Scar Management: Scarring is usually caused by aggressive cystic acne, trauma, burns, surgery or a result of severe chicken pox. Scars can be uncomfortable, unsightly, and impact one’s self esteem. Most patients seek treatment to improve appearance and the texture of the scar.

Various treatment modalities, alone or in combination, have been used to treat scars. These options have included chemical peels, dermabrasion, microdermabrasion, surgery, punch excision, punch float and punch grafting. Soft tissue augmentation using silicone, various forms of collagen, and the newer injectables such as Restylane, Perlane, Artecoll, DermaLive, and Dermadeep have been used. The development of high energy short-pulsed CO₂ lasers combined with the Erbium Yag lasers have greatly improved the resurfacing technique for some facial scars.

Intense Pulsed Light (I.P.L.) over the last few years has dramatically improved our approach to scars. This non-invasive broad spectrum light has an ability to flatten scars, blend the color, and mold collagen. Treatment of scars is a management project and almost all patients require a combination of treatment options. The sequence and timing of the treatments are very important in creating the best cosmetic result.

FACTORS INFLUENCING TREATMENT OPTIONS:

1. Age of both the patient and the scars
2. Skin type (fair vs. dark)
3. Scar type (usually a combination):
   1. Split pores
   2. Ice pick
   3. Atrophic (saucer, cup-shaped)
   4. Hypertrophic (thick elevated scars)
   5. Keloid (thick elevated scars)
   6. Vascular
   7. Carbon tattooing (auto & industrial accidents)
4. Extent of scars
5. Severity of scars
6. Cause of scars (acne, chicken pox, trauma, surgery, burns)
7. Tendency to form keloid scars (thick bumpy uneven scars)

MANAGEMENT
Successful improvement of scars often requires a combination of treatment options The treatment timing and number of treatments are variable. Some of the procedures available include:

1. Topical Treatments (Hypertrophic / Keloid scars)

• Steroids with occlusion
• Silicone gels and tapes
• Topicals including Kinerase cream

2. Intralesional Steroids with Wydase (Hyaluronidase) (Hypertrophic / Keloid scars)

3. Aldara (Imiquimod) has some unique properties that help with some types of scar circumstances. Patients that have thickened scars treated with a UltraPulse CO₂ laser either excised, vaporized or both Aldara works wonderful to lessen the recurrence rate of those scars. Aldara is used with tiny amounts applied topically 7 days after the laser treatment – Monday, Wednesday, and Friday without any Saran Wrap or tape for 21 days and then once a week for two months after that. Details will be discussed with you. This has an ability to help flatten the scars and lessen the thickening by Aldara’s ability to stop exaggerated collagen formation.

4. Botox for “painful” scars. Painful scars of any type can be treated successfully with Botox injected into the scar zone. This works because of Botox’s unique ability to stop substance “P”. Substance “P” is the material responsible for pain in sensitive tender scars. There are no side effects with this technique; however treatment is a maintenance project; some patients requiring Botox at intervals from 2 to 8 months depending on the patient’s clinical response. Positive results are noticed usually within 7-10 days of treatment.

5. ThermaLift (ThermaCool, Thermage). ThermaLift is clever use of radio frequency (RF) that allows for tightening of collagen without any damage to the overlying skin. There is no downtime from your personal life. This first phase of collagen tightening is followed by new collagen formation over a period of 6 months after treatment. Computerized controlled radio frequency tightens collagen in a uniform controlled pattern creating a smoother texture of the scar tissue. There is some evidence that radiofrequency also shrinks pores and oil glands making this an interesting option for those patients who have acne scars. Details of this can be discussed with you.

6. Microdermabrasion. Often used as a combination approach immediately prior to Intense Pulsed Light (Vascular lasers) on selected scars done on the same day.

7. Surgery

• Simple or creative excision
• Punch (excision, floats, grafts)

8. Laser Surgery (see separate articles)

• High energy pulsed CO₂ lasers
• Focused – excision mode
• Vaporization combined with Erbium Yag laser

9. Vascular lasers and Intense Pulsed Light (IPL). For many years our clinic and similar centres worldwide have used Pulsed Dye Lasers to improve the appearance of hypertrophic and keloid of scars. There has been great interest in the improvement of color, texture, pliability and the appearance of scars. With the availability of new vascular light systems such as the I.P.L. the approach to all types of scars has changed. I.P.L. has a broad spectrum of light that can be programed into the laser for your skin coloring and type of scar. With the improvement of spot sizes and speed of the systems, plus the availability of new topical anesthetics, this treatment has become the gold standard for improving scars. The improvement is in the ability to change texture, tone, and mold collagen. I.P.L. treatments, to be successful, are done at 2-4 week intervals for at least 5 treatments.

10. Soft Tissue Augmentation (Injectables - fillers). Depressed scars can now be greatly improved with newer fillers, such as Restylane Fine Lines, Restylane, Perlane, Artecoll and Dermalive or Dermadeep. These smooth injectables are often done with other treatment modalities the same day.

BENEFITS OF NON-INVASIVE INTENSE PULSED LIGHT (IPL) THERAPY VERSUS INVASIVE LASER TREATMENTS.

• no time away from your personal life
• less expensive
• no anesthetic needles required
• newer topical anesthetics (E-Max) makes your treatment very tolerable – often painless
• Relatively quick – 30 minutes for a full face treatment
• Aim of all scar treatments is a 50% improvement. If we can obtain 50% improvement with this unique concept, why have invasive therapy that has many challenges?

The approach to scars is complex and therefore the number and type of treatments you will require, and the interval between treatments, will be varied according to the location of the scars, type of scars, age group, and features noted in the above section (Features Influencing Your Treatment Direction).

MAINTENANCE
Topical therapy at home is part of your treatment program and involves a number of modalities that can improve the color, texture, tone, and pliability of the scars.

In some patients one IPL treatment (not a full 5-6 treatment session) every 6–12 months may be required to maintain this smoother texture, tone and color of the scar zone.