Dr Salinda Johnson outlines the most common types of scars and details some of the effective treatments available
Scarring occurs in a variety of forms with various differing characteristics. Scarring affects all skin types, regardless of ethnicity, and can appear anywhere on the face and body. Types of scarring include keloid, hypertrophic and atrophic. Each year in the developed world approximately 100 million patients acquire scars as a result of 55 million elective operations and 25 million operations after trauma,1 some of which can cause considerable problems such as psychological distress, restricted movement (especially larger scars that stretch over joints), itching or discomfort. Global figures are unknown but are likely to be much higher. People with abnormal skin scarring may face physical, aesthetic, psychological, and social consequences that may be associated with substantial emotional and financial costs.1
An atrophic scar can occur anywhere on the body, although most of my patients decide to have facial or more noticeable atrophic scars treated. The characteristics of atrophic scars are irregular with jagged edges and a pitted, sunken, chicken-pox-like appearance. They are generally caused by damage to the underlying tissue of the skin.2 This tissue damage is caused by a loss of muscle or fat and the lack of sufficient collagen production in the area resulting in a sunken, depressed structure. A few examples of causes include: severe acne, chicken-pox, surgery or accidents that cause trauma to these underlying structures. These scars are of a permanent nature if left untreated.2 Atrophic scars can be treated in a number of ways, with one of the most common being fractional laser or selective waveband technology (SWT). Other medical options available include subcision, hyaluronic acid fillers to raise the scar, chemical peels, microneedling or medical micropigmentation.
Hypertrophic scars (Figure 1) are usually raised and darker in colour than the surrounding skin and, unlike a keloid scar, they remain within the boundaries of the wound and can continue to thicken for up to six months. A hypertrophic scar is inflexible and can restrict movement.3
Hypertrophic scarring occurs after thermal and/or traumatic injury concerning the reticular dermis. In my professional observations I have noticed that a hypertrophic scar can take up to approximately two years to improve in appearance/heal fully. If there is no improvement within a year, the scar could potentially be a keloid scar. Treatments include: micropigmentation, silicone sheeting gel, scar revision surgery, steroid injections and electrosurgical excision.3
Keloids are benign, dermal, fibroproliferative tumours characterised by excess collagen at the site of previous skin injury.4 The treatment of keloid scars remains a challenging clinical dilemma for both patients and providers. Intralesional cryosurgery has emerged as a safe and effective new treatment by destroying the hypertrophic scar tissue with minimal damage to the skin surface.4 Keloid scars extend beyond the borders of the original wound because of the excess collagen formation when the skin heals. This is in contrast to hypertrophic scars, which are limited to the original wound site. Keloids often develop as soon as three months after injury, but may take several years to appear following the initial traumatic insult.4 Keloid scars are well-demarcated, rubbery, mildly tender, bosselated tumours with a shiny surface, often marked by telangiectasias and sometimes ulcerations. Lesions are pink to purple in colour and may display hyperpigmentation. The most common areas where keloids form are the anterior chest, shoulders, ear lobes, cheeks, and skin overlying joints. After development, keloid lesions continue to persist without spontaneous regression and have no malignant potential. Patients often complain of feeling pain, itching and hyperesthesia. These symptoms, along with the contractures from excessive scar formation, can be extremely uncomfortable for patients.5 A histological examination of a keloid reveals larger, thicker, and more disorganised collagen fibres than those seen in normal skin.4 They are pale-staining, hypocellular type I and III collagen bundles that lack nodules. Blood vessels are scattered and dilated, contributing to the poor vascularisation in keloid scars. Special stains can detect the overproduction of fibronectin, an extracellular matrix protein, which influences the formation of keloid scars.3 Excessive scar formation is due to abnormal wound healing following any injury to the deep dermis. Common causes include surgical procedures, piercings, vaccinations, lacerations, and burn injuries. Normal wound healing depends on the fine balance between extracellular matrix deposition and degradation.5 Keloid scars endure a longer inflammatory period compared to other scars, during which immune cells and pro-inflammatory cytokines continue to stimulate fibroblasts.5 The likelihood of developing a keloid scar is multifactorial with a strong genetic component. There is potential for all individuals (except those with albino skin) to develop keloid scars; however, the greatest incidence is observed in patients of darker skin colour. Keloids are most common in the second to third decades of life, and susceptibility decreases with age following this.5 Treatments include: electrosurgery and steroid injections.
