Research Paper

In our study we have used intraregional injection of long acting steroids, silicone gel sheeting, and surgery alone or in combination with terror injection or radiotherapy and compared these different modalities of treatment to find out the most workable method of treatment-6 Aims and objectives: 1 . To improve the cosmoses and symptomatically of patients with hypertrophied scars and solids. 2. To compare the results of different modalities of treatment of hypertrophied scars and solids. 3. To find out the most workable approach towards the problem.

Material and Methods: We included 72 patients in our study, 29 males and 43 females with hypertrophied scars and solids who came to outpatient department of Allied Hospital, Punjab Medical College, Fusillades from April 2009 to September 201 1 The age of the patients ranged from 10 to 55 years. The duration of study was 2 years and 5 months. We randomized the patients according to response adaptive randomization and applied different options of treatments in different patients and followed them up for improvement of their lesions and complications, if any, of our procedures.

Study design: Prospective randomized clinical trial with response adaptive randomization. In this type of randomization the probability of being assigned to a group increases if the espouses of the prior patients in the group were favorable. Inclusion criteria: All those patients were included in our study that came to outpatient solids. Exclusion criteria: All those patients unwilling for treatment were excluded from our study. We treated most of our patients on outdoor basis by intraregional injections of steroid and occlusive silicone gel sheeting.

We also admitted our patients in surgical wards of Allied Hospital, Punjab Medical Collage, Fusillades for surgical and other treatments. We took detailed histories and performed physical examinations of all indoor and outdoor patients. In history resenting complaints were asked and they were inquired of any previous treatment received for their lesions. The physical examination was performed in two parts. 1. Local examination. 2. Systemic review In local examination we noted site, size, color, thickness, tenderness and type of the lesion.

We also looked for cosmetic impairment caused by these lesions. Systemic examination was also done in case of indoor patients to rule Out any systemic disease that could make the patient unfit for general anesthesia. Preoperative investigations like hemoglobin, TTL, ODL, blood sugar and blood urea were performed for indoor patients. The following methods of treatment were adopted to combat these lesions. Five groups of patients were formed for the intermediation modalities of treatments according to outcome adaptive randomization. 1. Intraregional injections of determination actinide (Kennecott A). 2.

Treatment of hypertrophied scars and solids by application of silicone gel sheeting. 3. Combination of surgery and application of steroid injections. 4. Surgery followed by radiotherapy. 5. Surgery alone. We used insulin syringe with fixed needle to give intraregional injections of Kennecott-A. The dosage range varied from 40 MGM to 120 MGM for these attains. We repeated these injections after 1 and 3 months intervals. After giving the treatment the patients were instructed to pay regular visit to the outdoors for further treatment and follow up. Silicone gel sheeting is an occlusive type of dressing.

It is easy to apply, painless and is acceptable to the patients. The patients wore the dressing for 24 hours a day and took it off only at the time of bathing. The dressing could be reapplied after taking a bath. It is washable and can be reused after washing. Application of dressing was recommended for six months. The patients were also briefed about the allow up visits. We admitted 9 patients for excision of solids and postoperative untrained injection of determination actinide. In two patients we excised the solids and applied superficial X-ray irradiation to the wounds.

The radiation was given in fractionated doses to a total of 1600-1800 reads in 6 days at 300-400 reads ‘day. The beam was focused directly at the site of the lesion. The patients were advised to come back for follow up after this combined modality of treatment. In 5 patients with hypertrophied scars we did excision and covered the raw area with split thickness skin graft. The patients ere advised to pay regular visits to outdoor for follow up. We followed up the patients after applying the above mentioned treatments at one month, three months and six months intervals.

