• 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)
  • 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
  • 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
  • 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
  • Basal cell carcinoma
  • 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
  • Contractures limiting mobility
    • associated with hypertrophic scars

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