Hypertrophic Scar Formation Following Burns and Trauma: New Approaches to Treatment

H ypertrophic scar formation is a major clinical problem in the developing and industrialized worlds. Burn injuries, traumatic injuries, and surgical procedures can give rise to exuberant scarring that results in permanent functional loss and the stigma of disfi gurement. Figure 1 illustrates the scope of the problem. Annually, over 1 million people require treatment for burns in the United States [1], 2 million are injured in motor vehicle accidents [2], and over 34 million related surgical procedures are performed [3]. Although the incidence of hypertrophic scarring following these types of injuries is not known, it is a common outcome that creates a problem of enormous magnitude. Treatment of these cases is estimated to cost at least $4 billion per annum in the US alone [4]. The incidence of burns and traumatic injuries is even greater in the developing world [5]. This review will examine the process of hypertrophic scar formation, the results of current treatments, and areas likely to lead to signifi cant advances in the fi eld. Advances over the past 60 years have allowed us to extend the lives of patients whose injuries would previously have been invariably fatal. Fire disasters such as those at the Rialto concert hall (1930) [6] and the Cocoanut Grove nightclub (1942) [7] led to the development of new treatments, such as fl uid resuscitation, to prevent death in the early stages following burn injury. World War II led to the development of critical care medicine [8], further improving the ability to keep those with traumatic injuries alive until surgical management of their wounds was possible. Antibiotics and aggressive surgical debridement have also contributed to the survival of the great majority of burn and trauma patients. However, despite advances in life-saving technology, progress to prevent the late functional and aesthetic sequelae of hypertrophic scar formation has been slow [9]. Efforts to limit scar formation in burn and trauma patients have relied largely on immediate skin replacement [10] with human split-thickness allografts or dermal analogs such as Integra. Although these measures provide excellent barriers against infection and mechanical trauma, the long-term improvement in appearance has been modest [11,12]. After healing has occurred, massage, pressure therapies, steroids, and silicone dressings are frequently used to manage the massive scar burden in these patients [13]. Many of these treatments predate modern medicine and their benefi ts remain unclear [11]. As stated in a major review on …