Scar Management

Original Editor - Ashmita Patrao Top Contributors - Ashmita Patrao

Introduction

Scars are the normal and unavoidable outcomes of tissue healing where the fibrous tissue replaces normal tissue as a part of the remodeling phase of wound healing. The collagen synthesized initially is random and constituting bulky fibers, which eventually remodels along the lines of tension. As this normal process occurs there is a risk of adhesions in the adjacent tissues. Eventually, these collagen fibers are replaced with stronger and  more organized  collagen, representing a smoother and flat scar which is paler in appearance.[1]

A scar that stays within the boundaries of the original wound is a firm scar.

Hypertrophic scar

Keloid

Scars that progressively encroach on the surrounding area of skin tissue resulting in a cosmetic and emotional distress. They frequently develop in areas rich in blood supply like the ear lobe or the presternal area.

Hypertrophic scars

Prolonged inflammation causes excessive collagen deposition with an increased adhesiveness and contractility of the scar. The resulting scare is red, vascular, immobile and raised. This can adversely affect range of motion and cause functional limitations when present around a joint.[1]

Assessment

Objective measures:

Size: A scar usually undergoes a period of over growth before maturing and becoming flatter.

Method Use
Mark points along the scar and measure length, width, height and elevation with a ruler Easy method for rough quantification,
Photographing the scar or tracing it onto a piece of paper Easy, inexpensive in clinical use, however unable provide quantification
Negative impression made of the scar in a dental stone, used to later reproduce a positive impression of the scar. Objective and quantifiable, difficult to use in clinical setting
Ultrasonography of the scar Quantifies size of the scar both above and below the surface of the skin(depth of the scar), however this is time consuming

Color: This is a measure of vascularity as well as pigmentation (measure of the melanocytes, bile ad carotene pigments).

Method Use
Visual observation, photographic analysis Non standardized, rough method
Color control strips, computer packages like adobe allocate numerical values to colors Not validated, but convinient

Pliability: This refers to the extensibility or elasticity of skin

Methods Use
Range of motion assessment It however is an indirect assessment of function and not merely a measure of the scar
Vertical pressure tools

Cicatronometer: hand held tonometer that's held vertically on the skin, depressed is an indicator rod. The firmer the skin the higher the rod will move

Mdodified Shiotz tonometer: this device even gives a reading of the power required for a given deformation.

Properties good against the ultrasound, however not used frequently
Horizontal Stretch tools: These are the extensometer and elastometer The reliability of these tools is yet to be tested.
NK Derma Durometer: This is a computerised device that uses the pressure required to deform skin through the electric resistance of skin. Non invasive, esy to use, objective but expensive
Cutometer: Measures vertical deformation using a suction device Highly sensitive,

Temperature: The temperature of a scar is dependent o the vascularity and amount of metabolic activity.

Methods Use
Infrared camera or Infrared tympanic thermometer Non invasive method of assessing temperature
Biopsies to detect changes Histologic analysis

Transepidermal Water Loss and Transepidermal Oxygen: The water loss across the skin increases due to the destruction of stratum corneum. The deeper the wound the longer stratum corneum takes to normalize. Skin hydration also affects the skin elasticity, Scar maturity is related to the oxygen tension present transcutaneusly.[2]

Methods Use
Tewameter (Courage+Khazaka Electronic GmbH, Cologne, Germany) measures the skin hydration and rate of oxygen diffusion Useful in conducting research, however are noninvasive, commercially available.

Standardized outcomes

Burns scar index (vancouver Scar scale): Measures Pliability, pigmentation, vascularity and height

Hamilton scale: Proportion of irregular scar with its height, depth, color, vascularity and numerical scar rating scale

Numerical scar rating scale: Border height of the scar, scar stiffness, color difference and the thickness of the scar.

Scar prevention

Prevention of a scar of of priority and can be done by 3 preventive measures

(1) Tension relief

(2) Hydration/taping/occlusion

(3) Pressure garments.

The greatest tension of a wound is at its edges ie perpendicular to the langer lines, additional those in the sternal and deltoid regions are at a higher risk for developing excessive scarring. Stress shielding devices wen applied to the scar interface reduces the mechanical stresses and prevents excessive scar formation.

Botulinum toxin A reduces tensile forces on post surgical scar. Moisturizing and humectant creams reduce the scaring in itchy scar. Silicon products hydrate the scar across the stratum corneum and hence prevent excessive scaring. Altering the levels of inflammatory cytokines like TGF-β3, as it is necessary towards the end of wound healing. Avoiding exposure to sunlight an the continued use of sun screens until the scar has matured.[3]

Scar Management

Aim: Altering the physical an mechanical properties of the scar by influencing the scar maturation process. Also promoting tissue strength and gliding by preventing adhesions.

Scar massage: During the proliferative stage massage has a beneficial role in collagen synthesis, as it prevents adhesions and helps in collagen synthesis. Also this mechanical stress when applied to the intermolecular bonds, helps in realigning collagen.

Splinting: Splinting can be used at all stages of wound healing, to immobilize at the earlier stages and with the aid of passive or active stretches to modify collagen alignment. Static and dynamic splinting can alter the viscoelastic properties of tissues thus it can elongate and stretch tissues over time.

Silicon gel: Silicone gel through sheeting and elastomers are said to have a hydrating effect on the scar. It helps to soften and elongate a scar by increasing the pressure, temperature and in turn blood flow to the scar.

Ultrasound therapy: The known effect of ultrasound is to promote healing in the inflammatory and proliferative stages. It stimulated the synthesis of growth factor that in turn increase the strength and elasticity of the collagen fibers formed,

Laser: Laser inhibits collagen and improves keloid and hypertrophic scarring. It improves pruritus but ha no effect on he cosmoses of the scar.

Pressure Therapy: When used for edema management and cosmoses in case of keloid and hypertrophic scars. These garments inhibit collagen synthesis in a remodeling scare through a mechanism that is unknown. Pressure therapy can reduce the scar height and erythema when applied for 23 hours per day for 12 hours. This should be applied at 20 to 30 mmHg and replaced every 2 to 3 months. This reduce abnormal pigmentation and accelerates scar maturation[4]

Pressure garments: This is sued in case of more widespread scarring as in case of burns patients.[3]

Steroids: An intraleisonal injection of a steroid improves the scarring. This is painfull and is suggested with other routine treatments.[5]
  1. 1.0 1.1 Jones L. Scar Management in Hand Therapy–is our Practice Evidence Based?. The British Journal of Hand Therapy. 2005 Jun;10(2):40-6.
  2. McOwan CG, MacDermid JC, Wilton J. Outcome measures for evaluation of scar: A literature review. J Hand Ther. 2001 Apr 1;14(2):77-85.
  3. 3.0 3.1 Monstrey S, Middelkoop E, Vranckx JJ, Bassetto F, Ziegler UE, Meaume S, Téot L. Updated scar management practical guidelines: non-invasive and invasive measures. J Plast Reconstr Aesthet Surg. 2014 Aug 1;67(8):1017-25.
  4. Sharp PA, Pan B, Yakuboff KP, Rothchild D. Development of a best evidence statement for the use of pressure therapy for management of hypertrophic scarring. J Bur Care Res. 2016 Jul 1;37(4):255-64.
  5. Jones L. Scar Management in Hand Therapy–is our Practice Evidence Based?. The British Journal of Hand Therapy. 2005 Jun;10(2):40-6.