List of Abbreviations
HLA — Human Leukocyte Antigens, human leukocyte antigens, or the human tissue compatibility system.
ICD-10 — International Statistical Classification of Diseases and Related Health Problems, 10th Revision.
α-SMA — Alpha-smooth muscle actin (marker)
COX-1 — Cyclooxygenase 1
COX-2 — Cyclooxygenase 2
FPDL — Flashlamp-pumped pulsed dye laser
UHF — Ultra-high frequency radiation
SPF — Sun protection factor
Terms and Definitions
Langer's lines — topological lines drawn on the human body that correspond to the natural orientation of collagen fibers in the dermis and are generally parallel to the orientation of underlying muscle fibers.
Contracture is a restriction of passive movements in a joint caused by scarring of the skin, tendons, muscle diseases, and other causes.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Keloid scar – keloid (from Greek "kele" – claw and "oidos" – resembling) is a dense, nodular, tumor-like proliferation of connective tissue ranging from dark red to brown in color, with a complete absence of skin microrelief and pores. It belongs to the group of pseudotumorous fibromatoses and results from dysregeneration of dermal connective tissue. A keloid behaves like a benign tumor, always showing invasive growth beyond the borders of the initial lesion. The edges of the scar are indistinctly contoured or gradually blend into the surrounding tissue like "crab claws." The area of keloid involvement can be extensive.
Hypertrophic scar – a dense, tumor-like formation raised above the level of the surrounding skin, with a moderately or weakly bumpy, shiny surface, sometimes covered with scaling epidermis.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Scar tissue formation represents a normal physiological response to injury in an adult individual. However, alterations in extracellular matrix metabolism—an imbalance between its degradation and synthesis—can lead to excessive scarring.
General factors provoking the development of a keloid include: hereditary predisposition (a possible genetic link via human leukocyte antigens (HLA) B14, B21, Bw16, Bw35, DR5, and DQw has been studied, as well as in individuals with blood group A(II)); endocrine gland disorders causing hormonal imbalance.
Local factors of importance in the development of a keloid include tissue hypoxia, impaired intercellular interactions, and others.
Keloid scars typically form after deep and extensive injuries, prolonged and sluggish inflammatory processes, but sometimes they can also arise spontaneously on unchanged skin without apparent causes. Keloid scars are more commonly observed in individuals of dark-skinned races. A specific "dormant" period of 3-4 weeks to 2-3 months passes between wound healing and the appearance of a keloid scar, and its growth continues for several years. The formation of keloid tissue occurs via an embryonic pathway characterized by the skipping of the initial stage of collagen formation, which causes the scarring process to acquire a pathological character. The primary role in keloid formation is attributed to an imbalance between collagen degradation and synthesis in favor of increased synthesis. In keloid scars, areas of active synthesis and dystrophy (hyalinosis) of collagen fibers are identified. This cycle of changes repeats many times, and the equilibrium between cell production, vessel count, structures, and connective tissue ground substance synthesis differs from that of a normal scar. It has been proven that collagen synthesis in keloids occurs approximately 8 times more actively than in hypertrophic scars.
Keloid scars have preferred locations: the face, earlobes, neck, sternal region, and shoulder girdle.
The formation of hypertrophic scars is predisposed by the following factors: large size of the wound defect; constant trauma, especially if the scars are located parallel to the directions of muscle contraction; uncontrolled inflammation; secondary infection; decreased local immune responses; endocrine dysfunctions. There are no genetic or gender preferences. There is no association with the patient's age and race. They can be located on any part of the body. The growth of a hypertrophic scar begins immediately after healing and is characterized by the formation of "plus tissue" equal in area to the wound surface. A prolonged inflammatory reaction, microcirculation disorders, and hypoxia, along with delayed reparative processes, contribute to the accumulation of breakdown products in the wound that activate fibroblasts, driving their synthetic and proliferative activity. As a result, an excessive accumulation of type I and III collagen occurs at the site of the skin defect. Collagen formation prevails over its degradation due to increased synthesis of the collagen protein, leading to the development of fibrosis and scars acquiring a relief raised above the skin surface. Fibroblasts of hypertrophic scars have the ability to decrease normal mRNA expression of collagenases, leading to reduced collagen degradation and scar tissue remodeling. In addition, the increased activity of multinucleated lymphocytes and macrophages also leads to the formation of hypergranulations. During the maturation of scar tissue (from 6 months to a year), the loose scar, rich in blood vessels, cellular elements, and intercellular substance, transforms into a dense connective tissue structure. The reduction of the scar area occurs gradually due to a decrease in its moisture capacity, a decrease in the number of vessels, intercellular substance, and the contraction of collagen fibers. Thus, an "old," matured physiological scar consists mainly of densely packed, horizontally arranged collagen fibers, among which are elongated fibroblasts along the longitudinal axis, solitary lymphocytes, plasma and mast cells, intercellular substance, and rare blood vessels [1-7].
