July 2021
Management of Scarring
There are many causes of scarring, both avoidable such as acne scarring and unavoidable including post trauma, surgery, lipoatrophy, inflammatory skin diseasesetc. There are also a variety of different types of scars and the treatment to remodel and improve them is dictated by the individual morphology. It really is as simple as raised keloid/hypertrophic scars need to be flattened, depressed scars filled or lifted, thin atrophic scars thickened, red and pigmented scars made pale/ flesh coloured and pale scars pigmented eg by tattoo if possible!
We must bear in mind that not only are scars cosmetically unacceptable in our very visually orientated society of selfies and Instagram but they are also often symptomatic, restrictive of movements, can interfere with clothing and be painful and itchy. Also, some areas are far more amenable to improvement than others, the face responding best and the trunk/lower limbs the worst. Why do medical insurance companies regard treatment of scars eg acne scarring as totally cosmetic while the treatment of their causes eg acne, is considered medical? We do not consider it frivolous or vain to have our childrens’ teeth straightened with orthodontics but many children are left suffering embarrassment and low esteem with facial scarring caused by acne.
One of the positive offshoots from the rapid expansion of aesthetic medicine is that we now have many treatment modalities to tackle the various scar characteristics and a single patient with acne scarring might benefit from a combination of many devices to tackle a combination of scar types. We also have to take patients’ tolerability into account eg a young person with severe acne scarring might get a far better result with fractionated laser resurfacing but tolerate it so poorly that we treat them with the far less painful Intense Medical Microneedling instead and settle for a lesser result for the time being. Patient expectations must be managed carefully as scars can almost never be ‘cured’ ie made invisible, but will almost always get varying degrees of improvement.
Current common treatment modalities include:
- Lasers of various wavelengths ie fractionated resurfacing with Fraxel, ResurFx or CO2 will burn thousands of tiny channels, thinner than a hair, into the skin creating tiny columns of thermal injury which heal by contraction and collagen formation.
- Intense medical microneedling also creates non-thermal and less deep tissue injury which also heal with the formation of new collagen. This definitely works and though less effective than laser, it is also less painful and minimal downtime. Radiofrequency microneedling also helps.
- Intense Pulsed light therapy and the Yag laser both remodel scars and reduce redness. All of the above energy treatments improve hyperpigmentation.
- Steroid and/or 5-fluorouracil injections flatten out thickened, raised scars.
- Botulinum toxin injections reduce tissue tension in scars both reducing fibrous tissue growth or preventing abnormal tugging with facial expression.
- Hyaluronic acid filler injections give immediate volumizing effects and if the insult which caused the scar isn’t repeated eg acne, the results are usually permanent. In cases of traumatic lipoatrophy eg trauma to a cheek fat pad (I’ve had a few cases of this) or volume loss secondary to facial morphoea, deep placement of the more volumizing product can lead to an extremely long lasting correction and restoration of normal facial contours. This result can also be achieved with Calcium Hydroxylapatite (Radiesse) injections.
- Platelet rich plasma injections help stimulate collagen especially in young healthy people with abundant growth factors and widespread shallow acne scars or post-burns.
- Prescription grade creams containing hydroquinone, kojic acid, vitamin C and retinoids can also help scar remodelling and reduction of pigmentation.
- Pressure dressings and silicone gels help reduce keloid formation in extensive scarring eg burns. Simple application of inexpensive Mepore tape for 24hrs at a time can also help, as can the steroid impregnated Fludroxycortide tape (though ensure it is only applied to the raised areas until they are flattened).
- Where the pigment has been destroyed and a china white scar remains, even if completely flat, it can be very eye-catching. Medical tattooing of flesh coloured pigment can help disguise it further.
Obviously, where at all possible a scar should be prevented by avoiding unnecessary skin surgery eg with the use of mole mapping to monitor rather than excise every mole of concern; always using the least invasive surgical procedure to complete the task eg some benign lesions can be removed by superficial shave excision rather than excision and suture; early, active treatment of acne, 15% of mild papulopustular acne can get significant scarring (check the temples and forehead for the earliest signs) and appropriate treatment of skin infections and inflammatory disorders causing damage to the skin eg ecthyma and discoid lupus. Surgical scars can be improved perioperatively by reducing tissue tension, correct orientation, subcuticular sutures, early treatment of infection, warning against picking scabs, steroid injections, or in extreme cases radiotherapy, at locations prone to hypertrophic scars. Botulinum toxin injections can stop a scar exerting abnormal ‘pulling’ on the skin with facial expression eg if a scar is crossing the crow’s feet lines or with a large flap on a face. Scars from cryotherapy can be reduced by being less aggressive, not freezing tanned or deeply pigmented skin and being extra gentle on the backs of the hands and lower legs where the
skin is thinner and far more likely to scar. You can always call the patient back and repeat the treatment.
Before you dismiss a patient query regarding improvement of a scar, think twice, it’s not at all as hopeless as it once was.
https://www.restorativedermatology.ie/restorative-dermatology/common-skinconditions/general-scarring-conditions/
Worrying Research on Skin Cancer
A third of Irish people are ‘not at all worried’ about skin cancer, worrying new research has revealed.
Skin cancer is the most common form of cancer in Ireland and claims over 230 lives each year.
Meanwhile, a survey of 1,000 adults conducted by Core Research on behalf of the Irish Cancer Society during Skin Cancer Awareness Month in May has also found that 3 in 10 people never check their skin for signs of cancer.
And the number of people who are ‘not at all worried’ about skin cancer increases to 4 in 10 among some groups who are actually at higher risk, including males and those aged over 55.
The survey also found that people mostly associate skin cancer signs with moles, with over half of those queried saying they would seek attention within a matter of days if they noticed a worrying sign with a mole.
However this drops to 4 in 10 for other, less well understood skin cancer signs like lumps, spots and rough, scaly patches on the skin.
The Irish Cancer Society has recently spoken out about a ‘catchup phenomenon’ where patients have delayed getting warning signs of cancer checked due to the pandemic. As with all cancers, catching skin cancer early is vital for patients to have the best outcome possible.
Commenting on the research Dr Bláithín Moriarty, Dermatologist at St Vincent’s University Hospital, said, “If people notice the signs of skin cancer early treatment can be very straightforward with a low-risk surgical procedure. However, as a skin cancer such as melanoma develops into later stages the survival rate drops significantly from almost 100% when caught at stage 1 to approximately 20% at stage 4, and treatment becomes much more difficult.
“Fortunately skin is the type of cancer you can see with your own eyes and do something about immediately. It is worrying to think that people believe they are at low risk when that might not be the case, as weeks can make a difference when it comes to the stage of diagnosis.”
Kevin O’Hagan, Cancer Prevention Manager with the Irish Cancer Society, said, “We are asking everyone to be Skin Smart and know the signs of skin cancer. It is extremely treatable when picked up early, so a simple and frequent routine of checking your own skin for anything that is new, changing or unusual can be a lifesaver.
“This is particularly important for people who are at higher risk such as those aged over 50, or outdoor workers who are exposed to the sun more. With summer now here we are as always encouraging the public to mind their skin in the sun by seeking shade, wearing covering clothes, a hat and sunglasses as well as sunscreen on exposed skin, and knowing when the sun is strongest.”