Hand Microsurgery. The utility of onion extract gel containing topical allantoin and heparin after surgical treatment of upper extremity burn scars

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Hand Microsurgery & Original Research Hand Microsurg 2014;3:74-79 doi:10.5455/handmicrosurg.

1 Hand Microsurgery & Original Research Hand Microsurg 2014;3:74-79 doi: /handmicrosurg The utility of onion extract gel containing topical allantoin and heparin after surgical treatment of upper extremity burn scars Mehmet Ihsan Okur 1, Alpagan Mustafa Yildirim 2, Bilsev Ince 3 ABSTRACT Background: The development of hypertrophic scars after burns can lead to esthetic as well as functional disorders. The aim of the study was to determine the functional and cosmetic effects of Contractubex (onion extract, heparin, allantoin) gel applied in burn scar patients after surgery for scar excision and skin grafts. Patients and Methods: The study included seven male patients who presented to our clinic between 2005 and 2012 for the treatment of hypertrophic burn scar and were administered either single or combined medical hypertrophic scar treatments. Patients who had scars on the right upper extremity were included in group 1 and those with left upper extremity scars in group 2. In group 1, all scars were excised and closed with medium thickness skin graft. After surgery, the onion extract gel was applied to the right upper extremities. In group 2, only surgical treatment was applied. The results were evaluated with Vancouver scar scale. Results: Vascularity, flexibility, and height of the scars improved significantly in both groups. In addition, hyperpigmentation was observed on the skin grafts of all patients. Scar flexibility was less often observed in patients left upper extremities. However, no statistical difference between groups 1 and 2 was found. Conclusion: Although no significant difference was obtained with Contractubex gel treatment in this study, cosmetic and functional success can be achieved through excision of the scar and use of medium thickness skin graft in patients with upper extremity hypertrophic burn scarring that is resistant to conservative treatments. Key words: Hypertrophic scar, surgical treatment, onion extract, heparin, allantoin, Vancouver scar scale Introduction Hypertrophic scar tissue due to deep partial/fullthickness burns to the upper extremities can be esthetically displeasing and can lead to severe functional and psychosocial impairment. These psychosocial effects include disruption of daily activities, stigmatization at work place, low self-esteem, anxiety, and depression [1]. Various treatment modalities have been postulated for the treatment and management of hypertrophic scars; however, there is no single, optimal treatment modality that can eliminate or prevent hypertrophic scars [2,3]. Combined treatment procedures have been advocated by some studies, yet results from these studies have been insufficient in some cases [3,4]. Hypertrophic scarring poses a risk of recurrence even when excised with appropriate surgical methods. Therefore, the use of medical prophylactic treatment is important during post-surgical recovery. Treatment with silicone gel sheet, onion extract, compression, 5% imiquimod cream, and vitamins A and E, during the post-surgical recovery period has been attempted previously [5]. There have been several reports on the efficacy of some of these methods; however, the therapeutic role Author affiliations : Correspondence : Received / Accepted : 1 Firat University, Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Elazig, Turkey 2 Afyon Kocatepe University, Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Afyonkarahisar, Turkey 3 Necmettin Erbakan University, Faculty of Meram Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Konya, Turkey Bilsev Ince, Necmettin Erbakan University, Faculty of Meram Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery, Konya, Turkey bilsevince@yahoo.com November 07, 2014 / November 21, Turkish Society for Surgery of the Hand and Upper Exremity

