Scars are borne by everyone with few exceptions. The scarring process enables us to heal wounds, but can result in minor to severe disfigurement which can cause embarrassment and change social behaviors. In 2000, more than 71 million surgical procedures were performed in the United States, each typically resulting in one or more scars. Traumatic injuries, including burns, create hundreds of thousands more scars each year. Acne, affecting up to 80 percent of people 11 to 30 years of age, causes untold numbers of scars and is a significant social problem for its victims.

What can be done to treat a scar’s appearance? This still plagues the medical community. Scars have been around as long as mankind has. We are closer to a solution now but still have a long way to go.

To understand scar treatment, one must understand what scars are. Scars repair defects created by trauma, disease, or surgeons. They begin shortly after the defect is created and continue to remodel themselves for months to years depending on their location. Scars can fill a defect perfectly and be nearly inapparent or they can fill a defect imperfectly, which can result in minor to severe problems with the scars appearance and function.

There are several kinds of imperfect scars. Hypertrophic scars are large, raised scars — usually reddish in color — that is more scar tissue than needed to do the job of filling a defect. The worst of the hypertrophic scars are keloid scars. These are nodular, raised, firm scars and often extend even beyond the margin of the original wound. Keloid scars occur most commonly in people with dark skin tones and are related to a metabolic alteration in collagen formation which is at least in part inherited. Atrophic scars are usually pale in appearance and may fail to completely fill the skin defect. They appear sunken, flat and thin but often have irregular margins where the surrounding skin is pulled with uneven tension. With all these new wounds and all the resulting scars, what can be done for treatment? The best treatment of a scar is to prevent its formation.

The first step in prevention is avoiding wounds.  Sometimes this fails, despite our best intentions.  When a wound occurs, seek proper medical attention. If the wound is small, and formal medical attention is not needed, there are some things to do at home to help reduce scarring. Clean the wound well and remove all foreign material. Clean wounds are less likely to get infected and retained foreign material can cause a permanent, tattoo-like appearance in the scarred area. Covered wounds heal up to 50 percent faster than uncovered wounds. Avoid topical preparations like Vitamin E or harsh cleansers like hydrogen peroxide, as these have been shown to slow wound healing. Avoid sun exposure/tanning during the healing process (until the scars color matches your normal skin tone) as this can result in permanent discoloration of the scar. Eat a good diet and don’t smoke. Try to limit motion in the healing area to avoid stimulating further scar growth. Be careful.
Once a scar occurs, what can be done? Surgical treatment, pressure treatment, injection, and lasers are some common treatments employed. Each of these can work well in appropriate instances and proper surgical consultation can help patients decide which would be correct for them. Laser treatment is one of the newest treatments for scars which shows considerable promise.

Laser treatment of scars involves using laser light to affect the scarred area’s metabolism in order to improve the scar’s appearance. Scars are composed of collagen, blood vessels, and fibroblasts (the cells that make collagen) in addition to other tissue elements. Depending on the wavelength of the laser energy — and what tissue the laser effects — lasers can cause marked changes in the scar’s appearance. 

Some lasers, like the CO2 laser, can be used to mechanically recontour the scar by lowering the level of the surrounding skin. This is best used for atrophic scars, but results in significant pain, redness, and a period of cosmetic disability. Other lasers use non-ablative means to improve the scar’s appearance.

Among the non-ablative lasers are the Pulsed Dye Lasers (PDL) in the 540-590 nm wavelength range. The energy from these lasers is absorbed by hemoglobin and these lasers do well in reducing the red or purple appearance of scars as well as the raised tissue. Common side effects include bruising and some discomfort during the procedure and, due to the wavelength absorption of melanin — the material which determines skin color — these lasers cannot be used for dark skins and may change pigmentation of the treated skin permanently.

Another non-ablative laser technology is the Neodymium: Yttrium-Aluminum-Garnet (ND: YAG) laser of which several versions are available in the 1320-1450 nm wavelength range. Laser energy at this wavelength is absorbed by water-bearing tissues. This energy passes through the external layer of skin and is absorbed by the dermis of the skin. This creates a thermal injury to the dermis and can improve scar appearance. Side effects include redness, the possibility, though rare, of burns, and occasional permanent increases in the pigment of the skin in the treated area.

The newest non-ablative laser technology is the ND: YAG laser at 1064nm wavelength. At this wavelength, melanin absorption is minimal, so the laser can be used on all skin types including tanned skin. The laser targets hemoglobin and is good at reducing the reddish/purple discoloration in scars. By targeting blood vessels in the scars, the mass of hypertrophic/keloid scars is reduced as well. Side effects are minimal; possibly mild redness for a couple of hours. Pain is minimal and pigmentation changes rare, as is the risk of burns. This technology is exciting and may turn out to be the best non-ablative laser option available. 

As you can see, scars are a common and significant problem. No one treatment is right for any given patient. Some patients may need a combination of treatments. I encourage you to seek an experienced surgeon familiar with all modalities of scar treatment when considering treatment for scars. Scars are now treatable and their appearance can often be greatly improved.

~ John P. Lundeby, MD, FACS is a general and vascular surgeon who practices at Lake City Surgeons PLLC in Coeur d’Alene and is a co-founder of Reflections Med Spas also in Coeur d’Alene. Dr. Lundeby earned his bachelor’s degree from the University of Idaho and then graduated from the University of Washington School of Medicine. He is a board certified Fellow of the American College of Surgeons. Dr. Lundeby practiced for eight years in Moscow and Pullman before founding Reflections Med Spas. He can be reached at (208) 676-8346.