Scarring is the normal process with any wound or surgical intervention. Scarring potential varies in individuals and in most it finally results in a fine, well healed scar. However to get to this, the scar goes through a definite cycle.
Initially the scar is weak and undue stresses can cause the wound to gape. This is followed by a stage, when the scar is firm, lumpy and quite red. This phase typically lasts for 6-9 months. Subsequent to this the scar becomes softer and paler to a near skin tone. The total process of scar healing can take upto 2 years or more.
During scar healing there are important aspects of self care to help with the maturation process. These are:
- After the wound is closed and generally in 2-3 weeks time, it is good to start massaging the scar. Use a good, bland moisturizing cream like Doublebase/Diprobase/E45 and work the cream in using small circular movements of the fingertips. Use firm pressure so that the scar blanches. This should be done for about 15 minutes twice a day.
- Exposure to sun can lead to scar pigmentation and this should be avoided by covering the scar with SPF 30 cream. This should be done for the first year.
- Any evidence of scar healing abnormally after a few months may need treatment with silicone sheet. In some patients (especially from an Asian or African lineage) it is advisable to start pre-emptive treatment quite early with silicone sheets.
This can take numerous forms:
- Stretched scar (especially on the back)
- Atrophic scar (depressed type of scar)
- Contracted scar (this can create problems around joints, eyes, mouth)
- Lumpy scar (Hypertrophic scar)
- Keloid scar (scar which is lumpy and grows beyond the extent of the wound)
The most problematic scar is the keloid scar. It is frequently seen in dark skinned individuals but can occur in any skin type. Common areas include:
- Ear lobes
- Chest and breast bone area
The keloid scar can become quite large and is frequently itchy. It creates a substantial cosmetic issue. Treatment is difficult, protracted and often does not cure the condition. Any treatment undertaken needs careful planning and Mr Sanjay Azad will talk to you in some details about all the issues.
The treatment follows a progression as described below:
- Firstly simple methods like massage and use of pressure devices (garments or compression earrings is advised).
- The next step is to use Silicone sheets (Dermatix, Cica-Care). They are cut to size and applied over the scar for most of the day. They can be quite effective in some scars.
- Failure of trial with silicone sheets warrants the use of Steroid injections. The steroid is given in small amounts into the scar itself. The injection needs to be repeated over every 6-8 weeks and can be painful. To avoid this situation, Dr Sanjay Azad uses the combined method of first asking yourself to applying a surface numbing cream about 45 minutes before the procedure. This is followed on by injecting local anaesthetic under the scar, and finally steroid injection into the scar itself.
The steroid injection is given in a small dose and does not have any ill effects on the person. However steroid injections are not effective in all keloids and a partial response is not uncommon. Occasionally use of steroids can result in a depressed scar due to atrophy of tissue.
- If steroids fail to work then surgery may be necessary. This is done by the technique of removing the scar very carefully, leaving a thin rind of scar tissue behind. Every care is taken, to avoid going into normal unscarred tissue. If normal tissues are intruded on, then there is a significant chance of the problem spreading even more.
Surgery is not a first option and should be approached only after other options have been tried. Also surgery is generally accompanied by using steroid injections. This is because use of any single technique has an extremely high failure rate, so combination methods are essential.
- Other methods of treating keloids like radiotherapy are rarely used, especially in younger individuals because of harmful effects.
- Newer methods are being researched which may be available in the future.