แผลเปนชนิดชนิดนูนและคีลอยด Hypertrophic scars and Keloids นายแพทย บุญชัย ทวีรัตนศิลป หนวยศัลยศาสตรตกแตง ภาควิชาศัลยศาสตร วิทยาลัยแพทยศาสตรกรุงเทพมหานครและวชิรพยาบาล
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แผลเปนชนิดชนิดนูนและคีลอยดHypertrophic scars and Keloids
นายแพทย บุญชัย ทวีรัตนศลิป
หนวยศัลยศาสตรตกแตง ภาควิชาศัลยศาสตร
วิทยาลัยแพทยศาสตรกรุงเทพมหานครและวชิรพยาบาล
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Keloid ear lobeHypertrophic scars resulting from burn
Abnormal healing resulted in abnormal scars
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IncidenceTrue incidence : unknown
Dark skin > white skin
All age groups : More common in 10-30 years old
Common sites : Ear lobes, Deltoid areas, Sternum areas, Back
Less common sites : Eye lids, Perineum, Palms and soles
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EtiologyUnknown
Fields of Study :
– Cytokines, growth factors and inflammatory mediators เชน TGF-β, CTGF,
PDGF, IGF-1, VEGF, ECGF, PAI-1, PGE2
– Keloid fibroblast metabolic activity
– Mechanical strain and focal adhesion complexes
– Aberrant anabolic wound healing processes
– Abnormal regulation of apoptosis secondary to gene mutations เชน p53, p63, p73
– Keloid epithelial-mesenchymal signaling
Butler PD, Longaker MT, Yang GP. Current Progress in Keloid Research and Treatment. J Am Coll Surg 2008;206(4):731-41.
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Hypertrophic scars Vs. Keloid scarsNatural history
Management
DifferencesDifferences
– Clinical
– Histology
– Biochemical
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Clinical Differences
ดัดแปลงจาก : Rahban SR, Garner WL. Fibroproliferative scars. Clin Plast Surg 2003;30(1):77-89.
Hypertrophic Scars Keloid
Borders Remains within original wound Grows beyond original wound
Onset Often develops weeks after surgery May develop months following injury
Contractures Present Absent
Regression Often partial within 1-2 years Infrequent
Pruritis/erythema Present Present
Extent of scar Related to initial depth of tissue injury Can far surpass initial extent of tissue
injury
Response to Surgery Well, especially with adjunctive therapy Poor, often worsening
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Hypertrophic scar
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Hypertrophic scar
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Hypertrophic scar
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Keloid
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Keloid
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Keloid
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Keloid
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Histological differences
ดัดแปลงจาก : Rahban SR, Garner WL. Fibroproliferative scars. Clin Plast Surg 2003;30(1):77-89.
Hypertrophic Scars Keloid
Connective tissue Increased Increased
Collagen structure Flatter and less distinct bundles,
fine fibers
Larger fibers with closely packed
fibrils
Orientation of fibers Wavy, but parallel to epidermis Random to epidermis
Myofibroblast Present Absent
α-Smooth muscle actin Present Absent
Density of blood vessels Increased Increased
Number of cells Increased Increased
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Hypertrophic scar
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Keloid
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Abnormal fibroblasts in both scars
ดัดแปลงจาก : Burd A, Huang L. Hypertrophic Response and Keloid Diathesis: Two Very Different Forms of Scar. Plast Reconstr Surg
2005;116(7):150e-57e.
Hypertrophic scar fibroblast Keloid scar fibroblasts
Proliferation rate Normal Increase
MMP-2 Increase Increase
MMP-9 Decrease Decrease
Collagen synthesis Increase Increase
Decorin synthesis Decrease Increase
Versican synthesis Increase Increase
Biglycan synthesis Increase Increase
Elastin synthesis Normal Increase
TGF-β production Increase Increase
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Biochemical differences
ดัดแปลงจาก Broughton G, Rohrich RJ. Wounds and Scars. Selected Reading in Plastic Surgery. 2005;10:24-33.
Biochemical Alteration Observation
Propyl hydroxylase Activity Keloid > HTS > Normal
Total collagen Synthesis Keloid > HTS > Normal
Cross-linking Normal > Keloid
Collagen Type I Content Keloid > Normal
Plasminogen activator inhibitor 1 (PAI-1) Levels Keloid > Normal
Chondroitin-4-sulfate Content Keloid, HTS > Normal
Glycosaminoglycans Content HTS > Normal
Fibrinonectin Synthesis Keloid > Normal
Receptor expression Keloid > Normal
Elastin Synthesis Keloid > Normal
Hyaluronic acid Degradation Normal > HTS
Apoptosis Normal > Keloid
Transforming growth factor--β (TGF--β) Type 1 and 2 Keloid > Normal, Type 3 : Keloid = Normal
Vascular endothelial growth factor (VEGF) Content Keloid (keratinocytes) > Normal
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Management
Prevention
Treatment
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PreventionAvoid injury or incision in keloid-prone persons
Avoid incision in keloid-prone areas
Elective incision along relax skin tension lines
Meticulous surgical techniques
Good wound care : rapid healing
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Prevention
ดัดแปลงจาก : Mustoe TA, Cooter RD, Gold MH, Hobbs R, Ramelet A, Shakespeare PG, et al. International clinical recommendations on
scar management. Plast Reconstr Surg 2002;110(2): 560-571.
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Silicone gel sheet and Pressure garment
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Treatments
Hypertrophic scars Keloid scars
Spontaneous regression
Response well to
treatments
Less regression, sometime progression
Poor response to treatments
High recurrence rate
Multimodality therapy
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Treatments
ดัดแปลงจาก Mutalik S. Treatment of keloids and hypertrophic scars. Indian J Dermatol Venereol Leprol 2005;71(1):3-7.(10)
1. Surgical Excision
2 .Radiation
2.1 Superficial X-rays
2.2 Electron beam therapy
2.3 Interstitial radiotherapy
3. Pressure Garment
4. Intralesional steroid injections
5. Cryotherapy
6. Silicone gel dressing
7. Laser
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Surgery combine with Steroid injection
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Treatment Guideline
ดัดแปลงจาก : Mustoe TA, Cooter RD, Gold MH, Hobbs R, Ramelet A, Shakespeare PG, et al. International clinical recommendations on scar
management. Plast Reconstr Surg 2002;110(2): 560-571.(9)
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