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 Table of Contents  
CURRENT OPINION
Year : 2019  |  Volume : 57  |  Issue : 3  |  Page : 213-219

Nonsurgical management of periocular scars along with review of literature


Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Submission10-Aug-2019
Date of Acceptance27-Aug-2019
Date of Web Publication11-Nov-2019

Correspondence Address:
Dr. Bipasha Mukherjee
18, College Road, Sankara Nethralaya, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_69_19

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  Abstract 


Introduction: Facial scars in the periocular region may cause cosmetic blemish as well as functional deficits. There are several treatment options available for scar management, but many of these are unsuitable for periocular region because of their potential to cause damage to the ocular structures. This article aims to present an ophthalmic plastic surgeon's perspective of managing these scars safely and effectively. Methods: An extensive literature search was done using PubMed (Medline), Cochrane, and Google Scholar with multiple combinations of search terms such as scar, facial scar, contracture, and keloid. Articles in English language published describing the existing and emerging modalities of treatment for periocular facial scars were reviewed. Results: The scarring pattern in the face and periocular area is different as wound healing in these areas differs from that of the rest of the body. Various techniques ranging from simple scar massage to laser and intralesional steroids and antimetabolites have been described with good results for managing scars in various parts of the body. However, safety of some of these modalities in periocular region has not been established unequivocally as yet. Conclusion: Effective scar management requires a multipronged therapeutic approach. Facial and periocular scars deserve special care due to their close proximity to the eyes. Hence, it is paramount that safety of any approach be ascertained prior to the procedure, especially in periocular areas.

Keywords: Contracture, facial scar, keloid, scar


How to cite this article:
Shrirao N, Mukherjee B. Nonsurgical management of periocular scars along with review of literature. TNOA J Ophthalmic Sci Res 2019;57:213-9

How to cite this URL:
Shrirao N, Mukherjee B. Nonsurgical management of periocular scars along with review of literature. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2020 Jan 24];57:213-9. Available from: http://www.tnoajosr.com/text.asp?2019/57/3/213/270695




  Introduction Top


A scar is the result of wound healing. Multiple medications for scar management have been tried; some are supported by well-designed case–control studies, whereas others have been advocated on anecdotal evidence. Some therapeutic agents have been tried on a small scale and many still lack safety data. In the prevailing scenario, surgeons depend on their personal experience rather than clinical evidence to manage these scars. To address these lacunae, we performed a search of English Literature using PubMed (Medline), Cochrane, and Google Scholar with multiple combinations of search terms such as scar, facial scar, contracture, and keloid.


  Classification Top


Scar formation is the final stage of wound healing which involves migration and proliferation of fibroblasts; collagen production and deposition; and angiogenesis. Various growth factors and inflammatory mediators play an important role in this process.[1] An ideal scar is thin and flat, has a good color match with the surrounding skin, is oriented along the relaxed skin tension lines, and does not produce any distortion of the adjacent tissues.[2] Mustoe et al. have described a simple and clinically useful classification system for scars [Table 1].[3]
Table 1: Types of scars and their characteristics

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An immature scar is an erythematous, itchy, painful area [Figure 1] that eventually forms a mature scar, i.e., flat, light scar which has completed the process of healing. When a large dermal area has been damaged, there is permanent shortening of the skin, forming a contracted scar [Figure 2]. When the tension is perpendicular to the wound edges, especially in areas under high tension, a widened scar is formed. An atrophic scar is depressed and flattened below the dermal area [Figure 3]. Linear hypertrophic scars are confined to the borders of the surgical incision [Figure 4]. They grow rapidly for 3–6 months after which reach a static phase. They regress subsequently, but this process may take up to 2 years. Widespread hypertrophic scars are red, are raised, and are within the borders of the injury, most frequently burn injuries [Figure 5]. Keloids are usually seen in individuals with a genetic predisposition and do not regress on their own. A minor keloid is focally raised and extends over normal tissue, whereas a major keloid is larger, spreads over an area of 0.5 cm or more, and continues to grow for years. It may be red and itchy [Figure 6].
Figure 1: Raised, erythematous immature scar in the periocular area of the left eye