We looked for the relief of symptoms, improvement in appearance and function. We also observed color match of the lesion to the surrounding skin, decrease in the size and thickness of lesion and any complications resulting from our procedures. Results We studied 72 patients with hypertrophied scars and solids who came to Allied Hospital, Punjab Medical College, Fusillades from April 2009 to September 201 1 . Age of the patients varied from 10-55 years. Out of 72 patients 29 (40. 27%) were males and 43 (59. 72%) were females. 33 patients presented with solids, and out of these, 11 (33. 33%) were males and 22 (66. 6%) were females. 39 patients presented with hypertrophied scars and out of these, 18 (46. 15%) were males and 21 (53. 84%) were females. (Table No. 1) Table 1: Age and sex distribution and occupations of the patients Range of Age (years) I No. Of patients I Sex Distribution I No. Of patients with solids I No. Of pits with hypertrophied scars Total NO. Of patients 21 Males 11 -201 141 1 21 -301211 1 -40 | 19 | Females 51 -60131 TOTAL | 72 | Total | 33 1 391 721 41 1-10 | 501 13 We also noted the sites of the lesions in these patients. Out of 72 patients, 16 (22. 22%) had lesions on head and neck area, 15 (20. 3%) on anterior trunk, 10 (13. 88%) on shoulders and 14 (19. 44%) on posterior trunk. 4 patients (5. 55%) got lesions on arms, 6 (8. 33%) on forearms and hands, 5 (6. 94%) on thighs, and 2 patients (2. 77%) had lesions on legs and feet. We could not find any lesion on the perinea area of any patient. The size of the lesions ranged from LLC x LLC to CACM x CM in these 72 patients. The patients had presenting implants of burning or pain in their lesions or itching with or without pain / burning in the lesions. Almost all of them had some sort of cosmetic impairment. Out of 72 patients, 10 (13. 8%) complained of burning sensation or pain in their lesions, 15 (20. 83%) had itching while 1 1 (15. 27%) patients had both itching and pain in their lesions. Out of 72 patients, 23 (31. 94%) had history of sharp or blunt trauma resulting in wounds leading to hypertrophied and colloidal scarring. In 16 patients (22. 22%) previous history of surgery was present while 33 patients (45. 83%) gave history of burns. We could not find story Of any skin disease in these patients-We could not elicit history Of such lesions in the family members of the patients. General practitioners and hakes treated 15 (20. 3%) patients by topical application of medicament’s. 2 (2. 77%) patients received intraregional injections of steroid while 2 (2. 77%) patients underwent surgical excision for their scars. We admitted 16 patients in the wards for surgery and other treatments and treated 56 patients on outdoor basis. We applied 5 different options of treatments according to our management plan. 39 (54. 16%) out of 72 patients had hypertrophied scars and 3 (45. 83%) had solids. Out of 72 patients, 21 (29. 16%) had hypertrophying, 1 5 (20. 83%) had hypertrophied, 24 (33. 33%) had white and 12 (16. 66%) patients had pink to red lesions.

Out of these, 35 (48. 61%) patients had mildly elevated (1 mm to mm), 30 (41. 66%) had moderately elevated (mm to mm) and 7 (9. 72%) patients had severely elevated (mm to mm) lesions. 25 (34. 72%) patients had tenderness of their lesions and 47 (65. 27%) had non tender lesions. 4 (5. 55%) out of 72 patients had neck contractors associated with hypertrophied scars resulting in functional problems. The functional impairment ranged from mild to severe. 2 out of 4 patients had mild restriction of neck movements, 1 patient had moderate restriction of neck movements and 1 patient had severely restricted movements of the neck. 1 (29. 16%) out Of 72 patients had psychological upsets because Of these lesions. (Table NO. 2) Table 2: Types, color, thickness of the lesions and their associated problems Indoor/outdoor patients I No. Of patients Types of lesions No. Of patients I Color of the lesions I No. Of patients I Thickness/elevation No. Of patients I Tenderness I No. Of patients I Associated problems I No. Opts Cosmetic impairment I No. F pits I Indoor patients | 16 | TTS | 39(54. 1%) | Hypertrophying 21 Mild mm to 2 mm | 35 | Tender. Mild. Moderated. Severe | 2512103 Neck contractors with functional impairment. Mild.

Moderated. Severe | 4 211 | Mild | 40 I I Hypertrophied | 15 | Moderated mm to 4 mm | 30 | I I Moderate 11 Outdoor patients | 56 | Solids | 33(45. 8%) Whiter 241 Severer mm to 5 mm 71 Pink to red | 12 | I severe | 21 | I Non tender 471 Psychological upsets 21 Total 1 721 Total | 72 | Total | 72 | Total patients 72 Total 1721 Any other Nil Total | 72 | We divided cosmetic impairment in these patients into mild, moderate and severe types. Out of 72 patients, 40 (55. 55%) had mild cosmetic impairment, 11 (15. 27%) had moderate cosmetic impairment and 21 (29. 16%) patients had severe cosmetic problems.

We injected Kennecott-A internationally in 44 (61. 11%) patients on outdoor basis. We applied silicone gel sheeting on 12 (16. 66%) patients. We performed surgery and gave postoperative intraregional injections of Kennecott-A in 9 (12. 5%) patients. In 2 (2. 77%) patients, we applied postoperative radiation therapy after excising their lesions. In 5 (6. 94%) patients with hypertrophied scars we performed surgery without the addition of any other treatment. Out of 44 patients who were treated by intraregional injections of steroid, 21 patients had symptoms of burning, and itching and pain in their lesions. Out of 12 patients treated by silicone gel sheeting had such complaints. Out of 9 patients who were treated by surgery and intraregional steroid injections, 3 had symptoms of purists, burning and pain. 2 patients who were treated by surgery and radiotherapy complained of itching in their lesions. Out of 5 patients who were treated by surgery alone, 4 had symptoms of itching and pain along with neck conjunctures. In 44 patients who were treated by intraregional injections of terror, we noticed hyperventilation in 2 (5%) patients. 10 (22. 72%) patients experienced pain at the site of injections after giving the drug.

