The Best Treatment Modalities For Keloids & Hypertrophic Scars
Search History...
What are Keloid & Hypertrophic Scars?
Evidence...
- Originally, I was going to compare intralesional triamcinolone to the Pulse-Dye laser, but found that my PICO question was too narrow, so I broadened it to find more information.
- I began my search history using the Cochrane Database to see what was available on my topic, then I continued my search using Google Scholar, EbscoHost, ProQuest, and Medline databases.
- Keywords used were "steroids", "triamcinolone", "kenalog", "5-flurouracil", "pulse-dye laser", "keloids", and "hypertrophic scars"
- With this I was able to find an abundance of information and from there, I narrowed down the articles that were closely related to my PICO question and that proved to be good evidence.
3 Themes Emerged:
- Intalesional triamcinolone is very effective and has been used the longest. It is considered the 1st-line or Gold Standard in treatment.
BUT
- There are many other treatment modalities showing promise...such as (5-flurouracil, Silicone gel, Verapamil, Cryotherapy, and Cosmetic lasers)
AND
- Multi-Modality treatments are the most emerging and have shown to have a synergistic effect improving scars the most. Most often, triamcinolone is used in conjunction with another treatment such as 5-flurouracil, cryotherapy, and lasers to generate the best outcome.
1. Intralesional Triamcinolone has proven to be effective
2. Multiple other treatment modalities show promise
3. Emerging Multi-Modality Treatments seem to be superior
- Keloids are elevated fibrous scars that extend beyond the borders of the original wound, do not regress, and often recur.
- The term "Keloid" comes from the Greek word cheloides, meaning "crab's claw."
- Hypertrophic scars are similar, but are confined to the wound borders & usually regress over time.
- These cutaneous scars can be caused by any minor injury or trauma to the skin, such as ear piercing, abrasion, tattooing, and burns.
- Unlike scar characteristics of normal wound repair, the excessive scarring of keloid & hypertrophic scars can result in disfigurement, contractures, erythema, pruritus, & pain.
- Primary risk factor is darkly pigmented skin, which carries a 15-20 fold increased risk
Conclusion...
Gaps in evidence...
- No one treatment has been proven to be the best
- The multi-plicity of methods of treatment can be an indication that none of the treatments are entirely satisfactory (Sharma et el., 2007)
- However, there is enough evidence to prove the effectiveness of intralesional triamcinolone, as well as several other therapies that have a synergistic effect when used in combination with one another & significant improvement can be achieved, despite multiple limitations.
- Combination therapy has proven to decrease side effects as well as improve patient satisfaction and outcomes.
- More randomized, controlled clinical trials need to be done for the best evidence based practice to be confirmed.
- Most studies are based on anecdotal evidence, with most evidence available being of poor quality, with little to no high quality randomized clinical trials available.
- No globally accepted measurement tool to objectively measure the results of scars before & after treatments, making it hard to compare evidence from study to study.
- Many variables that can be changed (i.e laser settings, amount of drug being used, ethnicity, and stages of scars being treated.
- Lastly, most studies do not differentiate b/t a "keloid" & "hyertrophic" scar. Both scars have differences and should not be treated the same.
Recommendations...
- "The final decision to choose a therapy should depend on the size & site of lesion, age of patient, reported recurrence rate, esthetic outcome, treating physician's experience with particular treatment modality, availability, and above all, an informed patient's preference" (Gupta & Shama, 2011, p. 100).
- Prevention should be the first line of care, followed by the least invasive treatment modality available that will produce the best outcome, with the least side effects.
References
PICO Question...
Why is it important?
- Is the gold standard of treatment using intralesional triamcinolone still the best treatment modality for patients with hypertrophic or keloid scars compared to other current treatment modalities available?
- Hypertrophic & Keloid scars are a common problem, effecting millions of people each year.
- These scars can be very detrimental to patients and cause them psychological distress, especially when they occur over the face or other exposed body part.
- It is important for nurses to know the risk factors, the population most at risk, as well as the best treatment options available to treat these types of scars.
- Educating high-risk patients on prevention methods, such as avoiding unnecessary injury to the skin is essential in preventing these types of scars.
- It is our job as future nurse practitioners to be patient advocates; educating our patients on prevention, treatment options available, as well as making sure the patient is able to get the best treatment available.
Why I chose this topic...
- As a plastic surgery nurse, I often treat patients with unsightly scars.
- In my current practice, we have 3 different treatment modalities we currently use, depending on what stage the scar is in, how fresh or old the scar is, and what facet of the scar needs improved.
- These treatments include: 1) Intralesional triamcinolone ("kenalog 10", "kenalog 40", or "steroid"), 5-flurouracil ("5-FU" or "antineoplastic"), and Cosmetic lasers.
- Seeing first hand how devastating and bothersome these scars can be for patients, brought me to want to find out what the best treatment option is available???