Scar is a tissue formed by the body as a reparative healing response after an injury or inflammation. The triggering factors of an inflammatory reaction on skin may be acne, chicken pox, infections, trauma or surgery.

A newly formed scar goes through a series of changes during next few months towards its maturity. All scars to begin with are hyper vascular i.e. they are reddish in color due to abundantly formed capillary vessels during healing, slightly raised above the skin surface and symptomatic i.e. they can be itchy, tender to touch and even painful. These changes are at their maximum at about two months from wound healing and after this period they gradually reduce over next six to eight months till they disappear. This is due to remodeling of collagen, the main content of a scar. The process is called as scar maturity and the mature scars are free from any symptoms.

Early intervention after the scar is formed may affect the way a scar remodels itself and can minimize its appearance. Treatment of a scar mainly depends on its type, size, location on the body and presence of any sequele resulting from it. Treatment can be grossly divided into two categories: Surgical Intervention and Non Surgical Methods.

IPL: Intense Pulsed Light and Fractional CO2 laser has revolutionized scar treatment by reducing the scars and smoothening the skin in just few months

Depending on the way the scars are formed, they can be grossly divided in three categories:

1. Average healing level with the surrounding skin leads to normal scar

2. Under healing leads to weak, atrophic, depressed and stretched scars

3. Over healing leads to slightly raised hypertrophic scars

4. Continued over healing leads to large, raised and growing or spreading keloidal scars

ACNE SCARS

In grossly inflamed acne (nodulo-cystic or pustular) if the underlying collagen structure within the dermis gets disrupted it gets reflected as a depressed (sunken) part on the surface of the skin after healing. Some acne scars are small in diameter but deep, while others are wide and shallow. These are atrophic types of scars. Atrophic scars, though they are caused by an inflammatory reaction, ironically, they are also treated by deliberately inducing a controlled dermal inflammation. Inflammation increases blood flow within the dermis which promotes the release of Fibroblast Growth Factor (FGF). FGF is a potent stimulator of new cell growth from both axis (horizontal and vertical). Over time when the procedures are repeated the new collagen growth reduces the depth of the scars gradually.

Common after acne which have been forcefully squeezed, pinched or extracted by nailing. Ice pick scars are deep-pitted scars that make the skin look like it had been jabbed with an ice-pick. These are best treated by Fractional CO2 laser resurfacing.

Common after acne. Most often multiple saucer like scars coalesce together to form an irregularly shaped patch of scars. These are best treated with subcision, followed by Fractional CO2 laser. Depressed scar area can also be filled with Dermal Filler.

Combination of depressed and rolled scars, coalescing together and causing obvious disfigurement. Most often these type of scars are genetically influenced. Steroids are used to weaken the scar, followed by smoothening the skin with Fractional CO2 laser.

Hypertrophic or keloid scars occur due to the same triggering factors (inflammatory reaction). However, in hypertrophic scars, the disrupted collagen network is replaced by an overgrowth of dense fibrotic tissue; giving it the elevated, brownish, thick cord like appearance.

Though a rare type after acne, hypertrophic scars are more obvious and difficult to conceal. These patients have a tendency for keloid and have to be treated cautiously. Corticosteroid injections are used to flatten the scar, followed by smoothening the skin with IPL or Fractional CO2 laser.

These scars occur following trauma, in majority cases; road accidents. They appear as a combination of fine thickened lines, flat or raised areas of varying sizes, which may or may not be discolored.

Sometimes they have traumatic tattooing due to tar particles getting embedded. In addition to revision surgery, corticosteroid injections are used to flatten them, Q switched laser to remove pigment followed by smoothening the skin with IPL or Fractional CO2 laser.

These scars are the result of surgery. At their best, they appear as a fine, flat (hair line scar) or slightly thickened lines which may or may not be discolored. At their average, they have some unacceptable width, and dotted needle marks along both sides called cross hatches or multiple short transverse scars crossing the main scar line due to tight tying of sutures called rope ladder pattern. At their worst, they can be depressed, stretched, hypertrophic and even keloidal.

Surgical scars which result out of either suturing under tension or poor dermal apposition may lead to spread scars. Typically they are spindle shaped, widest at middle and depressed. They are covered with thin and atrophic epidermis.

This is similar to spread scar but here there is no scar on the surface to begin with. Instead, the dermal collagen gives way due to rapid stretching of the skin as commonly seen on abdomen during later pregnancy or in teenagers on shoulders, arms, breasts and thighs during rapid growth and weight gain.

Any of the above type of scars can be dark in color i.e. hyper pigmented, at least initially. Though the dark color improves over time, it may not and require treatment with de-pigmenting creams and/or lPL or Lasers.

1) Width: Width of a scar can be reduced by revision surgery. For linear scars, single stage elliptical excision and closure is appropriate while for broad scars a staged serial excision needs to be planned.

2) Level: Any level difference between the scar and its surrounding skin makes it more obvious as it casts a shadow. It can be corrected by revision surgery if gross or by derma planning if mild.finally , it can be well merged with surrounding skin by fractional CO2 Laser

3) Color: Either hypo or hyper pigmentation makes a scar more noticiable. If a scar is not revisable on merit of other elements, then by improving its color it can become more acceptable. Hyper pigmentation can be dealt with either de-pigmenting cream regimens or lasers & lights or both.

4) Surface: Surface irregularities can be reduced either by dermabrasion or by Fractional CO2 laser.

