‘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.
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.
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.
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.
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.
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.
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.
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.
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:
This stage lasts on average for a few hours.
This stage lasts on average between three and seven days.
This stage lasts for approximately two weeks.
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?
How many different scar types are there?
How long does the scar formation stage of the maturation process take?
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
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
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
But what should HCPs do when patients want help...
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
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.
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 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
Aesthetic treatments, which would not be available on the NHS include:
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
Alongside clinical experts, Bio-Oil has developed the SCAR guide for HCPs to work through with patients during consultations:
The SCAR Guide:
What percentage of people with scarring experience feelings of depression, anxiety or withdrawal from social activity?
Which of the following is a self-care management option for people with scarring?
In the SCAR guide, what does the ‘R’ refer to?
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.
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.
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.
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.
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?
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)
In the recent survey, what percentage of patients said that they would like to receive scarring advice from a HCP?
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.
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.
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.
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
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):
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.
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:
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?
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)
What can be provided to patients following a consultation to help them self-care?
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.
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).
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.
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We have developed some educational materials to help you address the topic of scarring with your patients. Click here for your free download.
The British Association of Skin Camouflage