Skin Science: Scar Care Part 2

Skin Science: Scar Care Part 2

Last week we covered the science behind scar formation and maturation and what to do with fresh scars. This week I want to talk about the tools we have to treat mature scars. This can be a scar you’ve had since childhood, acne scars from your teens, or a scar that you acquired as an adult from injury or prior surgery. Scars classically have two qualities that make them stand out from their surrounding skin - pigment and texture differences. These are the characteristics that we have tools to address. 

PIGMENT CHANGES

Hyperpigmentation

Scars are frequently hyperpigmented and appear either dark brown or bright red. This dark pigment often fades with time but not always. 

Hypopigmentation

A scar that heals optimally is often hypopigmented to some degree (lighter than the surrounding skin), however, some hypopigmentation can be blotchy and unsightly.

TEXTURE CHANGES

Scars can be raised, wide, irregular, and in the case of acne scars can appear like mountains and valleys with craters throughout. 

PATHOLOGIC SCARS

Hypertrophic and keloid scare are two types of scars that do not behave according to the normal wound healing process. These scars require a different approach that often includes surgical revision, steroid injections, and keloids can require local radiation. These scars and treatments are outside of the scope of this newsletter, but if you have one then find a plastic surgeon who can guide your treatment. 

TOOLS I HAVE TO TREAT SCARS

One thing you should know upfront is that scar treatment usually requires a series of interventions over time. It is possible you will see a dramatic change after one treatment but you should be prepared for several before you get to your goal. A good plastic surgeon will educate you during the process and help you understand what an achievable goal is. 

INJECTIONS

Steroid injections are a common practice and can help reduce both the pigment and raised appearance. A risk of this treatment is hypopigmentation of the area injected. This can resolve with time or be permanent. I have two stories I want to share about this, one my own scar, and another a patient I saw in clinic. 

I had an ugly red scar on my wrist from a splintered piece of wood that tore my skin off. A year later I developed an unrelated tendinitis in my wrist from boxing and the treatment was steroid injection and a wrist brace. My old scar was right over the tendon that was injected and over the next month it flattened out, became nearly invisible, but the surrounding skin lost all color. I had to keep sunscreen on my wrist because this hypopigmented area burned super easily. Now, 3 years later, all of the hypopigmentation has resolved and the scar is subtle.

Last week in clinic I saw a patient who had a steroid injection in her cheek by a doctor in her hometown. The doctor was trying to treat a nodule that resulted from poorly placed filler. The steroid injection caused atrophy of her normal soft tissue and it caused a crater in her face. There is no good solution for this. It is possible some of her own tissue will grow back with time but there is no assurance of this and the crater in her face looks worse than the nodule ever did. 

I share these two stories to say, it is of the utmost importance to think through the anatomy and the risks before performing an injection. Steroid injections are effective, however, in a cosmetically sensitive area may not be the right answer. In the hands of the right doctor all of these factors will be considered. 

5-FU is another medication injected into scars to reduce their unsightly appearance. The mechanism of action is different from steroid injections and it is often better tolerated. There is often less atrophy and hypopigmentation in the surrounding tissues with this medication. This medication is my go-to in cosmetically sensitive areas. 

LASER AND LIGHT THERAPY

There are two modalities that I love, BBL (broadband light) and fractional laser. 

BBL is a light therapy that targets red or brown pigment in scars by applying different filters to the device. And yes this is the same device that removes all of those unwanted sun spots. There is little aftercare except reducing sun exposure, consistent use of spf, and keeping your skin hydrated. 

Fractional laser can smooth out texture problems and it can also help reduce dark pigment, or stimulate normal pigment in the setting of pathologic hypopigmentation. I think fractional laser is where you are going to find the most dramatic results. You will still probably need a series of treatments but it will get you greater improvements with each treatment when compared to something less aggressive like microneedling. I do not think that microneedling is a bad treatment but as a physician I like to use the tools that are the most effective per treatment. 

Earlier this year a patient of mine underwent a skin cancer excision followed by reconstruction with a plastic surgeon. The scar was in a prominent part of the face and overall looked fantastic, but in order to speed up her recovery trajectory we decided to do my favorite combination, BBL and fractional laser. This helped decrease the redness and smooth the transition to the surrounding skin. We were both very pleased with the results after just one treatment. In this scenario a series is not needed because she already had wound healing optimized under the care of a plastic surgeon. She is set up for success and nothing could make me happier.

SURGICAL REVISION

There are some scars that require surgical revision and a superficial treatment will not get you to your goals. This is usually the case when the problem is a very wide scar or when there are big contour problems with surrounding tissue. Common scars that I revise are c-section scars, scars from prior cosmetic surgery, or scars from wounds that healed without a formal repair at time of injury. 

Surgical scar revision doesn’t necessarily mean going to sleep. Many scars can be revised with just local anesthesia, which means very little inconvenience to your busy schedule. 

The most important thing for scar care is being in the hands of a good plastic surgeon so that you can maximize your results and avoid poor outcomes. There is a risk and a benefit to every procedure and understanding this balance will help set realistic expectations for your own personal outcome potential. 

Here's to choosing how we age, on our own terms!

Dr. Lindsey Tavakolian, MD