RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2014
Disease of the skin and subcutaneous tissue associated with radiation, unspecified (L59.9), Keloid scar (L91.0), Complication of surgical and therapeutic intervention, unspecified (T88.9), Open wound head of unspecified location (S01.9), Open wound of other and unspecified part of abdomen (S31.8), Open wound of other and unspecified part shoulder girdle(S41.8), Open wound of other and unspecified part of the pelvic girdle (S71.8), Open wound of unspecified part of the chest (S21.9), Open wound of unspecified part of the forearm (S51.9), Open wound of unspecified part of the neck (S11 .9), Scalp avulsion (S08.0), Consequences of other specified injuries upper limb(T92.8), Sequelae of other specified head injuries (T90.8), Sequelae of other specified head injuries lower limb(T93.8), Consequences of other specified injuries of the neck and torso (T91.8), Consequences of complications of surgical and therapeutic interventions not elsewhere classified (T98.3), Consequences of thermal and chemical burns and frostbite (T95), Scar conditions and fibrosis of the skin (L90.5), Cellulitis of the trunk (L03.3), Chronic skin ulcer, not elsewhere classified (L98.4), Ulcer of the lower extremity, not elsewhere classified ( L97)
Combustiology
general information
Short description
Recommended
Expert Council of the Republican State Enterprise at the Republican Exhibition Center "Republican Center for Healthcare Development"
Ministry of Health and Social Development of the Republic of Kazakhstan
dated December 12, 2014, protocol No. 9
Consequences of thermal burns, frostbite and wounds is a symptom complex of anatomical and morphological changes in the affected areas of the body and surrounding tissues, limiting the quality of life and causing functional disorders.
The main outcomes of the above conditions are scars, long-term non-healing wounds, wounds, contractures and trophic ulcers.
Scar- this is a connective tissue structure that arises at the site of skin damage by various traumatic factors to maintain homeostasis of the body.
Scar deformities - a condition with limited scars, scar masses localized on the head, torso, neck, limbs without restriction of movements, leading to aesthetic and physical inconveniences and restrictions.
Contracture- This persistent limitation joint movements caused by changes in surrounding tissues due to the influence of various physical factors, in which the limb cannot be completely bent or straightened in one or more joints.
Wound- this is damage to tissues or organs, accompanied by a violation of the integrity of the skin and underlying tissues.
Long-term non-healing wound- a wound that does not heal within a period that is normal for wounds of this type or location. In practice, a long-term non-healing wound (chronic) is considered to be a wound that has existed for more than 4 weeks without signs of active healing (the exception is extensive wound defects with signs of active repair).
Trophic ulcer- a defect in the integumentary tissues with a low tendency to heal, with a tendency to recur, which arose against the background of impaired reactivity due to external or internal influences, which in their intensity go beyond the adaptive capabilities of the body. A trophic ulcer is a wound that does not heal for more than 6 weeks.
I. INTRODUCTORY PART
Protocol name: Consequences of thermal and chemical burns, frostbite, wounds.
Protocol code:
ICD-10 code(s):
T90.8 Consequences of other specified head injuries
T91.8 Consequence of other specified injuries of the neck and torso
T92.8 Consequence of other specified injuries of the upper limb
T93.8 Consequence of other specified injuries of the lower extremity
T 95 Consequences of thermal and chemical burns and frostbite
T95.0 Consequences of thermal and chemical burns and frostbite of the head and neck
T95.1 Consequences of thermal and chemical burns and frostbite of the torso
T95.2 Consequences of thermal and chemical burns and frostbite of the upper limb
T95.3 Consequences of thermal and chemical burns and frostbite of the lower limb
T95.4 Consequences of thermal and chemical burns, classified only according to the area of the affected area of the body
T95.8 Consequences of other specified thermal and chemical burns and frostbite
T95.9 Consequences of unspecified thermal and chemical burns and frostbite
L03.3 Cellulitis of the trunk
L91.0 Keloid scar
L59.9 Disease of the skin and subcutaneous tissue associated with radiation
L57.9 Skin changes caused by chronic exposure not ionizing radiation, not specified
L59.9 Radiation-associated disease of the skin and subcutaneous tissue, unspecified
L90.5 Scar conditions and fibrosis of the skin
L97 Ulcer of lower extremity, not elsewhere classified
L98.4 Chronic skin ulcer, not elsewhere classified
S 01.9 Open head wound, unspecified
S 08.0 Scalp avulsion
S 11.9 Open wound of the neck, unspecified
S 21.9 Open chest wound, unspecified
S 31.8 Open wound of another and unspecified part of the abdomen
S 41.8 Open wound of other and unspecified part of the shoulder girdle and shoulder
S 51.9 Open wound of an unspecified part of the forearm
S 71.8 Open wound of another and unspecified part of the pelvic girdle
T88.9 Complications of surgical and therapeutic interventions, unspecified.
T98.3 Consequences of complications of surgical and therapeutic interventions, not classified elsewhere.
Abbreviations used in the protocol:
ALT - Alanine aminotransferase
AST - Aspartate aminotransferase
HIV - human immunodeficiency virus
ELISA - linked immunosorbent assay
NSAIDs - non-steroidal anti-inflammatory drugs
CBC - complete blood count
OAM - general urine analysis
Ultrasound - ultrasonography
UHF therapy - ultra high frequency therapy
ECG - electrocardiogram
ECHOKS - transthoracic cardioscopy
Date of protocol development: year 2014.
Protocol users: combustiologists, orthopedic traumatologists, surgeons.
Classification
Clinical classification
Scarring classified according to the following criteria:
By origin:
Post-burn;
Post-traumatic.
By growth pattern:
Atrophic;
Normotrophic;
Hypertrophic;
Keloids.
Wounds divided depending on the origin, depth and extent of the wound.
Types of wounds:
Mechanical;
Traumatic;
Thermal;
Chemical.
There are three main types of wounds:
Operating rooms;
Random;
Firearms.
Accidental and gunshot wounds Depending on the wounding object and the mechanism of injury, they are divided into:
Chipped;
Cut;
Chopped;
Bruised;
Crushed;
Torn;
Bitten;
Firearms;
Poisoned;
Combined;
Penetrating and not penetrating into body cavities. [7]
Contractures classified depending on the type of tissue that caused the disease. Contractures are primarily classified according to the degree of restriction of movement in the damaged joint.
