Management of Patients with Scarring in Primary Care

A resource to incorporate scarring
advice and care into practice

Introduction to scars

‘Management of Patients with Scarring in Primary Care’ is an online educational resource for healthcare professionals (HCPs). The module is expected to take around 45 minutes, and counts towards your Continuing Professional Development (CPD).

Scar management is an important area of patient care. Patients will often want to discuss scarring with HCPs, seeking advice and solutions on improving scar appearance; and they may voice psychological concerns. This may be an impromptu question during a consultation, or a real concern due to a recent injury or surgery. As a dermatology nurse who works with primary health care professionals, I feel that nurses are often best placed to offer support and advice on scar management, however GPs, pharmacists, and many other HCPs may also be involved in this process.

I hope you enjoy learning more about scar management and how to care for your patients.

Julie Van Onselen
Dermatology Specialist Nurse

This module is supported by Bio-Oil.

After working through this module, you should have:

  • 1Updated knowledge on scar formation, types of scars and current evidence-based treatment and self-care options to reduce scarring.
  • 2 Increased awareness and clinical confidence on when to discuss scar management with patients and offer advice for self-care.
  • 3 Improved understanding and empathy of the physical, psychological and social impact of scarring.

Continuing Professional Development


This online educational resource can be used towards NMC revalidation and required CPD hours. The module should take you around 45 minutes to work through in total, depending on your pace of learning. It is also important that you spend extra time reflecting on your learning and setting an action plan for practice, which you should record for revalidation as a reflective discussion. The CPD section towards the end of the module provides more details and links to the NMC revalidation website, where you can download required templates.

The physiology of scars

A scar is an accumulation of collagen that forms as part of the healing process following trauma to the skin. When an injury to the skin occurs, the fibrous connective tissue in the subcutaneous layer of the skin lay down fibronectin, producing fibroblasts, which stimulate the growth of granulation tissue. This results in large bundles of type 1 collagen formed by the mass of granulation tissue, which heals the wound by physiological closure. The healing and scar maturation process takes between three weeks and two years, depending on the type of wound. A scar, when mature, will never attain the normal strength of the surrounding skin. Hair follicles and sweat glands at the scar site will not grow back.

Types of scars:1

Atrophic

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.

Widespread 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, they may be minor or major. They continue to grow over time, and usually recur after excision.

Types of scars:1

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, often occurring in a period of rapid weight gain, pregnancy or during growth spurts in puberty. The dermis breaks in places, allowing the deeper layers to show through.

Wound healing and scar maturation process2

Depending on the size and depth of the wound, scar formation can take up to two years. Here, we describe the four phases of healing in uncomplicated wounds:

Phase 1: Haemostasis


  • 1 Skin injury results in haemaostatic events, bleeding and platelets come into contact with collagen.
  • 2 The coagulation cascade, activated through intrinsic and extrinsic pathways, leading to platelet aggregation and clot formation to limit blood loss.

This stage lasts on average for a few hours.

Wound healing and scar maturation process2

Phase 2: Inflammation


  • 1 The complement cascade initiates molecular events leading to the infiltration of the wound site by neutrophils.
  • 2 Neutrophils start phagocytosis to destroy and remove foreign bodies, bacteria and damaged tissue – wounds with a bacterial imbalance will not heal.
  • 3 After a few days, neutrophil activity changes once contaminating bacteria are removed and then redundant neutrophil cells are eliminated by a process called apoptosis, producing slough.
  • 4 The late inflammatory phase (48-72 hours) after injury is when phagocytosis occurs due to macrophage activity. A myriad of cellular activity produces tissue growth factors activating kerinatocytes, fibroblasts and endothelial cells starting wound repair.
  • 5 The last cells to enter the wound are lymphocytes activated by interleukin, 72 hours after injury, which start collagen regeneration.
  • 6 This phase causes wound symptoms including; oedema and swelling, increase in wound temperature, induration, change in skin colour; and sensation loss, itching, burning or pain – with possible loss of function, depending on site.
  • This stage lasts on average between three and seven days.

Wound healing and scar maturation process2

Phase 3: Proliferation


  • 1 When injury has ceased, haemostatisis is achieved and immune response in place, the acute wound shifts to tissue repair.
  • 2 Fibroblast proliferate for three days and an extracellular matrix, composed of fibrin and fibronectin is formed by the end of the first week (an essential part of the repair process), to establish the wound edges.
  • 3 Fibroblasts are then eliminated by apoptosis resulting in the formation of a collagen matrix resulting in granulation tissue.
  • 4 New blood vessels are established, attracting neutrophils, macrophages and other cells to modulate cell growth and heal the wound by processes called adhesion, traction and epithelialisation.
  • This stage lasts for approximately two weeks.

