Scar Management: Types, Treatment and Know More

Nearly everyone develops scars, whether from accidents, surgical procedures, acne, or illnesses like chickenpox. These permanent marks on the skin represent the body's natural healing process, making effective scar management essential for many individuals.

With proper care and appropriate interventions, scars can significantly improve over a period of time, depending on the severity and location of the original wound. Let's explore the different types of scars and how to manage them.

Types of Scars

Doctors classify scars based on their appearance and how they develop during the healing process.

• Normal Fine-line Scars: Fine-line scars form after minor wounds or surgical incisions which heal properly. Initially appearing as red, raised lines, they gradually become flatter and paler over time. This natural healing process can take up to two years.
• Keloid Scars: Keloid scars develop when the body produces excessive collagen at the wound site. Unlike other scars, keloids grow beyond the boundaries of the original wound, behaving like benign tumours. 
• Hypertrophic Scars: Hypertrophic scars also result from excess collagen production but remain contained within the original wound area. 
• Atrophic Scars: Atrophic scars form indentations that sit below the surrounding skin surface. They develop when the skin cannot regenerate tissue properly, often following acne or chickenpox. Atrophic scars are the most common type of acne scarring and are typically categorised into three subtypes:
  • Ice pick scars: Small, narrow depressions resembling deep pores
  • Boxcar scars: Broader depressions with flat bottoms and defined edges
  • Rolling scars: Undulating depressions without distinct borders, usually found on cheeks
• Contracture Scars: Contracture scars typically result from burns. As these scars mature, they tighten the skin, potentially limiting movement, especially when they form across joints.

Why Do Scars Form?

The body has a remarkable healing mechanism. Scars form in the dermis (deep thick layer of skin) whenever skin damage occurs, a complex healing process begins immediately, and the body lays down collagen fibres to mend the damage, resulting in a scar. The new scar will have a different texture and quality from the surrounding tissue. 

Scar Formation Process

Factors Affecting Scar Formation

Multiple variables influence how scars develop, explaining why the same type of injury might result in drastically different scarring from person to person.

• Wound depth: Injuries affecting only the epidermis typically heal without scarring, while deeper wounds involving the dermis or subcutaneous tissue result in more noticeable scars
• Inflammatory response: Prolonged or excessive inflammation often leads to more pronounced scarring.
• Age: Younger individuals typically form wider scars than older people due to increased skin tension.
• Location: Areas with high skin tension or movement develop more noticeable scars
• Infection or complications: Wound infections, necrosis, or dehiscence significantly increase scarring

Non-surgical Scar Management Techniques

Several proven techniques can improve scar appearance and reduce associated discomfort without invasive procedures.

• Pressure therapy stands as a cornerstone treatment for scar management, particularly for hypertrophic scars following burns. This approach works by creating a state of hypoxia and reducing transforming growth factor-β1 expression, which limits fibroblast activity. 
• Silicone products represent another gold-standard approach for non-surgical scar management. Available as sheets or self-drying gels, silicone works through several mechanisms:
  • Increasing hydration of the stratum corneum
  • Facilitating fibroblast regulation and reducing collagen production
  • Protecting scarred tissue from bacterial invasion
  • Modulating growth factors that influence collagen production
• Combining approaches often yields superior results. Using silicone gel sheets under pressure garments can substantially improve outcomes for hypertrophic scars.
• Other non-surgical approaches include:
  • Scar massage prevents adhesions and assists in collagen realignment
  • Ultrasound therapy promotes healing by stimulating growth factors that increase collagen strength and elasticity. 
  • Laser therapy, particularly fractional CO2 lasers, can correct surface irregularities and pliability without damaging the epidermis.

Surgical Scar Revision

Surgical intervention becomes necessary for scars that significantly impact appearance or restrict movement. The type of surgical revision depends on the scar's size, location, and severity. For standard scar excision, surgeons remove the entire scar tissue and manipulate adjacent healthy skin to reform the area. This technique works best when the scar already follows natural skin lines. If simple excision isn't possible, surgeons may use a skin graft taken from cosmetically less important areas like the buttocks or inner thighs.

• Z-plasty procedure: Z-plasty is the most common revision technique, beneficial for elongating contracted scars. This procedure:
  • Changes scar direction to align with natural skin lines
  • Breaks up straight-line scars for less visibility
  • Releases tight scars and lenghthen it for better mobility. 
• W-plasty procedure: W-plasty creates a zigzag pattern that's harder for the eye to follow. The broken line helps the scar blend better with the surrounding skin, though this technique isn't suitable for eyelid areas.

Surgeons may use tissue expanders-expandable silicone implants placed under the skin for complex cases. Once the skin stretches sufficiently, the expanded healthy skin replaces the excised scar tissue.

Strategy to minimize Scarring 

Preventing scars from forming is far more effective than treating them after they've developed. Proper wound care immediately after injury can dramatically reduce the severity of scarring and, in some cases, prevent scars altogether.

• Cleaning the wound properly forms the foundation of effective scar prevention. Contrary to common practise, experts recommend avoiding hydrogen peroxide as it can increase inflammation and destroy healing skin, ultimately worsening scarring. Instead, gently wash wounds with mild soap and water to remove debris and bacteria.
• After cleaning, keeping the wound moist is essential. Apply petroleum jelly to the clean wound and cover it with an appropriate bandage. This prevents scab formation—wounds with scabs take longer to heal, often resulting in larger scars.
• Reducing tension on the wound significantly decreases scar formation. For areas with high movement, such as joints, zigzag suturing techniques like Z-plasty are particularly effective at minimising tension.
• For optimal scar prevention, consider these additional strategies:
  • Begin scar treatment early—ideally within one week after suture removal
  • Change bandages daily with clean hands to prevent infection
  • Avoid picking at scabs or scratching healing wounds
  • Minimise movement of the healing area to prevent wider scars
  • Apply sunscreen to healed wounds, as sun exposure can darken scars

Conclusion

Scar management requires a thorough understanding of how scars form and develop. While complete scar elimination might not always be possible, several effective treatment options exist for minimizing scars. The choice between surgical and non-surgical approaches depends on various factors, including scar severity, location, and individual characteristics.

Proper wound care stands as the most effective strategy against problematic scarring. Early intervention, combined with appropriate treatment selection, significantly improves outcomes. Patients who follow recommended care protocols and maintain consistent treatment schedules achieve better results.

FAQs

1. How long does scar healing take?

Scar healing progresses through multiple stages over an extended period. Complete scar maturation typically takes six to 18 months, though the final appearance may not be evident until after this timeframe. 

2. What is the best treatment for hypertrophic scars?

Silicone-based products represent the first-line treatment for hypertrophic scars, supported by multiple high-quality studies.
Corticosteroid injections, particularly triamcinolone acetonide, can reduce scar size and flatten raised tissue. 

3. Can scars be completely removed?

No treatment can completely remove scars once they have formed. Treatments aim to improve appearance rather than achieve total elimination.

4. Are there natural remedies for scar reduction?

Despite widespread use, products containing vitamin E lack substantial research supporting their effectiveness. 

Some natural approaches with limited supporting evidence include:

• Honey (possibly beneficial for open wounds but unproven for scars)
• Coconut oil 
• Massage (helps break up scar tissue when done consistently)