After burns, skin-scar contractures (dermatogenic) most often occur. According to the severity, post-burn contractures are divided into degrees:
I degree (mild contracture) - limitation of extension, flexion, abduction ranges from 1 to 30 degrees;
II degree (moderate contracture) - limit from 31 degrees to 60 degrees;
III degree (severe or severe contracture) - limitation of movement more than 60 degrees.
Classification of trophic ulcers by etiology:
Post-traumatic;
Ischemic;
Neurotrophic;
Lymphatic;
Vascular;
Infectious;
Tumor.
Trophic ulcers are classified according to their depth:
I degree - superficial ulcer (erosion) within the dermis;
II degree - an ulcer reaching the subcutaneous tissue;
III degree - an ulcer that penetrates into the fascia or subfascial structures (muscles, tendons, ligaments, bones), into the cavity of the articular capsule or joint.
Classification of trophic ulcers by area affected:
Small, up to 5 cm2 in area;
Medium - from 5 to 20 cm2;
Extensive (giant) - over 50 cm2.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic (required) diagnostic examinations carried out on an outpatient basis:
Additional diagnostic examinations performed on an outpatient basis:
Coagulogram (determination of clotting time, duration of bleeding).
The minimum list of examinations that must be carried out when referring to planned hospitalization
:
Blood coagulogram (determination of clotting time, duration of bleeding);
Blood group determination
Determination of Rh factor;
Bacterial culture from wounds (if indicated).
X-ray according to indications (affected area);
Basic (mandatory) diagnostic examinations carried out at the hospital level: According to indications, upon discharge, control tests:
Additional diagnostic examinations carried out at the hospital level:
Biochemical analysis blood (glucose, total bilirubin, alanine aminotransferase, aspartate aminotransferase, urea, creatinine, total protein);
Bacterial culture from wounds according to indications;
Diagnostic measures carried out at the emergency stage: not carried out.
Diagnostic criteria
Complaints: For the presence of post-traumatic or burn scars with functional disorders, pain or causing aesthetic discomfort. For wounds of various origins, their pain, limitation of movements in the joints.
Anamnesis: A history of trauma, frostbite or burns, as well as concomitant diseases that caused pathological changes in tissues.
Physical examination:
If there are wounds their origin (post-traumatic, post-burn), the age of the wound, the nature of the edges (smooth, torn, crushed, callous), their length and size, depth, bottom of the wound, mobility of the edges and adhesion to the surrounding tissues are described.
In the presence of granulations described:
Character;
The presence and nature of the discharge.
When describing contractures their origin is indicated:
Post-burn;
Post-traumatic.
Localization, degree and nature of changes in the skin (description of scars, if any, color, density, growth pattern - normotrophic - without rising above the surrounding tissues, hypertrophic - rising above the surrounding tissues), the nature of the restriction of movements, flexion, extension and the degree of restriction of movements. [ 8]
When describing scars indicate them:
Localization;
Origin;
Prevalence;
Character, mobility;
The presence of an inflammatory reaction;
Areas of ulceration.
Laboratory research:
UAC(for a long time non-healing wounds, trophic ulcers, especially giant ones): moderate decrease in hemoglobin, increased ESR, eosinophilia,
Coagulogram: increase in fibrinogen level to 6 g/l.
Blood chemistry: hypoproteinemia.
Indications for consultation with specialists:
Consultation with a neurosurgeon or neurologist in the presence of a neurological deficit due to the progression of the underlying or concomitant disease.
Consultation with a surgeon in the presence of exacerbation of concomitant pathology.
Consultation with an angiosurgeon for concomitant vascular damage.
Consultation with a urologist in the presence of concomitant urological pathology.
Consultation with a therapist in the presence of concomitant somatic pathology.
Consultation with an endocrinologist in the presence of concomitant endocrinological diseases.
Consultation with an oncologist to rule out cancer.
Consultation with a phthisiatrician to exclude tuberculous etiology of diseases.
Differential diagnosis
Differential diagnosis of contractures
Table 1 Differential diagnosis contractures
|
Sign |
Post-burn contracture | Post-traumatic contracture | Congenital contracture |
| Anamnesis | burns | Post-traumatic wounds, fractures, tendon and muscle damage | Congenital malformation (cerebral palsy, amniotic bands, etc.) |
| The nature of the skin | Presence of scars | Ordinary | Ordinary |
| How long ago did contracture appear? | After 3-6 months. after a burn | In 1-2 months. after an injury | From birth |
| X-ray picture | Picture of arthrosis, bone hypotrophy | Picture of osteoarthritis, improperly healed fracture, narrowing and homogeneous darkening of the joint space | Underdevelopment of joint elements |
table 2 Differential diagnosis of wounds and pathologically changed tissues
|
Sign |
Scarring | Long-term non-healing granulating wounds | Trophic ulcers |
| The nature of the skin | Dense, hyperpigmented, with a tendency to grow | The presence of pathological granulations without a tendency to close the wound defect | Adhesive to the underlying tissues, with callous edges and a tendency to recur |
| Duration of appearance of wounds | Immediately after physical exposure for a period of 3 to 12 months without the presence of a wound surface or with limited areas of ulceration | From 3 weeks or more after the injury | For a long time without the presence of a traumatic agent |
Treatment abroad
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Treatment
Treatment goals:
Increased range of motion in damaged joints;
Elimination aesthetic defect;
Restoring the integrity of the skin.
Treatment tactics
Non-drug treatment
Diet - 15 table.
General mode, in postoperative period- bed.
