TREATMENTS AVAILABLE FOR SCAR REVISION
What treatment you are offered will depend on the nature of your scar whether it is a depressed scar, raised scar or combination of both and also if the scar is associated with contractures and restriction of movements. There are a number of different treatment modalities available out there both invasive and non-invasive. After initial consultation, we will determine which combination of treatment will get you the most acceptable results. The following list provides an idea about the treatment options available for scar revision:
- Silicon gel and sheets
- Corticosteroid injections
- Injection of other chemotherapeutic agents
- Chemical peeling
- Fractionated Ablative Lasers
- Intense pulsed light (IPL)
- Micro needling and radiofrequency devices
- Dermal fillers
- Botulinum toxin (Botox)
- Plastic surgery and contracture release
Please book a free consultation to discuss the most appropriate treatment for your scars whether these are caused by acne or surgery or burns.
Topical treatments include vitamin E creams, gels and oils that claim to help fade the colour of prominent scars.2 These are extensively used and an enormous number of such products are widely available both in pharmacies and online, with some successful anecdotal results reported. However, a double-blinded study undertaken on 15 patients with scars following cancer surgery suggested that there was no evidence for the efficacy to the cosmetic outcome of vitamin E products and that it might even make some scars worse. Of the patients studied, 33% developed a contact dermatitis to the vitamin E.2 In addition, the Mayo Clinic grades the evidence on scars and vitamin E as grade D, which means there is fair scientific evidence against this use (suggesting it may not work).3
Peels in scar treatment have focused mainly upon acne scar treatment, although they may be used for any type of scar which has an element of hypertrophy, where the aim is to lower the scar to be flush with the skin. Examples would include scars created after burns, surgery or trauma, but not scars that are depressed. Trichloroacetic acid (TCA) peels and salicylic acid peels are frequently used and tend to be combined with other treatments such as microneedling and laser.4 There appears to be no consensus on the best combination, if any, of these elements of treatment, with many practitioners offering their own blend or package.
Corticosteroid injections are a mainstay of treatment for hypertrophic scars and keloids.5Usually triamcinolone is injected in multiple small aliquots along the length of the wound, or, if practical, a linear infiltration technique is used. The result is a reduction in redness of the scar and then slowing of growth, followed in most cases by regression of the bulk of the lesion.6
Silicone gel sheets, which can be placed on scars to encourage moisture accumulation under the scar to hydrate the skin, have also been shown to be effective for some scars and have led to a wide range of versions being made available for patients to purchase for themselves for self-treatment. Research has suggested they are safe and effective, and also well tolerated for the treatment of hypertrophic and keloid scars.7
Fillers are particularly suited to a couple of applications, namely pitted scars and acne scarring, such as ice pick scars. When combined with subcision,8 fillers can produce a cosmetically effective result. A single treatment can therefore provide both components of the treatment i.e. the subcision with the needle bevel, followed by the insertion of the filler material through the same needle to fill the space created by the subcision. This is an example of when a needle is more effective than a cannula as the latter cannot be used for subcision. The filler needle’s bevel can be inserted below the defect or ice pick scar and moved from side to side in an arc to divide the tissue, anchoring the base of the scar down to the subcutaneous tissue. Injecting the filler material, usually hyaluronic acid, will fill the defect from below and raise the surface of the scar to be consistent with the surrounding tissue, thus reducing its visibility for the life of the filler, which may last between to four to nine months depending on the product. Furthermore, the production of new collagen is stimulated in the same way as microneedling, which may lead to more permanent filling of the defect by the patient’s own tissue. Other types of filler materials such as calcium hydroxyapatite may be more effective for this latter function.9,10
It has been indicated that laser therapy for hypertrophic scars has approximately 70% efficacy
Microneedling therapy, also called collagen induction therapy (CIT), and percutaneous collagen induction (PCI), involves making large numbers of punctures into the scarred area using needles which can generally range from 0.5mm to 3mm in depth.11 The devices used can be pen-like or needle encrusted rollers, used under topical anaesthesia. The punctures are repaired by the body’s natural healing process of skin proliferation12 producing collagen and elastin to plug the wounds, which can reduce the appearance of the scar. This treatment is used for most types of scar.
Lasers have been used for scar treatment since their early incarnations and they have benefits based upon multiple modalities. The older and more basic lasers rely on tissue destruction to achieve results. With a raised scar, selective destruction of the raised portion can easily reduce the prominence of the scar tissue rendering it flatter and more amenable to camouflage with makeup. Non-fractional CO2 ablative lasers would be an example of these. The newer, fractional lasers only treat fractions of the skin surface at a time, effectively dividing the target into thousands of fine treatment areas producing perforations in the scar, which then heal in a manner similar to microneedling wounds over multiple treatments.13
Moving on to pulsed dye lasers, the wavelength of the beam allows the pigmentation of the scar to be targeted, helping it to pale back to skin colour, as the redness of the scar is usually caused by its vascular content for which the pulsed dye laser is optimised.14 It is logical that a combination of these technologies can be used to give a superior result over multiple treatments. For example, an ablative laser could be used to resurface an uneven scar by destroying the proud tissue, then a fractionated non-ablative laser could be employed to drill new channels into the scar to promote production of new tissue, followed by a pulsed dye non-ablative laser used to reduce pigmentation. It has been indicated that laser therapy for hypertrophic scars has approximately 70% efficacy.15 Another study advised that laser therapy should become an integral part of hypertrophic scar therapy and may reduce the need for surgical excision.19
Clearly there are numerous treatments that rely on similar methods to reduce scarring, which could be viewed as interchangeable depending on the practitioner’s skills and preference. For example, several use tissue destruction (laser, TCA peels) to remove excess scar tissue and others use tissue damage/growth stimulation (fractional laser, microneedling) to promote replacement of scar tissue with healthier collagen.