent contraction

19. Treatment
• Steroid Injections
• In the office
• Kenalog (triamcinolone acetonide)
• Can cause increase in BS in DM

20. Treatment
• Compression
• Garments to exert constant pressure on scar and remodel
collagen
• Massage is a form of pressure
• Orthoplastic devices

21. Compression Basic Science

22. Treatment
• Silicone
• Available commonly as a sheet or as a gel
• May have some effect on electrostatic forces
• Benefit of hydration of stratum corneum
• Recommend at least 12 hours/day of coverage

23. Silicone References

24. Treatment
• Occlusion
• Tape may have a mechanical stress relieving effect in addition to
occlusive benefit
• Paper tape simple to place on incisions
• Recent occlusive dressing with silicone (Neodynebio.com) holds
some promise

25. Occlusion References

26. Reference for References

27. Treatment
• Laser
• 585 nm Pulsed Dye laser improves redness, pliability, bulk, and
dysesthesia
• CO2 and Er:YAG may improve atrophic scars

28. Treatment
• Radiation Therapy
• Reserved for keloid scar
• Probably most effective when used postop excision of keloid
immediately following surgery (same day)
• Dose adjusted based on location, ethnicity, and character of the
keloid (10 to 20 Gy daily divided anywhere from 2 to 4 days)

29. Treatment
• Fat Grafting
• The promise of Stem Cells
• Grafted fat maintains the characteristics of the donor fat, but also
takes on some of the characteristics of the recipient tissue.
• Recipient characteristics are likely due to stem cells

30. Fat Grafting Reference

31. Summary
• Prevention
• Good Surgical Technique
• Minimize tension, Eversion, Identical tissue
• Minimize Inflammatory Phase

32. Summary
• Treatment
• Steroid Injections
• Massage
• Compression
• Taping
• Silicone
• Laser
• Radiation
• Sun Avoidance

33. Treatment Options to Reduce
Scarring in Wound Healing
Suresh Koneru, MD