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Figure 2: Contracted scar causing cicatricial ectropion of the left lower eyelid

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Figure 3: Atrophic depressed scar over the periocular area of the right eye (arrow)

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Figure 4: Linear hypertrophic scar caused by improper suturing

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Figure 5: Contracted hyperpigmented scar in the right periocular area after burn injury

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Figure 6: Keloid

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Hypertrophic scars and keloids require active management. It is important to recognize and differentiate between the two as the management approach is different. Recurrence rates after simple excision are much lower in cases of hypertrophic scars compared to keloids. Fortunately, keloids are rare in the periocular area.


  Nonsurgical Modalities Of Prevention And Treatment Of Periocular Scars Top


Prevention is better than cure, and this is true in the context of scarring. Certain agents, if used in early posttraumatic period, may minimize ugly scar formation and a cosmetically acceptable outcome in the long run. Some authors feel that the best treatment of hypertrophic scars is achieved when the scar is still immature.[2] In this article, we will also review the viable nonsurgical treatment options for scar management.

Scar massage

Wound healing can be hastened or modified by scar massage.[4] Manual massaging of the scar tissue decreases itching, redness, and pain associated with an immature scar, especially those following burns.[5] Massage with an emollient keeps the epidermal layer hydrated, thereby reducing the vascularity and erythema.

Studies have shown that massaging also shortens the time required for scar maturation.[6],[7] Massage causes mechanical disruption of fibroblast fibers, increasing the pliability of the wound, leading to a softer scar. Remodeling of extracellular matrix is modified by pressure which is thought to have an effect on structural and signaling pathways.[6],[7],[8] Ko et al.[4] have reported statistically significant reduction in scar thickness following massage. Scar-modifying agents such as Kelo-cote (silicon polymer) and Contractubex (contains heparin, allantion, and cepae extract) were found to have an additive effect. They found that the early remodeling phase was most crucial for scar modification and maximum changes were seen after 10 weeks.[4] However, further studies are required to evaluate the effect of massage alone as compared to hydration with topical agents.[4],[8] Despite the variations in the massaging schedule as recommended by various surgeons, it remains an easy and effective strategy to minimize scarring.[8] Massaging of the area should be started as soon as possible and should be continued 2–3 times a day till 6–8 weeks after the trauma or surgery.

Siliconegel

The efficacy of silicone gel sheeting has been reported by several investigators. It is the standard of care for plastic surgeons[3] to prevent as well as manage hypertrophic scars after surgery.[9],[10] The silicone gel sheet provides a hydrating environment for the epidermal layer and decreases the capillary activity, vascularity, and the metabolism of the scar tissue, thereby causing reduced collagen deposition. It provides an occlusive environment which acts like a pressure therapy, reducing the oxygen tension and increasing collagenolysis and fibroblast degeneration. It reduces the thickness of scar tissue along with redness, pain, itchiness, and rigidity. It also protects the scar tissue from bacterial invasion and prevents bacteria-induced excessive collagen production.[1],[11] Silicone products are available in the form of silicone gel sheets, gel cushions, and ointments. Silicone gel cushions are as effective as sheets.[12] Asian skin is more prone to hyperpigmentation and scarring, which is prevented by the use of silicone gel products.[10] The therapy with silicone gel products should be started as soon as the wound healing is complete and is recommended for more than 12 h/day for 2 months or more.[13]

Gel sheets, however, are uncomfortable, especially in the hot climate. They are difficult to apply on irregular surfaces, and compliance may be an issue in patients with scars on their face. In such situations, silicone gel ointments are useful as they dry after application and become invisible. Ointments easily blend with sunscreen and makeup, making them an ideal option to manage facial scars.[14] They are also useful in children. It is worthwhile to mention here that massage with a silicon-based ointment showed significant reduction in scar thickness compared to massage with a plain emollient.

