SPECIAL TOPIC

The Most Current Algorithms for the Treatment

and Prevention of Hypertrophic Scars and Keloids
Rei Ogawa, M.D., Ph.D.
Boston, Mass.; and Tokyo, Japan
Background: Previous reports on the treatment of hypertrophic scars and ke-
loids 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 develop-
ment 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/immuno-
suppressive agents such as 5-fluorouracil). Large and multiple keloids are dif-
ficult to treat radically and are currently only treatable by multimodal therapies
that aim to relieve symptoms. After a sequence of treatments, long-term fol-
low-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 algo-
rithms that are currently available are likely to be significantly improved by
future high-quality clinical trials. (Plast. Reconstr. Surg. 125: 557, 2010.)

M
any articles have suggested that there are
effective ways to treat abnormal scarring
of the skin, including hypertrophic scars
and keloids, but the use of these treatments and
their effectiveness when used in various combina-
tions remain to be clearly defined. Consequently,
an evidence-based review of the relevant literature
was performed, and the diagnosis, prevention,
and treatment of hypertrophic scars and keloids
are discussed here. At present, it is still difficult to
know the effectiveness of various treatments for
hypertrophic scars and keloids because of varia-
From the Division of Plastic Surgery, Brigham and Women’s
Hospital, Harvard Medical School, and the Department of
Plastic Reconstructive and Aesthetic Surgery, Nippon Med-
ical School Hospital.
Received for publication December 30, 2008; accepted Au-
gust 27, 2009.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181c82dd5
tions between studies in terms of the race, age,
and sex of the participating patients; the ana-
tomical area that is affected; the size of the le-
sion(s); the ways that treatment outcomes and
response rates are measured; the follow-up
term; and whether patient satisfaction is mea-
sured. Despite these limitations in the current
literature, there was sufficient information to
design the keloid/hypertrophic scar treatment
algorithms that are proposed in this article
(Figs. 1 and 2). If the necessary evidence-based
knowledge was missing or inadequate, this is
indicated to make it clear where additional high-
quality clinical trials that will improve the treat-
ment algorithms are needed.
Disclosures: The author has no financial disclo-
sures regarding the publication of this article.

www.PRSJournal.com 557
 Plastic and Reconstructive Surgery • February 2010

Fig. 1. Treatment algorithms for hypertrophic scars (HSs).

DIFFERENTIAL DIAGNOSIS OF pathologists distinguish keloids from hypertro-

HYPERTROPHIC SCARS AND KELOIDS
The pathogeneses of keloids and hypertrophic
scars are not well understood.1 Many traditional
textbooks classify hypertrophic scars and keloids
as completely different types of scars. Clinicians
define hypertrophic scars as scars that do not grow
beyond the boundaries of the original wound,
whereas keloids grow horizontally.2 In contrast,
phic scars histologically on the basis of thick eo-
sinophilic (hyalinizing) collagen bundles that are
absent in hypertrophic scars.3 However, there are
also many cases where the scar bears the growth
and histologic features of both hypertrophic scars
and keloids (Fig. 3).3 There is also the possibility
that hypertrophic scars and keloids are manifes-
tations of the same fibroproliferative disorder of

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Volume 125, Number 2 • Treatment of Hypertrophic Scars
Fig. 2. Treatment algorithms for keloids.
the skin that is expressed by a continuum of
features.4 However, alleged hypertrophic scars im-
prove naturally and gradually, although the full
maturation process may take up to 2 to 5 years,2
whereas alleged keloids do not resolve naturally.
Because these features shape how they should be
treated, they should be defined as shown in Table
1, and scars that bear features of both hypertro-
phic scars and keloids should be considered and
treated as keloids.
EXCLUDING THE POSSIBILITY THAT
THE LESIONS ARE ATTRIBUTABLE TO
SIMILAR-LOOKING DISEASES
Gulamhuseinwala et al.5 reported a pathologic
analysis of 568 scars that revealed the absence of
malignancies or dysplasias. Therefore, they con-
cluded that routine histologic analysis of scars is
not necessary. Wong and Lee6 have argued against
this approach, saying that malignant or local de-
structive tumors can be misdiagnosed clinically as
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 Plastic and Reconstructive Surgery • February 2010

Fig. 3. Hypertrophic scars and keloids can vary in their appearance. Left and right images can be considered as typical
hypertrophic scar and keloid cases, respectively. (Center) However, it is difficult to determine whether this scar is a hyper-
trophic scar or a keloid, and such lesions should be considered and treated clinically as keloids, although the possibility that
they are actually hypertrophic scars should be kept under consideration.

