Thickened Scars

What are thickened scars?

A scar is an abnormal response from your skin to mild or severe trauma.

There are several different types of scars: some are raised, some are flat and others are indented.

The term 'thickened scars' refers to raised scars which are actually just masses of tissue that have become overgrown from the body's over-zealous attempt to fill in the gap from a wound. These scars can range from soft and doughy to both rubbery and hard. Usually dome-shaped, they are also hairless and shiny.

Of these thickened scars, there are two types: hypertrophic scars and keloid scars. Hypertrophic scars don't extend beyond the site of the injury. Moreover, these scars diminish in size and the pink or red colour begins to fade over a period of 12-18 months - though complete regression may not occur.

On the other hand, keloids can be as large as a tennis ball (though such extreme proportions are rare) and may not diminish without treatment. Most are either round, rectangular or oval-shaped, particularly when found on the chest or back. In some cases, keloids are claw-shaped or adhere to other irregular forms.

Indeed, it's mainly the size of a keloid scar that distinguishes it from a hypertrophic scar. Like hypertrophic scars, keloids are thick and often rubbery. They can also bring itchiness, sensitivity upon contact with clothes or other skin, or an associated mild, burning-type pain. As such, these scars may not only be physically and psychologically disfiguring, but may also be a regular source of mild pain and irritation. Once keloids stop growing, they don't usually cause symptoms but if formed over a joint, it can restrict movement.

Who usually gets thickened scars?

The larger the wound, the greater the likelihood of developing a noticeable scar. Other factors that affect the size of a scar include the location on the body and the person's age. Younger skin is more active in healing itself than old skin is, and as such, is more likely to over-heal. This is one of the main reasons why most raised scars are formed between the ages of 10 and 30. A rise in heart surgery in recent times has increased the incidence of keloid formation among the elderly; with the exception of earlobe piercing, wounds on the chest, upper back and shoulders are most likely to result in raised scars such as keloids. On rare occasions, however, keloids have been known to develop without apparent injury to the skin.

Most people with keloids only have one or two of them but some seem to be genetically predisposed to forming them. If this is the case, multiple keloids can be triggered simultaneously by a skin condition like chicken pox or even acne.

Even though certain people are predisposed to keloid formation, they can affect anyone - particularly when exposed to some sort of skin trauma. Almost everyone has had their skin cut or scraped at some point and this is all it can take to bring about a keloid. Young women are most often affected due to their greater propensity for getting their ears pierced. Other than this group, thickened scar formation affects both women and men equally.

In terms of complexion, studies have found that keloids arise more often in those of darker skin. As such, black Africans are most regularly affected by keloids, followed by Asian people. White and albino people form thickened scars the least frequently.

There is a genetic aspect to thickened scars: they have been reported to be both autosomal dominant and autosomal recessive and associated with blood group A.

What preventative measures are recommended?

The best mode of treatment is prevention and there are several measures that can be undertaken to minimise the chance of first acquiring a thickened scar.

Firstly, when you are cut or wounded, it's necessary to treat the wound properly to avoid infection. Aside from the other dangers inherent to skin infection, it's a major cause of scar development and open wounds should be regularly cleansed with an antiseptic or antibiotic ointment. Importantly, you should never pick, squeeze, dig or scratch at your skin - this is a cause of many small wounds that can become thickened scars. Even after skin has returned to its normal appearance, it still takes several months to recover fully.

Secondly, therapeutic treatment for acne, eczema and chicken pox should be undergone as soon as possible to prevent scarring that may become thickened. If you have a wound or disease with associated scarring, your dermatologist may recommend compression treatments or silicone sheets. This may reduce the likelihood of your scars forming or becoming thickened.

Thirdly, if you're in a high-risk group - particularly if you've formed a keloid in the past and/or have dark skin - you should consider avoiding ear and body piercing and carefully assess the necessity of any elective surgery involving high-risk areas of the body.

What are the available treatments?

Standard modes of treatment

If a hypertrophic scar has arisen because of prior surgery or piercing, it is recommended that you wait at least one year before deciding on active methods of treatment. As mentioned, hypertrophic scars often subside in time on their own accord so a healthy dose of patience may be all that is required.

On the other hand, once a keloid has formed, it is beneficial to begin treatment as soon as possible. There are several different courses of action that may be taken and treatment is always judged on a case-by-case basis; no single method of treatment is always appropriate. The nature of the scar, the age of the patient and his/her past response to treatment all should contribute to your doctor's decision.

Sometimes, it is counterproductive to try to remove keloids completely. Instead, one should focus on attempting to minimise its appearance.

One effective method of treatment is injecting steroid or cortisone solutions into the scar itself. This procedure is safe and not very painful. Its benefits are that it usually eliminates any pain symptoms that may have been experienced and causes the keloid to reduce in size through its effect of reducing collagen synthesis in the skin. Your doctor may elect to use this procedure alone or in conjunction with other treatments. This method of local injection has been found to be more effective than topical steroid use or Cordran steroid tape.

Injections of an anti-cancer drug, is very useful in diminishing thickened scarring. It cannot be used in pregnant or breast-feeding women but is otherwise a safe and usually effective treatment.

A moderate degree of success has been achieved in improving scars' appearance through the application of dressings. These include silicone gel sheets, non-silicone occlusive sheets and Scarguard. In the course of this treatment, patients are required to keep the strips in contact with their scar as much as possible over a period of several months. Silicone-based products are considered safe for use by children and can diminish the size some keloids. They are also available without a prescription.

Long-term use of pressure bandages can be used to soften keloids and reduce their size due to the thinning effect that compression has upon the skin.

Surgical treatments

It is important to note that, even though it may be tempting, cutting off thickened scars should only be considered under certain circumstances since keloids may reform and become even larger. If such an approach is to be considered, it must be done in conjunction with other treatments and precautionary measures, such as the injection of cortisone or other agents.

Another new option exists that can make attempts to cut away keloids more reasonable. Immune Response Modifiers (IRMs) can be used after surgery to prevent thickened scars from reforming. IRMs are topical treatments that boost the body's immunity from infections. They also increase the body's production of a natural, anti-inflammatory substance called interferon that aids the healing process.

Laser therapies are perhaps the most effective for diminishing and fading thickened scars. The lasers provide a high degree of localised heat to the scar, resulting in microvascular thrombosis and/or collagen reduction.

Some of the lasers that may be used include the CO2, argon, erbium:YAG and pulsed dye lasers, each with the ability to smooth out the skin, flattening thickened scars. Other benefits of the pulsed dye laser are that it can reduce the itchiness or burning sensation associated with thickened scars and, like various Q-switched lasers, it can minimise their redness. For thickened scars, the pulsed dye laser has the best track record for safety, results and price for the patient. For all of these reasons it has been the preferred laser treatment to date.

Sometimes, however, it may be necessary to combine lasers to achieve the best results. On the other hand, some doctors prefer to combine laser treatments with other more traditional treatments such as steroid or cortisone injections into the keloid.

Some doctors may use cryosurgery, which involves the use of liquid nitrogen to flatten the keloid. However, it should be noted that a discoloration effect often accompanies this procedure.

Other treatments

Though radiation therapy has achieved good results, its use for the treatment of keloids is controversial given its dubious degree of safety.

Other treatments are being developed; some of which are geared towards decreasing the skin's transforming growth factor and others that reduce the rate of collagen production. These are still at the experimental stages of development.