ABSTRACT
To date, silicone gel and silicone occlusive plates are the most useful and effective treatment options for hypertrophic scars (surgical and traumatic). Use of silicone sheeting has also been demonstrated to be effective in the treatment of minor keloids in association with corticosteroid intralesional infiltration. In our practice, we encountered four problems: maceration, rashes, pruritus and infection. Not all patients are able to tolerate the cushion, especially children, and certain anatomical regions as the face and the upper chest are not easy to dress for obvious social, psychological and aesthetic reasons. In other anatomical regions, it is also difficult to obtain adequate compression and occlusion of the scar. To overcome such problems of applying silicone gel sheeting, we tested the use of liquid silicone gel (LSG) in the treatment of 18 linear hypertrophic scars (HS group) and 12 minor keloids (KS group) as an alternative to silicone gel sheeting or cushion. Objective parameters (volume, thickness and colour) and subjective symptoms such as pain and pruritus were examined. Evaluations were made when the therapy started and after 30, 90 and 180 days of follow‐up. After 90 days of treatment with silicone gel alone (two applications daily), HS group showed a significant improvement in terms of volume decrease, reduced inflammation and redness and improved elasticity. In conclusion, on the basis of our clinical data, we find LSG to be a useful method to overcome the difficulties of applying silicone gel sheeting on irregular surface.
Keywords: Dermatologic surgery, Hypertrophic scar, Keloid, Liquid silicone gel, Plastic surgery, Scar therapy, Scar treatment
Introduction
Keloids and hypertrophic scars, despite continuous improvement of the treatment techniques and new information available about the technology, remain a significant problem for aesthetic and plastic surgeons.
To date, silicone gel sheetings are the most useful and effective treatment option for surgical and post‐traumatic hypertrophic scars 1, 2.
Their use has also been recommended in the treatment of minor keloids in association with corticosteroid intralesional infiltration 1, 3, 4.
Some authors suggested that silicone gel sheeting should be routinely used to prevent hypertrophic scars and keloids 5, 6, 7 but in our practice, when using silicone gel sheetings and dressings, we encountered four different problems: maceration, rashes, pruritus and infection in 10–25% of case data in line with the existing literature 8, 9.
In some cases, it is difficult to obtain a good contact of the silicone cushion on the scar surface, especially when the scar is too prominent above the surrounding skin.
Likewise, in some anatomical regions such as the sternum, retroauricular region, penis, joints and flexures, it is complicated to obtain adequate compression and occlusion of the scar if complex retaining garments are not used.
In these cases, adhesive tapes must be used for fixing the silicone cushion or sheet, exposing the patients to the phenomenon of skin hypersensitivity.
Moreover, not all patients are able to tolerate the cushion for more than a few hours, especially children, and in some anatomical regions such as the face and décolleté for obvious social, psychological and aesthetic reasons 10, 11.
In these selected cases, to overcome the difficulties of applying silicone gel sheeting, we propose the use of liquid silicone gel (LSG) as an alternative to silicone gel sheeting or cushion.
However, the aim of this study is to determine if LSG is an useful and effective method to treat keloids and hypertrophic scars instead of silicone gel sheeting or cushions, especially when these devices are difficult to apply or not tolerated by patients.
Materials and methods
Thirty Caucasian patients (16 males and 14 females) with keloids and hypertrophic scars in different anatomical regions were enrolled to participate in the study. The patients were volunteers and they provided written informed consent to participate in this clinical study. Twelve of 30 patients were affected by keloids (KS) in anatomical regions where it is difficult obtain a good occlusion with silicone gel sheetings or cushions (two sternum, two earlobe, three neck, two mental region, two deltoid and one leg) (Table 1).
Table 1.