Drug treatment
Table 1. Medicines used in the treatment of the consequences of burns, frostbite, and wounds of various etiologies (except for anesthesiological support)
Post-burn scars and contractures
|
№ |
Drug, release forms | Dosing | Duration of use |
| Local anesthetic drugs: | |||
| 1 | Procaine | 0.25%,0.5%, 1%, 2%. No more than 1 gram. | 1 time upon admission of a patient to a hospital or when contacting an outpatient clinic |
| Antibiotics | |||
| 2 |
Cefuroxime Or Cefazolin Or Amoxicillin/clavulanate Or Ampicillin/sulbactam |
1.5 g IV 3g IV |
1 time 30-60 minutes before the skin incision; additional administration possible during the day |
| Opioid analgesics | |||
| 3 |
Tramadol solution for injection 100 mg/2 ml 2 ml in ampoules 50 mg in capsules, tablets Metamizole sodium 50% |
50-100 mg. IV, through the mouth. maximum daily dose 400 mg. 50% - 2.0 intramuscularly up to 3 times |
1-3 days. |
| Antiseptic solutions | |||
| 4 | Povidone-iodine | Bottle 1 liter | 10 - 15 days |
| 5 | Chlorhexedine | Bottle 500 ml | 10 - 15 days |
| 6 | Hydrogen peroxide | Bottle 500 ml | 10 - 15 days |
| Dressings | |||
| 7 | Gauze, gauze bandages | meters | 10 - 15 days |
| 8 | Medical bandages | PC. | 10 - 15 days |
| 9 | Elastic bandages | PC. | 10 - 15 days |
Medicines for wounds, trophic ulcers, extensive post-burn wounds and wound defects
|
№ |
Name of the drug ( international name) | Quantity | Duration of use |
| Antibiotics | |||
| 1 |
Cefuroxime, powder for solution for injection 750 mg, 1500 mg Amoxicillin/clavulanate, powder for solution for injection 1.2g |
5-7days | |
| Analgesics | |||
| 2 | Tramadol solution for injection 100 mg/2 ml 2 ml in ampoules 50 mg in capsules, tablets | 50-100 mg. intravenously, through the mouth. maximum daily dose 400 mg. | 1-3 days |
| 3 | Metamizole sodium 50% | 50% - 2.0 intramuscularly up to 3 times | 1-3 days |
| 4 | 1500 - 2000 cm/2 | ||
| 5 | Hydrogel coatings | 1500 - 2000 cm/2 | |
| 6 | 1500 - 2000 cm/2 | ||
| 7 | Allogeneic fibroblasts | 30 ml with a cell count of at least 5,000,000 | |
| 8 | 1500 - 1700 cm/2 | ||
| Ointments | |||
| 9 | Vaseline, ointment for external use | 500 gr. | |
| 10 | Silver sulfadiazine, cream, ointment for external use 1% | 250 - 500 gr. | |
| 11 | Combined water-soluble ointments: chloramphenicol/methyluracil, ointment for external use | 250 - 500 gr. | |
| Antiseptic solutions | |||
| 12 | Povidone-iodine | 500 ml | |
| 13 | Chlorhexedine | 500 ml | |
| 14 | Hydrogen peroxide | 250 ml | |
| Dressings | |||
| 15 | Gauze, gauze bandages | 15 meters | |
| 16 | Medical bandages | 5 pieces | |
| 17 | Elastic bandages | 5 pieces | |
| Infusion therapy | |||
| 18 | Sodium chloride solution 0.9% | Bottle ml. | |
| 19 | Glucose solution 5% | Bottle ml. | |
| 20 | SZP | ml | |
| 21 | Red blood cell mass | ml | |
| 22 | Synthetic colloidal preparations | ml | |
Drug treatment provided on an outpatient basis:
For post-burn scars and contractures. Onion extract liquid, sodium heparin, allantoin, gel for external use
For trophic ulcers
Antibiotics: Strictly according to indications, under the control of bacterial culture from the wound.
Antiplatelet agents
Pentoxifylline - solution for injection 2% - 5 ml, tablets 100 mg.
Drug treatment provided at the inpatient level:
Scar contractures and deformities
Antibiotics:
Cefuroxime, powder for solution for injection 750 mg, 1500 mg
Cefazolin, powder for solution for injection 1000 mg
Amoxicillin/clavulanate, powder for solution for injection 1.2g,
Ampicillin/sulbactam, powder for solution for injection 1.5g - 3g
Ciprofloxacin, solution for infusion 200 mg/100 ml
Ofloxacin, solution for infusion 200 mg/100 ml
Gentamicin, solution for injection 80 mg/2 ml
Amikacin, powder for solution for injection 0.5 g
List of additional medicines
(less than 100% probability of application).
Non-steroidal anti-inflammatory drugs:
Ketoprofen - solution for injection in ampoules of 100 mg.
Diclofenac solution for IM, IV administration 25 mg/ml
Ketorolac solution for intravenous, intramuscular administration 30 mg/ml
Metamizole sodium 50% - 2.0 i/m
Low molecular weight heparins
Nadroparin calcium release form in syringes 0.3 ml, 0.4 ml, 0.6
Enoxaparin solution for injection in syringes 0.2 ml, 0.4 ml, 0.6 ml
Solutions for infusion therapy
Sodium chloride - isotonic sodium chloride solution 400ml.
Dextrose - glucose 5% solution 400ml.
Antiplatelet agents
Pentoxifylline - solution for injection 2% - 5ml.
Acetylsalicylic acid tablets 100mg
Drug treatment provided at the emergency stage: not provided, hospitalization is planned.
Other types of treatment:
Compression therapy;
Balneological treatment (hydrogen sulfide applications, radon);
Mechanotherapy;
Ozone therapy;
Magnetotherapy;
Application of immobilization means (splints, soft bandages, plaster cast, circular plaster cast, brace, orthosis) in early dates after operation.
Other types of treatment provided on an outpatient basis:
Magnetotherapy;
Compression therapy;
Balneological treatment;
Mechanotherapy.
Other types of services provided at the stationary level:
Hyperbaric oxygenation.
Other types of treatment provided at the emergency stage: not carried out, hospitalization is planned.
Surgical intervention:
In the absence of positive dynamics of the main surgical interventions, or as an addition to them, transplantation of cultured allogeneic or autologous skin cells is possible, as well as the use of biodegradable dressings [2]
Surgical intervention performed in outpatient setting: not carried out.
Surgical intervention provided in an inpatient setting
For post-burn, post-traumatic scars and contractures:
Plastic surgery with local tissues; in the presence of linear scars, contractures with formed “sail-shaped scar cords”, in the presence of limited skin defects.
Plastic surgery with flaps on the feeding pedicle; In the presence of scars, tissue defects in the area of large joints, when tendons and bone structures are exposed, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, neck, torso, and pelvic area.
Free plastic surgery with flaps on vascular anastomoses; In the presence of scars, tissue defects in the area of large joints, when bone structures are exposed along the length, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, torso, and pelvic area.
Plastic flaps with axial blood supply; In the presence of tissue defects with exposure of joints, bone structures, defects of supporting surfaces (hands, feet).
Combined skin grafting; In the presence of scars or tissue defects in the area of large joints, when tendons and bone structures are exposed, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, neck, torso, and pelvic area.