Table 1. Differential Diagnosis of Hypertrophic Scars
and Keloids
Pathologists distinguish keloids from hypertrophic scars
histologically on the basis of thick eosinophilic
(hyalinizing) collagen bundles that are absent in
hypertrophic scars. These conditions can also be defined
clinically on the basis of their growth patterns. However,
clinicians and pathologists still have conflicting views
regarding the differential diagnosis of these conditions.
● Hypertrophic scar: A fibroproliferative disorder of the skin
that does not grow beyond the boundaries of the
original wound.
● Keloid: A fibroproliferative disorder of the skin that grows
beyond the boundaries of the original wound or has an
unrecognized origin.
keloids. Indeed, malignant tumors, including der-
matofibrosarcoma protuberances7–10 and giant
cell fibroblastomas,11 have been mistaken for hy-
pertrophic scars or keloids in previous reports.
Furthermore, our analysis of 378 patients who had
been diagnosed with hypertrophic scars/keloids
and were treated in our facility revealed that 1.06
percent of the lesions were actually caused by
other diseases although, fortunately, all of the dis-
eases were benign.12 Thus, we recommend that the
parameters listed in Table 2 be reviewed before
planning treatment for suspected keloids/hyper-
trophic scars (Fig. 1, A, and Fig. 2, A).
Table 2. Excluding the Possibility That the Lesions
Are Caused by Similar-Looking Diseases
The following parameters should be considered before the
treatment of keloids/hypertrophic scars is planned.
1. A biopsy should be conducted in anomalous cases.
2. Corticosteroid injections should be performed only
after carefully excluding the possibility that
malignancies or infections may be present.
3. It should be remembered that it is particularly
challenging to accurately differentially diagnose
African Americans because the color of their skin
scars and tumors is often similar.
PREVENTION OF HYPERTROPHIC
SCARS AND KELOIDS
Hypertrophic scars occur when there are
major skin wounds, including those resulting
from surgery, trauma, and burns. In contrast,
keloids can arise from very small injuries or weak
inflammation processes, including acne and in-
jections. Consequently, special care should be
taken when treating patients who have a history
of keloids. Risk factors that promote the devel-
opment of hypertrophic scars and keloids, and
that can be limited by physicians, are mechan-
ical force (stretching tension) on the wound,
wound infections, and foreign body reactions
(Table 3).

