Treatment of Thick Scars from Open Heart Surgery
First-Line Treatment: Intralesional Corticosteroid Injections
Intralesional triamcinolone acetonide injection is the most effective treatment for thick hypertrophic scars on the chest resulting from open heart surgery. 1 This approach directly targets the excessive collagen formation that characterizes hypertrophic scars.
Recommended Protocol:
- Medication: Triamcinolone acetonide
- Concentration: 10-20 mg/mL for hypertrophic scars 1, 2
- Administration: Inject directly into the scar tissue
- Frequency: Every 3-4 weeks 1
- Duration: Multiple sessions as needed until desired improvement is achieved
Mechanism of Action:
Intralesional corticosteroids work by:
- Decreasing collagen synthesis
- Increasing collagen degradation
- Reducing inflammatory mediators
- Inhibiting fibroblast growth 3
Second-Line Treatment Options
Topical Corticosteroids
For patients who cannot tolerate injections or as an adjunct therapy:
- Medication: Clobetasol propionate 0.05% (class 1 ultra-potent steroid)
- Application: Apply to scar twice daily
- Duration: Up to 4 weeks at a time 1
- Note: Effectiveness of topical steroids alone for thick scars is limited 4
Combination Therapies
For more resistant scars, consider:
Laser-Assisted Corticosteroid Delivery:
- Fractional ablative laser treatment followed by immediate application of triamcinolone acetonide
- Enhances penetration and effectiveness of the corticosteroid 5
- Average overall improvement of 2.73/3.0 in texture and hypertrophy
Corticosteroid with 5-Fluorouracil:
- Combination shows better results than either agent alone
- Fewer side effects than triamcinolone alone 2
Important Considerations
Potential Side Effects:
- Local: Skin atrophy, telangiectasia, pigmentation changes
- Systemic: Minimal with local injection, but can include adrenal suppression with repeated treatments 1, 3
Timing:
- Best results are achieved when treatment is initiated after the wound has fully healed but before the scar has fully matured (typically 4-8 weeks post-surgery)
- Mature scars (>1 year) may be more resistant to treatment 6
Monitoring:
- Assess for improvement in scar thickness, texture, and symptoms
- Watch for signs of skin atrophy or other adverse effects
- Photograph the scar before treatment and at follow-up visits to document progress
Additional Supportive Measures
- Silicone gel sheets or ointments can be used in conjunction with steroid therapy
- Pressure garments may help flatten the scar
- Sun protection is essential to prevent hyperpigmentation of the treated area
When to Consider Referral
Consider referral to a dermatologist or plastic surgeon if:
- No improvement after 3-4 sessions of intralesional steroid injections
- Development of significant side effects
- Scar continues to grow despite treatment
- Functional limitations due to scar contracture
Hypertrophic scars from sternotomy can be effectively managed with appropriate treatment, with intralesional corticosteroid injections offering the best balance of efficacy and safety for most patients.