The challenge of treating scars

The appearance and treatment of scarring depends on several factors: the depth and size of the wound, its location, and patient-specific factors such as age, sex, ethnicity and genetics.

Certain individuals are at a higher risk of developing scars, such as those with a history of keloid scarring, a family history of scars, severe acne or darker skin, as well as those who have undergone a surgical procedure in a ‘high tension’ area such as the chest and shoulders.

Dermatologists most commonly perform scar procedures for acne and surgical scar revision. Dermatologist and Fellow of Australasian College of Dermatologists (ACD) Dr Adrian Lim said that dermatologists are well positioned to deal with all types of scarring because they have procedural and laser expertise.

“Scarring remains a challenging condition with a variety of repair methods available, including a few more options for darker-skinned individuals,” Dr Lim said.

Acne scar revision is a specialised field of procedural and laser dermatology. Dr Russell Hills, also a dermatologist and Fellow of the ACD, explained, “There are many different types of acne scars requiring a patient-specific approach. Surgical techniques such as punch elevation and excision or subcision may be performed before laser resurfacing or fractional laser treatment. Multiple treatments are often required, particularly for severe scarring. It is generally not possible to remove all scarring, but the appearance can be softened and the scars less noticeable.”

Surgical scar revision is best carried out after removal of sutures. Techniques such as taping, silicone sheeting and gel, coupled with vascular or ablative fractionated lasers, can reduce scarring.

“Some scars, because of their position or shape, may be best managed by a formal surgical scar revision, whereby the scar is excised and sutured,” Dr Hills explained.

“Sometimes laser is used after the sutures are removed to help blend the revised area with the surrounding skin. Redness in scars often fades slowly over time, though vascular laser can help speed this process up, but multiple treatments are required for improvement.”

Raised scars known as hypertrophic and keloid scars can be treated with a steroid injected directly into the scar. This is a slow process requiring repeated injections.

Scar profiles

• Keloid scars result from an overly aggressive healing process, extending beyond the original injury site. These scars may impede movement and are most common in people with dark skin.
• Contracture scars result from burned skin. As they tighten, they can impair movement. The scarring also goes deeper, affecting muscles and nerves.
• Hypertrophic scars are raised, red scars that are similar to keloids but do not go beyond the boundary of the injury.
• Acne scars can range from deep pits to those that are angular or wavelike in appearance.

Image captions: An example of a hypertrophic scar along the jawline (L) and a keloid scar on the chest (R). Images courtesy of Australasian College of Dermatologists.

Advancing treatments for scars

Presentations at the 2019 American Society for Dermatologic Surgery (ASDS) meeting in Chicago covered the latest advances in preventing scars as well as strategies for improving scar treatment outcomes.

Botulinum toxin (BTX) is well known for its effectiveness in managing facial lines through muscle relaxation, and there is evidence that BTX can be effective in the prevention and management of pathological scars.

The benefits of BTX treatment are thought to occur through two mechanisms: by decreasing muscle tension as a direct result of muscle relaxation, and by decreasing the inflammatory response that occurs in every scar reaction.

BTX can be administered on the day of surgery and has been shown to improve the appearance of the normal scarring response associated with surgical processes. Although this strategy is an added cost to the surgical process, it may be considered to achieve the best possible outcomes.

A 2019 research paper supports the efficacy of carbon dioxide ablative fractional laser for paediatric hypertrophic (thickened or raised) burns scars. The study used objective (third-party) and patient assessment to measure improvement. Improvement was noted by observers after one treatment, with further improvement described after multiple treatments.

Another study has shown significant and sustained improvement in elasticity, thickness, appearance and symptoms of hypertrophic burns scars treated with ablative fractional laser, providing justification for using this type of laser to treat hypertrophic scars.

The pulsed dye laser does not ablate the skin but has been shown to minimise surgical scars, ultimately decreasing the thickness and improving the appearance of the scar.

Dr Hills also described a new approach to scar management that is generating interest — fractional laser-assisted drug delivery. In this procedure the laser can create holes to deliver drugs (corticosteroids) to treat scars.

Image credit: ©stock.adobe.com/au/amawasri