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Volume 125, Number 2 • Treatment of Hypertrophic Scars
Table 3. Key Points for Preventing Hypertrophic Scar
and Keloid Development
Key Points
1. Avoid excessive movements that stretch the wound, and
use bandages and appropriate garments.
2. Avoid subjecting the wound to direct mechanical force
(e.g., friction, scratching) and use gel sheeting and
taping.
3. For patients with earlobe wounds, minimize contact
with pillows when lying down to avoid friction.
4. For female patients with chest wounds, tight brassieres
and underwear should be worn to avoid the skin-
stretching tension caused by the weight of the breasts.
5. For patients with suprapubic wounds, a belly-warmer tie
or garment is recommended.
6. After surgery and injury, the wound should be kept
clean by means of irrigation and application of
antibacterial/antimycotic agents.
7. After surgery and injury, contact of the wounded
dermis (including earlobe pierce holes) with foreign
bodies should be avoided.
Mechanical Force (Skin Stretching Tension)
It is well known that hypertrophic scars/ke-
loids occur frequently on particular sites, includ-
ing the anterior chest, shoulder, scapular area,
lower abdomen, suprapubic region, and earlobe.13
These sites all have in common the fact that they
are frequently subjected to skin stretching caused
by the natural daily movements of the body. In
contrast, hypertrophic scars/keloids occur very
rarely on the scalp and the anterior lower leg,
where bones lie directly under the skin and the
skin is rarely subjected to stretching tension. This
site-specificity of hypertrophic scars/keloids sug-
gests that to prevent the development of keloids
and hypertrophic scars, it would be useful to avoid
subjecting wounded skin to sustained mechanical
force, thereby permitting the wound to rest and
heal normally. Supporting this is the fact that ke-
loid growth patterns can be simulated by com-
puter analysis of skin-stretching tension.14 More-
over, Aarabi et al.15 recently described an animal
model of hypertrophic scars where hypertrophic
scar–like lesions developed when mechanical
force was applied to wounds on the backs of mice.
To limit skin stretching during healing and
thereby facilitating appropriate wound resting,
wounds should be covered by fixable materials,
including tape, bandages, garments, or silicone
gel sheets. Supporting this is a study by Atkinson
et al.,16 who reported a randomized controlled
trial of the effect of tape fixation on the prevention
of hypertrophic scars after cesarean section in 70
subjects. They found that scar volume decreased
significantly when paper tape was used. The ran-
domized controlled trial of Gold et al.17 also
showed that silicone gel sheeting significantly re-
duces the incidence of hypertrophic scars or ke-
loids in high-risk subjects with a history of abnor-
mal scarring. The randomized controlled trial of
Chan et al.18 also revealed that silicone gels may be
able to prevent the development of hypertrophic
scars after sternotomy-associated wounding. How-
ever, when O’Brien and Pandit19 conducted a
meta-analysis of 13 trials involving 559 individuals,
they found that there was only weak evidence that
silicone gel sheeting can prevent abnormal scar-
ring in high-risk individuals. Further randomized
controlled trial studies will be necessary to eluci-
date this issue fully.
Wound Infections and Foreign Body Reactions
Both infections and foreign body reactions pro-
long the inflammation process associated with
wound healing. It is likely that infections and foreign
body reactions induce the abnormal secretion of
proinflammatory mediators that in turn prompt ab-
normal responses by fibroblasts.20 Thus, it is crucial
that wounds are kept clean by means of irrigation
after surgery and injury. Moreover, the contact of
wounded dermis (including in earlobe piercing)
with foreign bodies should be avoided.
TREATMENT OF HYPERTROPHIC
SCARS
Hypertrophic scars become obvious within
weeks after injury, after which they rapidly in-
crease in size for 3 to 6 months. Then, after a static
phase, they begin to regress. However, for those
hypertrophic scar cases with scar contractures (es-
pecially joint contractures) that could result in
functional dysfunction,21 surgery is indicated.
Surgery
Releasing scar contractures improves joint func-
tion and also accelerates the maturation of sur-
rounding immature scars and hypertrophic scars
(Fig. 1, B). Small and linear hypertrophic scars can
be treated by complete surgical resection (Fig. 1, C)
or nonsurgical multimodal therapy (Fig. 1, D). In
these cases, a type of tension-releasing technique,
which includes Z-plasty, W-plasty, and small wave
incision, should be applied to prevent the recur-
rence of hypertrophic scars.22 Intractable recurrent
hypertrophic scars should be treated according to
the keloid treatment algorithm, where the combi-
nation of surgery and adjuvant therapy is the treat-
ment of choice23,24 (Fig. 1, E, and Fig. 4).
With regard to suture materials, the random-
ized controlled trial performed by Luck et al.25
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 Plastic and Reconstructive Surgery • February 2010

Fig. 4. Treatment of hypertrophic scars by surgery: (left) 2 years after burn injury and (right) 1 year
afterskingrafting.Thehypertrophicscarsinthiscasehadnotimprovedinthe2yearssincetheburns
weresustained.Indeed,mildscarcontracturesdeveloped,especiallyonthefirstweb.Consequently,
all scars were removed and reconstructed by full-thickness skin grafts harvested from the inguinal
region. Surgery is sometimes effective for such intractable hypertrophic scar cases.

