With Dr Helen Douglas.

Today I’d like to welcome to the PodMD studio Dr Helen Douglas

Dr Helen Douglas is a Specialist Plastic Surgeon at The Scar Clinic Perth, specialising in burns, scarring and laser treatments.

Dr Douglas graduated in medicine in 2004, before starting her specialist plastic surgery training in the UK in 2011 which she completed in Perth, WA. Helen is a Fellow of the Royal Australasian College of Surgeons and the Royal College of Surgeons of England and was awarded the prestigious Ian McGregor Gold Medal for outstanding performance in her specialist examinations in 2015. Helen is currently a Senior Lecturer at The University of Western Australia and a Clinical Tutor at Cardiff University where she undertook her Master’s degree in Laser and Wound Healing and has done 2 laser fellowships.

Today, we’ll be discussing the topic of hypertrophic scar treatment.

*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The viewWe do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.s and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

The topic of today’s discussion is Hypertrophic scar treatment. Helen, can you first give us a brief overview about hypertrophic scars?

Helen: So I think we all learn at medical school that scars follow a very structured pathway. There’s the haemostasis and then there’s the inflammatory phase followed by proliferation of the scar, then remodelling and eventual maturity. And that is a process which takes about 18 months so it’s totally normal for scars to get a bit more vascular and get a bit thicker. That’s the proliferation phase. But I think when scars become hypertrophic and problematic is when they get stuck in that phase or there’s excessive time in the proliferative phase. Meaning that there is more scar tissue formed. They become very red, very itchy and sore because they swell in hot weather when the skin naturally gets more blood supply in the heat, the scar gets more blood supply and it throbs and feels hot and uncomfortable.

In the cold weather, when our skin gets cold everything goes a bit purple. The blood in the scar is achy. And these scars can be unsightly. Patients don’t like the look of them and often it’s associated with the event that caused it, which could be traumatic, it could be surgical but it’s a reminder. They can be very tight. They can restrict motion, particularly across joints. They’re often confused with keloid scars, and I think that’s been going on for a long time and I think really there are some that are very obviously keloid or hypertrophic. So for example, if you pierce your ear and then you get a scar the size of a golf ball, that is what most people classically think of as a keloid – a very minor injury with a very large response of the scar that almost grows like a benign tumour.

Whereas a hypertrophic scar stays within the bounds of the wound or line that it has. But gets very thick, itchy, red and sore and some people describe it as a thick red slug of scar tissue, but it’s not usually like a ball or a tumour that grows. It just has gotten very thick over the proliferative stage.

What are the most common causes of hypertrophic scar formation in patients?

So, I think these can be split into the types of injury that cause them. Some injuries are far more likely to produce her hypertrophic scars. Burns because it’s a larger surface area and partial thickness injury to the skin that can take a while to heal or require a skin graft. Trauma, so any kind of traumatic injury can damage the skin as it’s cut and produce some degloving effect and have some problems with healing. Post-surgical, if there’s any delay in healing or infection around the area, or if it’s particularly tight, so those types of injuries.

In anatomical areas, some are more prone to it, particularly around the neck, the jaw, over the joints and on the chest and in young people, so children very frequently have hypertrophic scars and teenagers. Because of the increased growth hormone that they’ve got as they grow, they put more tension on the scars. So it becomes a bit of a catch-22.

And the types of skin; some people are genetically predisposed to forming thicker scars, and we find that these are sometimes in the very, very pale in our society, and the very darker skinned types. But they can occur in anyone, and sometimes in none of these. They’re pretty unpredictable.

Could you provide an overview of the various treatment options available for hypertrophic scars?

Helen: Again, I think I’ll split these into non-invasive. So what we would call scar therapy and involves ways in which we can manage to improve the scar without trying to treat it with anything invasive, so massage, moisturiser and desensitisation – getting it used to being touched again. Silicon to ensure it’s being hydrated and pressure to try and squeeze the blood out of the scar either with garments or splints and this is usually under the advice of an occupational therapist experienced in scar management and can be incredibly effective.

After that, there are non-operative techniques which are things like CO2 laser, steroid injections and needling where you apply multiple needles to a scar. The CO2 laser I’ve talked about in a different podcast; involves drilling holes into the scar with the targeted micro damage that heals very quickly to try and flatten it down and re-modulate it. Steroids involve reducing inflammation.

And then there’s operative management, where if you’ve got a small scar that has healed poorly, you can excise it and start again. That’s not always possible or preferred by the patient. So you could try to reorientate the scar if it was a traumatic one that healed badly or in a direction that was unfavourable and you can do that with plastic surgery techniques such as a Z-plasty or W-plasty and usually combine it with some of the non-operative techniques which in my practice would be CO2 laser and certainly with some scar therapy.