Wound healing and scar maturation process2

Phase 4: Maturation and remodelling. Scar formation


  • 1 The final phase of wound healing is the development of new epithelium and scar tissue formation.
  • 2 This occurs by synthesis and breakdown of collagen with more extracellular matrix remodeling, due to collagen overproduction.
  • 3 Collagen fibres regain approximately 80% of their original strength after skin injury but original strength can never be re-gained.
  • It can take up to two years to form a scar depending on the size and depth of the wound.2

What is a scar?

  • An overproduction of collagen at the site of the wound
  • The end product of granulation tissue at the site for the wound
  • A bundle of connective tissue at the site of the wound
  • An underproduction of collagen at the site of the wound

How many different scar types are there?

  • 3
  • 4
  • 5
  • 6

How long does the scar formation stage of the maturation process take?

  • Up to two days
  • Up to two weeks
  • Up to two months
  • Up to two years

The psychological impact of scarring

The psychological impact of scarring

Outside of the physical burden related to scarring, psychological strains can also occur, with the majority of patients feeling that their scars are unsightly, and leaving them feeling abnormal. Scars can have long-lasting physical and psychosocial effects, even if remedial and cosmetic treatment is sought.3,4

A recent online survey of 1,000 UK patients living with scarring conducted by market research company Opinion Health, on behalf of Bio-Oil, found that 39% feel that their scar affects their day-to-day life, experiencing feelings of depression, anxiety and withdrawal from social activity.5 Additionally, people living with scarring can be impacted by societal pressures, with some feeling that they have been judged by others as a result of their scarring.5

Many patients feel unsupported psychologically, and can feel that their concerns regarding scarring are considered trivial.6

Working towards acceptance

Largely, patients want to move towards a state of acceptance, meaning that they don’t have to hide their scar. Others would like to move past negative feelings that they currently have when they look at their scars, and feelings that others are passing judgment as a result of their scarring.5

Where do patients turn for scar support?

For patients who have lived with scarring for a number of years, it may be difficult to know where to turn for support – the wound has healed, and they may feel uncomfortable raising the discussion with their HCP.

The survey found that the main reasons patients avoid raising the topic are:5

  • 1 A belief that there is nothing a HCP can do to help.
  • 2 Lack of awareness that HCPs can provide support.
  • 3 Embarrassment.

But what should HCPs do when patients want help...

What advice do patients want?

42% of patients would like to receive advice from a HCP rather than any other group (including support forums and family and friends). The recent survey highlighted that patients would like to receive:5

  • 1 Verbal advice about how to care for their scar.
  • 2Guidance on the healing process of their scar.
  • 3Recommendations for products they can use to help with scarring.

Those who have discussed their scarring with a HCP reported positive outcomes as a result, with 58% saying that the advice they received helped to improve the appearance of the scar tissue.5 Therefore, discussion should be encouraged, however HCPs should proceed with some caution, particularly with visible facial scarring, or scarring that is not an obvious result of surgical incision (e.g. caesarian section scar).

It is important not to ask how the person acquired a scar, unless the patient offers you this information. Scars may be acquired in different ways, including abuse or attack – these scars can have long-term emotional effects in addition to the physical discomfort and marring of the skin. This can be very difficult for the patient psychologically.

How can scarring be treated?

While there is no treatment that can make a scar disappear entirely, there are options that can help to improve the appearance of a scar. These include medical techniques and some self-care management measures, used alone or as part of combination therapy, which offer an opportunity to improve the scar’s appearance.

Medical intervention treatment options

Medical intervention is usually reserved for hypertrophic scarring and major keloids. If a patient has a scar that requires medical intervention they should be referred to an appropriate HCP i.e. a plastic surgeon or dermatologist. Treatments recommended by the International Consensus on Scar Management are listed below and combination approach to treatment is recommended for the maximum potential of successful treatment of hypertrophic scars and keloids:1

  • 1 Corticosteroids: intra-lesional injections; topical steroids under occlusion and steroid impregnated tape.
  • 2 Pulsed dye laser (or fractional laser therapy).
  • 3 Pressure therapy.
  • 4 Surgical revision.

Aesthetic treatments, which would not be available on the NHS include:

  • 1 Dermal fillers.
  • 2 Skin needling.

