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Scar management: what are the available options?

Jacky Edwards
BSc(Hons) PGDE RGN
Burns Nurse Specialist
Wythenshawe Hospital
Manchester
Treasurer
British Burn Association
E:jacky.edwards@smuht.nwest.nhs.uk

Scars are formed as a response to an injury of the skin. They form as a result of trauma, such as lacerations, abrasions, surgery and burns, or as a result of everyday wounds such as insect bites, vaccinations, tattoos, ear piercing or acne.(1) When a wound heals and the quantity of newly synthesised collagen is not excessive, there is no undue redness, the tissue is not hard and the elasticity of the skin does not restrict movement, it is regarded as normal (see Figure 1).(2) Normal scars become paler, softer and flatter over time, although they remain distinct from the surrounding skin.(3)

[[NIP16_fig1_69]]

Scars become problematic only if they become hypertrophic or keloid in nature. Keloid scars are benign fibrous growths, which only affect humans. They have a very gradual onset, can grow for years and spread, invading the surrounding tissues (see Figure 2).(1) They are very aggressive and difficult to treat, and as such their management is outside the remit of this article.

[[NIP16_fig2_69]]

Hypertrophic scars occur as a result of trauma. They are characterised by being raised above the level of normal skin, as a result of excess collagen production. They are often red, raised and itchy, as the area is invaded by extra blood vessels (see Figure 3).(1) Hypertrophic scars will usually blanch and soften with time, but the resulting contractures can restrict ­movement and function.(3)

[[NIP16_fig3_69]]

Scars are problematic not only because of the obvious psychological effect they may have on the patient, but also because they are painful and itchy, prevent sleep and can affect every aspect of the patient's life.

Management

Massage and creaming
Massage is an important first-line method of preventing abnormal scar formation. Massage is said to break up the collagen fibres, soften, flatten and fade scars. The evidence for this is unsubstantial, but ­correlates with the evidence for the use of pressure therapy.
 
Any type of cream can be used, such as E45 (Crookes), Nivea (Beiersdorf AG), Unguentum M (Crookes), or other emollients; however, oil- or petroleum-based creams should be avoided if the patient is wearing a ­pressure therapy device.
 
The massage must be systematic, involving small circular movements along the line of the scar or over the scarred area, blanching the scar (ie, the redness of the scar should fade as the fingers move over it). Cream should not be overapplied, as it can clog up the new ­sebaceous glands (see Figures 4 and 5).

[[NIP16_fig4_70]]

Silicone gels
Silicone gels are used when there are early signs of a hypertrophic scar. These signs include excessive itching, heat, redness, pain and the scar starting to rise above the level of the surrounding skin. Silicone gels are said to soften and reduce scars, although their mechanism of action is not completely known.(4)
 
Silicone gel sheets are comfortable and easy to apply, especially useful on flat surfaces, and many are available on FP10. They include Silgel Sheet (Nagor) (see Figure 6) and Cica-Care (Smith & Nephew). All such products last 2 months or longer and must be washed daily with soap and water.

[[NIP16_fig6_71]]
 
Silgel also comes in a nonsheet form, Silgel STC-SE (see Figure 7), which can be massaged directly into the skin and helps to maintain moisture for up to 24 hours. It is useful when the scar is on an area of skin where it is difficult for the sheet to be kept in place, such as the hands and face.

[[NIP16_fig7_71]]
 
Another useful gel sheet is Mepiform (Molynlycke). This gel is very thin, is adhesive and is very useful for areas like hands and faces. Patients like it because it is skin coloured. Each piece lasts up to a week, and no washing of the gel is required. However, it is the most expensive of all the products.
 
If a patient cannot tolerate silicone, then a product called Novagel (Southwest Technologies Inc), distributed by Tom Ford Medical, has proven to be useful. Originally developed as a wound product, it is a glycerine-based gel that seems to work on the principle of rehydration.
 
All gels should ideally be worn for 23 hours per day, being removed only for washing. If using topical silicone or glycerine gels, then creaming need not be carried out.

Pressure therapy
Pressure therapy was developed at the Shriners Burns Institute in Galveston, Texas.(5) The theory is that pressure results in hypoxia, which causes fibroblast degeneration and therefore altered collagen metabolism.(6) As well as being aesthetically pleasing to the patient, pressure garments have three main functions:

  • Restoration of function.
  • Relief of symptoms.
  • Prevention of recurrence.

Pressure garments are most useful when the scar is still immature, and should be applied as soon as the wound is healed or has been surgically closed.(7) Pressure therapy is 85% successful in compliant patients, but the garments are tight, often available in only one colour, and must be worn for 23 hours a day for up to 2 years, so compliance is often an issue.
 
Garments are tailormade for each patient, who are usually provided with three garments as they need to be handwashed in warm soapy water and dried by rolling in a towel and laying flat, so as not to perish the lycra. Garments are available commercially from Jobskin, Gilbert & Mellish, Second Skin or Kendall Camp. Alternatively, many burns and plastic surgery units make their own inhouse garments. Pressure garments are often used in ­conjunction with silicone gels, especially for difficult areas such as the chest and over joints, to provide more pressure.

Skin camouflage
Sometimes, even when the scar has settled and paled  it is still very obvious, and the patient may find it difficult to live with. Many services are available to provide cosmetic camouflage for patients to disguise the scar. Products such as Dermablend (Brodie & Stone) provide a natural-looking coverage, which gives patients, particularly those with facial scarring, the confidence to face the outside world.
 
Conclusion
Scar management is within the realm of every nurse. It is important that all nurses are able to educate patients about simple scar management techniques. Patients need to feel that they have some degree of control over what is happening to their scars, and should know where to go to get help. Simple techniques have been discussed, although it is important to remember that surgery is an option. However, if the patient is predisposed to abnormal scarring then further surgery may not rectify the problem. Prevention is obviously better than treatment, and prevention can be initiated as soon as the wound is healed if nurses have the knowledge with which to initiate it.

References

  1. Munro KJG. Hypertrophic and keloid scars. J Wound Care 1995;4(3):143-8.
  2. Carney SA. Hypertrophic scar ­formation after skin injury. J Wound Care 1993;2:299-302.
  3. Pape SA. The management of scars. J Wound Care 1993;2:354-60.
  4. Quinn KJ, Evans JH, Courtney JM, Gaylor JDS. Non-pressure treatment of hypertrophic scars. Burns 1985;12:102.
  5. Larson DL, Abston S, Evans EB, Dobrkovsky M, Linares HA. Techniques for decreasing scar ­formation and contractures in the burned patient. J Trauma 1971;11:807.
  6. Kirscher CW, Shetlar MR, Shetlar CL. Alteration of hypertrophic scar induced by mechanical pressure. Arch Dermatol 1975;111:60.
  7. Munro KJG. Treatment of ­hypertrophic and keloid scars. J Wound Care 1995;4(5):243-5.

Resources
Changing Faces
A charity that helps patients face disfigurement with confidence
W:www.changingfaces.co.uk

Let's Face It
A US nonprofit network that links people with facial disfigurement and those who care for them to useful
resources
W:www.faceit.org

British Red Cross
W:www.redcross.org.uk

British Association of Skin Camouflage
W:www.skin-camouflage.net

British Association of Plastic Surgeons
W:www.baps.co.uk

Scar Information Service
W:www.scarinfo.org