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CC BY-NC-ND 4.0 · Arch Plast Surg 2022; 49(04): 554-560
DOI: 10.1055/s-0042-1751027
Research/Experimental
Original Article

Extracorporeal Shock Wave Therapy for Hypertrophic Scars

Apirag Chuangsuwanich 
1   Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
,
Natthapong Kongkunnavat 
1   Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
,
Malika Kamanamool 
1   Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
,
Gulradar Maipeng 
2   Perioperative Nurse Division, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
,
Nanticha Kamanamool 
3   Department of Preventive and Social Medicine, Faculty of Medicine Srinakharinwirot University, Ongkharak, Thailand
,
Warangkana Tonaree 
1   Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Abstract

Background Hypertrophic scars cause aesthetic concerns and negatively affect the quality of life. A gold standard treatment for hypertrophic scars has not been established due to various responses of modalities. Extracorporeal shock wave therapy (ESWT) is a noninvasive and affects scar remodeling by fibroblast regulation. This study investigated the effectiveness of ESWT for hypertrophic scars.

Methods Twenty-nine patients were enrolled. All patients underwent ESWT once a week for 6 consecutive weeks. Their scars were assessed using the Patient and Observer Scar Assessment Scale (POSAS), erythema index, melanin index, and scar pliability before treatment and again 4 weeks after treatment completion.

Results Thirty-four hypertrophic scars in this study had persisted for between 6 months and 30 years. Most scars developed after surgical incision (55.88%). The chest and upper extremities were the predominant areas of occurrence (35.29% each). Most of the POSAS subscales and total scores were significantly improved 4 weeks after treatment (p < 0.05). Furthermore, the pain, itching, and pigmentation subscale were improved. The pliability, melanin index, and erythema index were also improved, but without significance. The patients were satisfied with the results and symptoms alleviation, although subjective score changes were insignificant. No serious adverse events were found. The patients reported pruritus in 62.5% and good pain tolerance in 37.5%. Subgroup analyses found no differences in scar etiologies or properties at different parts of the body.

Conclusion The ESWT is a modality for hypertrophic scar treatment with promising results. Most of POSAS subscales were significantly improved.

Keywords

extracorporeal shock wave - hypertrophic scar - wound healing - scar prevention

Ethical Approval

This study was approved by the Institutional Review Board of Faculty of Medicine Siriraj Hospital (approval number 295/2016). The Declaration of Helsinki protocol was followed.


Patient Consent

Informed consent was obtained from all individual participants included in the study.