Scar localisation in patients (N = 30)*
| Patients with minor keloid scars (KS group) | Scar location | Patients with linear hypertrophic scars (HS group) |
|---|---|---|
| 3 | Neck | 5 |
| 2 | Deltoid | 2 |
| 2 | Earlobe | 0 |
| 2 | Mental region | 1 |
| 2 | Sternum | 5 |
| 0 | Back | 4 |
| 0 | Nose | 1 |
| 1 | Leg | 0 |
| 12 | Total | 18 |
HS, hypertrophic scars; KS, keloidic scars.
Forty‐eight patients were divided in two groups related to the clinical appearance of the scars: patients with minor keloid scars (KS, n = 12) and patients with hypertrophic (surgical or traumatic) scars (HS, n = 18).
Eighteen of 30 patients were affected by hypertrophic scars (HS) in different anatomical regions (Table 1). Eleven patients with hypertrophic scars refused to use silicone gel sheets for dressing or tolerated it only for a few hours because localisation of the lesions was on the face or because they were children.
Thirty patients were divided into two groups related to the clinical appearance of the scars: patients with minor keloid scars (KS, n = 12) and patients with hypertrophic (surgical or traumatic) scars (HS, n = 18).
The assessment of scar volume modification was evaluated using an Elite H‐D Putty Vinyl polysiloxane high‐precision (>99·5%) impression material (Zhermack, Badia Polesine, Italy) and water displacement method. In addition, objective parameters (hardness and colour) were evaluated on a scale from 0 to 3 (the lowest score was better) by three separated plastic surgeons who did not participate in the study. The subjective complaints such as pain and pruritus sensation were examined using a Visual Analogic Scale (VAS) with values ranging from 0 to 10 (the lowest score meant a minor pain and pruritus). Symptoms and objective data were assessed when the therapy started and after 30, 90 and 180 days of follow‐up (Tables 2 and 3).
Table 2.
Changes in objective and subjective parameters in HS group (18 patients) treated with LSG *
| Baseline | 90 days after | 180 days after | |
|---|---|---|---|
| Volume (cm3) | 3·13 ± 0·53 | 1·1 ± 0·7 | 1 ± 0·1 |
| Redness† | 2·6 ± 0·52 | 1·1 ± 0·3 | 0·5 ± 0·3 |
| Hardness‡ | 2·1 ± 0·8 | 0·7 ± 0·6 | 0·7 ± 0·3 |
| Pain§ | 7·2 ± 0·3 | 3·5 ± 0·2 | 1·5 ± 0·3 |
| Pruritus¶ | 8·2 ± 0·2 | 3·3 ± 0·3 | 1·2 ± 0·2 |
HS, hypertrophic scars; LSG, liquid silicone gel; VAS, Visual Analogic Scale.
All results are mean ± standard deviation.
Redness: 3, severe redness; 2, redness disappears with pressure; 1, no redness, but alteration in skin tone; 0, no differences with surrounding skin.
Hardness: 3, very hard, like cartilage; 2, rubbery hard; 1, partially soft; 0, soft (like normal skin).
Pain: 10, maximum pain; 0, no pain (VAS).
Pruritus: 10, maximum pruritus sensation; 0, no pruritus sensation (VAS).
Table 3.
Changes in objective and subjective parameters in KS group (12 patients) treated with corticosteroid intralesional infiltration and LSG *
| Baseline | 90 days after | 180 days after | |
|---|---|---|---|
| Volume (cm3) | 3·82 ± 0·7 | 2·1 ± 0·3 | 1·8 ± 0·1 |
| Redness† | 1·9 ± 0·3 | 1·1 ± 0·3 | 0·7 ± 0·2 |
| Hardness‡ | 2·8 ± 0·4 | 1·9 ± 0·1 | 0·7 ± 0·1 |
| Pain§ | 8·8 ± 0·3 | 4·5 ± 0·3 | 2·5 ± 0·2 |
| Pruritus¶ | 8·7 ± 0·5 | 4·9 ± 0·3 | 2·8 ± 0·2 |
KS, keloidic scars; LSG, liquid silicone gel; VAS, Visual Analogic Scale.