1.3 Epidemiology of the Disease or Condition
Official morbidity and prevalence data for keloid and hypertrophic scars are lacking. According to modern studies, scar formation is observed in 1.5–4.5% of individuals in the general population. Keloid scars are detected equally in men and women, most often in young individuals. There is a hereditary predisposition to the development of keloid scars: genetic studies indicate autosomal dominant inheritance with incomplete penetrance [31].
According to modern studies, the formation of hypertrophic scars is observed with a frequency of 40–70% after surgical interventions and up to 91% after burn injuries [8].
1.4 Features of Coding the Disease or Condition
L91 Hypertrophic disorders of skin
L91.0 Keloid scar
L91.8 Other hypertrophic disorders of skin
L91.9 Hypertrophic disorder of skin, unspecified
1.5 Classification of the disease or condition
There is no universally accepted classification.
The following clinical forms are distinguished:
– normotrophic (textural) scars;
– atrophic scars;
– hypertrophic scars:
- linear hypertrophic scars;
- widespread hypertrophic scars;
– keloid scars:
- small keloid scars;
- large keloid scars.
By the degree of maturity, they are classified as:
- mature (stable);
- immature (unstable).
1.6 Clinical presentation of the disease or condition
The general appearance of scars depends on the area of injury, localization, type of initial trauma, duration of existence, patient's age, etc.
A keloid presents as an exophytic formation protruding above the skin surface of various sizes, with cartilage-like consistency, a smooth surface, and uneven, indistinct borders. On smooth skin, keloid scars sometimes acquire bizarre outlines of a completely different shape than the preceding trauma or inflammatory focus. This is due to the spread of the keloid scar along skin tension lines (Langer's lines). The color of the scar ranges from bright red to cyanotic, and the scar color may remain bright for several years. Scar growth is often accompanied by paresthesias, pain upon palpation or contact with clothing, and pruritus. Keloid scars are capable of penetrating into the subcutaneous fat tissue, but ulcerate very rarely.
Hypertrophic scars present, depending on clinical manifestations, as dome-shaped nodules of various sizes (ranging from small to very large) with a tendency to merge and form plaques, or as linear cords with a smooth or bumpy surface. Fresh scars have a reddish color, which later becomes pinkish or whitish. Hyperpigmentation is possible at the edges of the scar. Scar formation occurs during the first month after tissue damage, enlargement in size occurs over the subsequent 6 months; scars often regress within 1 year. Hypertrophic scars are limited to the borders of the initial wound and generally retain their shape. Lesions are usually localized on the extensor surfaces of joints or in areas subject to mechanical stress. When lesions are localized in the joint area, limitation of limb mobility is possible.
2. Diagnostics, medical indications and contraindications for diagnostic methods
2.1 Complaints and Anamnesis
Patients complain of the presence of an exophytic formation with subjective sensations (paresthesias, pain upon palpation or contact with clothing, pruritus).
2.2 Physical Examination
Objective clinical manifestations of keloid scars detected during physical examination are described in the "Clinical Presentation" section.
2.3 Laboratory Diagnostics
Not applicable.
2.4 Instrumental Diagnostics
To perform differential diagnosis, skin examination under magnification (dermatoscopy) may be carried out.
2.5 Other Procedures
It is recommended to perform pathomorphological examination of biopsy (surgical) material in patients with spontaneous (without anamnestic data of trauma, surgery, or a pathological process preceding scar development) solitary keloids for the purpose of differential diagnosis with skin neoplasms [60, 61].