2 Okur MI et al. of onion extract and vitamin E has not been investigated yet. Moreover, there is a small number of studies and insufficient data on the effective use of 5% imiquimod pomade and topical vitamin A. The compression method is effective only when scarring is in its active period, and its effectiveness in prophylactic treatment is limited [5]. While several studies have focused on the effectiveness of Contractubex (100 mg extractum cepae, 50 IU heparin, 10 mg allantoin) for hypertrophic scars, [6-9] to the best of our knowledge, no study has reported the effectiveness of Contractubex on the prevention of hypertrophic burn scars after surgical treatment. This study examined the functional and cosmetic effects of a treatment method in which scar excision and medium thickness skin graft were performed, and Contractubex was administered post-operatively for 6 months. All patients had deep burns that healed secondarily, and they developed hypertrophic scarring of the upper extremities, which was unresponsive to conservative treatment. Patients and Methods The study included seven male patients who presented to our clinic between 2005 and 2012 for the treatment of hypertrophic burn scar and were administered either single or combined medical hypertrophic scar treatments. The study was approved by the clinics ethics committee, and written informed consent was obtained from all study participants. Hypertrophic scars were defined as fluffy, pinkish-red, rough, and Figure 1. Appearance of hypertrophic scar on the hand. 75 Hand and Microsurgery itchy scars that were unresolved for at least 2 years. Included in the study were patients who had hypertrophic scars with areas of secondary healing of burns to both upper extremities following contact with flame or hot water. Patients who had scars on the right upper extremity were included in group 1 and those with left upper extremity scars in group 2. In group 1, all scars were excised and closed with medium thickness skin graft. After surgery, the onion extract gel was applied to the right upper extremities. In group 2, only surgical treatment was applied. Three patients had hypertrophic scars on both hands (Figure 1), while four had forearm or arm burns. All burns healed secondarily with medical dressings in different clinics and no surgery was performed. Conservative treatments received by study participants included silicone gel sheet, burn compression garment, steroids (intralesional injection), and onion extract gel. These conservative treatments were commenced in other plastic surgery clinics and continued in our clinic; however, no success was observed. Vancouver Scar Scale was used in the evaluation of the patients. The Vancouver burn scar score combines scores representing four features of scarring due to Table 1. Vancouver scar assessment scale. Characteristics Pigmentation Vascularity Flexibility Height Scale 0: Normal color 1: Hypopigmentation 2: Hyperpigmentation 0: Normal color 1: Pink 2: Red 3: Dark red 0: Normal 1: Soft, flexible 2: Bendable 3: Hard 4: Band-line like tissue 5: Contracture 0: Normal (flat) 1: <2 mm 2: 2-5 mm 3: >5 mm Year 2014 Volume 3 Issue

Effect of contractubex on the hypertrophic scars burns: pigmentation, flexibility, vascularity, and height (Table 1).

Scars were measured preoperatively and on the last patient visit by the same surgeon (BI).

Hypertrophic scar tissues in the upper extremities due to burn were completely excised (Figures 2-3). Partial-thickness skin grafts (0.4 0.

3 Effect of contractubex on the hypertrophic scars burns: pigmentation, flexibility, vascularity, and height (Table 1). Accordingly, the highest score is 13, and a scar of normal color, vascularity, flexibility, and height is scored 0 [2]. Scars were measured preoperatively and on the last patient visit by the same surgeon (BI). Upper extremity circulation in patients operated under general anesthesia was halted via a cuff placed on the arm. Hypertrophic scar tissues in the upper extremities due to burn were completely excised (Figures 2-3). Partial-thickness skin grafts ( mm) taken from the thigh were sutured to the area where the scars were excised using surgical staples and 4/0 absorbable stitches. On postoperative day 12, Contractubex was applied to the right upper extremities topically, four times a day for 6 months. Patients were advised to protect their surgical sites from sunshine after every application. No scar reducing treatment was given to the left upper extremities of patients after surgery. None of the patients used compression garments. Statistical Analysis All data were entered and analyzed by using SPSS 18.0 (USA). One-way analysis of variance and the Tukey s post hoc test were used to compare Vancouver burn scar assessment scores between the groups. A p- value of <0.05 was considered statistically significant. Results The study included 14 upper extremities of 7 male patients (Table 2). The mean age of the patients was 25.2 years (range, years). Patients were followed for an average of 16.8 months (range, months). During postoperative follow up, there was no recurrence of hypertrophic scars, and cosmetic results were acceptable. Except for hematomas, which occurred in all patients, no other complication occurred in graft areas (0.5 m 2 at most) during the early postoperative period. The average preoperative Vancouver burn scar assessment score of patients in group 1 was reduced from 11.3 to 2.4 on postoperative twelfth month and of patients in group 2 was reduced from 11.6 to 2.7 on postoperative twelfth month. Vascularity, flexibility, and height of the scars improved significantly in both groups (p < 0.05). In addition, hyperpigmentation was Figure 2. Appearance of the thickness of hypertrophic scar. Figure 3. Hypertrophic scar tissues in the upper extremities due to burn were completely excised. Figure 4. Hyperpigmentation was observed on the skin grafts of all patients. Hand and Microsurgery 76

