Aesthetic Dermatology MCQ - Management of Hypertrophic scars

A 25-year-old woman presents with a firm, raised, erythematous hypertrophic scar on her sternum, 6 months after a traumatic injury. The scar is pruritic and tender. Which of the following is the first-line, evidence-based treatment for this condition?

A) Intralesional triamcinolone acetonide
B) Pulsed dye laser therapy
C) Surgical excision
D) Topical silicone gel sheeting
E) Cryotherapy

Correct Answer: A) Intralesional triamcinolone acetonide

Explanation

Hypertrophic scars are characterized by excessive collagen deposition following skin injury, remaining within the boundaries of the original wound. They are common in high-tension areas like the sternum.

First-Line Treatment: Intralesional Corticosteroids

• Mechanism: Triamcinolone acetonide (typically 10-40 mg/mL) suppresses collagen synthesis, inhibits fibroblast proliferation, reduces inflammation, and decreases glycosaminoglycan production. It also alleviates pruritus and pain.

• Administration: Injected directly into the scar every 4-6 weeks. Multiple sessions are often required.

• Efficacy: This is the gold standard and first-line treatment for hypertrophic scars, supported by extensive clinical evidence.

Why Not the Other Options?

• (B) Pulsed dye laser (PDL): Excellent for reducing erythema and pruritus by targeting vasculature. It is often used as an adjunct to intralesional steroids but is not first-line monotherapy.

• (C) Surgical excision: High risk of recurrence (often worse than the original scar) due to renewed wound healing. Reserved for cases refractory to other treatments, often combined with postoperative intralesional steroids or radiation.

• (D) Topical silicone gel sheeting: Used primarily for prevention of hypertrophic scars and keloids. It improves hydration and regulates collagen production. Less effective for established scars.

• (E) Cryotherapy: Can be used for small keloids or hypertrophic scars but carries a risk of hypopigmentation and is not first-line. Often combined with intralesional steroids.

Combination Therapy:
For better outcomes, combination therapies are common:

• Intralesional triamcinolone + PDL: Targets both collagen and vasculature.

• Intralesional triamcinolone + 5-fluorouracil: Reduces fibroblast proliferation.

Prognosis:
With consistent treatment, hypertrophic scars can flatten and become asymptomatic. Early intervention yields better results.

Note: The sternum is a high-risk site for hypertrophic scarring due to skin tension. Intralesional corticosteroids remain the cornerstone of management. Always differentiate hypertrophic scars from keloids (which extend beyond the original wound and require more aggressive therapy).