LE 4Level of recommendation C (level of evidence 4)
Differential diagnosis
Keloid scar | Hypertrophic scar |
|---|---|
Infiltrative growth beyond the initial injury | Growth within the boundaries of the initial injury |
Spontaneous or post-traumatic | Post-traumatic only |
Predominant anatomical sites (earlobes, chest, shoulders, upper back, back of the neck, cheeks, knees) | No predominant anatomical sites (but usually occur on extensor surfaces of joints or in areas of alternating mechanical stress) |
Develop later. Appear 3 months or later after the initial trauma and then grow indefinitely. | Develop earlier. Appear within the first month, grow for 6 months, and frequently regress within 1 year. |
Not associated with contractures | Associated with contractures |
Pruritus and severe pain | Subjective symptoms are rarely reported |
Skin phototype IV and above | No association with skin phototype |
Genetic predisposition (autosomal dominant inheritance, localization to chromosomes 2q23 and 7p11) | No genetic predisposition |
Thick collagen fibers | Thin collagen fibers |
Absence of myofibroblasts and α-SMA | Presence of myofibroblasts and α-SMA |
Type I collagen > Type III collagen | Type I collagen < Type III collagen |
COX-2 overexpression | COX-1 overexpression |
Criteria for establishing the diagnosis/condition:
1) Anamnestic data.
2) Physical examination data and, in some cases, skin examination under magnification (dermoscopy).
3) Results of pathological examination of biopsy (surgical) material when differential diagnosis with other skin diseases and/or skin neoplasms is necessary.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Indications for treatment.
Presence of a pathological scar, pruritus, active growth in characteristic localization sites.
Treatment objective
- arrest of disease progression;
- relief of subjective symptoms;
- flattening of the pathological scar.
General therapeutic notes
The treatment of keloid scars is a challenging task for the physician due to the scar's tendency to respond with even greater growth to any traumatic impact. Despite numerous treatment methods, there is no unified strategy and tactic for managing keloids. Most conventional methods insufficiently suppress keloid growth, failing to achieve the expected aesthetic result. Furthermore, none of them guarantees the prevention of recurrence.
Hypertrophic scars are benign skin lesions. The need for therapy is determined by functional impairment (e.g., contractures / mechanical irritation due to the height of the formations), as well as aesthetic parameters, which can significantly impact quality of life and lead to stigmatization [20, 21].
3.1 Conservative Treatment
Recommended silicone-based products (polysiloxane and/or silicon dioxide) for the resolution of keloid and hypertrophic scars (gel, spray) in patients of all age groups with hypertrophic and keloid scars to reduce subjective symptoms, decrease scar tissue elevation, and reduce the degree of erythema [1, 6, 8, 13, 16, 21, 22, 47].
GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)
Comments: the gel is applied to the scar area 2 times a day for 3–12 months. Gels are used on the face, neck, and joint areas where polysiloxane-based dressings cannot be fixed. The drug can be prescribed to children from birth. Treatment efficacy is variable.
Recommended use of silicone dressings in patients of all age groups with hypertrophic and keloid scars to reduce subjective symptoms, decrease scar tissue elevation, and reduce the degree of erythema, to be worn for at least 23 hours per day for 3–12 months [6, 8, 13, 16, 47].
GRC ALEL 2Grade of Recommendation A (Level of Evidence 2)
3.2 Intralesional Injection Therapy
Recommended intralesional glucocorticoids for patients with hypertrophic and keloid scars to reduce scar tissue volume, alleviate subjective symptoms, and prevent regrowth:
#triamcinolone intralesional injection into the skin lesion with an interval of 4–6 weeks [1, 2, 4, 8, 10, 14, 16, 19, 21, 22, 23, 27, 32, 33, 34, 35];
GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)
or
betamethasone intralesional injection into the skin lesion with an interval of 4–6 weeks [58, 59].
GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)
Comments: the maximum single dose of #triamcinolone for children aged 12 to 18 years is 20 mg/mL [25], and for adults, 40 mg/mL. The maximum single dose of betamethasone for patients over 3 years of age is 0.2 mL/cm2 of the lesion, but not more than 1 mL per procedure. The drug is dissolved in water**. A 1–2 mL syringe and a 27–30 G needle are used for injections. The needle is inserted deep into the scar as parallel to the skin surface as possible. Injections are performed from multiple points. To prevent lipolysis of the subcutaneous adipose tissue in the scar area, the needle tip should be directed upward. The course of therapy lasts from several months to several years.
