Evaluation And Treatment Of Scars

Everyone has scars. Some we can see. Others we feel. And some are too deep to reach. Scars, whether from surgery or as a result of inflammatory skin conditions such as acne, burns, or trauma, are often associated with significant emotional and psychological impact. One of my biggest challenges and rewards comes from treating scar patients.

DEFINATION
Scars are areas of fibrous tissue that replace normal tissue after a skin injury. A scar is an integral part of the wound healing process and involves re-epithelialization, neocollagenase, neovascularization and pigment deposition. However, a prolonged inflammatory phase of 4 weeks or more during wound healing can lead to abnormal scarring.

CLASSIFICATION
Scars are classified according to color and texture.

Classification by color.

Red scars.
these are generally due to the presence of dilated blood vessels in the dermis in response to injury. Dilated blood vessels supply oxygen and nutrients to the skin to recover from the injury.

Brown scars.
Brown scars are due to the deposition of melanin and hemosiderin from red blood cells where the skin is damaged. Dark-skinned individuals are more prone to developing brown scars and post inflammatory hyperpigmentation as their skin heals from the lesions.

White scars.
These are due to the absence of melanin as the inflammation can partly destroy the melanin in the melanocytes.

Classification by Texture.

Elevated scarring.
These are the result of EXCESSIVE deposition of collagen and fibrosis at the injury site. These can be hypertrophic or keloid. Hyperthropic scars are raised but do not extend beyond the edges of the injured skin. Keloid scars are raised and always extend BBL Surgery Video beyond the edges of the injured skin. Darker skin types are genetically more susceptible to hypertrophic and keloid scar formation.

Depressed scars.
These can be ice picks, boxed or rolled up.
Ice pick scars are less than 2mm, superficial and at acute angles to the base.
Canned scars are larger, more than 2mm and at right angles to the base.
Rolled scars have rolled, non-angled edges, are large and often the result of a deep, involuted acne cyst or lump.

TREATMENT
This depends on several factors.

Age
Current thinking is to treat scars sooner rather than later. Hyperthropic scars take 4 weeks to form and can increase in size over 3-6 months.

The position on the sternum, chest, shoulders and back is more prone to keloids.

Color

Keloid type, hypertropic or atropic

Thickness
Characteristics of the patient. skin type, concomitant medical conditions.

RED SCAR treatment.
Actuality
Vasoconstrictors such as oxymetazoline, adrenaline can be used to narrow blood vessels, reducing scar redness. Silicone gel. for example Kelokote, have been shown to reduce scar redness when applied twice a day for 4 months

Camouflage.
BBL or broadband light and PDL or pulsed dye lasers are non-ablative lasers for treating the vascular component of the scar.

Treatment of brown scars
Actuality.
Lightening agents such as HQ, azelaic and kojic acid inhibit tyrosinase thus preventing the conversion of dopa to melanin.

Topical retinoids.
Tretinoin or tazarac reduces brown pigmentation by inhibiting tyrosinase and melanin formation. Side effects include redness, irritation, burning, itching, contact dermatitis, dryness and peeling.

TREATMENT OF TEXTURES AND THICKNESSES.
Elevated scarring.
Strategies for the prevention of hypertrophic and keloid scars during surgical procedures include reducing tension and expelling the edges of the wound during closure, avoiding the anatomical locations most prone to hypertrophic or keloid scars such as around the joints, corner of the jaw , shoulders, mid-chest and upper back, inserting incisions that follow along RSTL (lines of relaxed skin tension) and achieving efficient hemostasis.
Powerful topical steroids such as dermovate or Ultravate can be used for minimally hypertrophic scars. For thicker scars, 10-40mg / ml intralesional kenalog can help decrease elevation

Of hypertrophic and keloid scars.
Steroids are immunosuppressants and reduce collagen synthesis. Adverse effects include hypopigmentation, atrophy, telengiectasia and delayed wound healing. Topical imiquimod (Aldara) stim