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The NIP/Bio-Oil Survey: the results

In our latest online survey we looked at the subject of skincare and your experiences of treating patients with scars and stretchmarks. Read on for a summary of the results ...

Scars and stretch marks occur as a natural result of the healing process. However, research has shown that scarring can have a significant psychological impact, and many patients view their scars as unsightly and unwanted. Primary care nurses are well placed to provide advice and support for these patients, as well as recommend appropriate treatments.
Scars can be divided into the following types:

  • Keloid - an overgrown scar that can spread outside the original area of skin damage.
  • Hypertrophic - a scar that is raised above the surrounding skin, taking the form of a red raised lump.
  • Stretch marks - when the skin is stretched rapidly (during pregnancy, weight gain or loss, or adolescent growth spurts) or when skin is put under tension during the healing process.
  • Acne scars  - a scar that occurs when the wound tries to heal itself resulting in too much collagen in one area. These scars may be referred to as 'ice pick', 'box car' or 'rolling' scars.

Treatments include chemical peels, laser therapy, steroids, or over-the-counter topical remedies.

Although scarring and stretch marks are natural parts of the healing process and growth and weight loss respectively, many patients view them as unsightly and unwanted. The affected skin will go through numerous changes as it matures, but it often never attains the appearance of the surrounding skin. Therefore, it is not surprising that patients often seek help from a health professional as to how to prevent or reduce the impact of scars and stretch marks.

With this in mind, Nursing in Practice, in association with Bio-Oil, ran a survey to gauge the breadth of experience and knowledge of the treatment of scars and stretchmarks among primary care nurses (see Figure 1 for a breakdown).

[[Fig 1. Bio-Oil]]

Patient profile
We asked respondents to the survey about the types of scars they see in practice. The majority said they see patients who have scars due to surgery (73%), followed by stretchmarks due to weight gain (59%) and then scarring due to accidents/trauma (56%) (see Figure 2). The stage of healing is an important part of diagnosis and planning of treatment, and 76% of nurses said they see newly formed scars once wounds have healed. Around 56% of respondents see old scars, 18 months after wounds have healed.
Most of the scars seen in primary care practice, according to our nurses, are keloid scars (43%), followed by atrophic (30%) and hypertrophic (27%). With regard to the opportunistic questioning of patients about their scars, a total of 16% of nurses would bring up the subject if they noticed visible scarring while treating the patient for another condition; however, most (74%) said this would depend on the patient and their situation.

Psychological impact
The appearance of scars can have a huge impact on patients' psychological wellbeing, inhibiting them from daily activities, and occasionally causing depression or feelings of low self-esteem. Our nurses said that they felt approximately half of patients they see with old scars have experienced a psychological impact. This is largely related to concerns about the skin's appearance and 44% of nurses said they feel the impact is aesthetic rather than medical. When asked about patients' feelings about their scars, 75% described patients as feeling 'self-conscious' about their scars, in contrast to 'embarrassed' (8%) or 'worried/concerned' (6%).

It was clear from the survey that some patients experience delayed recovery from accidents due to the psychological effects their scars have. Around 26% of nurses have experienced this in practice, emphasising the need for care to encompass mental as well as physical health issues.

Most nurses (67%) who responded to the survey said they always discuss care and treatment of scars with patients who are having stitches or dressings removed. Nurses offer a wide range of advice about the treatment of scars and stretchmarks, and most (89%) discuss with patients the best methods of improving the appearance of new scars. Other forms of advice are:

  • Reducing the appearance of old scars (56%).
  • Reducing the appearance of uneven skin tone (32%).
  • Reducing the appearance of newly formed stretch marks (47%).
  • Reducing the appearance of old stretch marks (32%).
  • Preventing the formation of stretch marks (48%).

There are a number of treatments that nurses can advise to promote healing (see Figure 3). The majority (49%) suggest using topical oils, and perhaps surprisingly, 14% said they do not suggest patients use any treatment as the scars will fade with time.

Nurses' confidence
Just over half of nurses (66%) said they feel confident or fairly confident discussing scarring with patients, with 3% feeling 'unconfident', and the majority do not feel they are giving the best advice they possibly could. This is due to an inadequate level of training for most, although 31% attributed their lack of confidence to the fact that no best practice guidelines exist on scar treatment. With regard to patient outcomes, 31% stated they do not believe patients are satisfied with the level of advice they receive from health professionals about scar treatment.

It is clear from the results of the survey that primary care nurses require more training in how to manage and treat scars and stretchmarks, with a large number of professionals seeing patients with scars who have experienced a negative psychological impact. Keep an eye out for further discussion and advice in future issues of Nursing in Practice.

This survey ran from 15 June to 1 July 2011. A total of 251 primary care nurses completed the survey, the majority of whom were practice nurses who have been working in a primary care setting for more than 10 years. The survey was sponsored by Bio-Oil.