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Painful plantar hypertrophic scar

Discussion in 'General Issues and Discussion Forum' started by markdsack, May 15, 2006.

  1. markdsack

    markdsack Welcome New Poster

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    I have a patient who came to me recently. She has a painful plantar hypertrohic scar in the medial arch area from a skin lesion excision about 1 1/2 years ago. Since she has such a severe planovalgus deformity, this area is bearing weight and is a significant source of pain for her. I believe this is a hypertrophic scar and not a keloid, for it remains linear and does not extend more than a millimeter or two on either side of the incision. However, it is thickened, relatively hard, and significantly darker than her surrounding skin.

    I believe that she has had 2 steroid and 2 sclerosiing agent injections (dilute dehyrdogentated etoh) with no improvement, and she has used mederma for a long time. Does anyone have any experience with injectable as well as topical scar reduction agents? Any help would be appreciated.
  2. Craig Payne

    Craig Payne Moderator

    I have not seen many in the arch (they tend not to be problematic) so have not used topical agents. I have generally used a total contact type orthotic with cavity.

    What about surgical revision? ie 'fish mouth' excision of scar and meticulous stitching for a "new" very neat linear scar...
  3. Tuckersm

    Tuckersm Well-Known Member

    Has she tried Cica Care
  4. markdsack

    markdsack Welcome New Poster

    Thank you so much for your replies. I really appreciate it.

    Regarding surgical revision, this pt has a hx of keloid/hypertrophic scars (from injuries, chicken pox, etc) on other locations on her body. I would rather not incise on the plantar skin again if possible. Dorsally I might feel a little differently.

    She has had 2 pairs of orthotics from the previous doctor(s) which she does not tolerate well. I haven't seen them yet, but I told her to bring them in next visit. I believe that a good accommodative orthotic might alleviate some of her situation.

    Regarding cica care, I have heard good things as well, and I will apply this to her foot.

    Is there anything injectable? I spoke with someone about Wydase (hyaluronidase), which I have never personally used. From what I understand it has been off the market for several years, but there is another type called Vitrase. Both were used mainly for opthalmic surgery. Does anyone know about the indications for this and would it apply to scar reduction? I have not read anything about Vitrase and scar injections, but it is hyaluronidase, and the Wydase form was previously used for scar injections.
  5. summer

    summer Active Member

    In my experience, you will most likely have to try surgical excision with wide elipse. Follow with ABSOLUTE non weighbearing for 3 weeks and use intralesional steroid after sugery. Another good adjunctive measure is to have them apply medical grade silicone sheeting under occlusion for a few months.
  6. nigelroberts

    nigelroberts Active Member

    Painful plantar scar

    Dear Mark

    Some clinicians have used acupuncture needling directly into the scar. Not sure how this works but it certainly appears to reduce sensitivity.

  7. markdsack

    markdsack Welcome New Poster

    Craig Payne, Tuckersm, Summer, and Nigel Roberts:

    Thank you very much for your assistance. Hopefully with all of our combined knowledge, this cruel world will be minus one scar. This is a cool site. Peace to you and yours.

    Mark Sack
  8. musmed

    musmed Active Member

    Dear Mark

    Trapped free nerve endings is far more common than thought.

    Tender painful scars are usually only found by the clinician by asking the patient if they have painful scars.

    Arthroscopy to the knee is an extremely common cause of very small painful scars at the site of the portal skin entry. These small scars produce reduced ROM to the knee upwards of 20+ degrees of flexion and once released the ROM returns instantly.

    Studies show that 11-13% of all hernia repairs develop entrapment of some form of nerve fibre leading to CRPS. Thses patient present as scrotal or testicular pain. The urologist on my floor at work told me he sees about one case every two weeks!

    I have had success using an 830NM laser. This frequency is in the red infrared spectrum.

    The dose time is dependent on the strength of the laser. Mine is 100Milliwatt therefore one need 10secs to deliver 1 watt. The dose I use is 15 joules to the scar three times in a week.

    The patient just comes in a uses it themselves. The usual time to recover from the problem is about 8-10 visits.

    An aside. There is a myofascial technique using extremely light pressure and tension on the scar. It is called simply scar release. Not many people can do it.

    Ask around there may be someone out there who has learnt the technique and CAN perform it.

    I have seen a major chest (cardiac) keloid scar converted into butter in 30 minutes or so.

    Ask around.

    Paul Conneely

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