All results are mean ± standard deviation.
Redness: 3, severe redness; 2, redness disappears with pressure; 1, no redness, but alteration in skin tone; 0, no differences with surrounding skin.
Hardness: 3, very hard, like cartilage; 2, rubbery hard; 1, partially soft; 0, soft (like normal skin).
Pain: 10, maximum pain; 0, no pain (VAS).
Pruritus: 10, maximum pruritus sensation; 0, no pruritus sensation (VAS).
KS group was treated with five intralesional corticosteroid infiltrations (triamcinolone 1 mg/ml diluted with 4 ml of saline solution NaCl 0·9%, injected using a 2·5 ml syringe with a 25G needle) at time 0 and at 15, 30, 60 and 90 days, in association with a daily topical application of LSG (Kelo‐cote® Sinclair Pharmaceuticals Ltd, London, UK) that is a liquid, transparent gel containing 100% liquid polysiloxane.
HS group was treated with LSG alone, two daily applications for 90 days.
The study received the approval of the Ethical Committee of our Institution.
All results are presented as mean ± standard deviation.
Results
All patients tolerated the application of LSG well, and no complications were encountered during the clinical course of the study.
Age of scars was 15·1 ± 3·5 months (mean ± SD). Compared with the baseline appearance, a satisfactory clinical improvement (moderate to significant) was observed in 89% (16 of18) of hypertrophic scars after the treatment, whereas 11% (2 of 18) showed minimal improvement. At baseline, the average volume was 3·13 ± 0·53 cm3 (range 1·3–4·9 cm3) for HS group and 3·82 ± 0·7 cm3 for KS group (range 1·7–5·3 cm3). After 90 days of treatment, both groups showed a significant decrease in volume (Tables 2 and 3).
Volume reductions go together with a reduction in objective parameters (hardness and redness) for the HS group.
After 3 months of treatment with silicone gel alone (two daily applications), HS group showed a significant improvement in colour, thickness and associated symptoms (pain and pruritus) (Table 2; Figures 1 and 2).
Figure 1.
Hypertrophic scar.
Figure 2.
Hypertrophic scar after 180 days of treatment.
Alleviation of objective parameters, such as hardness and redness, and subjective complaints (pain and pruritus) was achieved after 90 days of treatment with silicone gel in KS group.
Improvement in scar characteristics and symptoms were also noticed.
Discussion
Nowadays, there is no ideal therapy for the treatment of keloids and hypertrophic scars, but there have been studies and progress in this field recently.
The best treatment includes various combinations such as the use of intralesional steroids (triamcinolone), surgical excision, silicone gel and others. We propose the use of silicone gel alone for hypertrophic scars and in association with intralesional infiltration of steroids in keloids. Analysing the results, we noticed that after about 3 months of treatment with LSG alone (two daily applications), the HS group showed a significant improvement of colour and thickness and the associated symptoms such as pain and pruritus decreased as well (Table 2).
Furthermore, the treatment has been tolerated well by patients and this is the rationale of our recommendation to use LSG, especially in children and in patients who have not had improvements with other treatment options.
In the 12 patients with keloid scars, the combination of intralesional corticosteroids and the application of silicone gel have been successful and physical characteristics of silicone gel explain the clinical benefits:
Partial occlusion and hydration of the stratum corneum.
Protection of the scar from infections and environmental stimuli.
The effect of static‐electric field induction – in order to repel the specific cells that promote scar growth.
In conclusion, to overcome the difficulties of applying silicone gel sheeting on irregular surfaces, silicone creams have been used to treat scars; several reports claimed improvement in scar characteristics and symptoms; however, these studies were anecdotal and uncontrolled.
On the basis of our clinical data, we find that LSG is a useful method to overcome the difficulties of applying silicone gel sheeting on irregular surfaces.
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