revealed that absorbable and nonabsorbable su-
tures do not differ significantly in terms of the
rates at which facial hypertrophic scars form. How-
ever, when Durkaya et al.26 performed a similar
randomized controlled trial, this time on hypertro-
phic scars that develop after midline sternotomy in-
cision, they found that the use of nonabsorbable
sutures diminished the risk of hypertrophic scars.
Thus, the choice of suture materials depends on the
site of application, with nonabsorbable sutures being
more suitable for high-skin-tension sites such as the
anterior chest wall.
Nonsurgical Therapies
Hypertrophic scars without scar contractures
improve naturally during the process of scar mat-
uration (Fig. 5). However, various nonsurgical
therapies can accelerate this process and improve
the subjective symptoms. Thus, it is recommended
that hypertrophic scars without scar contractures
should be treated by one or more of the multiple
nonsurgical therapies available, especially the
noninvasive therapies, which include compression
therapy and gel sheeting (Fig. 1, D).
Compression Therapy
The randomized controlled trial of Chang
et al.27 that examined the effectiveness of pressure
therapy in 122 cases found that when pressure
garment–treated and untreated groups were com-
pared in terms of their average age, surface area
of the burn on the body, length of hospital stay, or
time to wound maturation, significant differences
between the groups were not observed. However,
when Van den Kerckhove et al.28 performed a
similar randomized controlled trial, but more pre-
cisely measured the pressure applied, they found
that pressure garments that deliver a pressure of
at least 15 mmHg tend to accelerate scar matura-
tion. The mechanisms by which pressure can ac-
celerate scar maturation should be elucidated. In
the meantime, it seems that applying appropriate
amounts of pressure on hypertrophic scars could
be a useful therapeutic technique.
Gel Sheeting
Gel sheeting therapy can be used in two set-
tings, namely, to prevent hypertrophic scars after
surgery and to treat hypertrophic scars.19 Regard-
ing the latter application, Maján29 reported a ran-
domized controlled trial that revealed that pa-
tients treated with soft silicone dressings showed
greater and more rapid improvement in hyper-
trophic scar maturation than untreated patients.
Moreover, the randomized controlled trial con-
ducted by Li-Tsang et al.30 indicated that silicone
gel sheeting helps to reduce the thickness, pain,
itchiness, and rigidity of severe hypertrophic scars.
Regarding the materials from which gel sheets
are made, de Oliveira et al.31 examined the effec-

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Fig. 5. Naturally healing hypertrophic scars. (Left) Granulation tissues immediately after the burn wounds were sustained. (Center)
Hypertrophic scars 2 years after the burn wounds were sustained. (Right) Mature scars 5 years after the burn wounds were sustained;
hypertrophic scars without scar contractures improve gradually during the process of scar maturation, despite minimal noninvasive
treatment being applied. However, textural improvements take longer to manifest.

