Scar therapy mainly focuses on relieving the patient’s inconveniences. However, there is limited evidence supporting the effect of different treatment options on scar maturation.
Time is the most important factor for the treatment of scar related problems, as most scar related problems will improve over time. However, this process may take years. It is vital to inform the patient about what to expect, as this may affect whether they decide to accept or decline a proposed treatment.
Scar-related problems from a patient’s perspective and the related treatment options
Burn scars can affect patients in various ways, and the issues they experience should guide treatment decisions. Here are recommended treatment approaches for various scar-related issues.
Itchiness and pain
Skincare can alleviate itchiness and pain, including avoiding heat if possible, applying cooling showers or baths, and using moisturizing ointments and/or cooling ointments.
Physiotherapy and occupational therapy focusing on silicones combined with pressure therapy, splinting, and massage therapy are also helpful.
Altered thickness compared to healthy skin
Physiotherapy and occupational therapy focusing on skincare, silicones combined with pressure therapy, splinting, and massage therapy can help balance thickness.
For small and linear hypertrophic scars, you can perform surgical resection of the scar and primary closure. In such cases, be sure to wait until the scar has completely matured.
Dermabrasion can be used to smoothen the irregular surface of the scar by controlled mechanical removal of the epidermis and partial-thickness dermis.
Color difference between healthy skin and scar
Redness disappears over time when the maturation phase has ended. A dark color appears over time when the scar is exposed to direct sunlight. Advise the patient to apply sun protection daily to reduce the progression of color changes.
Any remaining redness or hyperpigmentation can be treated with laser therapy. Dermabrasion might also be an option.
Stiffness of the scar and related functional impairment
Physiotherapy and occupational therapy focusing on stretching and mobilization, and anti-contracture positioning and splinting, can reduce stiffness and functional impairment.
In selected cases, fat grafting may be indicated.
In cases of functional impairment as a result of a scar contracture, burn scar reconstruction may be indicated.
Scar related psychological problems
Ensure the patient and family have access to psychological support when indicated.
Scar-related problems from a clinician’s perspective – diagnosis and treatment options
As a clinician, you may notice various scar-related problems. Here are recommended diagnosis and treatment options.
Increased vascularization is a sign of an active scar in the early maturation phase.
Diagnosis: You can assess increased vascularization by pressing a finger or Plexiglas on the scar, to see if the red or purple color disappears.
Treatment: Over time, during the maturation phase, vascularization will disappear. No specific treatment options are available for increased vascularization.
This can include hyperpigmentation (most visible in light skin types) and hypopigmentation (most visible in dark skin types). Intralesional injections of corticosteroids, sometimes used for the treatment of hypertrophic scarring, are frequently the cause of pigmentation disorders.
Diagnosis: After eliminating the influence of vascularization, you can observe the extent of scar pigmentation.
Treatment: Skincare in the form of daily sun protection helps to prevent hyperpigmentation. Where resources permit, laser therapy and dermabrasion may be used to treat hyperpigmentation disorders.
Diagnosis: Hypertrophic scars are characterized by thick, raised skin that does not extend beyond the boundary of the original wound. Keloids grow past the boundaries of the original wound.
Treatment of hypertrophic scars: Treatment options include physiotherapy and occupational therapy focusing on skincare, and silicones combined with pressure therapy. Intralesional injections of corticosteroids are sometimes used, but there is no protocol that specifies the appropriate concentration. In selected cases, dermabrasion and excision and primary closure may be indicated. When primary closure is not an option because of minimal tension margins, you may use other surgical techniques.
Treatment of keloids: There is no optimal treatment for keloids. All general conservative measures apply, including physiotherapy and occupational therapy focusing on skincare, and silicones combined with pressure therapy and splinting. If these treatments are not successful after 4-6 weeks, you may consider intralesional injections with corticosteroids, 5-FU, bleomycin, or verapamil. If this is also unsuccessful after 12 months, you may consider surgical excision and closure (with or without local flaps), combined with iridium, intralesional injections of corticosteroids, localized radiotherapy, or intralesional cryotherapy.