The normal wound healing process involves a complex and precise interaction of numerous cells, hormones, cytokines and growth factors in a particular sequential order. This process however, may be disrupted at any of its stages, leading to a non-healing chronic wound or excessive scar formation. While the majority of wounds heal on their own but without the aid of preventive measures, aberrant scarring often occurs. Hypertrophic scars and keloids represent an unwanted healing response and may cause functional and psychological disturbances in patients. Their management poses a true challenge.
Many of the actual treatment strategies have a defined biologic background while others are based on anecdotal reports. The growing knowledge of the bimolecular processes of normal and abnormal wound healing has produced new treatment modalities and has also led to a better understanding of the working mechanisms of older treatments.
Although the optimal treatment regime of severe scars remains undefined, substantial improvement can be achieved with combined multidisciplinary therapeutic approaches.
An ideal scar is flat, relatively narrow, slightly paler than the surrounding skin and does not disturb the appearance of the patient. Whether or not such an ideal normal scar will develop depends on many factors, some of which can be modified but others not.
Risk factors for unaesthetic scarring are related to:
- 1.The initial trauma: the depth (e.g. deep burns) of the wound, the extension of the injury, whether or not the (surgical) wound is made in a fold or parallel to the Langer lines (or perpendicular to it), whether it was an irregular crushed wound or a clear-cut wound... etc.
- 2.The acute treatment: adequate debridement and/or wound dressings, prevention of inflammation/infection, delayed reepithelialisation, surgical treatment or not, closure with or without tension, postoperative complications... etc.
- 3.The location of the wound: some areas of the body are especially susceptible to develop "bad quality scars" (Figure 14). The pre-sternal and the deltoid region tend to develop hypertrophic scars while scars in the back and the shoulders also over extension areas of joints are usually wide spread and atrophic. The more tension there is on the wound edges, the more chances there are for unaesthetic scar formation.
- 4.Age is also a determining factor since scars in childhood have much more tendency to become hypertrophic, at least transiently. It is important to tell the parents this risk factor and provide information about preventive actions.
- 5.The risk of developing excessive scar formation is also dependent on skin type, probably related to genetic factors: dark skin is more susceptible to develop hypertrophic and keloid scars, a risk which is also increased in red haired patients.
Scarring results from the body's natural healing process after body tissue has been damaged. Tissue damage can occur for a number of reasons, including:
- Accidental Injuries – such as cuts from falling off a bicycle
- Deliberate harm from a weapon or from self-harm
- Cuts made during surgery – such as a Caesarean section birth
- Bites and scratches from animals or people
- Burns and scalds from hot objects or liquids
- Body piercings – such as ear or nose piercings
- Injections – such as vaccination against tuberculosis (BCG vaccination)
Scarring can also be a side effect or a complication of other conditions. For example, if you have a condition that causes a rash, such as chickenpox or acne, you may be left with scars where the rash was (this is more likely to happen if you scratch or pick at the affected areas).
It is thought that keloid scarring and hypertrophic scarring may run in families. This means you have an increased risk of developing keloid scarring or hypertrophic scarring if a member of your family has previously had these types of scars. Internal scarring can be caused by injuries or surgery.
Scar revision surgery is meant to minimize the scar so that it is more consistent with your surrounding skin tone and texture. Scars are visible signs that remain after a wound has healed. They are unavoidable results of injury or surgery, and their development can be unpredictable. Poor healing may contribute to scars that are obvious, unsightly or disfiguring. Even a wound that heals well can result in a scar that affects your appearance. Scars may be raised or recessed, different in color or texture from surrounding healthy tissue or particularly noticeable due to their size, shape or location.
Your treatment options may vary based on the type and degree of scarring and can include:
- Simple topical treatments, such as bioCorneum+
- Minimally invasive procedures
- Surgical revision with advanced techniques in wound closure
Although scar revision can provide a more pleasing cosmetic result or improve a scar that has healed poorly, a scar cannot be completely erased.
border Types of Scars
These scars are the result of an overly aggressive healing process. They extend beyond the original injury. Over time, a keloid scar may hamper movement. Treatments include surgery to remove the scar, steroid injections, or silicone sheets to flatten the scar. Smaller keloids can be treated using cryotherapy (freezing therapy using liquid nitrogen). You can also prevent keloid formation by using pressure treatment or gel pads with silicone when you are injured. Keloid scars are most common among people with dark skin.