tiveness of nonsilicone gel sheeting in their ran-
domized controlled trial and concluded that sili-
cone and nonsilicone gel dressings are equally
effective. Akaishi et al.32 used a computer analysis
to show that silicone gel sheeting reduces the ten-
sion on the hypertrophic scar. They concluded
that it is vital that gel sheets are soft and elastic.
However, So et al.33 reported that improved
patient education increases their compliance in
silicone gel sheeting therapy, as patients partici-
pating in an improved education program had
significantly better ratings regarding scar border
height and thickness at 6 months than the con-
ventionally educated patients. These observations
suggest that hypertrophic scars are most effectively
treated with gel sheets if the patients are properly
educated, whereas the type of material used to
construct gel sheets may be a less important factor.
Corticosteroid Injection
It has been suggested that synthetic cortico-
steroids decrease the production of inflammatory
cytokines, chemokines, adhesion molecules, lyso-
somal enzymes, and tissue inhibitor of metallo-
proteinase, and inhibit fibroblast proliferation.34
However, the disadvantages of corticosteroid
treatment include severe pain caused by the in-
jection and systemic side effects that include men-
strual dysfunction in women, the suppression of
adrenal cortical function, and the development of
cataracts or glaucoma. The local side effects in-
clude thinning and atrophy of the skin and sub-
cutaneous tissues, development of steroid acne,
capillary dilatation, and hypopigmentation. These
complications can hamper the use of corticoste-
roids in combination treatments. Indeed, cortico-
steroid-based treatment of hypertrophic scars re-
quires careful planning with the patient. An
international panel of experts that reviewed the
available clinical literature has recommended that
corticosteroid doses of 2.5 to 40 mg per site should
be used,2 but additional randomized controlled
studies are needed to determine the appropriate
site-specific dose.
Laser
Wittenberg et al.35 and Alster36 reported ran-
domized controlled trials examining the efficacy
of pulsed dye laser therapy combined with silicone
gel sheeting and steroid injection, respectively,
but found that these combination therapies did
not yield significant effects. However, pulsed dye
laser irradiation alone effected a substantial clin-
ical and histologic improvement. The randomized
controlled trial performed by Allison et al.37 also
suggested that pulsed dye laser is an effective treat-
ment for the intense pruritus that is often expe-
rienced during the healing process after a burn
injury. However, this study did not reveal other
significant benefits, including reductions in scar
redness or improvements in the height and texture
of the scar. Manuskiatti and Fitzpatrick38 reported
that pulsed dye laser applied at a pulse width of 0.45
msec was more effective in decreasing scar size and

