Scar Treatment
Scar formation is normal. It happens following any injury or surgery. A scar is part of the way the body heals. Scar tissue may involve only the superficial skin, called the epidermis. It can also affect the deeper skin, called the dermis. The scar may also involve tissue under the skin including fat, nerves, muscles, and tendons. An active scar can be red, raised, firm and thick. Scars can become sensitive and limit motion and function. Scars change over time, where some will improve with time and others worsen, but no scar disappears entirely.
Some scars can take up to a year to mature. How a scar changes over time depends on location, size, and type. There are features to tell when a scar has completed healing including change of appearance, texture, and sensitivity.
Personal and Societal Effects of Scars
Scars can sometimes lead to aesthetic and functional impairments. Scars that progress and enlarge require careful treatment planning, tailored to each patient.
Patients who have prominent scars may experience a reduction in their quality of life. They can be subjected to bullying, feel anxiety in social situations, and experience sadness or frustration in relation to their scar, causing stress.
Scar Healing
After the skin and deeper tissues have healed, the scar heals in several phases. An active scar is typically red, raised, firm, and thick. Sometimes this change can be confused with infection. The scar will often enlarge and become more reddened over the following 4-6 weeks, with the outermost layer often loosening or peeling. This is normal, more commonly seen with scars in the palm of the hand than the back of the hand. Next, the wound becomes smaller and paler over the next several months (Figure 1). Later, the scar becomes soft and has a more natural color in most people. Scar appearance depends on the amount of blood supply. Higher blood flow areas may heal with finer scars.
Types of Abnormal Scars
Hypertrophic scars often appear within 1 month of injury and continue to grow over 6 months. After that, they can stabilize or improve for up to 1 year. Hypertrophic scars are different from keloids. Hypertrophic scars are found within the original injury borders and can occur anywhere on the body. However, they are more common in areas of high tension, often seen on the side of a joint that bends. For example, they form on the front of the elbow or back of the knee. They are red, raised, and itchy. They are more common in people aged 10-30 years old and do not seem to have higher genetic risk.
Keloids are different from hypertrophic scars and often develop later after skin injury. They may take 3-12 months to develop, forming both in the original injury site and spreading outside of it. They occur most commonly on the ear lobes, chest, shoulders, upper back, posterior neck, cheeks, and knees. They have symptoms like burning, itching, pain, and extra feeling. Keloids occur equally in men and women and are more common in younger people. They are seen more often in certain groups of people, including those from Africa, Asia, or Hispanic countries. There may also be genetic risks and cluster in families that can cause keloids to develop.
Prevention of Excess Scar Formation
Scar treatment begins with the doctor or advanced practitioner closing the wound well. By preventing further skin injury and reducing tension during wound closure, the scar heals better. During wound closure, the skin should be pinched with forceps as little as possible. Skin eversion and lining skin edges up as best as possible also helps.
Treatment
Your hand surgeon or hand therapist may recommend a variety of treatments for your scar. The timing of scar treatments varies depending on the type of injury or surgery.
Therapy approaches can be divided into categories. They include passive modalities, manual therapies, and active motion-based therapies. Passive modalities may be defined as therapies that do not require active work from the patient. In other words, they involve a treatment applied to the scar. Examples include heat/ice application, electrical stimulation, and ultrasound therapy. Manual therapies involve direct manual manipulation by a therapist. Commonly used manual therapies include massage or instrument-assisted soft-tissue mobilization (IASTM) (i.e., Graston technique). Active motion-based therapies require the physical participation of the patient. These patient-initiated motions include supervised performance of multiple exercises. Early controlled exercise programs can prevent stiffness of nearby joints. Exercises keep tendons and nerves gliding under the skin.
Massage
Massage can help with the underlying elasticity of the scar tissue, as it breaks down adhesive tissue, increasing pliability and glide. Moderate effects of massage therapy on itchiness have been shown. Massage creates sensations other than itch to be sent from the scarred skin receptors to the brain. Scar massage can help decrease sensitivity and loosen any deeper areas that seem “stuck,” helping produce a smooth, moveable scar. During massage, application of over-the-counter creams can help. Common products include petroleum ointment (Vaseline), cocoa butter, vitamin E oil, or hand lotion. The tissue should be massaged in the direction of the scar for ten minutes two times a day. This is useful for 3-6 months or for as long as it seems to be helpful.
Pressure Therapy
Pressure therapy may reduce local blood flow to the wound that may result in less inflammation. It may also reduce collagen build-up and amount of scar formation. Pressure can be applied by silicone gel sheets, tape, and other elastic garments.
Silicone
Silicone gel can be placed on the scar in sheets or in liquid form (Figure 2). Silicone sheets can be washed and reused. They are soft and self-adhesiveand protect the wound. Silicone gel dries as a very thin layer and will stay on curved skin surfaces. Sheets and gel both provide passive mechanical support and reduce tension in the skin. Scar reduction is felt to occur by creating a barrier. This barrier also hydrates the outer layer of the skin. Silicone prevents water evaporation from the wound. Silicone produces static electricity and decreases inflammation and itching as well.
Silicone sheeting should be started about 2 weeks after the primary wound treatment. They should be left on as much as possible each day ideally 12-24 hours. They should be used for a minimum of 2 months and up to 3-6 months. If sheets are hard to use, silicone gel can be tried. Consult your doctor before using silicone gel or sheets.
Tape
Taping or wrapping of the scar can help reduce swelling and tension. Paper tapes reduce hypertrophic scarring and tension on wound edges and minimizes shearing. Non-stretch tapes can prevent linear surgical scarring and reduce height, color, and itch. Tape should start early in the healing. However, paper tapes can improve scar even when started in the medium or late scar healing phases. Color, thickness, and scar movement all improved.
Steroid tape is an option for troublesome keloid and hypertrophic scars, although it is not widely used. Consult your doctor before using tape of any kind.
Sunscreen
Avoiding excess sun exposure for several months is recommended, as UV rays from the sun increase scar pigmentation. If you can’t avoid the sun, use sunscreens with a high protection factor. Reapply sunscreen frequently, especially after water exposure or if sweating a lot.
Surgery
Surgical excision can be required for severe scars. Hypertrophic scars have a low chance of returning after surgery, whereas keloids can return in 45-100% of cases. The timing of surgery should be when scars are at least several months old and at their most mobile and soft. Hypertrophic scars often demonstrate resolution for up to 1 year. Thus, operations may be best to wait until the 1-year mark, especially if the scar is improving.
With any surgery, postoperative care is important. Good nutrition is important. Glucose control should be as strict as possible. Smoking cessation is vital for the protection of wound healing success. Activity precautions should be taken to prevent undue stress on the wound.
Other Treatmets
Other treatments for scar formation may include:
- Corticosteroid injections
- Cryotherapy
- Laser therapy
- Radiation
- Botulinum Toxin A
- Stem Cells
- Fat (adipose) Cells
- Dermabrasion
- Medical Needling
- Topical lidocaine (patch), which blocks pain sensation
- Topical capsaicin
- Massage, vibration, and rubbing the scars with various textures, which desensitizes the scar
- Trigger point injections with local anesthetics and clonidine
- Corticosteroid injection
- Botulinum toxin A
© 2024 American Society for Surgery of the Hand
This content is written, edited and updated by hand surgeon members of the American Society for Surgery of the Hand.Find a hand surgeon near you.