Scars, scars, scars!

Scars are inevitable and have been around since the beginning of time. My explanation to patients is … back in the day, when we were being chased by lions in the safari, and we somehow luckily got away with a scratch, whoever healed the fasted survived – survival of the fittest. There was no antibiotics to put on a dirty wound… if the cut was too deep and did not heal quickly… that was it, it was over. So if you are healing well, with scars all over your body, I say, you have won the game of evolution, be proud!

Why does it leave a mark?

So healing quickly is important, but why must there be a mark left over from skin injuries? Why does it happen? Why can’t we be little babies and scratch our faces with our sharp fingernails but have it not leave a mark? The answer lies in our age, depth of the injury, and genetic makeup.

As we get older, the cells that make some of our skin, keratinocytes and fibroblasts get older. They don’t work as hard, and start to slow down. I used to grow leftover baby foreskin cells and adult skin cells in petri dishes, and compared to baby skin, adult skin cells grow VERY VERY SLOW.

Finally, genetics play a role. Thicker scars such as keloids are more common in certain populations such as Asians and Blacks. Usually, patients have a family history of keloids.

Epidermal injuries generally do not scar, dermal injuries do scar

How deep the cut determines how your scar will heal. When babies scratch their faces with their sharp sharp nails, usually it’s an epidermal injury – meaning they only scratch the very top surface of the skin. So miraculously, by the next day, their scratches heal. For adults, the same thing applies, if only the epidermis is injured. This rarely leaves a mark. Remember how when you fell and “scraped your knee” as a kid, you scraped off some epidermis. Nowadays, as adults, you would be hard pressed to find any marks now where those scrapes once were.

If somehow one manages to accidentally a finger with a knife… or for my patients who come into my office who have skin cancers and I have to do an “EXCISION” to remove the skin cancer, it always leave a mark. Why? Well in both examples, the cut is beyond the epidermis, into the dermis, resulting in a scar. Some people heal very well, whereas others leave hypertrophic scars or keloids with these injuries.

What is the difference between hypertrophic scars and keloids?

When scars heal normally, that’s a regular scar. When scars gets a little more raised and thick, that’s called a hypertrophic scar. When scars grow beyond the actual area of injury, and become raised and thickened, this is called a keloid. What this mean on a cellular level, is that fibroblasts are continually making more of itself and depositing collagen at the site of injury.

Studies show that scars are more likely on areas where there are lots of movements for example, you are constantly breathing and moving your upper body around, so chest and shoulders are common sites of scars.

How to prevent scars from happening?

The answer is, you really can’t. If the skin injury is beyond the dermis, it likely will scar.

Vaseline under occlusion with a bandage is the most important thing to help the wound heal faster; for my patients who get skin surgery, I always tell them not to keep the wound dry, but rather keep it moist with lots of vaseline until it fully heals. Then one can switch over to silicone sheets if desired. There are some studies that demonstrate silicone sheets such as ie. ScarAway, when applied to wounds may help skin heal better. Sun protection is also crucial to helping the skin heal.

What are the treatments for scars?

Depends on the type of scar and location of scars:

For acne scarring – I use a combination of microneedling, ablative or nonablative lasers, medium-deep chemical peels, subcision [method where you numb the skin and use a needle to break up the scar tissue under the skin], TCA cross [chemical peel directly on each deep scar to remodel that area of skin]. Recently platelet rich plasma (PRP) may be used in conjunction with microneedling or lasers to improve acne scarring as well.

For hypertrophic scars – I use a combination of kenalog (triamcinolone) injections of varies strengths – 5 mg/ml on the face, 10 mg/ml or higher on the body. Sometimes this is combined with all the treatments above such as microneedling or lasers to soften the scar’s appearance on the skin.

For red scars – I would use an intense pulse light or pulse dye laser to remove some of the underlying blood vessels under the skin as to remove the appearance of redness on the skin.

For indented scars (ie. boxcar or rolling scars) – I would do the subcision method above, then add in hyaluronic acid (fillers) to lift up the scar tissue as to minimize the valleys.

For scars that do not respond to any treatment above, or are too large to even be treated with devices or injections, one can remove the entire scar with an excision. In this case, I would perform an excision of the scar, then see patients back every week to inject kenalog into the wound to prevent the scar from creating another keloid at the site.

Scars may often need multiple modalities above, separated by 4-6 weeks to allow the skin to heal between each treatment. The idea is to either calm down the fibroblasts and prevent it from making too many cells (i.e. kenalog)or to injure the skin in a way as to allow the skin to heal on its own better (microneedling, lasers, or chemical peels). Each scar on each individual requires a specific approach catered to that individual’s skin color and genetic makeup. There is no 1 way to make any 1 scar improve. Speak to your dermatologist for specific recommendations to your scars.

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