Everyone has scars. Some we can see. Others we feel.
And some are too deep to ever reach.
Scarring, whether from surgery or the result of inflammatory skin conditions such as acne, burns or trauma is often associated with considerable emotional and psychological impact.
One of my greatest challenge and rewards come from treating patients with scars.
Definition of a Scar
Scars are areas of fibrous tissue that replace normal tissue after skin injury.
A scar is an integral part of the wound healing process and involves reepithellialisation, neocollagenasis, neovascularizatin, and pigment deposition. However a prolonged inflammatory phase of 4 weeks or more during wound healing may lead to abnormal scarring.
Classification of Scars
Scars are classified according to both color and texture.
Classification by color.
These are generally due to the presence of dilated blood vessels in the dermis in response to injury.The dilated blood vessels provide oxygen and nutrients to the skin to recover from the injury.
Brown scars are due to the deposition of Melanin and hemosiderin from the red blood cells where the skin is injured.Dark skin individuals are more prone to develop brown scars and post inflammatory hyper pigmentation as their skin heals from injury.
These are due to the absence of melanin as the inflammation may partly destroy the melanin in the melanocytes.
Classification by Texture.
These are the result of EXCESSIVE collagen deposition and fibrosis at the site of injury.
- These may be hypertropic or keloid.
- Hypertropic scars are raised but do not extend beyond the margins of the injured skin.
- Keloid scars are raised and always extend beyond the margins of the injured skin.
- Darker skin types are more genetically susceptible to the formation of hypertropic and keloid scars.
These can be ice pick, boxed or rolled.
- ice pick scars are less than 2 mm, superficial and at acute angles to the base.
- Boxed scars are larger, more than 2 mm and at right angles to the base.
- Rolled scars have rolled and non angled borders, are large and often the result of a deep acne cyst or nodule that has involuted.
Treatment of Scars
This depends upon several factors.
Age of the scar.
Current thinking is to treat scars earlier than later. Hypertropic scars take 4 weeks to form and may increase in size for 3-6 months.
Scars on the sternum, chest, shoulders and back are more prone to keloid.
Type of scar.
Keloid, hypertropic or Atropic.
Thickness of the scar.
Patient characteristics, skin type, comorbid medical conditions.
Treatment of RED SCAR.
- Vasoconstrictors such as oxymetazoline, epinephrine can be used to constrict blood vessels, decreasing scar redness.
- Silicone gels, e.g. Kelokote, have been shown to reduce the scar redness, if applied twice a day for 4 months
- BBL or broad band light and PDL or pulsed dye laser are non ablative lasers to treat the vascular component of the scar.
Treatment of BROWN SCARS
- Lightening agents such as HQ, Azelaic and Kojic acid inhibit tyrosinase thereby preventing the conversion of dopa to melanin.
- Topical Retinoids.
- Tretinoin or Tazarac reduce brown pigmentation by inhibiting tyrosinase and formation of melanin.
- Side effects include redness, irritation, burning, itching, , contact dermatitis, dryness and scaling.
Treatment of Scar Texture and Thickness
Strategies for prevention of hypertrophic and keloid scars during surgical procedures include minimizing tension and everting wound edges during closure, avoiding anatomic locations more prone to hypertrophic or keloid scars such as around joints, angle of jaw, shoulders, mid chest and upper back, placing incisions that follow along RSTL( relaxed skin tension lines) and achieving efficient hemostasis. Potent topical steroids such as dermovate or Ultravate may be used for minimally hypertrophic scars.
For thicker scars, intralesional kenalog 10-40mg/ml may help to decrease the elevation Of hypertrophic and keloid scars.
Steroids are immunosuppressants and diminish collagen synthesis. Adverse effects include Hypopigmentation, atrophy, telengiectasia, and delayed wound healing.
Topical imiquimod ( Aldara) stimulates interferon and nightly application of Aldara to keloid scars over an 8 week period has been shown to Improve the cosmetic appearance of these scars.
Silicone gels or sheets have been shown in clinical studies to prevent the development of keloid or hypertrophied scars and may be used as a first line prophylactic strategy.
Gels are preferable to sheets as they are better able to contour the flexural areas as optimal occlusion is achieved by close apposition of the product with the scar.
Cosmetic camouflage using makeup creams and powders in patients normal skin tone will help fill and conceal dark shadows created by scar depressions.
Chemical peels exfoliate the skin surface, decreasing the depth of depresses scars.
Soft tissue fillers such as Juvederm, Radiesse, are good options to treat scars that are distensible.
Subcision, punch or surgical excision.
Total Ablative Laser resurfacing or fractional non ablative resurfacing is an excellent option for resurfacing depressed scars but involves considerable downtime and time off work.
All scars can be classified by their color and texture.
Many topical therapies are available to improve scar appearance. Failing this, a referral to a dermatologist for further management should be considered.