What are the recommended treatment options for a patient with a hypertrophic scar?

Hypertrophic Scar Management

Silicone-based products (sheets or gels) are the gold standard, first-line treatment for hypertrophic scars, recommended by international expert consensus as the primary non-invasive option for both prevention and treatment. 1

First-Line Treatment Approach

Silicone Therapy

• Silicone gel sheeting (SGS) or silicone gel should be applied as the initial treatment for all hypertrophic scars, representing the most evidence-based non-invasive option 1
• Apply silicone products continuously, with regular re-evaluation every 4-8 weeks to assess treatment response and determine if additional interventions are needed 1
• While the evidence base is limited, silicone therapy may slightly reduce scar severity compared to topical onion extract (mean difference -1.30) and may reduce pain levels compared to no treatment (mean difference -1.26) 2

Adjunctive Preventive Measures

• Implement compression therapy for scars in appropriate anatomical locations 1
• Apply taping techniques to reduce tension on healing wounds 1
• Use moisturizers regularly to maintain skin hydration 1
• Strictly avoid sun exposure to prevent hyperpigmentation and worsening of scar appearance 1

Second-Line Treatment Options

Intralesional Corticosteroid Injection

• Intralesional triamcinolone acetonide injection is the most commonly used invasive treatment when first-line silicone therapy fails or for more severe hypertrophic scars 3
• In a large single-center series, intralesional steroid injection represented 50% of all procedural therapies for hypertrophic scarring 3
• Administer triamcinolone acetonide at concentrations of 5-10 mg/cc for localized lesions 4
• Initial doses range from 2.5 mg to 5 mg for smaller scars and 5 mg to 15 mg for larger scars, with adult doses up to 40 mg for larger areas 4
• Common pitfall: Subcutaneous fat atrophy can occur if injection is not properly placed deeply into the scar tissue 4

Combination Therapy with 5-Fluorouracil

• Intralesional 5-fluorouracil may be combined with corticosteroids for refractory scars 1, 5
• This combination approach is particularly useful when corticosteroid monotherapy proves insufficient 5

Third-Line Treatment Options

When both silicone therapy and intralesional injections fail to achieve adequate improvement:

Energy-Based Laser Devices

• Pulsed-dye laser (PDL) therapy can be effective for hypertrophic scars, particularly for residual vascular components 5, 3
• Fractional non-ablative lasers represent an alternative laser modality, comprising 24.5% of procedural therapies in clinical practice 3
• Important caveat: Laser therapy carries risks of atrophic scarring and hypopigmentation, particularly in darker skin types 6
• The complication rate for PDL is less than 1% based on port wine stain treatment data 6

Cryotherapy

• Cryotherapy can be used for resistant hypertrophic scars as part of a multimodal treatment strategy 1, 5

Surgical Excision

• Surgical excision represented 25.3% of procedural therapies in a large clinical series 3
• Critical warning: Simple surgical excision alone typically results in recurrence and should only be performed with adjunct therapies (radiation, intralesional steroids, or pressure therapy) 5
• Consider surgical excision for small, localized scars in anatomically favorable locations where the resulting scar will not be worse than the original 3

Treatment Selection Algorithm by Anatomical Location

Treatment modality selection varies significantly by anatomical site 3:

• Trunk scars (54.8% of cases): Most commonly treated with intralesional steroids or surgical excision due to lower visibility concerns 3
• Head and neck scars (19.5% of cases): Require more conservative approaches with silicone therapy and laser treatments to minimize additional scarring in highly visible areas 3
• Extremity scars (25.4% combined): May benefit from compression therapy in addition to standard treatments 3

Additional Treatment Considerations

Pressure Therapy

• Pressure garments may be less effective than SGS for pain reduction (mean difference favoring SGS: -1.90) 2
• Pressure therapy is most useful for large surface area scars, particularly on the trunk and extremities 1

Topical Agents with Limited Evidence

• Topical onion extract shows inferior results compared to silicone gel sheeting 2
• Imiquimod 5% cream, vitamins A and E, and polyurethane dressings have been described but lack robust evidence 7

Common Pitfalls to Avoid

• Never use corticosteroid monotherapy without concurrent silicone therapy as initial management—always start with the least invasive, evidence-based option 1
• Avoid surgical excision as a first-line treatment unless there is diagnostic uncertainty requiring histological examination 5
• Do not perform intralesional injections in the presence of active infection at the treatment site 4
• Monitor for systemic corticosteroid effects including HPA axis suppression, immunosuppression, and metabolic disturbances when using repeated intralesional injections 4
• Recognize that hypertrophic scars may regress spontaneously—overly aggressive early intervention may cause more harm than benefit 2

Monitoring and Follow-Up

• Re-evaluate patients every 4-8 weeks to assess treatment response and adjust therapy accordingly 1
• Treatment intensity should be scaled to the patient's risk factors for excessive scarring and their level of concern about appearance 1
• Document scar characteristics at each visit using standardized assessment tools, photography, or body maps to track progression 6