Local administration may lead to skin atrophy, hypo- and hyperpigmentation, scar ulceration, and Cushing's syndrome. When administered in large quantities and high concentrations, systemic side effects may occur (edema, osteoporosis, mental disorders, peptic ulcer disease, and other complications). Injections in the periorbital areas are extremely undesirable as they may cause glaucoma or cataracts.
After 3–4 injections, telangiectasias develop in almost 100% of cases.
Recommended #botulinum toxin type A-hemagglutinin complex** for intralesional injection in patients with keloid and hypertrophic scars to reduce scar tissue volume and alleviate subjective symptoms:
- #botulinum toxin type A-hemagglutinin complex**, intralesional injection every 8 weeks [36–40].
GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)
Comment: the drug is administered at a dose of 5 IU per cm3 of scar tissue volume. The solution is prepared according to the manufacturer's recommendations. A disposable insulin syringe with a fixed needle is used for injections. The needle is inserted deep into the scar as parallel to the skin surface as possible. Injections are performed from multiple points. The course of treatment is determined individually, but should be at least 3 procedures.
Local administration of #botulinum toxin type A-hemagglutinin complex** promotes the rapid disappearance of subjective symptoms and a reduction in scar tissue volume.
Side effects include headache and short-term pruritus at the injection site.
Recommended #fluorouracil** for intralesional injection in patients with keloid scars to reduce scar tissue volume and alleviate subjective symptoms; 5% solution, 50–150 mg once a week. Course of therapy ranges from 3 to 16 injections [3, 6, 8, 14, 15, 19, 21, 22, 24, 28, 41–44, 66].
GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)
Comments: the main side effects of this therapy method are severe injection pain and hyperpigmentation (in 100% of cases). To reduce pain, preliminary administration of a 2% lidocaine** solution into the tissues beneath the scar is possible. Scabs and ulcerations are observed in rare cases. Recommended from 18 years of age.
3.3 Surgical Treatment
Not recommended surgical excision of keloid scars as monotherapy [1, 6, 22].
GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)
Comments: is used extremely rarely, as trauma to the scar almost always leads to keloid recurrence. An exception is a keloid localized on the earlobe. Surgical treatment must necessarily be accompanied by other methods of prevention and treatment of pathological scars [1, 6, 22].
Recommended surgical excision of hypertrophic scars older than 1 year using special surgical techniques (Z-plasty, W-plasty, etc.), choice of surgical defect closure method, and various local tissue plastic surgery options [1, 2, 6, 8, 13, 16, 21, 22, 47].
GRC BLEL 3Grade of Recommendation B (Level of Evidence 3)
Comments: surgical treatment must be accompanied by other methods of prevention and treatment of pathological scars.
3.4 Other treatment
It is recommended to perform laser coagulation of telangiectasias in the lesion using laser radiation with a wavelength of 585 nm and 595 nm in patients with keloid and hypertrophic scars in order to reduce the volume of scar tissue and decrease the degree of erythema [48 – 52].
GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)
Comment: the procedures are carried out at energy density values of 4.5 – 6 J/cm2, a working spot diameter of 5-10 mm, a pulse duration of 0.45 – 1.5 ms, overlap of no more than 10%, with cooling applied. The interval between procedures is 4-8 procedures, depending on the anatomical location. The number of procedures is 2-12. Possible side effects are most likely when using high energy density values and short pulse duration, and are represented by purpura, blistering, and hyperpigmentation.
It is recommended for patients with keloid and hypertrophic scars to undergo local cryotherapy using the contact cryoprobe application method in order to reduce the volume of scar tissue; the procedures are carried out in 2-3 cycles of 20-40 seconds each. The procedure is repeated after 3-4 weeks [2, 4, 6].
GRC BLEL 3Grade of Recommendation B (Level of Evidence 3)
It is not recommended for patients with keloid and hypertrophic scars to undergo local cryotherapy by the "open spray" method for irrigation with a gaseous jet and the "reed" method using an applicator with cotton tightly wrapped around it moistened with liquid nitrogen, since it is impossible to provide the necessary compression and prolonged exposure to a constantly low temperature [1, 2, 3, 4, 6, 15, 16, 22, 53-57].
Level of Evidence BGrade of Recommendation 2Level of Evidence B (Grade of Recommendation 2)
Comments: monotherapy for keloids leads to recurrences in 51-84% of cases, therefore, for the treatment of keloid scars, it is recommended to combine cryodestruction with intralesional injection of #triamcinolone or #betamethasone.