4 Okur MI et al. Table 2. Features of patients about burn, scar and operation. Gender Age Cause Recovery Period Scar Area (cm) The area with hypertrophic scar Operation Time Follow-up time after surgery The period between burn-surgery M- 30 Flame 21 days M- 35 Flame 16 days M- 24 Hot water 18 days M- 16 Flame 20 days M- 13 Hot water 22 days M- 42 Flame 21 days M- 17 Hot water 18 days x x x x6 10x5 Both hands 185 min 18 months 24 months Both hands 160 min 16 months 25 months Both forearms 53 min 12 months 21 months Both forearms 52 min 14 months 24 months Right arm Left hand 44 min 20 months 17 months Both hands 140 min 22 months 25 months Right forearm Left hand 39 min 16 months 20 months observed on the skin grafts of all patients. Scar flexibility was less often observed in patients left upper extremities (Figure 4). However, no statistical difference between groups 1 and 2 was found. When the pigmentation, vascularity, and height of scars were compared between both groups, no statistically significant difference was seen. One patient developed a 14 3 cm hypertrophic scar in the donor area. This scar was treated by excision and suturing. Discussion Newer approaches have been presented for the treatment of hypertrophic scarring; however, these treatment methods only reduce but cannot eliminate hypertrophic scarring completely [5]. Various conservative methods are used in the treatment of scars due to burns; the most effective are compression treatments, silicone gel sheet, silicone based ointment, polyurethane covering, onion extract gel containing heparin and allantoin, and 5% imiquimod cream [4,5,10,11]. Although some studies have described hypertrophic scarring as a self-limiting physiological process that can resolve spontaneously with time,[2] one study has reported that spontaneous resolution is rare in hypertrophic scars lasting more than 9 months [4]. This suggests little possibility of spontaneous resolution in our patients, whose scars had not healed for 2 years. Currently, different treatment methods are used in the treatment of hypertrophic scars, the most promi- 77 Hand and Microsurgery nent of which are silicone gel sheet, intralesional steroid injection, and the use of a burn compression garment [3,5,11]. The use of these methods in non-refractory cases before surgery can reduce the frequency and risk of surgery. In the present study, all patients were treated with most of these therapeutic modalities alone or in combination; however, none of them responded to treatment. The surgical treatment method for hand dorsal hypertrophic scarring is excision of the tissue and closure of the defect with a skin graft [1,2]. Cosmetic appearance and skin elasticity are better when a full thickness skin graft is used. Although this method is basically consistent with our present study, it can only be applied in limited areas due to donor area restrictions. The thickness of partial-thickness skin grafts shares cosmetic similarity with the normal skin. At the same time, greater thickness reduces the possibility of hypertrophic scarring in the recipient site. However, a hypertrophic scar may develop in the donor area [3]. One patient in the study developed a 14 3 cm hypertrophic scar in the donor area, from where a thick graft was taken; this was treated with surgical excision. We had difficulty in controlling bleeding following the opening of the cuff after scar excision; however, blood transfusion was not necessary in any of the patients. The only cosmetic challenge we encountered in this study was hyperpigmentation (Figure 4), which has been previously reported in partial-thickness skin Year 2014 Volume 3 Issue