Plastic surgery with estension flaps (through the use of endoexpanders); In the presence of extensive cicatricial lesions of the skin.
Use of external fixation devices; In the presence of bone fractures, arthrogenic contractures, correction of the length or shape of bone structures.
Transplantation or relocation of muscles and tendons; If there are defects along the muscles or tendons.
Endoprosthetics of small joints. When articular components are destroyed and other treatment methods have not been successful.
Long-term non-healing ulcers and scars:
Free autodermoplasty; in the presence of limited or extensive skin defects.
Surgical treatment of granulating wounds: in the presence of pathologically altered tissues.
Skin allotransplantation; in the presence of extensive skin defects, extensive ulcers of various origins.
Xenotransplantation in the presence of limited or extensive skin defects, for the purpose of preoperative preparation.
Transplantation of cultured skin cells in the presence of extensive skin defects, extensive ulcers of various origins.
Combined transplantation and the use of growth factors in the presence of extensive skin defects, extensive ulcers of various origins.
Plastic surgery with local tissues: in the presence of limited skin defects.
Plastic surgery with pedicle flaps: In the presence of scars or tissue defects in the area of large joints, when tendons and bone structures are exposed along the length, in case of tissue defects in the hands and on the supporting surfaces of the feet, for the purpose of reconstructing defects in the head, neck, torso, and pelvic area .
Preventive actions:
Sanitation of residual wounds and scars;
Reducing the area of the scar;
Absence of inflammatory processes in the wound;
For wounds and trophic ulcers:
Healing of a wound defect;
Restoring integrity skin
Drugs ( active ingredients), used in the treatment
| Allantoin |
| Allogeneic fibroblasts |
| Amikacin |
| Amoxicillin |
| Ampicillin |
| Acetylsalicylic acid |
| Biotechnological wound dressings (acellular material or material containing living cells) (xentransplantation) |
| Vaseline |
| Hydrogen peroxide |
| Gentamicin |
| Heparin sodium |
| Hydrogel coatings |
| Dextrose |
| Diclofenac |
| Ketoprofen |
| Ketorolac |
| Clavulanic acid |
| Onion bulb extract (Allii cepae squamae extract) |
| Metamizole sodium (Metamizole) |
| Methyluracil (Dioxomethyltetrahydropyrimidine) |
| Nadroparin calcium |
| Sodium chloride |
| Ofloxacin |
| Pentoxifylline |
| Fresh frozen plasma |
| Film collagen coatings |
| Povidone - iodine |
| Procaine |
| Synthetic wound coverings (Foamed polyurethane, combined) |
| Sulbactam |
| Sulfadiazine silver salt |
| Tramadol |
| Chloramphenicol |
| Chlorhexidine |
| Cefazolin |
| Cefuroxime |
| Ciprofloxacin |
| Enoxaparin sodium |
| Red blood cell mass |
Groups of drugs according to ATC used in treatment
Hospitalization
Indications for hospitalization, indicating the type of hospitalization.
Emergency hospitalization: No.
Planned hospitalization: Patients who have suffered frostbite, thermal burns of various origins with long-existing wounds or trophic ulcers, scars, contractures are eligible.
Information
Sources and literature
- Minutes of meetings of the Expert Council of the RCHR of the Ministry of Health of the Republic of Kazakhstan, 2014
- 1. Yudenich V.V., Grishkevich V.M. Guidelines for the rehabilitation of burnt patients, Moscow medicine, 1986. 2.S. Kh. Kichemasov, Yu. R. Skvortsov Skin grafting with flaps with axial blood supply for burns and frostbite. St. Petersburg 2012 3.G. Chaby, P. Senet, M. Veneau, P. Martel, JC Guillaume, S. Meaume, et al. Dressings for the treatment of acute and chronic wounds. Systematic review. Archives of Dermatology, 143 (2007), p. 1297-1304 4.D.A. Hudson, A. Renshaw. An algorithm for the release of burn contractures of the extremities/ Burns, 32. (2006), pp. 663–668 5.N.M. Ertaş, H. Borman, M. Deniz, M. Haberal. Double opposing rectangular advancement elongates tension line as much as Z-plasty: an experimental study in the rat inguinal. Burns, 34 (2008), pp. 114–118 6 T. Lin, S. Lee, C. Lai, S. Lin. Treatment of axillary burn scar contractures using opposite running Y-V plasty. Burns, 31 (2005), pp. 894–900 7 Suk Joon Oh, Yoojeong Kim. Combined AlloDerm® and thin skin grafting for the treatment of postburn dyspigmented scar contracture of the upper extremity. Journal of Plastic, Reconstructive & Aesthetic Surgery. Volume 64, Issue 2, February 2011, Pages 229–233. 8 Michel H.E. Hermans. Preservation methods of allografts and their (lack of) influence on clinical results in partial thickness burns // Burns, Volume 37. - 2011, P. - 873–881. 9 J. Leon-Villapalos, M. Eldardiri, P. Dziewulski. The use of human deceased donor skin allograft in burn care // Cell Tissue Bank, 11 (1). - 2010, P. - 99–104. 10 Michel H.E. Hermans, M.D. Porcine xenografts vs. (cryopreserved) allografts in the management of partial thickness burns: Is there a clinical difference? Burns Volume 40, Issue 3, May 2014, pp. 408–415. 11 Alekseev A. A., Tyurnikov Yu. I. Application of the biological dressing “Xenoderm” in the treatment of burn wounds. // Combustiology. - 2007. - No. 32 - 33. - http://www.burn.ru/ 12 Ryu Yoshida, Patrick Vavken, Martha M. Murray. Decellularization of bovine anterior cruciate ligament tissues minimizes immunogenic reactions to alpha-gal epitopes by human peripheral blood mononuclear cells. // The Knee, Volume 19, Issue 5, October 2012, pp. 672–675. 13 Celine Auxenfansb, 1, Veronique Menetb, 1, Zulma Catherinea, Hristo Shipkov. Cultured autologous keratinocytes in the treatment of large and deep burns: A retrospective study over 15 years. Burns, Available online 2 July 2014 14 J.R. Hanft, M.S. Surprenant. Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast derived dermis. J Foot Ankle Surg, 41 (2002), p. 291. 15 Steven T Boyce, Principles and practices for treatment of cutaneous wounds with cultured skin substitutes. The American Journal of Surgery. Volume 183, Issue 4, April 2002, Pages 445–456. 16 Mitryashov K.V., Terekhov S.M., Remizova L.G., Usov V.V., Obydeinikova T.N. Evaluation of the effectiveness of the use of skin epidermal growth factor in the treatment of burn wounds in a “wet environment”. Electronic journal - Combustiology. 2011, No. 45.