563
 Plastic and Reconstructive Surgery • February 2010
improving scar pliability than a pulse of 40 msec. In
conclusion, pulsed dye laser on its own may be useful
for treating hypertrophic scars.
Others
Invasive treatments, including cryotherapy and
5-fluorouracil injections, should not be used to treat
hypertrophic scars, although they may be effective
with keloids (see below). However, noninvasive ex-
ternal and internal agents such as ointments and
gels, tape, and nonsteroidal antiinflammatory drugs
are useful for treating hypertrophic scars, although
their effects are limited because they mainly reduce
subjective symptoms (e.g., itching and pain).
Corticosteroid ointments, tape, and nonste-
roidal anti-inflammatory drugs have been shown
to be effective in reducing symptoms, but further
randomized controlled trials are required to fully
elucidate the therapeutic potential of these agents.
Several randomized controlled trials have been per-
formed to test the benefits of onion extract gels39,40
and mugwort lotion,41 but these agents do not seem
to improve objective symptoms.
Oral administration of another internal agent,
namely, the antiallergic drug tranilast,42 appears to
reduce the symptoms of hypertrophic scars. It is well
known that tranilast also effectively reduces the rate
of restenosis of coronary arteries (which is a type of
fibrosis similar to hypertrophic scars) after percuta-
neous transluminal coronary angioplasty.43 Thus,
this drug is promising as a hypertrophic scar therapy.
Finally, to manage the psychological stress of
patients, makeup or camouflage therapy44 should
be considered, as these therapies improve not only
the cosmetic appearance of the scars, but also
reportedly promote physiologic changes.45 This
issue warrants scientific study.
TREATMENT OF KELOIDS
Unlike when hypertrophic scars are treated, the
size and number of keloid lesions should be deter-
mined before planning the treatment. In other
words, are the keloid lesions small and single or large
and multiple? This categorization is necessary be-
cause small (early) and single keloids can be treated
radically (Fig. 2, B), which is an approach that has
been facilitated by the improvement in our under-
standing of adjuvant therapies after primary surgery
(Fig. 2, D).23,24,34,46–48 Several therapeutic approaches,
including laser treatment,38,49 are also effective as
monotherapies in the radical treatment of early ke-
loids (Fig. 2, E). Nonsurgical conservative therapies
alone do not seem to be effective for treating
keloids.2 In particular, careful discussions and goal-
setting with patients are essential steps in the man-
agement of large and multiple keloids (Figs. 2 and
564
6, below, left). Patients with such keloids usually have
major problems, including infections (e.g., inclu-
sion cysts) and pain. Consequently, mass reduction
surgery (Fig. 2, F) and symptomatic multimodal ther-
apies (Fig. 2, G) can be considered on a case-by-case
basis.
Surgery
Surgery can be used to treat keloids in two
ways: first, radically resecting keloids (Fig. 2, D);
and second, reducing keloid mass (Fig. 2, F). Rad-
ical resection should be combined with adjuvant
therapy because keloid excision alone is associated
with a high rate of recurrence (45 to 100 percent).2
With regard to the mass reduction approach, it
should be used only to remove infected regions and
to reduce enough of the keloid(s) to effect symp-
tomatic improvement. Adjuvant therapy after mass
reduction surgery is not recommended because this
could lead to excessive exposure to radiation or the
side effects of corticosteroids.
Corticosteroid Injections
Corticosteroid injections can be used to treat
keloids in three ways: first, as an adjuvant therapy
that is to be combined with surgery (Fig. 2, D);
second, as a monotherapy for the radical treat-
ment of keloids (Fig. 2, E); and third, as a com-
ponent of multimodal therapy for the treatment
of symptoms (Fig. 2, G). In a prospective trial
performed by Kiil,50 52 patients were treated with
triamcinolone injections alone, whereas 15 pa-
tients received the steroid therapy together with
keloid excision. The combined treatment and in-
jection therapy alone were similarly effective.
However, partial recurrence was observed in one-
third of the cases after 1 year, regardless of the
treatment that had been applied, whereas after 5
years, the recurrence rate was 50 percent. Muneu-
chi et al.51 reported that corticosteroid injection
monotherapy had beneficial long-term outcomes,
with 82 percent of 63 patients experiencing an
improvement in subjective symptoms. Combining
corticosteroid injections with 5-fluorouracil,38,52
pulsed dye laser,52 and cryotherapy53–55 has been
reported to be more beneficial than corticosteroid
injection monotherapy, although there are too
few randomized controlled trials testing these is-
sues to be able to draw solid conclusions.
Cryotherapy
Cryotherapy has been used to treat keloids ei-
ther as a monotherapy or in combination with in-
tralesional triamcinolone injection. Cryotherapy de-
Volume 125, Number 2 • Treatment of Hypertrophic Scars

Fig. 6. Typical severe keloids: (above, left) 9 years ago, (above, right) 5 years ago, (below, left) 2 years ago, and
(below, right) in their current state. Keloids grow not only vertically but also horizontally. In the case presented here,
the various keloids grew over 9 years to the point they had merged. However, the central area of the keloid mass
has become depressed and become mature scar.

livery methods include contact,56 sprays,55–57 and Radiation

intralesional needles.58,59 Layton et al.60 found from
their randomized controlled trial that early, vascular
lesions responded to cryosurgery significantly better
than larger lesions. It should be noted that cryother-
apy should be limited to small regions, as it induces
severe pain and hypopigmentation.
The mechanism by which cryotherapy reduces
keloids is very interesting. It is well known that
hypertrophic scars and keloids occur on burned
skin areas but not on frostbitten areas. It appears
that although burning and frostbite both induce
apparent tissue necrosis, they induce the secretion
of quite different proinflammatory mediators; the
response to these inflammatory signals by the fi-
broblasts may also differ. Further basic research
should be performed to elucidate these mecha-
nistic discrepancies.
Combining surgery with postoperative radiation
therapy has been suggested to more effectively treat
keloids than radiation monotherapy.61 The success
rate of this combined approach varies between 67
and 98 percent,62 although few randomized con-
trolled trials have been performed to test the effec-
tiveness of this technique. In many institutions, radia-
tion is initiated right after surgery, and the total dose is
limited to 20 Gy over several administrations.23,24,47
Guix et al.46 described keloid treatment using high-
dose-rate brachytherapy and concluded that it treats
keloids more effectively than superficial x-ray or low-
energy electron beam administration.
An important concern associated with keloid ra-
diation therapy is the risk of inducing malignant
tumors. However, in the reported cases where
malignant tumors arose after keloid radiation