Silicone appears to be efficacious as well as safe as there are only few reports of its adverse effects in literature compared to other treatment modalities available to manage hypertrophic scars.[15],[16]

Pressure therapy

Pressure therapy is the standard of care for burn scars worldwide.[17] Compression of the scar aggravates the hypoxic condition of the scar tissue, increasing degeneration of fibroblasts and collagen as well as a decrease in the collagen synthesis.[18],[19]

Studies evaluating the efficacy of compression therapy have led to contradictory results. A study of a large series of 122 patients with burns, which compared pressure therapy versus no pressure therapy, did not find any statistically significant difference in the quality of scars between two groups.[20] However, another study, which compared pressure garment alone, silicone spray alone and silicone sheeting with pressure garment, found all the three approaches to be similarly effective in preventing hypertrophic scarring. This perhaps indicates that compression therapy alone may be effective [Figure 7].[17]
Figure 7: Left lower eyelid cicatricial ectropion (a) improved after silicone gel sheet application (b) and scar massage (c)

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However, pressure therapy is not a practical approach for facial scars, especially periocular scars. In these patients, application of silicone gel sheet is preferred as it provides occlusion and pressure along with hydration.[4]

Cryotherapy

Cryotherapy is useful for hypertrophic scars and keloids in combination with intralesional steroid injections.[13],[21] Freezing induces vascular damage and anoxia, which eventually leads to tissue necrosis.[13],[21] Several weeks of interval may be required between two sessions of cryotherapy for the healing to be complete.[22],[23] However, hypopigmentation is often observed following cyro application in darker-skinned individuals due to destruction of the melanocytes which occurs at a higher temperature (−4°C–−8°C) compared to fibroblasts (−30°C–−40°C).[24]. Intralesional cryotherapy may be used to avoid hypopigmentation.[25] Other side effects which have been reported are skin atrophy, blistering, and postoperative pain.[22],[23] Particularly, it may lead to loss of lashes, destruction of  Meibomian gland More Detailss leading to dry eyes, lid deformities, conjunctival scarring, and destruction of the lacrimal system.[26] Cryo therapy in this area is thus limited to very small scars, and patients should have an ophthalmic evaluation by an ophthalmologist.

Radiotherapy

Radiotherapy (RT) in the form of superficial X-rays, electron beam therapy, and low or high dose–rate brachytherapy has been used successfully as an adjuvant therapy following surgical excision of keloids.[13],[21],[27] RT is effective due to the inhibition of neovascularization and proliferating fibroblasts, resulting in decreased collagen production.[28] RT with a dose of 40 Gy was found to be effective in managing recurrent keloids according to a 12-year study. Possible adverse effects associated with RT are pigmentary changes, telangiectasia, and skin atrophy.[29] Ophthalmic complications of RT include radiation retinopathy, cataract, glaucoma, dry eye, and destruction of lacrimal drainage system. These side effects can be minimized by appropriately shielding the eyes during the therapy.[30],[31]

Lasers

Lasers have been tried for treating keloids, hypertrophic scars, and even atrophic scars.[3],[13] They are mainly effective in reducing erythema and nonspecific tissue destruction.[1],[3] Pulsed dye laser therapy causes selective destruction of tissue microvasculature, resulting in ischemia and reduction in the collagen content of the scar. Neodymium:Yttrium-aluminum-garnet (Nd: YAG) laser is currently being evaluated for its possible use to manage facial scars. The authors have reported a success rate of 60% in flattening keloids, improving the scar texture, erythema, and pruritus[32],[33] with the laser. The laser sessions are usually spread out over 2–6 sessions at weekly interval which may be sufficient for keloids or young hypertrophic scars.[34] The therapy can cause pigmentary changes (hypo- or hyperpigmentation) and posttreatment purpura. However, compared to other invasive therapies, risks of adverse effects are less.[1],[33],[35],[36] Pulsed dye lasers for keloids are as effective as lasers combined with intralesional steroid injections.[35]

Ablative fractional laser skin resurfacing 2940 nm Erbium: YAG laser combined with either intralesional 5-fluorouracil (FU) or triamcinolone injections and laser-assisted delivery of topical 5-FU into the microscopic treatment zones (i.e., vertical channels of ablated tissue) have been described to be an effective treatment for cicatricial ectropion secondary to burns.[37]