There was recurrence of the lesions in 8 (20%) patients. We did not see any infection in these patients. Out of 44 patients only 40 patients came back for follow up while 4 patients did not return after application of first dose of Kennecott-A. We observed recurrence in 3 (25%) patients out of 12 patients in whom we applied silicone gel sheeting. 2 (16. 66%) patients developed itching at the site of the lesions and one (8. 33%) patient got superficial ulceration . We observed occurrence in 2 (25%) out of 9 patients in whom we combined surgery with steroid therapy. Hyperventilation was observed in 1 (12. 50%) patient. 2 (22. 2%) patients developed infection postoperatively. 8 (88. 88%) patients felt pain at the site of operation after surgery. 3 (33. 33%) patients got fever after surgery and 1 (11. 11%) patient developed chest infection. 1 patient did not turn up for follow up after first month interval. In 2 patients we applied superficial X-ray irradiation after surgery and delayed healing and recurrence was observed in 1 (50%) patient. No other complication was noticed In these attains. We performed surgery and split thickness skin grafting in 5 patients with hypertrophied scars. 2 (40%) patients developed infection at the recipient site. (20%) patient got hematite formation. 2 (40%) patients had displacement of grafts. Pain was experienced at donor site by 4 (80%) patients. 1 (20%) patient developed infection at the donor site. We observed fever in 1 (20%) patient. Recurrence was seen in 1 (20%) patient after this type of treatment. We did follow up of all these patients whom we treated on outdoor basis or in the surgical wards at intervals of one, three and six months. In the follow up of these patients we observed improvement of the symptoms of burning, itching and pain in their lesions or any functional problems associated with them.

We also observed the cosmetic improvement of these patients and categorized it into four grades as excellent, good, satisfactory and poor. In excellent cosmetic results there was complete or nearly complete color match of the lesion to the surrounding skin with complete flattening and marked decrease in size Of the lesion or no elevation of scar after surgery. In good cosmetic results there was mild difference In lour of the lesion from the surrounding skin and moderate flattening and moderate decrease in the size of the lesion or mild elevation of scar after treatment.

In satisfactory cosmetic results there was moderate difference in color of the lesion from the adjacent skin and mild flattening and mild decrease in the size of the lesion or moderate elevation of scar after surgery. In poor cosmetic results there was marked color difference of the lesion and the surrounding skin with no flattening and decrease in size of the lesion or even increase in height and size of the scar. We also observed complications f our procedures in the follow up. Out of 72 patients, 5 patients did not return for follow up. Patients who received intraregional injections of steroid did not come back after having the first dose of intraregional injections while 1 patient did not turn up at three and six months intervals who got surgery with intraregional steroid injections. The patients in whom we applied intraregional injections of steroid, 40 out of 44 patients came back at one, three and six months intervals for follow up while 4 patients did not turn up at all for follow up. Out of 40 patients, 21 had complaints of itching, pain and burning. The remaining 23 patients did not have such complaints. Out of these 21 patients, 12 (57. 4%) got complete relief, 6 (28. 57%) had moderate relief and 3 (14. 28%) patients got mild relief of their symptoms at first month interval. Out of 40 patients 1 (2. 5%) patient developed excellent cosmoses, 22 (55%) patients had good cosmetic results and 9 (22. 5%) patients had satisfactory cosmetic results. 8 (20%) patients had marked difference of color of the lesions from the surrounding skin with no flattening and decrease in size of the lesions. At 3 months interval, out of 21 patients, 18 (85. 71%) patients got iterate relief and 1 (4. 76%) patient had mild relief of the symptoms.

So there was improvement in the symptomatically of the patients at 3 months interval. Regarding cosmetic improvement color change and decrease in size and thickness, out of 40 patients, 5 (12. 5%) patients had excellent cosmoses, 18 (45%) had good and 10 (25%) had satisfactory cosmetic results. 7 (17. 5%) patients started having signs of recurrence with marked color difference with some elevation and increase in the size of the lesions. 2 (5%) patients developed hyperventilation of the surrounding skin. At 6 months interval, UT of 21 patients who had symptoms of burning, itching and pain, 19 (90. 7%) patients were relieved completely of their symptoms while 2 (9. 52%) patients had moderate relief of their symptoms. Regarding cosmoses, color match and flattening of the lesions, 25 (62. 5%) out of 40 patients had excellent results, 6 (15%) had good results and 1 (2. 5%) patient had satisfactory cosmetic results. At 6 months interval, 8 (20%) patients showed recurrence and 2 (5%) patients got hyperventilation of the skin. In the follow up of silicone gel sheeting 7 out of 12 patients had symptoms of purists, pain and burning sensation.