At the London Cosmetic Clinic we use a device that aims to rapidly and selectively destroy tissue by the passage of an electric current, which works to burn off the tissue in question. Small skin lesions can be treated without anaesthesia, however the procedure for multiple scars or larger areas may require topical or local anaesthesia, depending on the patient’s pain threshold. The device works by emitting low-power high frequency alternating current. Electrical pulses travel via a probe, directly to the affected area of the body. The amount of output power needed is adjustable, and the device is equipped with different tips, electrodes and forceps depending on the electrosurgical requirement. We would then follow the treatment with steroid injections. This treatment has minimal pain and scarring; however, due to it initially leaving an abrasion wound, the correct aftercare (saline wash, an antibiotic ointment and the correct dressings) is recommended to all my patients to avoid potential infection. Inflammation and swelling in the treated area may occur, however this resolves itself within a few days. My advice when it comes to using equipment is to be sure that physicians have been fully trained and are comfortable with using it. Injury burns to both patient and staff can occur through carelessness during a procedure. Approximately 50-100% of keloids respond to the injection of a corticosteroid as it suppresses inflammation and mitosis while increasing vasoconstriction in the scar.6 Injections are given every two to six weeks until improvement is seen. This may cause subsequent side effects such as a network telangiectasia due to the thinning of the scar tissue or due to trauma to the area. These do subside as the scar tissue thickens, however I usually recommend a laser/SWT session to my patients to reduce or permanently remove telangiectasia.6 Pigment change can also occur in the treated area. This is temporary and usually returns back to normal once the injections are reduced or stopped. If hyperpigmentation occurs, I usually prescribe a 4% hydroquinone-based product to lighten the area and to treat post-inflammatory hyperpigmentation.6
In my clinic I use the medical micropigmentation method to treat scarring. This procedure is done by depositing micro amounts of coloured pigments into the skin leaving a trace of pigments, in order to re-colour an achromia or reconstruct a structure. The aim of re-pigmenting a scar is to diminish the visibility of the scar with regard to the adjacent healthy skin. In order to obtain a good colour match, close examination of the scar and the surrounding skin is required. This treatment is also referred to as a scar camouflage. If the scar is still pink-red or pink the tissue may not have healed sufficiently and it is not suitable to proceed with re-pigmentation. In this case patients will be advised on additional treatments with our skincare specialist such as laser/SWT treatment. We can reduce the redness of a flat scar with a laser system and then perform medical micropigmentation on the area. The patient could require up to four sessions. Types of scars you can treat on the face and body with micropigmentation:
Most scar re-pigment procedures will require multiple sessions, due to the area being damaged tissue. Every patient will be advised upon consultation, as it is completely dependent on the area, however it generally takes between two to four sessions. Patients must be aware that maintenance is required every 12 to 18 months and so they must be motivated to pursue the relevant sessions as per recommendations by the specialist. During and after the procedure the area will display redness and perhaps capillary breakage that resembles the original trauma. Areas with substantial hyper-pigmentation may not be suitable for medical micropigmentation as needle intrusion can worsen the condition. In these cases, I would rather prescribe a 4% hydroquinone cream to reduce the colour. The thickness of the scar will influence the final colour outcome and pigment retention. Some scars can either reject pigment, in which case additional sessions will be required, or they may retain pigment creating dark patches in which case I would prescribe a 0.1% tretinoin cream and chemical exfoliator to exfoliate the area. Correct and diligent aftercare is given to all our patients to avoid potential infection from occurring. Redness, inflammation and scabbing is a natural part of the healing process which usually subsides within four to seven days. The scar will not appear camouflaged immediately after the initial procedure, in most cases results are seen after two weeks.
Fractional laser resurfacing
Fractional laser resurfacing is a popular treatment utilised for the treatment of atrophic scarring, surgical scarring and striae. At the London Cosmetic Clinic we use a fractionated non-ablative laser that delivers a large number of very small spots per square centimetre of the skin. These columns of energy create a heat reaction in the dermis, which works on the principle of injury and repair leading to reversible necrosis resulting in collagenases, angiogenesis and structural changes within the dermis and scar tissue.7,8,9 Treatments are performed at six-week intervals and a course of three treatments is recommended. A topical anaesthetic such as EMLA or LMX 4 is applied prior to the application of the laser to reduce any discomfort. There is little to no downtime associated with this procedure, the patient will usually feel a mild sunburn sensation and there will be mild to moderate erythema present, depending on the sensitivity of the patient.
For any residual redness such as post-acne inflammation, post-surgical scarring, or pre-medical micropigmentation procedures, the laser treatment aims to diminish the redness of a flat scar. This can be performed as soon as three weeks after surgery for optimal results, providing sutures have dissolved/been removed. SWT will treat the very light salmon-coloured scars using the sub millisecond pulse.10 Practitioners should be trained thoroughly on the administration of SWT and take care to ensure that the appropriate energy levels are delivered safely with the most suitable pulse duration used.
Surgery can improve the appearance of scars, change the shape of the scar and release a tight scar that is close to a joint in order to improve movement. Scar revision is a process of removing scar tissue. After the excision the new wound is usually closed in order to heal by primary intention, instead of secondary intention. Deeper cuts need a multi-layered closure to heal optimally, otherwise depressed or dented scars can result. Surgical excision of hypertrophic or keloid scars is often associated with other methods such as pressotherapy or silicone gel sheeting. Be aware that performing surgery on a scar will leave a new scar and I have found that may take up to two years to heal. There is also an increased risk of further keloid and hypertrophic scarring following surgery. After surgery the recurrence rate for keloid scarring is approximately 50-80%.10
Above all, it is my aim to make patients feel as comfortable and relaxed as possible, and to make them aware of their options and the realistic outcome of any treatment. At my clinic, we pride ourselves on patient care and experience, ensuring our patients’ visit and treatment is as informative, comfortable and professional as possible. A thorough medical consultation should always be undertaken to ensure all concerns are managed successfully. Pre and post information should be supplied to all patients prior to the selected treatment, as well as scheduled follow-up appointments to ensure the correct result has been achieved.