After obtaining the detailed history of scar formation and analyzing the scar elements, main decision is taken whether this scar can be improved by surgery or not. If yes, then appropriate method of surgical revision is suggested. If there are more ways to improve it, then they are suggested in order of preference as per the expected outcome.

Based on the skin type, type of scar and its severity, the physician may recommend either one or combine any of the following treatment modalities. It is important for patients to realize that the appearance of scar can be significantly reduced with these treatments, but cannot be restored to the original skin condition. In addition to medical treatments, a healthy lifestyle and a positive mindset is equally crucial.

Scar improvement procedures

Fractional CO2 laser is the latest in skincare technology and is considered to be the gold standard for improving scars. Fractional CO2 laser creates numerous microscopic laser punctures, which help promote microcirculation and new cell genesis. Regular treatments will help to replace the scar tissue with newer healthier cells. Over time, the scar reduces and the skin appears healthier.

Immediately after the treatment the skin will appear red and minimally swollen. There will be numerous fine white dots in a mesh pattern on the treated area, which will change color to light and then dark brown and finally develop into fine black scabs within next few days. The scabs will start falling within 3 - 4 days; after which the skin is smoother and clearer. The entire recovery process takes from 5 - 15 days. During this time, patients are advised to apply more moisturizer and sun block to soothe the skin and stay away from excessive sun exposure. An individual may require 6 to 7 treatments done once in 4-6 weeks. The actual number of treatments will depend on the skin type, severity of the skin condition and how strong was the treatment. Fractional CO2 laser can be used for skin rejuvenation or skin resurfacing. Fractional CO2 laser rejuvenation procedure is done for mild scars while Fractional CO2 laser resurfacing procedure is done for moderate to deep scars. Fractional CO2 laser resurfacing is an intense treatment which may not be suitable for certain skin types.

Non Ablative Laser Rejuvenation (NALR) using carbon peel is a new technique of using medical grade Lasers for skin rejuvenation. This technique uses the Q switch Nd:YAG laser at 1064 nm. A layer of carbon is first applied onto the skin. The carbon acts like a magnet and adheres to the dead cells, both on the skin surface and the walls of the open pores. The laser is fired onto the carbon. The carbon absorbs most of the laser energy and is fragmented along with the dead cells, resulting in a perfect skin exfoliation. Simultaneously, the laser energy is distributed as heat into the dermis without affecting the outer layers of the skin (the epidermis). The heat energy stimulates new collagen / cell growth which helps to fill up the depressed scars. The scar tissue is replaced by new healthier cells. An individual may require 5 to 7 treatments done once in 4-6 weeks. The actual number of treatments will depend on the severity of the skin condition, skin type and lifestyle.

Intense pulsed light (IPL) is useful to treat scars that are associated with discoloration, especially recently formed reddish colored acne, traumatic or surgical scars. IPL treatment distributes light energy as heat beneath the skin's layers without affecting the outer layers of the skin (the epidermis). A layer of cold gel is applied onto the skin. The gel keeps the epidermis cool while the heat is distributed into the dermis. The IPL energy produces heat energy beneath the skin which stimulates new cell growth and help to reduce the scar. The light energy also helps to even out the skin discoloration. IPL does not help to treat fibrotic scars.

Immediately after the treatment, the skin may appear red. Very rarely, there may be scab formation, which disappears within 3 - 4 days. During this time, patients are advised to apply more moisturizer and sun block to soothe the skin and stay away from excessive sun exposure. An individual may require 5 to 7 treatments done once in 3 weeks. The actual number of treatments will depend on the severity of the skin condition, skin type and lifestyle.

Subcision is a simple procedure that helps to treat fibrotic ice pick scars. In ice pick or fibrotic type scars, the base of the scar (at the dermal layer) is normally anchored by fibrous bands. Lasers might not help in reducing the scars until the fibrous bands are released. During subcision, the skin is first anaesthetized with a cream. Under sterile practices, a needle is used to release the fibrous bands. This procedure also induces an inflammatory and healing process which helps to stimulate collagen growth and reduce the scar. It is an almost painless procedure with zero downtime, so you can resume your activities immediately. For best results, subcision should be followed by a series of collagen stimulation procedures such as Fractional CO2 laser or Non Ablative Laser Rejuvenation.

Soft tissue augmentation with injectable filler is another option for some of the shallower (hypotrophic / atrophic) scars. Depending on the depth of the scar, dermal fillers of different molecular weight are selected as implants. These fillers are injected beneath the scar using tiny needles. Initially, the injected fillers work by plumping up the injected site and reduce the depth of the scars. After a few weeks to months, injected fillers attract new collagen growth around them if followed by laser rejuvenation or resurfacing. The new endogenous collagen growth helps to reduce the scars further.

Most injuries or wounds in people with skin of color heal with normal scars. However, darker races & skin types like African, Latina and of Asian descent are more prone to develop hypertrophic scars and keloids than fairer skin types I to IV. Hypertrophic scar is a raised red and thick scar, which remains confined to the boundaries of the injury site means that it does not grow beyond the boundaries of the injury site. Common reason for its occurrence is excessive healing.

Once a scar, always a scar is a dictum. Once a scar is formed it is supposed to be permanent. Medical science can attempt to improve or make scars almost invisible. Presently available methods of scar management like cosmetic scar revision, followed by use of scar gels and silicone, pressure garments, IPL / Pulse dye and Q switched laser treatments initially and Fractional CO2 Laser treatment later on can make scars almost invisible.

Even though 100% removal of any scar is considered impossible, achieving a Scarless Scar state is a major breakthrough.

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