The main side effects of cryodestruction are skin pigmentation disorders.
It is recommended to use Grenz ray therapy (Bucky therapy) for diseases of the skin, subcutaneous adipose tissue, and skin appendages in patients with keloid scars in order to reduce the volume of scar tissue, reduce subjective symptoms, and prevent regrowth [16, 26, 62, 63].
GRC BLEL 2Grade of Recommendation B (Level of Evidence 2)
Comments: "young" keloid scars, after surgical interventions, removal of neoplasms (papillomas, keratomas, etc.) - generation voltage 10 kV. Single dose 25.8*102 C/kg per 1 field. Interval between sessions 1.5-2 months. Total number of sessions no more than 5 per one irradiation field. Total dose per one field – 5000-6000 R.
"Old" keloid scars – performed after surgical excision of the primary keloid scar or liquid nitrogen cryotherapy after complete healing of the wound surface. Maximum anode generation voltage 50-300 kV. Dose per 1 field 25.8*102 C/kg (850 R). Interval between sessions 1.5-2 months. Total number of sessions no more than 5 per 1 irradiation field. Total dose per 1 field – 5000-6000 R.
Prevention of keloid scar formation: - generation voltage 10 kV. Dose per session should not exceed 32.3*102 C/kg (1250 R). Interval between sessions at least 1.5 months. Total number of sessions – no more than 3 per 1 irradiation field. Total dose per 1 field – no more than 2000-3000 R [1, 6, 15, 22].
The procedure is performed by a radiologist or radiation therapist in an X-ray room that meets the requirements of SanPiN 2.6.1.1992-03, SanPiN 2.6.1.802-99, NBR-99, SP 2.6.1.759-99, OSPORB-99, SP 2.6.1.799-99.
It is recommended to use low-level laser irradiation of the skin in patients with keloid and hypertrophic scars in order to reduce the volume of scar tissue and reduce subjective symptoms [5, 22].
Following the intralesional injection of #bovine #hyaluronidase #azoximer into the skin lesion, the skin is exposed to low-intensity infrared laser radiation with a pulse power of 2-8 W/pulse at a pulse repetition rate of 80 Hz or 1500 Hz. The total exposure time is 15 minutes, the course is 15 procedures [5]. Low-level laser irradiation of the skin can be prescribed in the acute stage in the presence of an inflammatory component [5, 22].
GRC CLEL 5Grade of Recommendation C (Level of Evidence 5)
It is recommended to use occlusive therapy in patients with keloid and hypertrophic scars in order to reduce the volume of scar tissue and reduce subjective symptoms. Airtight dressings for the treatment of "young" scars. Apply to the lesion without additional compression for 12-20 hours, then remove, wash with soap, and reapply to the lesion [1, 6, 13, 16, 21, 22]. The products are recommended for children from birth.
Level of Evidence CGrade of Recommendation 3Level of Evidence C (Grade of Recommendation 3)
It is not recommended to perform skin tissue laser destruction and laser resurfacing procedures using 10600 nm laser radiation (carbon dioxide laser) in patients with keloid scars. Treatment of keloid and hypertrophic scars with a CO2 laser can be performed in total or fractional modes. Following total destruction of a keloid scar with a CO2 laser as monotherapy, recurrence is observed in 90% of cases, therefore this type of treatment cannot be recommended as monotherapy [64, 65].
Grade of Recommendation 1Level of Evidence A (Grade of Recommendation 1)
Dietary therapy is not used.
Pain management is not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable.
5. Prevention and Dispensary Observation
Individuals with a history of hypertrophic and keloid scar formation or those scheduled for surgery in a high-risk area for their development are recommended:
For wounds with a high risk of scarring, it is preferable to use a silicone-based product (polysiloxane and/or silicon dioxide) for the resorption of keloid and hypertrophic scars (gel, spray). Silicone gel or dressings should be applied after the incision or wound has epithelialized and continued for at least 1 month. For gel, at least 12 hours of daily use or, if possible, continuous 24-hour use with hygienic cleaning twice a day is recommended. The use of gel may be preferable for extensive lesions, when used on the face, and for individuals living in hot and humid climates.
For patients with a moderate risk of scarring, the use of silicone gel or dressings is possible (preferred).
