The Best Way To Treat Scars

I had a beautiful kiddo come into my office this week after falling and splitting her forehead open. Naturally, the parents had concerns about scarring. Even though the repair went perfectly, she is going to have some amount of scarring. The question remains, what can the parents do to reduce the scar?

Types of scars

1. Keloids: Have scar tissue that extends beyond the original injury. More common in people with dark skin. Do not get better with time.
2. Hypertrophic or pathogenic scars: Grow really fast the first 6 months (but never go beyond the original boundary of the injury) and can gradually regress over 1-3 years. More common in areas with lots of tension on the skin (chest, knees, shoulder, etc.)
3. Atrophic Scars: Collagen is lost in the skin (think divots and “ice-pick” scars like from acne)

Prevention

I wouldn’t be a good doctor if I didn’t at least mention prevention of scars in my discussion. One of the major reasons kids develop big scars (especially after seemingly small wounds) is development of infection. So when your child gets a cut/scrape, make sure you thoroughly clean it right away. The time to properly clean a wound is right after it has happened (i.e., when it’s still bleeding). After you clean the wound and get it to stop bleeding (by applying pressure), put some antibacterial ointment on it (to keep the wound moist) and cover it.

Treatments (what works and what doesn’t)

The science basics to scar prevention and treatment centers around keeping the area covered and moisturized. This basic tenant helps you see why some treatments work better than others.

1. Silicone Sheeting (or gels). Studies show it works. It improves color, elevation (how raised the scar is) and hardness of pathogenic scars. There may be some place for prevention of scarring as well. They are supposed to be used for 12 + hours a day.
2. Pressure bandages. This type of therapy aims at prevention. The problem is that the pressure dressings (think gauze and wraps) need to be on for 23 hours a day for at least 6 months while the scar is still forming in order to work. As for me, that sort of commitment is far too involved.
3. Massage therapy. This type of therapy works by increasing collagen maturation. Ideally, it is done 10-15 minutes a night (starting a few weeks after the wound is healing). It reduces scar thickness, pain, and itching.
4. Perpendicular taping. Works especially well for post op wounds in areas of high tension. In this method, paper tape is applied in the opposite direction of the wound to relieve the tension on the wound. This decreases the risk of scarring. Amazingly, this method still works even when started up to 3 months after the initial wound.
5. Onion extract (a popular ingredient in many OTC scar treatments, known for its anti-inflammatory properties). Unfortunately, science doesn’t support that this works at that well.
6. Vitamin E (also a popular ingredient in many OTC scar treatments. It is an antioxidant with anti-inflammatory properties). Sorry mom (this was her method), science also doesn’t support that this works. There have been a few studies showing minimal effect, but many that don’t support it at all. Unfortunately, skin irritation is a common side effect of Vitamin E.
7. Topical corticosteroids. Not commonly used and scientifically shown to have little effect. One study showed that a high potency steroid used with tretinoin was effective (only by prescription).
8. Corticosteriod shots. Unlike the topical treatment, shooting the medicine into the scar (especially keloids) is highly effective. Typically treatment is 3-4 injections every 4 weeks. The major limitation is that it hurts and is only done in a doctor’s office.
9. Autologous Fat Transfer (AFT). Essentially taking fat from one part of your body to fill in an atrophic scar (the divot type scar). Clearly this is an involved treatment option, but has a lot of scientific promise.
10. Surgical Revision. In extreme scarring (or those where other methods haven’t helped), sometimes a revision is helpful. Essentially, you’re trading one big, ugly scar, for a smaller, controlled surgical scar.
11. Laser therapy. This is the Cadillac of scar treatment. In general, it is highly effective, but expensive and painful.

Wow that’s a lot, break it down!

In short, do the cheap, easy stuff first. Prevent infection in new wounds. Keep the wound clean, moist, and covered. If it’s in a high tension area, consider perpendicular (90 degree) paper taping. Once it’s healing consider massage and silicone sheeting. If it’s still ugly later (and you have money), consider fancier interventions like lasers. Hope this helps.