5 Effect of contractubex on the hypertrophic scars grafts [2,3]. These problems may be prevented when the graft is thicker and a full thickness graft is used. However, this approach may result in distinctive problems, such as the occurrence of hypertrophic scarring in the donor area. In addition, full-thickness grafts can be taken from a limited number of sites. The excision of hypertrophic scars in extremities might cause exposure of tendons. Local or distant flaps should be used in this situation [1]. Gousheh et al. [12] reported successful results in 34 patients when using super-thin abdominal skin flaps in the treatment of hand dorsal hypertrophic scarring. Although this technique has better cosmetic appearance, it is disadvantageous as there are two or three sessions and the hand stays at the abdominal wall for 3 weeks. When onion extract is combined with heparin and allantoin (Contractubex gel), it represses fibroblast activity, causes the scar to soften, and reduces erythema [6-10]. Some studies have reported the effectiveness of Contractubex on hypertrophic scars, [8,9] whereas others suggest that it is not effective on its own and should be combined with silicone gel sheet [13]. Recently, it has been shown that the preventive use of the onion extract gel on Pfannenstiel s incision scar in Asian patients improved scar height and scar symptoms [14]. A randomized, controlled, single-blind study demonstrated that better scar appearance can be obtained by using the onion extract gel on the shaving excision wounds of seborrheic keratoses [15]. In this study, the flexibility of scars was better in patients in whom Contractubex was used. However, no statistical difference between group 1 and group 2 was found. The reason may be the small number of patients in our study. The patients regained function and had cosmetically improved results. Hypertrophic scars in three patients were sufficiently large to restrict their work and social lives. Surgical treatments enabled these patients to return to work. Hypertrophic scar developed in the skin graft donor area of one patient. Although emergence risk of hypertrophic scar in the skin graft donor area is present for cases with surgical treatments, the risk would be acceptable for patients receiving such long-term treatment. In conclusion, although no significant difference was obtained with Contractubex gel treatment in this study, cosmetic and functional success can be achieved through excision of the scar and use of medium thickness skin graft in patients with upper extremity hypertrophic burn scarring that is resistant to conservative treatments. References 1. Cetinkale O. Hand burns: early and late treatment. Turkiye Klinikleri J Surg Med Sci 2007;3: Lorenz HP, Longaker MT. General principles. In: Mathes SJ, Hansen SL, eds. Plastic surgery. Saunders Elsevier, Philadelphia, 2006; Thorne CH. Principles, techniques and basic sci ence. In: Thorne CH. Grabb and Smith s Plastic Surgery. Lippincott-Williams & Wilkins, Philadelphia; 2007; Karakuzu A. Treatment of hypertrophic scar and keloid. Turkiye Klinikleri J Int Med Sci 2005;1: Zurada JM, Kriegel D, Davisc IC. Topical treatments for hypertrophic scars. J Am Acad Dermatol 2006;55: Vogt J. Scars. Hippokrates Verlag GmbH, Stuttgart, Karagoz H, Yuksel F, Ulkur E, Evinc R. Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars. Burns 2009;35: Maragakis M, Willital GH, Michel G, Gortelmeyer R. Possibilities of scar treatment after thoracic surgery. Drugs Exp Clin Res 1995;21: Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract, heparin, allantoin gel in prevention of scarring in chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg 2006;32: Karagoz H, Sever C, Bayram Y, Sahin C, Kulahci Y, Ulkur E. A Review of the Prevention and Treatment of Hypertrophic Scars: Part I Clinical Aspects. Arch Clin Exp Surg 2012; 1: Özerdem ÖR, Anlatıcı R, Dalay C, Erol Kesiktaş, Acartürk S, Çeliktaş M. [Çocuklarda Görülen Hand and Microsurgery 78

6 Okur MI et al. Anormal Skar Oluşumlarının Silikon Jel Blok İle Tedavisi] [Article in Turkish]. 2002;10: Gousheh J, Arasteh E, Mafi P. Super-thin abdominal skin pedicle flap for the reconstruction of hypertrophic and contracted dorsal hand burn scars. Burns 2008;34: Hosnuter M, Payasli C, Isikdemir A, Tekerekoglu B. The effects of onion extract on hypertrophic and keloid scars. J Wound Care 2007;16: Chanprapaph K, Tanrattanakorn S, Wattanakrai P, Wongkitisophon P, Vachiramon V. Effectiveness of onion extract gel on surgical scars in asians. Dermatol Res Pract 2012;2012: Draelos ZD, Baumann L, Fleischer AB Jr, Plaum S, Avakian EV, Hardas B. A new proprietary onion extract gel improves the appearance of new scars: a randomized, controlled, blinded-investigator study. J Clin Aesthet Dermatol 2012;5: Hand and Microsurgery Year 2014 Volume 3 Issue

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