Intralesional steroid injection

Steroids inhibit keratinocyte proliferation and inflammatory compounds.[38] In an experimental study, dexamethasone was found to inhibit fibroblast proliferation in keloids. It exhibited anti-angiogenic effect by suppressing the expression of the vascular endothelial growth factor and insulin growth factor by the fibroblasts.[39] Dosage and regimens for intralesional triamcinolone acetate (TA) injections vary anywhere between 1 and 40 mg/ml depending on the site of scar at 2–6 weeks' intervals.[3],[40],[41] Success rates hover between 40% and 100% for keloids. Recurrence rates vary between 9% and 50%.[3],[40],[42] Intralesional TA is more useful for young keloids and hypertrophic scars as its efficacy reduces with time.[23] Severe pain at the injection site can be a deterrent. Other adverse effects are skin atrophy, depigmentation, telangiectasia, delayed wound healing, and, later, widening of the scar.[43],[44],[45] Intralesional TA is the first line of therapy in young keloids and second line of therapy in young hypertrophic scars in cases where other noninvasive modalities were not useful.[3],[12] Data for the use of intralesional TA for facial scars are lacking, and more studies are needed before we consider it as a viable option.


  Emerging Therapies Top


Various modalities have been tried in isolated case studies or experimental studies and have been reported to be useful.

5-Fluorouracil

5-FU is a pyrimidine analog and an antimetabolite often used in chemotherapy. It exerts an antifibroblastic action by increasing fibroblast apoptosis and inhibits wound healing. In vitro, it causes inhibition of proliferation and differentiation of myofibroblasts.[46],[47] Fitzpatrick reported his experience in more than 1000 patients with 5-FU claiming it to be safe and effective for the treatment of inflamed hypertrophic scars in combination with TA.[48] Another comparative study has reported comparable results.[49] Hatamipour et al. evaluated the outcomes of treatment of keloids at various sites with surgical excision followed by silicone gel sheeting in one group versus silicone gel sheeting and 5-FU injections in the second group. The second group achieved a 75% success rate as compared to 43% in the first, with an extremely low rate of recurrence (1%).[50] Combination therapy reduces the side effects associated with prolonged steroid therapy alone.[48] However, there is no available data on the use of 5-FU for facial and periocular scars. Further studies are warranted before this mode can be declared safe for periocular scars.

Bleomycin

Bleomycin is an antibiotic with antineoplastic properties. It inhibits collagen synthesis by inhibiting DNA synthesis, transforming growth factor beta 1, increase in fibroblast apoptosis and inhibition of lysyl oxidase, an enzyme that helps in collagen synthesis.[51],[52],[53],[54],[55] It was first used for scars by España et al. who found complete flattening of scars in 6 out of 13 patients.[52] Few authors have reported that bleomycin at a concentration of 0.375 IU for 1 cm2 of a keloid was safe and effective. Bleomycin when combined with TA enhanced its effects by reducing the complications.[56] The use of bleomycin led to improvement in scar height, pliability, erythema, pruritus, and pain.[52],[57],[58] Local side effects such as dermal atrophy and hyperpigmentation are seen, but systemic side effects are rare.[59],[60]

Hyaluronic acid injection (fillers)

Hyaluronic acid is derived from natural glycosaminoglycans and is used for static facial wrinkles. Romero et al. demonstrated dramatic resolution of lower lid cicatricial ectropion after a single injection of filler into the area of lid skin shortening. Short-term complications such as erythema, ecchymosis, edema, and fullness have been noted. The effect was maintained up to at least 1 year of follow-up.[61]

Topical agents

Various topical agents have been advocated as effective in the management of scars, but few have been supported by evidence-based studies and are used mostly on the basis of anecdotal evidence.