Information
III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION
List of protocol developers with qualification information:
1. Abugaliev Kabylbek Rizabekovich - JSC National science Center oncology and transplantology", chief specialist of the department of reconstructive plastic surgery and combustiology, candidate of medical sciences, chief freelance specialist in combustiology of the Ministry of Health and Social Development of the Republic of Kazakhstan
2. Mokrenko Vasily Nikolaevich - State Enterprise at PVC " Regional center Traumatology and Orthopedics named after Professor Kh.Zh. Makazhanova" of the Health Department of the Karaganda region, head of the burn department
3. Khudaybergenova Mahira Seidualievna - JSC National Scientific Center of Oncology and Transplantology, chief expert clinical pharmacologist department of examination of the quality of medical services
Disclosure of no conflict of interest: No.
Reviewers:
Sultanaliev Tokan Anarbekovich - Advisor to the Chief Surgeon of JSC National Scientific Center of Oncology and Transplantology, Doctor of Medical Sciences, Professor
Indication of the conditions for reviewing the protocol: Review of the protocol after 3 years and/or when new diagnostic/treatment methods with a higher level of evidence become available.
Attached files
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The formation of scar tissue is a physiological response to damage to the skin and mucous membranes. However, changes in the metabolism of the extracellular matrix (imbalance between its destruction and synthesis) can lead to excessive scarring and the formation of keloids and hypertrophic scars.
Wound healing and hence scar tissue formation involves three distinct stages: inflammation (in the first 48-72 hours after tissue injury), proliferation (up to 6 weeks) and remodeling or maturation (for 1 year or more). A prolonged or excessive inflammatory phase may contribute to increased scarring. According to the results of modern research, in people with a genetic predisposition, first blood group, IV-V-VI skin phototype, scar formation can develop under the influence of various factors: IgE hyperimmunoglobulinemia, changes in hormonal status (during puberty, pregnancy, etc.) .
A key role in the formation of a keloid scar is played by abnormal fibroblasts and transforming growth factor - β1. In addition, in the tissues of keloid scars, an increase in the number of mast cells associated with increased level fibrosis promoters such as hypoxia-inducible factor-1α, vascular endothelial growth factor and plasminogen activator inhibitor-1.
In the development of hypertrophic scars, the main role is played by disruption of the metabolism of the extracellular matrix of newly synthesized connective tissue: hyperproduction and disruption of the remodeling processes of the intercellular matrix with increased expression of collagen types I and III. In addition, disruption of the hemostatic system promotes excessive neovascularization and increases the time of re-epithelialization.
There are no official figures for the incidence and prevalence of keloids and hypertrophic scars. According to modern research, scar formation is observed in 1.5-4.5% of individuals in the general population. Keloid scars are detected equally in men and women, more often in persons young. There is a hereditary predisposition to the development of keloid scars: genetic research indicate autosomal dominant inheritance with incomplete penetrance.
Classification of skin scars:
There is no generally accepted classification.
Clinical picture (symptoms) of skin scars:
The following clinical forms of scars are distinguished:
- normotrophic scars;
- atrophic scars;
- hypertrophic scars:
- linear hypertrophic scars;
- widespread hypertrophic scars;
- small keloid scars;
- large keloid scars.
There are also stable (mature) and unstable (immature) scars.
Keloid scars are well-defined, dense nodules or plaques, pink to purple in color, with a smooth surface and irregular, indistinct borders. Unlike hypertrophic scars, they are often accompanied by pain and hyperesthesia. The thin epidermis covering the scars is often ulcerated, and hyperpigmentation is often observed.
Keloid scars form no earlier than 3 months after tissue damage, and then can increase in size for an indefinitely long time. As they grow like pseudotumors with focal deformation, they extend beyond the boundaries of the original wound, do not regress spontaneously, and tend to recur after excision.
The formation of keloid scars, including spontaneous ones, is observed in certain anatomical areas (earlobes, chest, shoulders, upper back, back of the neck, cheeks, knees).
Hypertrophic scars are dome-shaped nodes of various sizes (from small to very large), with a smooth or bumpy surface. Fresh scars have a reddish color, later it becomes pinkish and whitish. Hyperpigmentation is possible along the edges of the scar. Scar formation occurs within the first month after tissue damage, and an increase in size occurs over the next 6 months; Scars often regress within 1 year. Hypertrophic scars are limited to the boundaries of the original wound and, as a rule, retain their shape. Lesions are usually localized on the extensor surfaces of joints or in areas subject to mechanical stress.
Diagnosis of skin scars:
The diagnosis of the disease is established on the basis of the clinical picture, the results of dermoscopic and histological examinations (if necessary).
When carrying out combination therapy, consultations with a therapist, plastic surgeon, traumatologist, and radiologist are recommended.
Differential diagnosis
| Keloid scar | Hypertrophic scar |
| Infiltrating growth beyond the original lesion | Growth within the original damage |
| Spontaneous or post-traumatic | Only post-traumatic |
| Predominant anatomical areas (earlobes, chest, shoulders, upper back, back of the neck, cheeks, knees) | No predominant anatomical sites (but usually localized to extensor surfaces of joints or areas subject to mechanical stress) |
| Appear 3 months or later after tissue damage, may increase in size indefinitely | They appear within the first month after tissue damage, can increase in size within 6 months, and often regress within 1 year. |
| Not associated with contractures | Associated with contractures |
| Itching and severe pain | Subjective sensations are rare |
| Skin phototype IV and higher | No connection with skin phototype |
| Genetic predisposition (autosomal dominant inheritance, localization on chromosomes 2q23 and 7p11) | No genetic predisposition |
| Thick collagen fibers | Thin collagen fibers |
| Absence of myofibroblasts and α-SMA | Presence of myofibroblasts and α-SMA |
| Type I collagen > type III collagen | Type I collagen< коллаген III типа |
| Overexpression of COX-2 | Overexpression of COX-1 |
Treatment of skin scars:
Treatment Goals
- stabilization of the pathological process;
- achieving and maintaining remission;
- improving the quality of life of patients:
- relief of subjective symptoms;
- correction of functional deficiency;
- achieving the desired cosmetic result.