Are there emerging therapies or innovative techniques in the field of hypertrophic scar treatment?

There certainly are. It’s an exciting field. So all of these involve stimulating collagen to remodel whilst minimising the damage and the downtime. The one that I’ve got the most experience with is the CO2 fractionated laser. In the last 15 years, that has really emerged as a powerhouse in scar modulation by perforating tiny columns into the scar and then heating the scar underneath it to make that collagen flatter and more like normal skin. And there’s good evidence behind that. And a couple of large randomised controlled trials that came out of WA. And some large series over from Sydney as well, mostly concentrating on hypertrophic scars.

There are also things like needling, which is like the Derma Roller which does a similar thing but inserts needles 4 millimetres into the skin rather than lasers. But the theory is the same you’re creating damage to the scar and then stimulating it to remodel and heal. And then there are some newer things emerging, such as radio frequency. That involves applying electrical currents through needles or non-invasively into the scar to try again to modulate the collagen. And like I said, I think the evidence is there for CO2 laser now, and it’s probably going to be emerging for the other therapies soon.

What are the criteria for determining whether a patient is a suitable candidate for surgical or laser interventions?

Helen: Well, I think the first thing to say is it’s not a binary option; like the scar therapy, the CO2 laser is an adjunct sometimes to surgery or it can be monotherapy. But I think if you’ve got a thick, red and angry scar, as I’ve said before, I would have to be pretty convinced that re-operating would help. You know, it’s that classic, isn’t it? If Plan A doesn’t work and Plan B doesn’t work, Plan C should be different to A&B, so I’d have to look at the reasons why they got a poor outcome and if there are none, would I get a better result next time with scarring with reoperation on the scar. So if not, the CO2 laser is very safe and low risk to try and flatten the scar, improve the symptoms and then at the end of that scar journey treatment you can reassess.

Also, it can help make the tissue better prior to any surgery. So an example is if you have a thick red scar, particularly over something like a hand and it’s tight and you think, right, well I need to release this with surgery because I need more tissue into it. Cutting through that scar when it’s still in that 18-month maturation phase, particularly if it’s tight – cutting into that, can be like cutting bleeding concrete and risks of graft loss, the risks of wound healing being poor are a lot higher if you are operating early and I think the CO2 laser is great at also buying you time and improving that scar. So if you do need eventual surgery, it’s more successful and certainly that’s what I’ve found doing my burns work.

I think if anything’s thick, red and unpleasant and you want to make it flatter and paler, it’s very low risk and very effective at that. If there’s a reason that the scar is poor, like delayed healing from a dog bite or it’s stretched or angry, you’d want to revise that scar but keep laser and scar therapy in your pocket.

How can patients actively participate in their own hypertrophic scar management?

Helen: I think that’s a really good question because it can really empower them to make them feel like they’re helping change what can be very unpleasant. And so all of the things that we mentioned to do with scar therapy can be very patient-directed. They can have their own symptom diaries. They can choose serial photographs to help us monitor and involve them in how to moisturise and massage their scar, and which silicone products to use that fit them and their lifestyle better. In some people, pressure garments and making sure that it helps them feel like they’re changing their scar as well.

What is the typical role of a GP in the initial assessment and management of patients with hypertrophic scars?

Helen: Well, I think the patient’s own GP is going to know them best and we all know that the timing of the intervention is key. The hypertrophic scar follows a natural process and I think they’ll know at which point the patient is

getting bothered by it and would prefer to have an intervention. It’s incredibly unpleasant, even early in the journey, they might think, well, this is going to be a long haul for this patient. And they might know them very well and know that they’re prone to keloid scarring cause they’ve seen them before, or if they have an excessive reaction scar. I think they’ll be able to see and assess whether or not they’ve got poor scars for a reason, or if this is part of their makeup.

When should a GP refer a patient for treatment?

Helen: I think if they feel their patient’s got a scar that would like to be improved. And like we said before, it can be a reminder of trauma and just seeing their GP and discussing the impact, not only aesthetically, but functionally and psychologically. Seeing a scar specialist to discuss the options. I think that I’ve had people tell me that can really help because they feel like they’re being listened to and the impact of that scar on them is being understood. So if the GP thinks that it can be improved we are very happy to have a look.

Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on hypertrophic scar treatment

Helen: So I think my first one is that:

The emerging therapies, in particularly CO2 laser, have been a real game changer in non-surgical treatments of hypertrophic scarring

Laser and surgery combined can give excellent results with scar therapy

And finally, the multimodal approach is necessary with all of these to empower the patient and that’s key.

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