There is a growing evidence supporting the potential use of therapies such as Imiquimod cream, photodynamic therapy, and botulinum toxin A in scar management, however further research is required.7

Self-care management options

  • Massage with oils and emollients
    • 1 Massaging and moisturising with oils and emollient lotions, creams or ointments has been shown to be beneficial for reducing itch and pain in scars, as well as reducing the size and improving the scar appearance.8
    • 2 Massage is also thought to be psychologically beneficial, as touch can help the patient to connect with their scar.
  • Silicone gels or sheets
    • 1 These are soft semi-occlusive medical grade silicone sheets, which can be applied to scars (not open wounds). Several clinical studies have indicated the beneficial effects of silicone sheets in the prevention and treatment of scarring.8
  • Skin camouflage
    • 1 Skin camouflage cannot alter the texture of a scar, but can cover up a scar. The immediate visual effect does help the patient to regain self-esteem and confidence.
    • 2 A trained camouflage practitioner will assess and colour match the patient and teach them how to effectively apply camouflage to their scar. This service is generally provided voluntarily by Changing Faces and The British Association of Skin Camouflage.

What practical guidance can you share with patients?

Alongside clinical experts, Bio-Oil has developed the SCAR guide for HCPs to work through with patients during consultations:

The SCAR Guide:

  • Site - Identify whether the scar is on a mobility area and if the location of the scar or patient’s skin type is likely to produce abnormal or worse scarring. It may also be helpful to consider whether the location of the scar will allow a patient to conceal the scar.
  • Category - What type of scar does the patient have? Is it atrophic/widespread hypertrophic, minor/major keloid, contracture scar or stretch marks?
  • Age - Is the scar new, still maturing or fully matured? Explaining the maturation process of scarring can help to set realistic expectations.
  • Reassure, recommend, refer - Help to alleviate psychological worry by reassuring patients of commonness of scarring and that scars improve over time with the skin’s natural regeneration process. It may also be helpful to recommend further sources of advice such as Changing Faces, who support people living with disfigurement, or the Bio-Oil Facebook page, where people living with scarring come together to support each other. Recommend treatment options and refer where necessary.

What percentage of people with scarring experience feelings of depression, anxiety or withdrawal from social activity?

  • 22%
  • 32%
  • 39%
  • 52%

Which of the following is a self-care management option for people with scarring?

  • Pressure garments
  • Skin needling
  • Laser or light therapy
  • Regular massage with oil or cream

In the SCAR guide, what does the ‘R’ refer to?

  • Reassure, recommend, refer
  • Read, realise, recommend
  • Refer, repeat, reduce
  • Reassure, reinforce, reduce

Managing patients with existing or old scarring

Managing patients with existing scarring

For people living with scarring, the negative impact can be attributed to many different (or a combination of) considerations, for example; it may remind them of a difficult time in their life in acquiring the skin trauma, they may experience judgment within social settings, or it may serve as a reminder that their body isn’t what it used to be.

HCPs should proceed with some caution with discussion on scarring, particularly with visible facial scarring, or scarring that is not an obvious result of surgical incision (e.g. caesarian section scar). It is important not to ask how the person acquired a scar, unless the patient offers you this information. Scars may be acquired in different ways, including abuse or attack – these scars can have long-term emotional effects in addition to the physical discomfort and marring of the skin.

A guide to scar consultation

Patients with existing scarring may be less likely to proactively discuss scarring with you as it will have been some time since the wound healed, however 46% of patients would like HCPs to proactively discuss scarring with them.

You may become aware that a patient is living with scarring during a consultation in various ways. If the opportunity presents itself, it can be useful to proactively, yet sensitively, raise the topic.

Scar acceptance may be a future aspiration, and some level of concealment may be required in the immediate term – skin camouflage can be an option if the scar is in a visible area.

Address the subject sensitively

Indirectly raise the subject if you’re aware that a patient is suffering from scarring. Raising the subject in relation to scars resulting from surgical intervention or injury is advised.

Provide reassurance

Explain that the patient isn’t alone in their concerns, the average person has three scars on their body, and anxiety, or feelings of depression or withdrawal are common in people with scarring. Provide advice on options available for improving the appearance of the scar, such as massaging the area, and support groups that can help with feelings of isolation i.e. Changing Faces, or the Bio-Oil Facebook page.

Refer if necessary

If further treatment is needed, for example surgical excision, you may need to refer the patient to an appropriate HCP, for example a plastic surgeon or dermatologist. Additionally, it may be that the psychological impact is moderate or severe – in this case you should firstly discuss this with the patient’s GP, who may make a decision to refer the patient to the local mental health services for support from a psychologist.

