Assessment of intralesional injection of botulinum toxin type A in hypertrophic scars and keloids: Clinical and pathological study.

Keloids and hypertrophic scars are cosmetic problems with significant morbidity. Many clinical modalities were tried in order to modulate the disfigurement related to these pathologic scars. To evaluate the clinical and histopathological effects of Botulinum toxin type A (BTX-A) injection on keloids and hypertrophic scars. Twelve patients with keloids and 8 with hypertrophic scars were enrolled in this study. Botulinum toxin type A was injected intralesional (1 session/month) for three sessions. Clinical outcome was assessed via Vancouver Scar Scale (VSS), Observer Scar Assessment Scale (OSAS), and the Patient Scar Assessment Scale (PSAS). Histologic grading scores were used to assess the changes in the quality of collagen and elastic tissues and image analysis was used to detect their quantitative morphometric changes. This study showed a high statistically significant difference between baseline and the result after each of the three sessions of injection and 3, 6 months after the last session regarding VSS, OSAS, and PSAS with p value ≤0.001 for each. The study also showed that there was a statistically significant difference between the histopathologic findings before injection of BTX and 1 month after the third session regarding all parameters used. Botulinum toxin type A can be a good therapeutic maneuver for management of keloid and hypertrophic scars with significant clinical and histologic improvement.

Assessment of laser-assisted delivery vs intralesional injection of botulinum toxin A in treatment of hypertrophic scars and keloids.

Keloids and hypertrophic scars could impair the psychological, physical, and cosmetic aspects of the patient's quality of life. Unfortunately, there is no curative treatment available till now. This study aimed to evaluate the efficacy and safety of intralesional vs topical botulinum toxin A combined with Fractional CO2 laser in the treatment of hypertrophic scars and keloids. Twenty patients with Keloids and hypertrophic scars were enrolled in the study. Each scar was divided into two halves, one subjected to intralesional injection of botulinum toxin type A once a month for 4 months and the other was subjected to four sessions of CO2 laser therapy at 1 month interval followed by topical application of botulinum toxin A. Significant improvement was noted in Vancouver Scar Scale in hypertrophic scars in laser group than intralesional botulinum toxin A. In keloid cases, the improvement was significantly higher with intralesional botulinum toxin A. Clinical improvement showed significant negative correlation with scar duration and size. Botulinum toxin A is a promising treatment for hypertrophic scars and keloids. The use of fractional CO2 laser as a mode of delivery enhanced the efficacy of botox in hypertrophic scars.

Assessment of intralesional injection of botulinum toxin type A injection for hypertrophic scars.

BACKGROUND: Hypertrophic scars are dermal fibroproliferative disorders that typically develop after a skin injury heals. They can cause physical, psychological, and cosmetic problems. The management of such scars remains a matter of debate due to lack of effective treatment methods and the inability to prevent recurrences. Recent reports have demonstrated that botulinum toxin type A improves wound healing so it may play a role in treating hypertrophic scars. AIMS: We assessed the effectiveness of intralesional botulinum toxin type A injection for treating hypertrophic scars. METHODS: This prospective clinical study included twenty patients with hypertrophic scars. Intralesional injection of botulinum toxin type A was given once a month for three months with a follow-up period of six months. Each lesion was injected until slight blanching occurred. Therapeutic satisfaction of the patient and physician were recorded. Lesions were assessed for erythema, itching and pliability. Each item was assessed on a 5-point scale. RESULTS: Therapeutic satisfaction was recorded as 'good' in 14 patients and 'excellent' in the remaining six. The mean erythema score decreased from 3.2 to 1.0, the mean pliability score from 3.3 to 0.8 and the mean itching score from 2.7 to 0.7. All of these were statistically significant. LIMITATIONS: A larger sample size and longer follow-up period would have given a better evaluation but was not feasible due to the high expenses involved. CONCLUSION: Botulinum toxin type A is a novel and promising therapy for hypertrophic scars with few side effects.

Evaluating an outreach service for paediatric burns follow up.

Complications following paediatric burns are well documented and care needs to be taken to ensure the appropriate follow up of these patients. Historically this has meant follow up into adulthood however this is often not necessary. The centralisation of burns services in the UK means that patients and their parents may have to travel significant distances to receive this follow up care. To optimise our burns service we have introduced a burns outreach service to enable the patients to be treated closer to home. The aim of this study is to investigate the impact of the introduction of the burns outreach service and within this environment define the optimum length of time needed to follow up these patients. A retrospective analysis was carried out of 100 consecutive paediatric burns patients who underwent surgical management of their burn. During the follow up period there were 43 complications in 32 patients (32%). These included adverse scarring (either hypertrophic or keloid), delayed healing (taking >1 month to heal) and contractures (utilising either splinting or surgical correction). Fifty-nine percent of these complications occurred within 6 months of injury and all occurred within 18 months. Size of burn was directly correlated to the risk of developing a complication. The outreach service reduced the distance the patient needs to travel for follow up by more than 50%. There was also a significant financial benefit for the service as the follow up clinics were on average 50% cheaper with burns outreach than burns physician. Burns outreach is a feasible service that not only benefits the patients but also is cheaper for the burns service. The optimum length of follow up for paediatric burns in 18 months, after which if there have not been any complications they can be discharged.

A modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA): Inter-rater reliability of an innovative burn scar assessment method.

BACKGROUND: Current scar assessment methods do not capture variation in scar outcome across the burn scar surface area. A new method (mVSS-TBSA) using a modified Vancouver Scar Scale (mVSS) linked with %TBSA was devised and inter-rater reliability was assessed. METHOD: Three raters performed scar assessments on thirty patients with burn scars using the mVSS-TBSA. Scoring on pigmentation, vascularity, pliability and height was undertaken for the 'best' and 'worst' areas of each scar. Raters allocated the total body surface area of the scar (%TBSA) to three mVSS categories (<5, 5-10, >10). Intra-class correlation coefficient (ICC) and weighted kappa statistic (kw) were used to assess inter-rater reliability. The data were also analysed for clinically relevant misclassifications between pairs of raters. RESULTS: Total mVSS scores showed 'fair to good' agreement (ICC 0.65-0.73) in the 'best' area of the scar while there was 'excellent' agreement in the 'worst' scar area (ICC 0.85-0.88). The kw of the individual mVSS components ranged from 0.44 to 0.84 and 0.02 to 0.86 for 'best' and 'worst' scar areas, respectively. Determination of scar %TBSA had 'excellent' reliability (ICC 0.91-0.96). Allocation of scar %TBSA to severity category <5 mVSS demonstrated 'good to excellent' reliability (ICC 0.63-0.80) and 'fair to good' reliability (ICC 0.42-0.74) for 5-10 mVSS category. However, misclassifications were observed for the total mVSS score in the 'worst' scar area and the allocation of scar %TBSA in the <5 mVSS category. CONCLUSION: Inter-rater reliability of mVSS scores depends on the severity of the scar area being assessed. The mVSS-TBSA method of allocation of scar %TBSA to two broad mVSS categories, namely <5 and ≥5 mVSS, has 'good to excellent' reliability. The mVSS-TBSA has demonstrated utility for both clinical and research purposes; however, there is potential to misclassify scar outcome in some cases.

Computerised colour: a technique for the assessment of burn scar hypertrophy. A preliminary report.

A technique for the objective measurement of one parameter of burn scar hypertrophy is described. The technique involves capturing a video camera image on a computer and subsequent quantitative analysis of the colour of the scar using a custom-written computer programme. By analysing multiple areas and comparing the identical areas over the course of treatment, it is theoretically possible to measure the progress and compare differing modes of therapy.

The cutometer and ultrasonography in the assessment of postburn hypertrophic scar--a preliminary study.

Sixteen patients with various degrees of postburn hypertrophic scars were evaluated by ultrasonography and elastometry. An Aloka Echo Camera (SSD-500) with a 7.5 MHz probe and a Cutometer SEM 575 skin elastometer were used. Serial monthly examinations were performed using both pieces of equipment. In some patients, more than one scar was assessed. The assessments were correlated with clinical grading of the progress of the scars. It was noted that ultrasonography was very sensitive in the localization of scar tissues, distinguishing them from normal skin, assessment of thickness and also delineation of the extent of scar tissues. The subcutaneous part of the scar could be assessed. Cutometer SEM 575 is a new machine that applies a gentle suction to the skin to measure its viscoelasticity. It is sensitive, the inter-observer variation is low, and it could be used for the grading of a scar. These two assessment techniques compliment other methods of scar assessment and will prove useful when assessment of response to treatment is required.

The 1996 Clinical Research award. Use of a pneumatonometer in burn scar assessment.

The evaluation of wound outcome after burn injury is a challenging problem in the performance of clinical trials evaluating potential impact on wound healing and scar formation. The purpose of this study was to determine whether an ocular tonometer could be adapted to provide an objective measurement of scar compliance. A pneumatonometer was used to perform measurements of cutaneous compliance at 8 anatomic areas (14 separate sites) on each of 17 normal volunteers and on 59 burn scars. Comparison of different anatomic sites showed there to be significant differences in the cutaneous compliance of different areas. The aggregate compliance of the burn scars in all sites was less than that of the control sites. These results indicate that the pneumatonometer can discern differences in the compliance of normal skin and differences between normal skin and scar and suggest that it may be a useful tool in the objective assessment of scar formation.

A method of recording and objective assessment of hypertrophic burn scars.

A technique for recording the shape and size of hypertrophic burns scars during conservative treatment is described. This technique is extremely useful not only for an objective assessment of the healing process but also as an adjunctive research method for comparing two or more differing techniques of treatment. After taking a negative impression of the scar using dental impression material, a positive cast model of the scar is made, which is a three-dimensional copy of the scar. These cast models can be easily obtained and are very precise. They represent the height, size and general appearance of the scar, so that by taking positive impression models at regular intervals, and combining them with photographic and tonometric evaluations, they help in the evaluation of conservative treatment or in studying the mode of action of treatment.