General notes on therapy
Hypertrophic and keloid scars are benign skin lesions. The need for therapy is determined by the severity of subjective symptoms (eg, itching/pain), functional impairment (eg, contracture/mechanical irritation due to the height of the formations), as well as aesthetic indicators, which can significantly affect quality of life and lead to stigmatization.
None of the currently available scar treatment methods in the form of monotherapy allows achieving scar reduction or improvement in all cases. functional state and/or cosmetic situation. Almost all clinical situations require a combination of different treatment methods.
Drug therapy
Intralesional administration of glucocorticosteroid drugs
- triamcinolone acetonide 1 mg per 1 cm 2 intralesional (with a 30-gauge needle 0.5 inches long). The total number of injections is individual and depends on the severity of the therapeutic response and possible side effects. Intralesional administration of triamcinolone acetonide after surgical excision of the scar prevents recurrence.
- betamethasone dipropionate (2 mg) + betamethasone disodium phosphate (5 mg): 0.2 ml per 1 cm 2 intralesional. The lesion is punctured evenly using a tuberculin syringe and a 25-gauge needle.
Non-drug therapy
Cryosurgery
Liquid nitrogen cryosurgery results in complete or partial reduction of 60-75% of keloid scars after at least three sessions (B). Main side effects cryosurgery are hypopigmentation, blistering and delayed healing.
The combination of cryosurgery with liquid nitrogen and injections of glucocorticosteroid drugs has a synergistic effect due to a more uniform distribution of the drug as a result of intercellular edema of scar tissue after low-temperature exposure.
Scar treatment can be carried out using the open cryospray method or the contact method using a cryoprobe. Exposure duration – at least 30 seconds; frequency of use – once every 3-4 weeks, number of procedures – individually, but not less than 3.
- Carbon dioxide laser.
Scar treatment with a CO 2 laser can be carried out in total or fractional modes. After total ablation of a keloid scar with a CO2 laser as monotherapy, relapse is observed in 90% of cases, so this type of treatment cannot be recommended as monotherapy. The use of fractional laser treatment modes can reduce the number of relapses.
- Pulsating dye laser.
The pulsed dye laser (PDL) produces radiation at a wavelength of 585 nm, which corresponds to the absorption peak of red blood cell hemoglobin in blood vessels. In addition to its direct vascular effects, PDL reduces the induction of transforming growth factor-β1 (TGF-β1) and the overexpression of matrix metalloproteinases (MMPs) in keloid tissues.
In most cases, the use of PDL has a positive effect on scar tissue in the form of softening, reduction in erythema intensity and standing height.
Surgical correction of scar changes is accompanied by relapse in 50-100% of cases, with the exception of keloids of the ear lobes, which recur much less frequently. This situation is associated with the peculiarities of the surgical technique, the choice of method for closing the surgical defect, and various options for plastic surgery with local tissues.
Radiation therapy
Used as monotherapy or adjunct to surgical excision. Surgical correction within 24 hours after radiation therapy is considered the most effective approach for treating keloid scars, significantly reducing the number of recurrences. Relatively high doses of radiation therapy over short exposure times are recommended.
Adverse reactions of ionizing radiation include persistent erythema, skin peeling, telangiectasia, hypopigmentation and the risk of carcinogenesis (there are several scientific reports of malignant transformation following radiation therapy of scars).
Requirements for treatment results
Depending on the method of therapy, positive clinical dynamics (reduction in scar volume by 30-50%, reduction in the severity of subjective symptoms) can be achieved after 3-6 procedures or after 3-6 months of treatment.
If there are no satisfactory treatment results after 3-6 procedures / 3-6 months, modification of therapy is necessary (combination with other methods / changing the method / increasing the dose).
Prevention of skin scarring:
Persons with a history of hypertrophic or keloid scars or those who are undergoing surgery in the area increased risk their development, it is recommended:
- For wounds with a high risk of scarring, silicone-based products are preferred. Silicone gel or sheets should be applied after the incision or wound has epithelialized and continued for at least 1 month. For silicone gel, a minimum of 12 hours daily use or, if possible, continuous 24 hours use with hygienic treatment twice daily is recommended. The use of silicone gel may be preferable when the affected area is large, when used on the face, and for persons living in hot and humid climates.
- For patients with an average risk of developing scars, it is possible to use silicone gel or sheets (preferably), hypoallergenic microporous tape.
- Patients at low risk of developing scars should be advised to follow standard hygiene procedures. If the patient expresses concern about the possibility of scar formation, he may use silicone gel.
An additional general preventative measure is to avoid exposure to sunlight and use sunscreens with a maximum sun protection factor (SPF > 50) until the scar matures.
Typically, the management of patients with scars can be reviewed 4-8 weeks after epithelialization to determine the need for additional interventions to correct the scars.
IF YOU HAVE ANY QUESTIONS ABOUT THIS DISEASE, CONTACT DOCTOR DERMATOVENEROLOGIST KH.M. ADAEV:
WHATSAPP 8 989 933 87 34
EMAIL: [email protected]
INSTAGRAM @DERMATOLOG_95
A keloid scar (ICD 10) is a scar formation that forms on the area of the affected skin. The damage must be treated, otherwise marks may remain for life. A keloid scar also indicates the rapid healing of destroyed skin tissue.
Keloid scar according to ICD 10 code is classified as a physiological phenomenon. This is the result of restoration of tissues deformed artificially. Often, scars heal and become invisible, but keloid scars have a distinct character and appearance.
A keloid is a dense growth that may externally resemble a tumor, characterized by the following features:
- The scar is located outside the damaged area. Grows in a horizontal direction.
- A keloid is a scar that is characterized by sharp pains, itching. A striking example is the feeling of skin tightening.
- If over time it becomes practically invisible, then the colloidal one does not change color or size. This occurs because blood vessels grow inward.
Causes and symptoms of formation
Even minor skin defects lead to the formation of painful scars. Among the main reasons are:
- Self-treatment of wounds. If the edges of the incision are not connected correctly, the skin becomes deformed and illness cannot be avoided. This mistake can also be made by a doctor.
- Keloid appears as a consequence infectious infection. Disinfection and the use of appropriate products is a must safe treatment wounds.
- As confirmed by the ICD 10 code, it is formed after too much skin tension during suturing. This spoils the appearance initially and subsequently becomes a destructive factor.