How many scars does the average person have on their body?

  • 2
  • 3
  • 4
  • 5

A patient presents to you with scarring. After initially discussing self-care and options for improving the appearance of the scar, it becomes apparent that the patient is suffering severe emotional distress as a result of their experience. Do you (tick all that apply)

  • Discuss your concerns about the patient with their GP
  • Direct them towards support groups
  • Send them away as a scar is a cosmetic issue that does not require medical intervention
  • All of the above

In the recent survey, what percentage of patients said that they would like to receive scarring advice from a HCP?

  • 22%
  • 32%
  • 46%
  • 60%

Managing patients with new scarring or planned procedure

What are the considerations for patients with new scarring?

Patients with new scarring, for example as a result of an accident resulting in skin trauma, will experience both physical and emotional concerns.

Scars can be acquired as a result of many different experiences, however this does need due consideration. If a scar was the result of a troubling experience, for example a severe burn or self-harm, the patient’s response and resulting behaviour will be very different from someone who acquired the scar as a result of an everyday cut or graze.

Talking scars with your patients

The emotional distress experienced as a result of the scar acquisition will inevitably have a bearing on how the patient communicates. Some patients will initiate the discussion themselves, however others may need some help.

Patient case study

Anna, is a 32-year-old lady with three children, all born by caesarian section. She is having a routine smear and I noticed that she had a hypertrophic scar on her lower abdomen. I asked her if she was worried by her caesarian scar and Anna started to weep and said that she is really bothered by her scar, which makes her feel unattractive in herself and to her husband, she explained that she had lost a lot of confidence, due to her ‘ugly scar’.

I sensitively addressed Anna’s concerns and asked whether she would like some help to try and improve the appearance and she immediately responded very positively and said that no one had ever asked her before and she thought it would be a trivial thing to bother a HCP with, as, after all, she has three healthy children. I recommended Anna use an oil to gently massage her scar twice a day for the next twelve weeks. As her scar psychologically affected Anna, I felt that it was necessary to see her for a review after she had tried this in three months.

At the review, Anna was smiling and appeared much more relaxed, she said the massaging with an oil had made a difference in the appearance of her scar. She also said that touching her scar had helped her accept and even connect with her scar, realising that it is part of her and a positive result of having three lovely children.

Recent survey highlights

The recent survey highlights that despite being impactful on patients’ psychological well-being, a large number (67%) of patients have never sought advice from a HCP about their scar. However, those who have, report positive outcomes as a result, with 58% saying that the advice they received helped to improve the appearance of the scar tissue, demonstrating the value of providing advice.5

Reactive discussion

You can respond to a patient's questions regarding scarring using this simple process, developed by Bio-Oil - the SCAR guide (as shown in Phase 2, screen 8):

  • Site - Identify whether the scar is on a mobility area and if the location of the scar or patient’s skin type is likely to produce abnormal or worse scarring. It may also be helpful to consider whether the location of the scar will allow a patient to conceal the scar. Scar acceptance may be a future aspiration, and some level of concealment may be required in the immediate term – camouflage can be an option here if the scar is in a visible area.
  • Category - What type of scar does the patient have? Is it a keloid, hypertropic, atrophic, contracture scar or stretch marks?
  • Age - Is the scar new, still maturing or fully matured? Explaining the maturation process of scarring can help to set realistic expectations.
  • Reassure, recommend, refer - Help to alleviate psychological worry by reassuring the patient of commonness of scarring and that scars improve over time with the skin’s natural regeneration process. It may also be helpful to recommend further sources of advice such as Changing Faces, or the Bio-Oil Facebook page. Recommend treatment options and refer where necessary.

Proactive discussion – early intervention

Proactive discussion needs due consideration, and it’s important that the subject is raised sensitively. This is an important part of pre-operative wound care, even with a small procedure, such as a minor operation for removal of a skin lesion. The patient should be informed that scarring is likely, but when the wound has healed there are self-management measures that can really help to improve the appearance of the skin and minimise scarring.

Patient case study

Sean is a 55-year-old builder who has had lots of sun exposure as an outdoor worker. He was diagnosed with a basal cell skin carcinoma on his upper arm. When preparing Sean for the procedure, I informed him that his wound will be closed with a few sutures but scarring was likely to occur. Sean immediately asked if anything can be done to reduce scarring. I responded with advice on preventing scarring with massage with a moisturiser, such as an oil, as part of his postoperative care and instructions to start when the sutures have been removed and wound is healed.