At one month interval after silicone gel sheeting 4 (57. 14%) patients got completely relieved of their symptoms, 1 (14. 28%) patient got moderate relief and 2 (28. 57%) patients got mild relief. As regards cosmoses out of 12 patients treated thus 4 (33. 33%) patients got excellent cosmetic results, 5 (41. 66%) had good results and 2 (16. 66%) patients had satisfactory cosmetic results. 1 (8. 33%) patient showed no signs of promise as the lesion did not flatten and decrease in size. 1 (8. 33%) patient developed superficial ulceration, which got better at 3 months interval.

At 3 months interval, 5 (71. 2%) out of 7 patients got complete relief of their symptoms and 2 (28. 57%) got moderate relief. Regarding the cosmetic improvement 5 (41. 66%) patients got excellent results, 3 (25%) patients had good results and 3 (25%) patients had satisfactory cosmetic results. 1 (8. 33%) patient got marked color difference from the surrounding skin with elevation and increase in the size of the lesion. Thus, 1 patient got recurrence at 3 months interval. 2 (16. 66%) patients got problem of itching after 3 months interval following application of silicone gel sheets.

We treated these patients with antihistamine and they got better after this treatment. At 6 months interval, 6 (85. 71%) patients got complete relief of their symptoms and 1 (14. 28%) patient had moderate relief of the symptoms. Regarding cosmoses, 6 (50%) out of 12 patients got excellent results, 2 (16. 66%) had good results and 1 (8. 33%) patient had satisfactory results. 3 patients had marked color difference from the surrounding skin with elevation and increase in the size of their lesions. Thus, 3 (25%) patients got recurrence of their lesions at 6 months interval.

In cases of surgery and postoperative untrained steroid injections, 3 out of 9 patients had symptoms of burning, itching and pain. 2 (66. 6%) of them got rid of their symptoms at 1 month interval while 1 (33. 33%) patient had moderate relief of the symptoms. Regarding cosmetic improvement, 2 (22. 22%) patients had excellent results with perfect color match to the surrounding skin, complete flattening and no elevation in scar height. 4 (44. 44%) patients had good results with mild color difference from the surrounding skin and mild elevation of their scars. 3 (33. 3%) patients had satisfactory results with moderate difference in color and moderate elevation of their scars. At 3 months interval, 2 (66. 66%) patients had complete relief of their symptoms and 1 (33. 3%) patient had moderate relief. 2 (25%) patients had excellent cosmetic results and 3 (37. 5%) had good results with mild color difference and mild elevation in scar height. 3 (37. 5%) patients had satisfactory results with moderate difference in color and moderate elevation of their scars One patient with this mode of therapy did not return at 3 and 6 months intervals.

At 6 months interval, all the 3 patients got rid of their symptoms. 4 (50%) out of 8 patients had excellent cosmetic results, 1 (12. 5%) had good results with mild difference in color and mild elevation of the scar and 1 (12. 5%) had satisfactory results. (25%) patients developed recurrence at 6 months interval with appreciable color difference and increase in the heights of their scars. 1 (12. 5%) patient developed hyperventilation of the surrounding skin. 2 patients who were treated by surgical excision followed by radiotherapy had big and recurrent colloidal scars with history of previous surgical treatment.

They had symptoms of itching in their lesions. We admitted them for surgery and radiotherapy. After excising their solids superficial X-ray irradiation was given. At 1 month interval, 1 (50%) patient got complete relief of itching and 1 (50%) patient got iterate relief. As regards cosmetic improvement, 1 (50%) patient got good cosmetic results while other (50%) patient got satisfactory results with moderate difference in color and moderate elevation of scar. At 3 months interval, both of them got complete relief of their symptoms of itching.

One of them had good cosmetic results while other had satisfactory results as regards cosmoses. At 6 months interval one of them was relieved of the symptoms while other had moderate relief. 1 (50%) patient had good results with mild color difference and mild elevation of scar and 1 (50%) patient plopped signs of recurrence with marked elevation of scar and appreciable color difference of the lesion from the surrounding skin. In 5 patients with hypertrophied scars in whom we performed surgery and split thickness skin grafting, 4 of them had also neck conjunctures.

At 1 month interval, 3 patients had complete relief of their symptoms with free movement of their neck. 1 patient had somewhat restricted movement Of the neck. We advised him physiotherapy and application of soft neck collar. As regards cosmetic improvement, 2 (40%) patients had excellent results, 1 (20%) had good results while 2 (40%) had satisfactory cosmetic results. At 3 months interval, 3 (75%) patients had free neck movements and 1 (25%) patient had restricted neck movement.