Supplementary Material



Publication History

Article published online:
30 July 2022

© 2022. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Lorenz P, Bari AS. Scar prevention, treatment, and revision. Neligan PC. ed. Plastic Surgery 3rd ed London: Elsevier Saunders; 2013: 297-318
    Google Scholar
  • 2 Gauglitz GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Mol Med 2011; 17 (1-2): 113-125
    CrossrefPubMedGoogle Scholar
  • 3 Rabello FB, Souza CD, Farina Júnior JA. Update on hypertrophic scar treatment. Clinics (São Paulo) 2014; 69 (08) 565-573
    CrossrefPubMedGoogle Scholar
  • 4 Fioramonti P, Cigna E, Onesti MG, Fino P, Fallico N, Scuderi N. Extracorporeal shock wave therapy for the management of burn scars. Dermatol Surg 2012; 38 (05) 778-782
    CrossrefPubMedGoogle Scholar
  • 5 Qureshi AA, Ross KM, Ogawa R, Orgill DP. Shock wave therapy in wound healing. Plast Reconstr Surg 2011; 128 (06) 721e-727e
    CrossrefPubMedGoogle Scholar
  • 6 Speed C. A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence. Br J Sports Med 2014; 48 (21) 1538-1542
    CrossrefPubMedGoogle Scholar
  • 7 Cui HS, Joo SY, Cho YS. et al. Effect of extracorporeal shock wave therapy on keratinocytes derived from human hypertrophic scars. Sci Rep 2021; 11 (01) 17296
    CrossrefPubMedGoogle Scholar
  • 8 Joo SY, Lee SY, Cho YS, Seo CH. Clinical utility of extracorporeal shock wave therapy on hypertrophic scars of the hand caused by burn injury: a prospective, randomized, double-blinded study. J Clin Med 2020; 9 (05) E1376
    CrossrefPubMedGoogle Scholar
  • 9 Ito K, Fukumoto Y, Shimokawa H. Extracorporeal shock wave therapy for ischemic cardiovascular disorders. Am J Cardiovasc Drugs 2011; 11 (05) 295-302
    CrossrefPubMedGoogle Scholar
  • 10 Li H, Liu ML. Cardiac shock wave therapy: an alternative non-invasive therapy for refractory angina. Eur Rev Med Pharmacol Sci 2018; 22 (16) 5402-5410
    PubMedGoogle Scholar
  • 11 Wang W, Liu H, Song M, Fang W, Yuan F. Clinical effect of cardiac shock wave therapy on myocardial ischemia in patients with ischemic heart failure. J Cardiovasc Pharmacol Ther 2016; 21 (04) 381-387
    CrossrefPubMedGoogle Scholar
  • 12 d'Agostino MC, Craig K, Tibalt E, Respizzi S. Shock wave as biological therapeutic tool: from mechanical stimulation to recovery and healing, through mechanotransduction. Int J Surg 2015; 24 (Pt B): 147-153
    CrossrefPubMedGoogle Scholar
  • 13 Frairia R, Berta L. Biological effects of extracorporeal shock waves on fibroblasts. A review. Muscles Ligaments Tendons J 2012; 1 (04) 138-147
    PubMedGoogle Scholar
  • 14 Ogawa R. Mechanobiology of scarring. Wound Repair Regen 2011; 19 (Suppl. 01) s2-s9
    CrossrefPubMedGoogle Scholar
  • 15 Pinheiro NM, Melo PR, Crema VO, Mendonça AC. Effects of radiofrequency procedure on hypertrophic scar due to burns. J Eur Acad Dermatol Venereol 2015; 29 (01) 187-189
    CrossrefPubMedGoogle Scholar
  • 16 Sukubo NG, Tibalt E, Respizzi S, Locati M, d'Agostino MC. Effect of shock waves on macrophages: a possible role in tissue regeneration and remodeling. Int J Surg 2015; 24 (Pt B): 124-130
    CrossrefPubMedGoogle Scholar
  • 17 Wang JH, Thampatty BP, Lin JS, Im HJ. Mechanoregulation of gene expression in fibroblasts. Gene 2007; 391 (1-2): 1-15
    CrossrefPubMedGoogle Scholar
  • 18 Cui HS, Hong AR, Kim JB. et al. Extracorporeal shock wave therapy alters the expression of fibrosis-related molecules in fibroblast derived from human hypertrophic scar. Int J Mol Sci 2018; 19 (01) E124
    CrossrefPubMedGoogle Scholar
  • 19 Moortgat P, Anthonissen M, Van Daele U. et al. The effects of shock wave therapy applied on hypertrophic burn scars: a randomised controlled trial. Scars Burn Heal 2020; 6: 2059513120975624
    Google Scholar
  • 20 Wang CJ, Ko JY, Chou WY, Cheng JH, Kuo YR. Extracorporeal shockwave therapy for treatment of keloid scars. Wound Repair Regen 2018; 26 (01) 69-76
    CrossrefPubMedGoogle Scholar
  • 21 Gollmann-Tepeköylü C, Nägele F, Graber M. et al. Shock waves promote spinal cord repair via TLR3. JCI Insight 2020; 5 (15) 134552
    CrossrefPubMedGoogle Scholar
  • 22 Holfeld J, Tepeköylü C, Kozaryn R. et al. Shockwave therapy differentially stimulates endothelial cells: implications on the control of inflammation via toll-like receptor 3. Inflammation 2014; 37 (01) 65-70
    CrossrefPubMedGoogle Scholar
  • 23 Draaijers LJ, Tempelman FR, Botman YA. et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg 2004; 113 (07) 1960-1965
    Google Scholar
  • 24 Durani P, McGrouther DA, Ferguson MW. The Patient Scar Assessment Questionnaire: a reliable and valid patient-reported outcomes measure for linear scars. Plast Reconstr Surg 2009; 123 (05) 1481-1489
    Google Scholar
  • 25 Durani P, McGrouther DA, Ferguson MW. Current scales for assessing human scarring: a review. J Plast Reconstr Aesthet Surg 2009; 62 (06) 713-720
    CrossrefPubMedGoogle Scholar
  • 26 Nicholas RS, Falvey H, Lemonas P. et al. Patient-related keloid scar assessment and outcome measures. Plast Reconstr Surg 2012; 129 (03) 648-656
    Google Scholar
  • 27 Verhaegen PDHM, van der Wal MBA, Middelkoop E, van Zuijlen PPM. Objective scar assessment tools: a clinimetric appraisal. Plast Reconstr Surg 2011; 127 (04) 1561-1570
    CrossrefPubMedGoogle Scholar
  • 28 Fearmonti R, Bond J, Erdmann D, Levinson H. A review of scar scales and scar measuring devices. Eplasty 2010; 10: e43
    PubMedGoogle Scholar
  • 29 Neto P, Ferreira M, Bahia F, Costa P. Improvement of the methods for skin mechanical properties evaluation through correlation between different techniques and factor analysis. Skin Res Technol 2013; 19 (04) 405-416
    PubMedGoogle Scholar
  • 30 Antonic V, Mittermayr R, Schaden W, Stojadinovic A. Evidence supporting extracorporeal shock wave therapy for acute and chronic soft tissue wounds. Wounds 2011; 23 (07) 204-215
    PubMedGoogle Scholar
  • 31 Mittermayr R, Antonic V, Hartinger J. et al. Extracorporeal shock wave therapy (ESWT) for wound healing: technology, mechanisms, and clinical efficacy. Wound Repair Regen 2012; 20 (04) 456-465
    PubMedGoogle Scholar
  • 32 Romeo P, Lavanga V, Pagani D, Sansone V. Extracorporeal shock wave therapy in musculoskeletal disorders: a review. Med Princ Pract 2014; 23 (01) 7-13
    CrossrefPubMedGoogle Scholar
  • 33 van Zuijlen PP, Angeles AP, Kreis RW, Bos KE, Middelkoop E. Scar assessment tools: implications for current research. Plast Reconstr Surg 2002; 109 (03) 1108-1122
    CrossrefPubMedGoogle Scholar
  • 34 Draaijers LJ, Botman YA, Tempelman FR, Kreis RW, Middelkoop E, van Zuijlen PP. Skin elasticity meter or subjective evaluation in scars: a reliability assessment. Burns 2004; 30 (02) 109-114
    CrossrefPubMedGoogle Scholar