Skin Deep

Scars may be reminders of obstacles overcome, but can become one more challenge for the healthcare team to tackle.

Scars are fibrous tissue that replace normal skin during the healing process; however, when scars become enlarged, red, itchy and painful, they can negatively affect quality of life and physical function. A slight derailment in the wound-healing process, such as excessive connective tissue cells and overproduction of collagen, can result in abnormal scarring, such as keloid and hypertrophic scars.

Hypertrophic scars, which typically develop within a month of surgery, are raised, red or pink, and sometimes itchy. Keloid scars appear as firm nodules that extend beyond the margins of the original wound and are often itchy and painful. Unlike hypertrophic scars, keloids may develop months or years after surgery and continue to grow over time.

Causes > Certain types of trauma, wound infection and delayed wound healing increase the risk of abnormal scars. Many studies report an increased incidence of keloids and hypertrophic scars in areas of high skin tension, such as the chest, shoulders and neck as well as across joints and on sterna skin, upper arms, earlobes and cheeks. Keloids occur 15 times more often in individuals with darker skin. Breast and thoracic surgeries are associated with a high incidence of scarring, and studies show hypertrophic scars develop in about 40 to 70 percent of patients following any surgery.

Research is ongoing to understand the physiology of scarring and to determine whether some people are more susceptible to scarring and keloid formation.

Prevention > The International Advisory Panel on Scar Management recommends silicone gel sheeting—a soft topical dressing that is tacky on one side—as the first-line preventive measure for hypertrophic scars and minor keloids. This therapy should begin soon after surgical closure and continue for at least one month. The panel suggests that silicone ointments may be appropriate for the face and neck, although their effectiveness in preventing scarring isn’t supported by controlled trials.

For more severe cases, the panel recommends concurrent intralesional corticosteroid injections as a second-line preventive measure. Corticosteroid injections can soften and flatten 50 to 100 percent of keloids but can’t narrow hypertrophic scars.

Management > Because abnormal scars are among the most common and frustrating problems after injury, a variety of effective treatment options is available.

The panel recommends combining silicone gel sheeting and intralesional corticosteroids—such as triamcinolone acetonide—for keloids. However, silicone gel sheeting can be inconvenient since sheeting must be worn 12 to 24 hours a day for a few months for best results.

The panel also recommends pressure dressings, such as wrapping the wound with elastic bandages, as an effective treatment for hypertrophic scars. This has shown significant improvement in 60 percent of patients. Again, compliance is low because the dressing must be worn 18 to 24 hours per day for at least four to six months.

For more severe or resistant scars, second-line and combination therapies may be helpful. Options to consider include surgical excision followed by corticosteroid injections for keloids.

On the other hand, silicone gel sheeting after surgical excision prevents recurrence of keloids and hypertrophic scars in 70 to 80 percent of cases and also helps treat scar symptoms of erythema (abnormal skin redness), pain and itching.

Other treatment options showing some efficacy include radiation following surgical excision of keloids to reduce recurrence rates and pulsed-dye laser treatments to flatten scars. There is little evidence that vitamin E is helpful.

Research is ongoing to understand the physiology of scarring and to determine whether some people are more susceptible to scarring and keloid formation—which may help patients and doctors make decisions about certain surgical procedures.