Patients with a low risk of scarring should be advised to follow standard hygiene procedures. If the patient expresses concern about the possibility of scar formation, they can use a silicone-based product (polysiloxane and/or silicon dioxide) for the resorption of keloid and hypertrophic scars (gel, spray).
An additional general preventive measure is avoiding sun exposure and using sunscreens with the maximum sun protection factor (SPF > 50) until the scar matures.
As a rule, the management tactics for patients with scars can be reviewed 4-8 weeks after epithelialization to determine the need for additional scar revision interventions.
6. Organization of Medical Care
There are no indications for hospitalization in a medical organization.
Keloid and hypertrophic scars should be treated on an outpatient basis.
Depending on the therapy method, positive clinical dynamics (a 30-50% reduction in scar volume, a decrease in the severity of subjective symptoms) can be achieved after 3-6 procedures or after 3-6 months of treatment.
7. Additional Information
None.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance evaluation |
|---|---|---|
1. | External therapy was performed using a silicone-based product (polysiloxane and/or silicon dioxide) or silicone dressings. | Yes/no |
2. | Intralesional injection of #triamcinolone or #betamethasone into the skin lesion was performed. | Yes/no |
3. | Occlusive therapy was performed. | Yes/no |
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Appendix A1. Working Group Composition
Kubanov, Alexey Alekseevich – Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, President of the Russian Society of Dermatovenereologists and Cosmetologists.
Martynov, Andrey Alexandrovich – Doctor of Medical Sciences, Professor, Head of the Department of Dermatovenereology and Cosmetology at the Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Vlasova, Anna Vasilyevna – Candidate of Medical Sciences, Associate Professor at the Department of Dermatovenereology and Cosmetology of the Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Gallyamova, Yulia Albertovna – Doctor of Medical Sciences, Professor, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Zubareva, Elena Yuryevna – Candidate of Medical Sciences, Associate Professor at the Department of Dermatovenereology and Cosmetology of Omsk State Medical University of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Krivonos, Nikolai Viktorovich – Candidate of Medical Sciences, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Mahakova, Yulia Buyandylgerovna – Candidate of Medical Sciences, Head of the Educational Department of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Novikov, Yury Alexandrovich – Doctor of Medical Sciences, Associate Professor, Head of the Department of Dermatovenereology and Cosmetology at Omsk State Medical University of the Russian Ministry of Health, Chief Medical Officer of the Clinical Skin and Venereology Dispensary of Omsk Region, Chief freelance specialist in Dermatovenereology and Cosmetology of the Ministry of Health of Omsk Region, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Pravdina, Olga Valeryevna – Candidate of Medical Sciences, Associate Professor at the Department of Dermatovenereology and Cosmetology of Omsk State Medical University of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Radul, Elena Vladimirovna – Candidate of Medical Sciences, Associate Professor at the Department of Dermatovenereology and Cosmetology of Omsk State Medical University of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Saitburkhanov, Rifat Rafailevich – Dermatovenereologist at the Consultative and Diagnostic Center of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Sokolova, Anna Viktorovna – Doctor of Medical Sciences, Professor, member of the Russian Society of Dermatovenereologists and Cosmetologists.
Conflict of interest:
The authors declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Dermatovenereologists;
Surgeons;
Cosmetologists;
Radiologists, radiation therapists;
Medical students, residents, and postgraduate students.
Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Rating scale for levels of evidence (LE) for preventive, therapeutic, and rehabilitation methods (interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Rating scale for grades of recommendation (GR) for preventive, diagnostic, therapeutic, and rehabilitation methods (interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Current instructions for medications mentioned in these clinical guidelines can be found at grls.rosminzdrav.ru
Appendix B. Physician Action Algorithms
Flowchart of patient management with keloid scars.
*Subsequent prophylactic therapy is required; IIT – intralesional injection therapy, BT – #botulinum toxin type A-hemagglutinin complex**.
Appendix C. Patient Information
People with risk factors for keloid scars are advised to avoid skin trauma, such as tattoos, piercings, and unnecessary surgical procedures / cosmetic skin surgeries, especially in high-risk areas such as the chest or earlobes.
If these patients develop inflammatory dermatoses, timely and effective medical therapy is important to reduce the risk of scar formation.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Special rating scales, indices, and questionnaires are not used in the examination of patients with hypertrophic skin changes.