Introduction to skin scarring

Introduction to skin scarring

 

What is a scar?

A scar is a growth of collagen that forms as a natural part of the healing process following an injury to the skin. While scar tissue will go through numerous changes as it matures, it will never attain the normal strength of the surrounding skin. Hair follicles and sweat glands at the scar site will not grow back.

Why do we scar?

When an injury to the skin occurs, the body acts as quickly as possible to repair the affected area, devoting its energy and resources to healing quickly rather than perfectly. As a result, there is an overproduction of collagen at the site of the wound which leads to scar tissue.

How do scars form?

Depending on the size and depth of the wound, scar formation can take up to two years, and consists of the following three stages:

Haemostasis & inflammation

  • Blood rushes to the site of the wound to form clots
  • Cells in the blood release chemicals, which cleanse the wound and prepare it for healing
  • This stage lasts up to seven days

Proliferation

  • Collagen and ground substances, the bricks and mortar of scar tissue, are laid down
  • New capillaries are formed and the outer layer of the skin is healed
  • This stage lasts approximately two weeks

Maturation & remodelling scar formation

  • Collagen continues to build and fill in the area, creating the scar
  • The scar covers and protects the site of the wound, though it can easily be disrupted
  • This stage can take up to two years depending on the size and depth of the wound
  • The resulting scar tissue often never attains the appearance or strength of the surrounding skin, and hair follicles and sweat glands at the scar site will not grow back

Scar types 

Due to the fact that everyone heals differently, the final appearance of a scar will vary from individual-to-individual. Factors like skin type, scar location, type of injury, age and even nutritional status will play a role in determining what a scar will look like. Scar types can be divided roughly into the following categories:

Atropic – Typically small and form indentations below the surface of the skin, for example surgical incision. Indented or depressed/sunken scars are also described as atrophic, for example like those from acne or chickenpox.

Hypertrophic – Take the form of red lumps, raised above the surface of the skin. They can continue to thicken for up to six months, can be itchy or painful, but remain within the boundaries of the original wound site.

Keloid – Raised scars that spread beyond the original area of skin damage may be minor or major. They continue to grow over time, and usually recur after excision.

Scar contractures – Develop when scars cross joints or skin creases at right angles, often as a result of burn injuries. They can cause tightening of the skin, and may cause discomfort or affect movement. If a patient is experiencing these symptoms, referral to a plastic surgeon should be discussed for scar revision.

Stretch marks (striae) – The result of the skin suddenly stretching. The dermis breaks in places, allowing the deeper layers to show through. Often occurring in a period of rapid weight gain, pregnancy or during growth spurts in puberty.

Scars facts

A scar is a growth of collagen that forms as a natural part of the healing process following an injury to the skin. While scar tissue will go through numerous changes as it matures, it will never attain the normal strength of the surrounding skin. Hair follicles and sweat glands at the scar site will not grow back.

  • The average person has three scars on their body1
  • Scar tissue is formed in many different ways, and most new scars are as a result of:2
    • Accidental injuries
    • Surgery
    • Burns and scalds
    • Intentional harm
  • Just under half (46.7%) of people state that they are unaware of how best to look after their scars3
  • Two thirds of people (67%) have never discussed scarring with a HCP3

Scar Treatment

Scars usually fade over time, and while there is no product that can make a scar disappear entirely, there are various solutions which offer an opportunity to improve the scar’s appearance.

Medical intervention:
Should further medical intervention be required for the treatment of a scar, the options below are available for consideration:

  • Corticosteroid injections
  • Surgery
  • Laser or light therapy
  • Pressure Therapy

Aesthetic treatments, which wouldn’t be available on the NHS include:

  • Dermal fillers
  • Skin needlingy

Practical tips for self-care

Following a wound or procedure, there is a window of opportunity to help ensure a scar heals well. Factors such as bleeding, infection and wound opening up (dehiscence), as well as smoking, can delay the healing process. There are a number of measures patients can be advised to take to counteract these.

To minimise bleeding, patients can be advised to:

  • Firmly apply a dressing and bandage
  • Apply pressure with a clean cloth or sterile gauze until bleeding stops
  • To minimise infection, patients can be advised to:
    • Keep any dressings on unless advised to remove them
    • Keep areas dry (damp dressings leave the area susceptible to infection)
    • Wrap cling film over the treatment site when showering
    • If the wound is exposed, salt water bathing daily is helpful, ensuring the area is gently dried afterwards

To minimise wound dehiscence, patients can be advised to:

  • Take extra care before the stitches are removed
  • Avoid vigorous exercise
  • Avoid stretching the site
  • Apply micropore tape or steri-strips to the site to help strengthen the area

Post-healing, patients can be advised to:

  • Massage an oil or moisturiser into the scar daily in order to keep the scar hydrated and soften the scar tissue
  • Apply silicone gels or sheets to the scar
  • Wear a sun cream as sun exposure on new scars can cause pigmentation that can take time to settle
  • If desired by the patient, consult a trained camouflage practitioner

How does scarring effect patients?

In an image-conscious society that places a large importance on how we look, scars can cause some people to experience a loss of confidence and self-esteem. In a recent survey only a third (36.6%) of women described themselves as happy with their appearance.3 These psychological effects often vary depending on the location of the scar, how it occurred, as well as the age and sex of the person. Studies show that one in two women suffer ongoing psychological issues due to scarring.4 One in 10 (8.9%) people have reported feeling isolated as a result of their scar.3 In addition to the psychological effects of scarring, in some instances scars can cause physical discomfort, including pain, itchiness and tenderness. This is particularly relevant if the scar occurs across a joint, where it can limit mobility.

 

 References:
1. NHS Choices. Stretch marks. Available at: www.nhs.uk/conditions/stretch-marks/pages/introduction.aspx.
2. NHS Choices. Scars. Available at: www.nhs.uk/conditions/scars/pages/introduction.aspx.
3. Survey conducted by Opinion Health on behalf of Bio-Oil in February 2016, n=1000 adult respondents in the UK with scars.
4. Bayat A, et al. Skin scarring. BMJ. 2003; 326(7380): 88–92.

 

The Patient Perspective

Georgia Purser, age 21

After battling breast cancer, Tricia is proud of the scar that shows she survivied.

Tricia was diagnosed with breast cancer – multiple invasive tumours and node spread. She needed a breast removed and lymph nodes removed. She chose not to have reconstruction because (in her case) it would have meant “harvesting” a strip of shoulder muscle, and as she loves to rock-climb she would have lost too much power and mobility.

She then had aggressive chemotherapy and more surgery to finish removal of the lymph nodes. She chose a second round of surgery rather than radiotherapy, again, because she wanted to maximise her long term mobility. This all means that she has a stunning scar from her sternum to the back of her arm-pit. Stunning because it is perfectly straight and flat, no wrinkles or puckers, to her it is clean and beautiful – she is proud of it because it represents that fact that she has overcome cancer.

When it was new, Tricia says that it itched as it healed. Her friend Gemma sent her a bottle of Bio-Oil as it had really helped her scar when she had pins put in her ankle. Tricia started using it twice a day. Then she started using it on her face too. At her check-ups the surgeon commented on how well it was healing and how the skin was recovering from the trauma really well.

It is now nearly 2 years since the second surgery and she still regularly oils her scar after she showers. The chemotherapy has left her skin really sensitive – many of the creams and cleansers she used before now make her skin red and rough, but she says that Bio-Oil always leaves her skin soothed and soft. Tricia is now cancer free, and getting better and stronger and fitter every day.


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