If your skin has been burned, you may have a contracture scar. These scars tighten skin, which can impair your ability to move. Contracture scars may also go deeper, affecting muscles and nerves.
These are raised, red scars that are similar to keloids but do not go beyond the boundary of the injury. Treatments include injections of steroids to reduce inflammation or silicone sheets, which flatten the scar.
If you've had severe acne, you probably have the scars to prove it. There are many types of acne scars, ranging from deep pits to scars that are angular or wavelike in appearance. Treatment options depend on the types of acne scars you have.
border Treating scars at r5 aesthetics
Corticosteroid injections are used to treat some keloid and hypertrophic scars.
Multiple small injections are made into the scar to reduce any swelling (inflammation) and to flatten the scar. Depending on the type of scar, these may need to be repeated. Injections are usually given on three occasions, at four- to six-week intervals, to assess your body's response. Treatment may sometimes continue for several months if the scar is improving.
This treatment cannot remove scars, but it can improve their appearance.
Silicone gels or sheets
Silicone gels or sheets are available from some pharmacies. They are used on healing skin (not open wounds) to reduce redness and to try to minimise hypertrophic or keloid scars.
To be effective, silicone gels or sheets should be placed over the scar for 12 hours a day, for at least three months.
You can ask your GP, dermatologist or pharmacist for more advice about a range of silicone-based scar treatments.
Surgery for scars
Surgery can sometimes improve the appearance of scars, as it can be used to:
- change the positioning of the scar
- change the width or shape of the scar
- release a tight scar that is close to a joint, to improve movement
Be aware that having surgery on your scar will leave a new scar that will take up to two years to improve in appearance. If surgery is used to treat a hypertrophic scar, there is a risk that the scarring may be worse after the surgery.
Surgery alone is not advised for keloids, as they tend to grow back larger. Surgery for keloids is often combined with corticosteroid injections at the site of the removed scar immediately after surgery. Some plastic surgeons also add other treatments, such as X-ray therapy and oral antibiotics, to try to minimise the recurrence of a keloid that has been surgically treated. You can talk to your surgeon about this treatment.
Pressure dressings for scars
The aim of pressure dressings is to flatten and soften scars. They are most often used for large burn scars or after skin grafts.
Pressure dressings are usually made from a stretchy, elastic material. They are worn over the scar 24 hours a day, for around 6 to 12 months. They can also be used in combination with silicone gel sheeting, to improve the appearance of scars over a long period of time.
Pressure dressings are usually used under specialist supervision.
Make-up for scars
Cosmetic camouflage (make-up) can help cover up scars and can be particularly useful for facial scars. Some are waterproof and can stay in place for two or three days.
Camouflage make-up that is specially designed for covering up scars is available over the counter at pharmacies. You can also ask your GP for advice.
Please note that camouflage colour testing (to get a good colour match for your skin type) can be a lengthy process, sometimes taking over an hour, and needs to be performed by someone who is qualified.
Laser or light therapy (pulses of light) can reduce the redness in a scar by targeting the blood vessels in the excess scar tissue. For some pitted scars, laser surgery (laser re-surfacing) is used to try to make the scar flatter. This involves using a laser to remove the top layers of skin, which stimulates collagen production in the deeper layers.
However, there are very few long-term studies to prove the effectiveness and safety of this therapy. If you have laser therapy, it's important to make sure that the person carrying it out is a fully trained medical practitioner with experience in improving scars.
Dermal fillers are injections (often of a man-made acid) used to "plump up" pitted scars. Treatments can be costly and the results are usually temporary. Repeat treatments are needed to maintain the effect.
Skin needling, which involves rolling a small device covered in hundreds of tiny needles across the skin, is also reported to be helpful, but repeat treatments are often needed to achieve an effect, and results vary considerably.
Low-dose, superficial radiotherapy may reduce the recurrence rate of hypertrophic and keloid scars after surgery. It is effective in about 70% of cases but, because of the possibility of long-term side effects, it is only reserved for the most serious cases.