questions 3

Hypertrophic Scars & Keloids

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Topic updated on 09/08/17 12:52pm

Snapshot
  • A 26-year-old Chinese woman presents to her dermatologist for a persistent growth on her chest. She had previously burned a small portion of her pre-sternal skin while curling her hair 2 years ago. While the burn healed without any problem, she noticed a protuberance where the burn previously was. She reports that this growth seems to be larger than the original burn. On physical exam, she has a 5 cm elliptical firm, pink, and shiny growth. While counselling that this may not go away completely, her dermatologist agrees to start intralesional steroid injections. (Hypertrophic scars)
Introduction
  • Clinical definition
    • abnormal and excessive scarring in response to dermal injury, resulting in hypertrophic scars or keloids
  • Epidemiology
    • incidence
      • keloid
        • 6-16% of African population
    • demographics
      • most commonly in ages 10-30
    • risk factors
      • keloid
        • ↑ in groups with darker skin
        • patients of African, Hispanic, or Asian descent
        • family history
        • wounds on chest, shoulders, upper arms, earlobes, or cheeks
      • hypertrophic scar
        • wounds on areas of high skin tension
          • shoulders, neck, knees, and ankles
      • both
        • dermal injury caused by burns
        • wounds that take > 3 weeks to heal
  • Etiology
    • keloid
      • previous trauma
      • spontaneous
    • hypertrophic scar
      • previous trauma
  • Pathogenesis
    • dysregulation of wound healing
      • recall normal wound healing stages are
        • inflammation, proliferation, and remodeling/maturation
    • keloid
      • ↑↑ type I and type III collagen
        • this is disorganized and extends beyond the original wound
        • abnormalities in melanocyte stimulating hormone may contribute
    • hypertrophic scar
      • ↑ type III collagen
        • this is organized as parallel and confined to the original wound
        • increased activation of myofibroblasts may contribute
  • Prognosis
    • keloid
      • recurrence is frequent
      • will not regress over time
    • hypertrophic scar
      • recurrence is rare
      • may regress over time
Presentation
  • Symptoms
    • abnormal scarring occurs after trauma or injury
    • often itchy or painful (keloids > hypertrophic scar)
    • keloid
      • may take months to years to develop
    • hypertrophic scar
      • usually appears within 1 month
  • Physical exam
    • scarring along previous site of wound
    • well-defined, firm, and shiny
    • pink, purple, or hyperpigmented
    • irregular borders
Studies
  • Biopsy
    • indications
      • only if clinical diagnosis is uncertain
  • Histology
    • keloid
      • thick collagen fibers with abundant mucoid matrix
      • disorganized type I and III collagen
    • hypertrophic scar
      • thin collagen fibers with minimal mucoid matrix
      • myofibroblasts
      • parallel type III collagen
Differential
  • Basal cell carcinoma
Treatment
  • Medical
    • intralesional corticosteroid injections
      • indication
        • first-line for treatment that is often used with silicone sheeting
    • silicone sheeting
      • indication
        • first-line for treatment that is often used with intralesional corticosteroid injections
  • Operative
    • surgical excision
      • indication
        • for scars that are associated with contractures
Complications
  • Contractures limiting mobility
    • associated with hypertrophic scars


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Qbank (1 Questions)

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(M1.MK.20) You are seeing a 21-year old African American male in clinic. He recently got his ear pierced, but had to remove the piercing due to the findings in Figure A.

What is the mechanism underlying this patient's findings? Topic Review Topic
FIGURES: A          

1. Excessive melanocyte proliferation
2. Excessive collagen deposition
3. Neoplastic fibroblasts
4. Excessive inflammation
5. Congenital Malformation

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