The end result is dependent on
- Factors Relating To The Trauma Itself – (eg a clean-cut sterile surgical wound vs a zig-zag or stellate wound, with tissue necrosis resulting from an infected injury).
- Host Factors (the body’s response) which could consist of hyperpigmentation, tethering or dimpling of the skin, neovascularization (the growth of tiny new capillaries)– giving the scar a pink appearance, or a hypertrophic reaction (tissue overgrowth) leading to a keloid scar
Acne Scarring
Hyperpigmentation
Acne Scarring
A common response to the inflammatory component of acne, this can be treated with skin lightening agents such as kojic or azelaic acid, or glycolic /salicylic/light TCA peels, or *pulse dye laser. Contraindications to chemical peels would be the use of Accutane within the preceding year, pregnancy, previous allergy or sensitivity; active dermatitis; and in the case of TCA – darker skin types. A series of peels will be needed 2-4 weeks apart. Fraxel Dual laser 1550/1927 can also be used.
*As of the time of writing, we currently do not have PDL;
Atrophic Scars
Can be divided into:
Icepick: Small deep scars
Boxcar: Round or oval scars with well-defined edge
Rolling scars: Deep dermal tethering gives a wavy appearance to the skin.
Boxcar Scars
Will respond better to laser resurfacing, either fractional ablative Smartxide CO2 or non-ablative NdYag – Affirm Multiplex or Erbium the Fraxel Dual. Contraindications to treatment include the use of Accutane within a year, active infectious lesions, recent herpes virus infection (cold sore) ,and the tendency to develop keloid or hypertrophic scars.
Fractional CO2 resurfacing has been demonstrated to reduce the depth of acne scarring by 50-80%, however, it may take several treatments. CO2 lasers are doubly as effective vs. Erbium lasers, as the thermal effect amplifies the production of myofibroblasts and matrix proteins such as hyaluronic acid.
Non-ablative resurfacing works by stimulating collagen formation, tissue tightening and raising the scarred tissue towards the surface (decreasing the depth of the scar)
Non-ablative lasers (such as Affirm Multiplex) are particularly effective for rolling scars, but you can expect a course of 6 treatments at a month apart. Some advantages of Affirm Multiplex over Smartxide are, no downtime and can be used for darker skin, however, results are not as dramatic for the boxcar scars. Fraxel Dual can also be used.
Other Treatments For Boxcar Scars:
- Dermal fillers: collagen-stimulating fillers such as Radiesse have been used; or so-called permanent fillers such as Artecoll/Artesense. Artecoll/Artesense consists of polymethylmethacrylate beads suspended in a solution of bovine collagen. The collagen disappears over time while the beads remain permanently in the skin, stimulating native collagen production. Because of the bovine collagen component, a skin test is mandatory before proceeding with injections. Occasionally, some persons may develop granuloma (lumps) in response to this product.
- TCA- CROSS* technique: *(Chemical Reconstruction of Scarred Skin) The application of 50% TCA to the base of boxcar scars for a few seconds, repeated at 4 week intervals, to a total of 3 treatments will encourage collagen formation, filling in the individual scars with little risk of hypopigmentation or scarring of the surrounding skin. This technique has been enhanced by following with subcision, and subsequent laser therapy (called triple therapy)
- Punch Excision Of Scars– using a punch biopsy, areas of scarred tissue can be excised, and the subsequent healing stimulates collagen formation, resulting in flatter scars
- Selphyl Platelet-Rich Fibrin Matrix- injecting the scarred areas with the patient’s own activated platelets to stimulate filling in of the depressed areas- see Website: Fillers;
- Fat Grafting– as above, except using autologous fat cells to fill in the depression
Hypertrophic Keloid Scars
Hypertrophic & keloid Scars May Form As A Result Of
- Surgery
- Cuts
- Burns
- piercing/puncture wounds ( inc piercings, tattoos)
- Scratches
- Post Acne, Chicken Pox, Herpes Zoster
They are characterised by excess collagen deposition and decreased collagenase (an enzyme that breaks down collagen) production.
Hypertrophic scars are pink, raised and firm, remaining within the boundaries of the injury; while keloids tend to be nodular and spread beyond the borders of the original injury.
Keloids are more common in the age group 10-20 years, may have a familial history and are more likely in darker skins. Having a keloid scar in one part of the body does not necessarily mean that they will form in other parts (but there is a higher risk). Keloids will turn darker in sunlight and may be itchy or painful. If extensive (e.g. after burns), they may restrict movement of the affected part.
Treatment Options:
- Surgery – unfortunately, 50% of the time, the keloid may recur or get worse. The use of imiquimoid cream or silicone gels afterwards may reduce the risk of recurrence
- Cryotherapy
- Steroid Injections
- Laser Treatments- pulse dye lasers- for red scars in lighter skin types; CO2 lasers have been used for blade-free excision of keloids, or alternately, using the multipulse (deep) fractional mode to break down the deep layers of collagen- multiple treatments are needed, and there is a significant risk of recurrence.
- Silicone Gels-. Studies have demonstrated up to 50% reduction in thickness with twice daily use over an eight week period
- Combination approaches using cryotherapy and intralesional steroids.
- Other approaches that are being studied-intralesional injections of 5-Fluorouracil or bleomycin; radiation, interferon, or imiquimod.
Stretch Marks
Otherwise known as striae, these red/purple/pink indented streaks are often seen on the abdomen, buttocks, thighs, breasts or upper arms following rapid weight gain/loss or in the latter third of pregnancy and beyond. They are due to stretching of the dermis, in the setting of decreased fibroblast activity which results in inadequate elastin and collagen production to maintain skin elasticity, and are influenced by familial, genetic or hormonal factors.
Outside of pregnancy or rapid weight gain, they can be seen in puberty, with muscle growth, in genetic conditions such as Marfan’s or Ehlers-Danlos syndromes, or disorders affecting the adrenal glands (Cushing’s syndrome).
