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Wednesday, December 2, 2015

Scar Management and time frame of healing


A Scar is the inevitable result of damage to the dermis of the skin ,characterised by excessive amounts of collagen deposition

Normal Healing Process

a.       Bleeding Phase 6 hours – 24 hours
b.      Inflammatory Phase  few hours –two weeks
c.       Proliferation Phase  2 days – several months
d.      Remodelling Phase 2 week – 2 years !

Optimal Scarring Follows
·         Non infected wound
·         Tension free wound
·         Well aligned edges
·         Patient with no underlying medical history

Excessive scarring can result from… 
·         Infection
·         Foreign bodies #
·         Haematoma
·         Poorly aligned wound edges #
·         Crush injury #
·         Genetic factors #
·         Pregnancy #
·         Mechanical tension
( # factors out with therapist control )

Hypertrophic scars (Definition)
Exuberant scar that remains within the limits of the original wound

Clinical Characteristics
1.      Red, itchy, and raised
2.      Develops 6-8 weeks after epithelialisation
3.      Regresses spontaneously
4.      All areas are susceptible

Keloid Scars (Definition)
Exuberant scar that exceeds the boundaries of the original wound (William 1996)
Derived from the Greek word ‘Chele’ meaning crab claw

Clinical Characteristics
·         Common in 10-30 year olds
·         Florrid and grossly raised
·         Hypersensitive
·         Does not usually regress spontaneously
·         Familiar/genetic
·         Africans more susceptible
·         Regressive and difficult to treat

Hypertrophic and Keloid scars are most common
·         Areas of high tension/movement
·         Earlobe
·         Anterior surface of the neck
·         Shoulder
·         Chest wall
·         Flexor surface of the extremities

Methods of scar management
·         Surgery
·         Radiation
·         Pharmacological

By enhancing the endogenous electrical activity of damaged tissues the growth/healing processes can be stimulated (Brighton et al 1981)
Injured tissues are electrically active as shown in skin repair ( Barker et al )

Modalities :  Ultrasound
Acoustic streaming main affect increases protein synthesis
Useful in proliferation and remodelling phases
Pro inflammatory
Increases wound strength ( Dyson 1981)
Affects A beta fibres ( help hypersensitivity?)

Modalities : Laser
Works by photobioactivation and monochromaticity
Triggers the regression of bld vessels and decreases fibroblasts
Dose 0.4 – 4 j/cm2
Effective in bleeding and inflammatory phases

Therapeutic methods of scar management
·         Pressure garments
·         Massage
·         Splints
·         Active and passive exercises
·         Hypersensitivity program
·         Silicone products

1.      Detailed Medical History esp. aspirin steroids etc
2.      Predisposing factors for abnormal healing i.e. genetic, pregnancy etc
3.      Limit reduction of dressings in first two weeks
4.      Encourage anti inflammatory in high risk pts
5.      Limit mechanical tension from splintage
6.      Use accessory mobilisations to increase joint ROM rather than passive stretching
7.      Use laser in bleeding / inflammatory phases
8.      Use ultrasound in  proliferation/remodelling phase
9.      Start hypersensitivity programme as soon as possible with high risk patients
10.  Avoid heavy tapping in high risk pts
11.  Avoid firm massage in high risk patients 
12.  Use silicone gel  as prevention  in high risk patients


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