Scars and Keloids Revision

A scar is the result of the biological process of wound repair in the skin and other tissues. It is a natural process during which normal skin is replaced by fibrous tissue. Every wound, surgical or traumatic, (with the exception of very minor lesions) results in some degree of scarring.

There are many different types of scars:
Atrophic scars: the skin appears to be stretched, thin and usually white. Stretch marks are a typical example, but atrophic scars can also appear as the consequence of acne, recurrent cysts and infections on the body.

Pitted and sunken scars: mainly caused by acne and chickenpox, but also as the result of accidents and surgery. These are the result of the loss of underlying structures supporting the skin.

Hypertrophic scars: often mistaken for keloids, but unlike what happens in the latter, the excess scar tissue remains within the margins of the original lesion. They are red and protruding, and often itchy and moderately painful.

Keloids: pathological scars: ones that grows too much and that usually grow beyond the margins of the original wound. They are raised, red or purple, shiny, hairless lesions often painful or itchy. Most people with keloids have only one or two. However, some people have many, especially if they have come up after acne or chickenpox scars.

A keloid can occur after surgery, after major skin trauma but also after very minor skin damage, such as acne spots. It is also possible to develop a keloid even if there has been no obvious damage to the skin at all.

Keloids usually occur on the upper chest and shoulders - particularly over the breastbone (sternum) - and on the earlobes. In dark skinned individuals they very often occur in the beard area and on the scalp.

Asians and dark skinned people develop keloids much more easily than those with a paler skin. A tendency to develop keloids certainly runs in some families.

Fig.1 Hypertrophic scars.		Fig.2 Pre-operative programme.
Fig.3 Incisions & Z plastic surgery.		Fig.4 Result and scars.

Is it possible to remove scars?

Unlike what many people think, scars are permanent marks that cannot be eliminated by any surgical technique: they can only be improved upon.

What influences the quality of a scar?

The impact and severity of a scar can be influenced by a number of factors which include whether it is as a result of surgery or an accident, whether you are fair or dark-skinned (if dark, the scar will likely be worse) where on the body it is and how it is treated.

What kind of treatment can be used to improve scars?

First of all the correct care of a wound is essential: topical antibiotics to cure or prevent infections, continuous pressure (if possible), occlusion with silicone gel sheets or daily application of silicone gel for several months. Following this there are a number of cosmetic and surgical procedures that can be used including excision of the scars, intralesional steroid injections, chemical peels and laser treatment.

Atrophic scars: the most difficult type of scar to treat. Chemical peels and laser treatment may some times improve their appearance. Very good results have been obtained with the new fractional lasers which improve both the texture of the skin and the color. If the atrophic scars are very wide it is advisable to perform an excision of the scar.

Pitted and sunken scars: pitted scars due to acne can be improved with chemical peels and laser resurfacing with fractional lasers or surgical lasers. If very deep, they can be treated, like sunken scars, with injections of collagen or hyaluronic acid.

Keloids and hypertrophic scars can be improved both through medical and/or surgical treatments.
The gold standard treatment for keloids is intralesional injections of steroids. Multiple sessions are necessary at 4 weeks intervals. However, when keloids are particularly big or localized on the ear region a surgical treatment may be necessary before the steroid injections.

The surgical treatments consist of:
"Intralesional" excision of the keloids which mean that only part of the keloid will be removed. As regards hypertrophic scars laser resurfacing or complete surgical excision of the scar are the best treatments.

Your consultant will be able to advise on the most suitable course of treatment according to your personal condition and circumstances.

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