- Medical examinations identify keloids as a result hormonal imbalance. Among the causes is immunodeficiency.
The international classification of the disease takes into account hereditary predisposition. The abundance of scars in relatives may indicate a high probability of the formation of a keloid scar.
Possible complications
The international classifier does not define keloids as dangerous diseases posing a threat and leading to serious complications. This will not cause future tumors, malignant formation, which poses a risk to life.
Scar removal and modification is initiated for two reasons:
- Aesthetic. Looks unsightly on exposed skin. The scar is not disguised as a tan and when it germinates blood vessels stands out on the body.
- Practical. Scars located on the bend of the joints hinder movement. When wearing tight, tight clothing, discomfort and itching from rubbing occur.
Prevention of occurrence
You can prevent the appearance of a keloid in the following ways:
- Bandages. Special dressings that create strong pressure, localize the source of spread. However, not every wound allows the use of such solutions.
- Balanced treatment. Seeing a doctor in a timely manner will help disinfect the wound and develop individual program recovery. The use of vinegar and other aggressive agents leads to side effects.
- Caution. Do not squeeze out the abscess or massage the scar due to itching. This indicates an inflammatory process, so you should consult a specialist.
- Cold peace. Baths, saunas and high temperatures contraindicated in patients with keloids.
In most cases, deformation of scars is a consequence of wound infection. If you receive an abrasion or mechanical damage to the skin, the main thing is to consult a doctor in a timely manner, do not put strain on the deformed tissues and do not self-medicate.
Pronounced skin pigmentation Certain localization of initial lesions (deltoid muscle area, chest, earlobe) Pregnancy Puberty.
Pathomorphology
Histological examination reveals elongated convoluted bundles of eosinophilically stained hyalinized collagen, thinning of the dermal papillae and decreased elasticity of the fibers. Morphological basis
consists of excessively growing immature connective tissue with a large number of atypical giant fibroblasts that have been in a functionally active state for a long time. IN
keloids
few capillaries, mast and plasma cells.
Keloid: Signs, Symptoms
Clinical picture
Pain Soreness Hyperesthesia Itching Hard, smooth scars raised above the surface of the skin with clear boundaries At the beginning of the disease, there may be pallor or slight erythema of the skin The scar occupies a larger area than the original damage Even after years
continue to grow and can form claw-like outgrowths.
Symptoms of keloid scars
Keloid and hypertrophic scars are accompanied by redness (hyperemia) and pain after pressing on the scar. In this place, the tissues are highly sensitive. The scars begin to itch. Keloids develop in two stages:
- Active is characterized by the dynamic growth of keloid tissue. This is accompanied by itching, numbness of the affected areas and tissue soreness. This stage begins with epithelization of the wound and lasts up to a year.
- During the inactive period, the final formation of a scar occurs. It is called stabilized, acquiring normal skin color. The resulting scar does not cause concern to the owner, but on open areas of the body it looks unaesthetic.
There are two types of keloids. True ones rise above the skin and have a whitish or pink color. The scars are dense, with a smooth shiny surface with a minimal content of capillaries.
The formation of keloids is accompanied by the following symptoms:
- hyperemia (redness) in the scar area;
- painful sensations when pressing;
- increased sensitivity in the area of affected tissues;
- itching when scratching.
The development of keloids goes through two stages - active and inactive.
During the active stage, dynamic growth of keloid tissue occurs, which causes physical discomfort in the patient: itching, soreness and/or numbness of the affected tissues. This stage begins from the moment of epithelization of the wound and can last up to 12 months.
The inactive stage ends with the final formation of the scar. Such a keloid is otherwise called stabilized, since its color resembles the natural color of the skin, and the scar itself does not cause much concern, except for its unaesthetic appearance, especially on open areas of the body.
Keloid: Diagnosis
There are true (spontaneous) and false keloids.
Differential diagnosis
Hypertrophic scars Dermatofibroma Infiltrating basal cell carcinoma (confirmed by biopsy).
Conservative treatment
Keloid scar - how to get rid of it with conservative treatment? First, a diagnosis is made and a biopsy is prescribed to exclude a malignant neoplasm.
Treatment begins with conservative techniques. They help well if the scars are not yet old, formed no more than a year ago.
During compression, pressure is applied to the affected area. The growth of the keloid is stopped by compression. The nutrition of scar tissue is blocked, its blood vessels are compressed. All this helps stop the growth.
Ointment for keloid scars is only an auxiliary method. It is rarely used as an independent remedy. Ointments are usually prescribed as additional drugs that have antibacterial, anti-inflammatory and blood circulation-restoring effects.
Various techniques are used for cosmetic correction of acne keloid: dermabrasion, peelings. All of them are aimed at changing the appearance of scars.
Mesotherapy and other cosmetic methods are carried out only for the upper skin layer, in order to avoid the growth of connective tissue. Correction is indicated only for old scars.
In other cases, three main conservative methods are most often used to remove them. The first way to remove a keloid scar is treatment with silicone plates.
They begin to be used immediately after the first wound healing. Silicone sheets are mainly indicated for people who have a tendency to form keloids.
The essence of the technique is based on squeezing capillaries. As a result, collagen synthesis decreases and tissue hydration ceases. A special patch with plates is used daily for 12-24 hours. The course of therapy is from 3 to 18 months. Compression is a variation of this method.
Second method: treatment of keloid scars with corticosteroids is indicated for local use. An injection is made into the bulge, which includes a suspension of triamcinolone acetonide. It is allowed to inject from 20 to 20 milligrams of the drug per day, 10 mg is spent on each scar.
The purpose of the injections is to reduce collagen production. At the same time, the division of fibroblasts that produce it decreases and the amount of collagenase increases.
Treatment is most effective for non-old scars. In this case, small doses are sufficient for therapy.
After a month, the course of treatment is repeated until the scars are even with the surface of the skin.
The third main method of how to get rid of keloid scars is called cryodestruction. This is a destructive effect on scar tissue with liquid nitrogen. As a result, a crust appears on the treated area.
Healthy tissues form underneath. After the process is completed, the crust falls off on its own, leaving an almost imperceptible mark. The cryodestruction method is effective only for new keloid and hypertrophied scars.
Aggressive removal of keloid scars is done in two ways: surgically or using a laser. In the first case, during the operation, not only the overgrown tissue is excised, but also the affected area of skin.