I saw Sean for a blood pressure check six months later and he showed me his scar and said how grateful he was for the advice he received as he feels his scar responded very well to massage and has a good appearance as a result.

Patients with new scarring or a planned procedure provide a window of opportunity for us to get it right early. By setting expectations ahead of emotional stress manifesting, we can ensure long-term comfort and encourage self-care in an efficient way.

The Bio-Oil CARE guide has been developed alongside clinical experts to be provided to patients following a consultation, this allows them to have something to refer back to for long-term confidence in managing their own scarring:

  • Connect & contact - Massaging your scar(s) twice a day can help to stimulate the repair process and help you connect with the scar emotionally.
  • Application - Wait until your wound has fully healed and allow four weeks after any stitches have been removed before you start to apply an oil or cream. To apply, massage in a small amount until it has been fully absorbed.
  • Regular - You need to be dedicated and ensure you regularly massage and moisturise your scar twice a day for at least three months. This will help to speed up the skin’s natural regeneration process.
  • Expectation - If you are in the care of a nurse or surgeon, ask them how long your scar(s) will take to heal and how you should expect it to look and feel as it heals. Alternatively, your local pharmacist can help with advice and recommend useful websites for further information.

You can download the CARE guide as part of the Bio-Oil Aftercare Pack at the end of the module.

In recent research, what percentage of patients reported that the appearance of their scar improved following recieving advice?

  • 16%
  • 26%
  • 36%
  • 58%

When is the optimal time you should provide information on improving the appearance of scarring to a patient who is having a planned surgical procedure? (tick all that apply)

  • When the patient has their sutures removed
  • When the wound is healed
  • During pre-operative preparation
  • If they ask you about the scar when it has already formed

What can be provided to patients following a consultation to help them self-care?

  • SCAR guide
  • CARE guide
  • CUT guide
  • GRAZE guide

Congratulations

You have successfully completed the module. Please complete the information below to receive your e-certificate, and remember that this module can be used towards your CPD. Your details will only be used for the purpose of providing you with your certificate, unless you state otherwise.

If you are interested in learning more about managing scarring, please visit www.biooilprofessional.co.uk.

Revalidation

This e-learning module can be used towards CPD for revalidation with the Nursing and Midwifery Council. After completing this module, please complete the Reflective Discussion form on the NMC website; this is a written reflective account on your CPD and learning from this module, including how you have incorporated this learning into your practice.

You should download and store the reflective discussion sheet and e-certificate (a log of CPD) in your portfolio document as a hard or e-copy, ready to show your verifier when you have your revalidation meeting (or yearly appraisal).

http://revalidation.nmc.org.uk/what-you-need-to-do/reflective-discussion

This module can be logged as hours towards your CPD quota of 35 hours in three years. We estimate this module should take 45 minutes to complete.

Please tick if you would like to hear about developments in scarring and receive educational materials direct to your inbox

Submit

Your e-certificate

Download Certificate

We have also emailed you a link to your certificate.

Download the aftercare pack

We have developed some educational materials to help you address the topic of scarring with your patients. Click here for your free download.

Free download

References

  • 1. Gold et al., Updated international clinical recommendations on scar management: part 2—algorithms for scar prevention and treatment. Dermatol Surg. 2014;40:825–831.
  • 2. Velnar et al., the wound healing process: an overview of the cellular and molecular mechanisms. 2009. The Journal of International Medical Research; 37:1528-1542.
  • 3. Brown B.C., et al. The hidden cost of skin scars: quality of life after skin scarring. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2008; 61, 1049-1058.
  • 4. França et al., Psychological impact of scars. Scars and scarring: causes, types and treatment options. 2013; 25-38.
  • 5. Bio-Oil 2016 survey.
  • 6. Davies K, et al., Nurse-led management of hypertrophic and keloid scars. Nursing Times. 2004; 100(5):40-44.
  • 7. Gauglitz. Management of keloids and hypertrophic scars: current and emerging options. Clinical, Cosmetic and Investigational Dermatology. 2013:6 103–114.
  • 8. Monstrey et al., Updated scar management practical guidelines: non-invasive ad invasive measures. Journal of Plastic and Reconstructive and Aesthetic Surgery. 2014; 67:1017-1025.

Further reading

The British Association of Skin Camouflage
www.skin-camouflage.net

Changing Faces
www.changingfaces.org.uk/skin-camouflage