Hypertrophic cutaneous scars are an abnormal, fibroproliferative form of scarring. They are raised above the level of the surrounding skin but do not progress beyond the margins of the original injury. Usually, there is an initiating injury to the skin. Symptomatically, the scar may be pruritic and occasionally, painful. On examination, a hypertrophic scar is erythematous, firm and papular to nodular in its early stages - typically the first three months - before typically regressing over many months to a pale, flat scar.
Proposed aetiological factors include foreign body reactions to damaged tissue, chronic inflammation, burn injuries and increased skin tension. Hypertrophic scars are very common after thermal injuries that progress to the level of the deep dermis or beyond.
Distinguishing hypertrophic scars from keloid scars may be difficult. Both may be erythematous and elevated. Both may reoccur after surgical excision. However, hypertrophic scars are more common and ultimately regress whereas keloid scars tend to progressively enlarge. They have no predisposition for a particular age group or gender. There appears to be no genetic predisposition. The natural history of regression is said to be more characteristic of the hypertrophic scar than the keloid scar.
Hypertrophic scars result from increased collagen production and decreased collagen degradation. They are believed to have slightly increased type I collagen synthesis and ground substance, usually peaking at around six months from the original insult. Again, histological differentiation from keloid scars may be difficult but possible indicators of hypertrophic scars include a pushing, as opposed to an infiltrating, margin, a foreign body reaction and less obvious refractile collagen bundles.
Treatment options include conservative approaches such as compression therapy, splinting, silicone dressing application and antihistamines. Surgical options include surgical excision or release with skin grafting or local flap application. Care must be taken to distinguish the hypertrophic scar from a keloid scar as the latter may have a recurrence rate of up to 80% after surgery; a hypertrophic scar that is potentiated by tension may improve dramatically with surgical realignment along relaxed skin tension lines.
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