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Old 12-04-2011
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Skin Treatment of hypertrophic disfiguring scars!

A 19-year-old African American woman comes to see you for treatment of a large scar on the back of her left arm. While trying to replace a mirror in her bathroom last month, the mirror slipped and the broken glass cut her arm. The wound was sutured in the emergency department and originally healed well. Since then, however, the scar has become large, disfiguring, and painful. She had a similar problem at age 16 years. At that time she had both her ears pierced and had to have scar tissue surgically removed 6 months later. Aside from an appendectomy at age 14 years, her past medical history is unremarkable. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 118/70 mm Hg, pulse 62/min, and respirations 20/min. Examination of her skin shows a 4-cm scar on her left arm with heaped-up margins approximately 1 cm above the skin. Examination of her abdomen shows an additional hypertrophic scar with margins approximately 0.5 cm above the surface of the abdomen. Which of the following is the most appropriate first-line treatment for this patient?

A. Cryosurgery
B. Empiric antibiotics
C. Intralesional corticosteroids
D. Radiation therapy
E. Surgical resection
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Old 12-04-2011
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keloid = Intralesional corticosteroids
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Old 12-04-2011
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intralesional corticosteroid.
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Old 12-04-2011
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C. Intralesional corticosteroids
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Old 12-04-2011
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C. Intralesional corticosteroids
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Old 12-04-2011
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why cant it be a hypertrophic scar?
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Old 12-05-2011
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Reasons why its not a hypertrophic scar and more likely a keloid

1. african american woman
2. history previously in ear lobes
3. typical location in the present wound..

first step is intralesional steroids
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Old 12-05-2011
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The correct choice is C. This patient has a keloid. Keloids are benign fibrous growths present in scar tissue that form because of altered wound healing. Up to 70% of patients respond to intralesional steroids. For patients who do not respond or in whom the lesions recur, combination therapy with steroids and surgical resection is an appropriate strategy.
Cryosurgery (choice A) is an effective treatment for keloids, with a response rate of 50% when used alone. Its major usefulness is as combination therapy with another treatment modality. In dark skinned patients, however, cryotherapy creates patchy areas of hypopigmentation and should not be considered a first-line agent.
There is no role in this patient for empiric antibiotics (choice B). An infectious agent does not cause keloids.
Radiation therapy (choice D) is highly effective in reducing keloid lesions and can be combined with surgery to treat severe cases. Given the risks associated with radiation therapy, however (internal fibrosis, malignancy), it is not a good first choice for the treatment of keloids.
Surgical resection (choice E) alone is likely to cause more scar formation. If intralesional steroids fail, surgery as combination therapy is a good strategy. Referral to a plastic surgeon or dermatologist with experience removing keloids is indicated, as surgical resection has a high rate of recurrence.
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