The surgical method has its drawbacks - there is a high probability of the formation of new keloid scars.
This risk is somewhat reduced by removing the affected area of skin. However, relapses occur in 74-90 percent of cases. Surgery is indicated only in cases where conservative treatment has proven ineffective.
With the help of laser therapy, keloid scars that minimally affect the surrounding tissue are removed or cauterized. The correction is applied in complex treatment and is combined with corticosteroid and local methods. With laser therapy, relapses are much less common - 35-43 percent.
Treatment of keloid on the ear occurs according to a certain scheme. First, diprospan or kenologist-40 is prescribed.
Injections are made into the scar tissue. A month after the start of treatment, laser therapy using Bucca rays is performed.
The patient wears a special compression clip on the ear (at least 12 hours daily).
At the end of therapy, phono- and electrophoresis with collagenase or lidase is prescribed to consolidate the effect. At the same time, ointments and gels are prescribed (Lioton, Hydrocotisone, etc.).
If after this the growth of scar tissue does not stop, then close-focus radiotherapy is added to the treatment. In severe and complex cases, methotrexate is given.
A keloid scar after a cesarean section can be treated in many ways. In some cases, deep chemical peeling can help get rid of keloid scars.
First, the scar is treated with fruit acids. After this, chemicals are applied.
This method is ineffective, but also the most cost-effective.
For the treatment of keloid scars after removal of a mole or caesarean section plates and gels containing silicone are prescribed. There are many anti-scar products with a collagenase base.
Hyaluronidase preparations are used. Hormone-based products with vitamins and oils help eliminate keloid scars.
To remove mature scars, physiotherapy is prescribed: phonoelectrophoresis. These are effective and painless procedures. IN as a last resort plastic surgery or laser resurfacing is performed. A more gentle method is microdermabrasion. During the procedure, microparticles of aluminum oxide are used.
There are many ways to treat keloid scars using traditional methods. The scars are not completely removed, but they become less visible.
Funds are used for plant based. For example, take 400 g of sea buckthorn oil and mix it with 100 g of beeswax.
The solution is heated in a water bath for 10 minutes. Then a gauze pad is dipped into the mixture and applied to the scar.
The procedure is carried out twice a day. The course of treatment is three weeks.
To remove scars, compresses are made with camphor, in which the bandage is moistened. Then it is applied to the scar. The compress is done daily for a month. Only after this will the result be visible.
You can make a tincture from delphinium. The roots of the plant are greatly crushed. Alcohol and water are added to them, mixed in equal proportions. The container is removed for two days in a dark place. Then a gauze pad is soaked in the liquid and applied to the keloid scar.
You can make your own ointment based on Japanese styphnolobia. A couple of glasses of plant beans are crushed and mixed with badger or goose fat in equal proportions.
The mixture is infused for 2 hours in a water bath. Then, at intervals of a day, it is heated twice more.
After this, the mixture is boiled, stirred and transferred to a ceramic or glass jar.
Keloid scars do not pose a threat to health or life, but can cause nervous disorders due to the unaesthetic appearance of the body. In the early stage, neoplasms are much easier to treat than in the advanced version.
According to statistics, keloid scars are not very common - only 10 percent of cases. Women are most susceptible to this disease. To prevent scars, you must follow all doctor's instructions and not self-medicate.
The nature of keloid is not fully understood, so to date no universal treatment method has been developed. The doctor chooses the methods individually for each patient, depending on the clinical picture of the disease.
Treatment methods can be divided into conservative and aggressive (radical).
It is preferable to start with conservative ones, especially if the scars are young - no older than one year. Three methods are recognized as the most effective:
- use of silicone coating/gel;
- corticosteroid injection therapy;
- cryotherapy.
Application of silicone plates
You should start using silicone plates in the form of a patch immediately after primary healing wounds in people who are predisposed to developing keloids.
The mechanism of this technique is based on squeezing capillaries, reducing collagen synthesis and hydration (moistening) of the scar. The patch must be used from 12 to 24 hours a day.
The treatment period is from 3 months to 1.5 years.
A variation of this treatment method can be considered compression (squeezing), as a result of which the growth of the keloid stops, nutrition is blocked and the vessels of the scar are compressed, which leads to a stop in its growth.
Corticosteroid injections
This technique is used locally. A suspension of triamcinolone acetonide is injected into the scar using an injection.
You can administer 20-30 mg of the drug per day - 10 mg for each scar. Treatment is based on reducing collagen synthesis.
At the same time, the division of fibroblasts that produce collagen is inhibited, and the concentration of collagenase, the enzyme that breaks down collagen, increases.
Treatment in small doses is effective for fresh keloid scars. After 4 weeks, the treatment is repeated until the scars are compared with the surface of the skin. If there is no therapeutic effect, a triamcinolone suspension containing 40 mg/ml is used.
Treatment with steroids can cause complications:
Treatment
Lead tactics
Local injections of HA are most effective. Pressure on the damaged area prevents the development of
Bandages are used that create a pressure of up to 24 mm Hg over the injury site. Art. , for 6–12 months. The bandage can be removed for no more than 30 minutes/day. Radiation therapy in combination with GC - if other treatment methods are ineffective.
Surgery
indicated only in cases of extensive damage and ineffectiveness local treatment GK. Celebrate high frequency relapses, therefore surgical treatment is recommended no earlier than 2 years after formation
with immediate preventive treatment (as with emerging
Drug therapy
On one day, the drug can be injected into 3 scars (10 mg for each scar) The needle should be inserted in different directions for better distribution of the drug The effectiveness of the method is higher with fresh keloid scars Treatment is repeated every 4 weeks until the scars are compared with the surface of the skin If there is no effect, you can use triamcinolone suspension containing 40 mg/ml for surgical excision.
keloids
You can use a mixture of triamcinolone solution (5–10 mg/ml) with local anesthetics. To prevent relapses after surgery, injections of HA into the area of scar excision after 2–4 weeks and then 1 time per month for 6 months.
Course and prognosis
Under the influence of triamcinolone
decrease over 6–12 months, leaving flat, light scars.
ICD-10 L73. 0 Acne keloid L91. 0 Keloid scar.
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Prevention
To reduce the risk of relapses after surgical operations to remove a keloid, it is customary to carry out preventive measures already in the process of forming a new scar (on days 10-25).
All therapeutic (conservative) methods are used as preventive measures. After surgery, you should constantly use sunscreen with a high level of protection.
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