Most injuries to the skin result in scars – tattoos are one of the few exceptions. We all have some scars and, of course, anyone who has been damaged in an accident or had a surgical operation will be left with a scar.
Why scars occur
After injury to the skin, our body’s priority is to make a rapid and strong repair. This would have been particularly important for primitive man, living in dirty and dangerous conditions. Although scars may look unattractive, they are an efficient way of healing. To regenerate tissue that was the same as before would take longer, with the wound remaining vulnerable during the process.
Surgeons are very keen to minimize scarring after their operations, because they know that scars can be distressing. Whenever possible, they make their incisions along lines in the skin that will heal best. They also take great care with ‘sewing up’ the skin. But sometimes a nasty scar cannot be avoided.
Questions to ask yourself if you are bothered by a scar
How recent is the scar? A recent scar will probably become less noticeable in time. Most scars take 2–3 years to become pale. If you see a doctor for advice about a scar that is less than 1 year old, you will probably be advised just to wait and see.
What is really bothering me? Is the appearance of the scar the main problem? Or does the scar interfere with movements (which may happen with a large scar over a joint, especially a burn scar) Is the scar causing any other problems such as itching or discomfort?
How much trouble and expense am I prepared to go to? There are lots of treatments for scars. The simplest are creams and oils, or ‘scar plasters’ (special adhesive strips). You can buy these treatments from pharmacies, but you have to use them for some time, and it is uncertain whether there will be any result. So you could spend a lot of money for nothing. At the other end of the spectrum, doctors might advise cutting the scar out, which is a surgical operation.
What type of scar do I have? Not all scars are the same! Different types of scar need different types of treatment, so try to work out what type you have.
Stretch marks are common after pregnancy.
Stretched scars can also occur after surgery. The original scar is satisfactory, but over a few weeks it gradually widens to become a pale, soft scar. These scars are not usually uncomfortable, but the appearance may bother you.
Keloids are large, bulky, raised scars. They can be very unsightly. Unlike other scars, they gradually grow bigger. They are most common in black skin.
Other raised scars (not all raised scars are keloids) can occur after burns or surgery but, unlike keloids, they do not keep growing. They are often red and itchy.
Chickenpox and acne scars are flat, small and slightly sunken.
Shrunken scars are common after burns and can cause problems if they lie across joints. The medical term for these scars is ‘contractures’.
What can I expect from treatment? Whatever treatment you go for, it is best not to have too high expectations. Do not expect that any treatment will get rid of the scar completely, and then you will not be disappointed.
Treatments for scars
Creams and massage may help. Any sort of moisturizing cream will do; ‘cocoa butter’ cream is a popular choice. Apply the cream and then gently massage it into the scarred area with a circular movement. Do this for about 5 minutes twice a day. Do not use steroid cream; it will not help (British Medical Journal 2004;328:1329–30).
Sunblock is important if the scar is on exposed skin. Scars do not contain the normal pigments that protect skin, so burn easily.
Silicone gel can be bought from pharmacies. Silicone gel sheeting is used by hospitals to soften and flatten scars, but it is questionable whether the gel has an equivalent effect (British Medical Journal 2004;328:1329–30). It is also very expensive.
Consider camouflage with special make-up (see useful contacts). Camouflage creams can stay on the face for up to 18 hours and on the body for 3–4 days. If applied properly, they are waterproof so you can swim or shower without losing the cream (MIMS Dermatology 2006;2:44).
Specialist treatments. If simple treatments do not help, discuss the matter with your doctor. Explain clearly to your doctor what the problem is – whether it is the appearance of the scar, or discomfort, or perhaps interference with movement of a joint if it is near the scar. Your doctor can then refer you to an appropriate specialist. For example, acne scars might be best dealt with by a dermatologist, while a plastic surgeon would be the best person to deal with keloid scars.
Different scars need different treatments. The specialist might recommend compression therapy, laser therapy, injection of a special steroid, freezing or application of a special silicone sheet (which has to be worn 24 hours a day for up to 1 year). A wide, stretched scar could be cut out by a surgeon to leave a thin, neat line.
Keloid scars are particularly difficult to treat, because if they are cut away another keloid often forms in the new scar. A combination of surgery with radiation, steroid injection or pressure therapy may be used. Keloid scars can also be treated by a combination of laser treatment and steroid injection (Surgery 2006;24(1):18–20, Lancet 2009;373:1264–74).
Do not be surprised if the specialist advises leaving the scar alone, and just waiting for it to become less noticeable; this might be the right thing to do.
Private treatment. If you decide to see a cosmetic surgeon privately, be very careful. Ask your family doctor for advice, and look at the section on choosing a cosmetic surgeon.
For the future, a drug called avotermin is showing promise. This is a substance that is normally made by some of the healing cells in the skin. Researchers cut the skin of volunteers, and found that injecting avotermin at the same time reduced later scarring (Lancet 2009;373:1264–74). More research needs to be done, and it is not clear if this treatment would improve old scars.
Special thanks to Dr A Bayat and Professors D A McGrouther and M J W Ferguson for their excellent article from which I obtained many of my facts on this topic (Bayat A, McGrouther DA, Ferguson MJW. Clinical review: skin scarring. British Medical Journal 2003;326:88–92).
Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Tuesday, August 2nd 2011
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