Vitamin E

Vitamin E is a lipid-soluble antioxidant vitamin that has a favorable effect on wound healing and scars.[62],[63] Zampieri et al. reported superior cosmetic results following application of Vitamin E to the surgical incision site in children compared to plain emollient which was used in controls. None of the study group patients developed keloids as against 6.5% in the control group.[64] The incorporation of Vitamin E in silico ne gel sheets led to a superior outcome (95%) than in the group using plain silicone gel sheets (75%) at the end of 2 months.[65] Khoo et al. in their series of 122 patients, however, did not find any statistically significant difference between Vitamin E and a placebo after an extensive clinical, photographic, and laser imaging assessment of the scars.[66] Another study showed that topical Vitamin E was ineffective in controlling the scar formation in grafts for postburn contractures.[67] The safety of topical Vitamin E is also unproven yet, with several investigators reporting a high incidence of contact dermatitis, urticaria, eczematous dermatitis, and reactions similar to erythema multiforme.[67],[68]

Vitamin A

Retinoic acid has been widely used as a topical agent in the management of hypertrophic scars and keloids. Retinoids affect cell growth and differentiation, modulating the extracellular matrix synthesis by fibroblasts and increasing angiogenesis.[69],[70] Studies have proved that topical retinoids increase distensibility and reduce elasticity and resistance of the post burns skin.[71] Topical tretinoin has been successful in reducing the size and weight of the scar and in providing relief from itching.[69],[70] Salles et al. found that topical tretinoin, when combined with glycolic acid, improved scar distensibility and resulted in a soft pliable scar as measured by an increase in mouth opening similar to patients with graft.[72] It was also as effective as silicone gel sheet for the prevention of scarring in surgical wounds at the end of 24 weeks of therapy.[73] Side effects which have been reported by the investigators include “retinoid dermatitis” (temporary cutaneous irritation characterized by erythema, peeling dryness, and itching), postinflammatory hyperpigmentation, and telangiectasia.[69],[70],[71] Hence, the use of topical retinoids in periocular areas should be tampered with caution.

Onion extract

Allium cepa or onion extract is an important ingredient in many nonprescription creams for scar treatment. It appears to have anti-inflammatory, collagen-inhibiting, and bacteriostatic properties, and is said to improve the arrangement of collagen in experimental models.[62] It was found to be better compared to no topical treatment in terms of improving the softness, redness, texture, and global appearance of surgical excision sites and reducing neoangiogenesis in the scar.[74],[75] Topical agents with Allium extract when compared to plain petroleum emollients showed better scar management in a double-blinded, randomized, split-scar study,[76] whereas in another similarly designed study, the investigators found no statistically significant difference between the two groups.[77] Some investigators claim that Allium extract products are useful to improve the scar color, but ineffective in controlling symptoms and reducing scar height.[78] It was found inferior to silicone gel in the treatment of hypertrophic scars.[79] However, no adverse effects have been reported.[74],[76],[78]

Imiquimod 5%

Imiquimod is a topical immune response modifier approved for use in basal cell carcinoma, genital warts, and actinic keratoses. It stimulates interferon, thereby increasing collagenolysis, and also alters the expression of apoptosis-associated genes.[62] Topical application of imiquimod 5% over scars has showed better outcomes compared to plain vehicle cream. In one study, imiquimod was used once daily for 3 weeks and then three times/week under an occlusive dressing for further 6 months. The recurrence rate for keloid was lower in the study group, but the difference was statistically insignificant.[80] Nonetheless, the role of imiquimod in the prevention of postsurgical scars requires further exploration.


  Conclusion Top


Facial scars may have well-signified valor in the medieval times, but are unacceptable for the millennial generation. Patients expect perfection when they seek treatment for esthetic procedures. Surgical manipulation of scars, especially in the periocular area, may result in suboptimal outcome and lead to patient dissatisfaction. This review article focuses on the various alternative non–surgical modalities available for the prevention and treatment of periocular scars. Some of the therapeutic options described here are substantiated by reliable evidence, but several require further analysis to prove their efficacy and safety. A multipronged approach which combines anti-inflammatory, anticollagen, or antifibroblastic activities is perhaps in order. While dealing with periocular scars, it is essential that oculoplasty surgeon to be on the team so that the safety of ocular structures is assured.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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