565
 Plastic and Reconstructive Surgery • February 2010
therapy,63– 67 it remains unclear whether the radia-
tion therapy involved appropriate radiation doses
and adequate protection of the surrounding tissues,
especially the mammary glands and thyroid. To ad-
dress this issue, Leer et al.68 performed a question-
naire-based study in which radiation oncologists in
508 facilities throughout the world were asked about
the indications of radiation therapy for keloids. The
radiation oncologists in 78 percent of the facilities
replied that keloids are an accepted indication for
radiation therapy. Moreover, of the 77 facilities lo-
cated in the United States and Canada, over 90 per-
cent found that radiation therapy for keloids is ac-
ceptable. It should be noted that plastic surgeons
generally avoid radiation therapy for benign tumors,
including keloids, for fear of inducing malignant
tumors. The latter study suggests that surgeons
should perhaps liaise more closely with radiation
oncologists before excluding the possibility of radi-
ation therapy for keloids.69
Antitumor/Immunosuppressive Agents
Uppal et al.70 and Nanda and Reddy71 have
reported randomized controlled trials that tested
the efficacy of 5-fluorouracil for treating keloids.
The keloid scar scores of the majority of patients
improved by more than 50 percent after 5-flu-
orouracil treatment. Haurani et al.72 found from
studying a prospective case series (n ⫽ 32) that
intralesional 5-fluorouracil treatment after sur-
gery prevented recurrence, as the recurrence rate
was 19 percent at the 1-year follow-up. The authors
recommended the use of 50 mg per session, with
a total exposure of 500 mg. However, Fitzpatric73
and Gupta and Kalra74 have reported using up to
150 mg per session, with total doses being between
1200 and 2400 mg. Further work to determine the
appropriate dose should be initiated.
Naeini et al.75 have reported that bleomycin is
effective in treating keloids, and the randomized
controlled trial of Broker et al.76 revealed that inter-
feron ␥ therapy is also effective. However, Davison et
al.77 reported that their randomized controlled trial
of interferon ␣-2b showed it was not effective in
treating the 39 keloids examined and they con-
cluded that it is not useful for the clinical manage-
ment of keloids. These therapies should be studied
by additional randomized controlled trials.
LONG-TERM FOLLOW-UP OF
HYPERTROPHIC SCARS AND KELOIDS
AFTER TREATMENT
It is important that sequentially treated hyper-
trophic scar and keloid patients are followed up
566
over the long-term and are appropriately edu-
cated about managing their scars (Fig. 1, F and
Fig. 2, H). With regard to hypertrophic scars, it is
important that wounds are not subjected to me-
chanical force (skin-stretching tension) and are
allowed to rest by using gel sheeting or tape fix-
ation, and that these measures be sustained until
the hypertrophic scars become mature scars. With
regard to massage therapy for hypertrophic scars,
Patiño et al.78 reported that it did not appreciably
improve the vascularity, pliability, or height of hy-
pertrophic scars, although a decrease in pruritus
was observed in some patients. Thus, there is little
evidence that suggests massage accelerates hyper-
trophic scar maturation.
CONCLUSIONS
Many plastic surgeons, especially those in non-
Caucasian societies, avoid treating abnormal scars
because of their high frequency of recurrence.
However, over the past decade, many more ran-
domized controlled trials addressing abnormal
scar management and treatment have been per-
formed. This means there is now sufficient evi-
dence-based information for us to start devising
standard international algorithms of abnormal
scar treatment. Here, algorithms for the treatment
of hypertrophic scars and keloids have been pro-
posed. However, these algorithms should be opti-
mized for each human race. They are also likely to
improve significantly as our knowledge of scar biol-
ogy progresses, higher quality clinical trials are per-
formed, and new agents to treat scars are developed.
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
r.ogawa@nms.ac.jp
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