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The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids

Ogawa, Rei M.D., Ph.D.

Plastic and Reconstructive Surgery: February 2010 - Volume 125 - Issue 2 - p 557-568
doi: 10.1097/PRS.0b013e3181c82dd5
Reconstructive: Trunk: Special Topic

Background: Previous reports on the treatment of hypertrophic scars and keloids have not described clear algorithms for multimodal therapies. This article presents an evidence-based review of previous articles and proposes algorithms for the treatment and prevention of hypertrophic scars and keloids.

Methods: The methodologic quality of the clinical trials was evaluated, and the baseline characteristics of the patients and the interventions that were applied and their outcomes were extracted.

Results: Important factors that promote hypertrophic scar/keloid development include mechanical forces on the wound, wound infection, and foreign body reactions. For keloids, the treatment method that should be used depends on whether scar contractures (especially joint contractures) are present and whether the keloids are small and single, or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (which includes radiation or corticosteroid injections) or by nonsurgical monotherapy (which includes corticosteroid injections, cryotherapy, laser, and antitumor/immunosuppressive agents such as 5-fluorouracil). Large and multiple keloids are difficult to treat radically and are currently only treatable by multimodal therapies that aim to relieve symptoms. After a sequence of treatments, long-term follow-up is recommended. Conservative therapies, which include gel sheeting, taping fixation, compression therapy, external and internal agents, and makeup (camouflage) therapy, should be administered on a case-by-case basis.

Conclusions: The increase in the number of randomized controlled trials over the past decade has greatly improved scar management, although these studies suffer from various limitations. The hypertrophic scar/keloid treatment algorithms that are currently available are likely to be significantly improved by future high-quality clinical trials.

Boston, Mass.; and Tokyo, Japan

From the Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, and the Department of Plastic Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital.

Received for publication December 30, 2008; accepted August 27, 2009.

Disclosures: The author has no financial disclosures regarding the publication of this article.

Rei Ogawa, M.D., Ph.D., Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street; Boston, Mass. 02115,

©2010American Society of Plastic Surgeons