Salmon Bay Physical Therapy

View Original

Seven Tips For Scar Management

Some people may look at their scar as a symbol of pride, or a battle wound of sorts, while others may not care much for a scar at all. This article is primarily written for the latter, although it is safe to assume no one wants the itching, stiffness, tenderness, or pain that often comes with a scar.

Whatever your thoughts about scars, let’s clear something up first: scar tissue is your body's glue, so to speak. Scar tissue doesn’t really discriminate between bone, skin, muscle, or tendon. No matter the tissue, the process is the same. The first step in the process is the inflammation stage. This is our body’s way to ward off infection and control bleeding. The process starts with cellular damage. Involved cells really don’t know if the damage is from stepping on a rusty nail or a major tendon strain. The damaged cells release chemicals to make the area swell in order to keep infection from spreading to other areas and slows bleeding. Pretty cool huh? Even so, it hurts! The second step is scar formation, otherwise know as the proliferation stage. This may sound bad to some, and, if uncontrolled, can be. However, we need and want it to happen for healing to occur. Scar is our body’s glue, right? This “glue” creates the scaffolding for new tissue to grow on/into. That is where this article centers around: how to manage scar tissue as it matures into the tissue it is trying to remodel. This process is known as the maturation stage.

WHAT TO EXPECT WITH A POST-SURGICAL SCAR

A lot of surgeries are performed by making a very small incision and inserting a camera to see inside. When performed to a joint, this is known as arthroscopy. Other procedures, such as a total knee replacement, or even a C-section, can leave behind a larger, more obvious scar that may take greater time to fully heal. In general, scars can take months to years to finish the maturation stage. If the healing goes as it should, the scar should be smooth and flush with the skin. Unfortunately, this does not always happen, as scars sometimes end up raised or widespread. There are two types of abnormal scars to watch out for:

  • Hypertrophic scars are raised, but tend to stay in the confines of the original incision, containing mostly well-organized Type III collagen. The good news is that it is possible for hypertrophic scars to spontaneously improve over time.

  • Keloid scars are excessive scars that grow beyond the confines of the original incision, containing mostly disorganized Type I and II collagen bundles. Keloid scars don’t improve on their own and tend to come back, even after being treated surgically. People develop keloid scars usually as a result of a genetic predisposition for abnormal scar formation, not necessarily because the surgical incision was done incorrectly. 

Although they can present differently, both hypertrophic and keloid scars can be managed similarly.

TIPS FOR SCAR MANAGEMENT

The first priority in scar management is to prevent abnormal scarring. While fancy treatment strategies, such as laser therapy, steroid injections, and surgery are available, these are costly and carry inherent risks. Consequently, here are treatment strategies you can do yourself to decrease abnormal scarring. 

  1. Silicone Scar Gel is universally considered to be the gold standard for prevention and treatment of hypertrophic and keloid scarring. Silicone gel products are widely available over-the-counter and can even be used on scars that likely won’t become abnormal. When using a silicone scar gel, be sure the incision is fully healed before application. Silicone scar gels have been shown to decrease the size or thickness of scars, while often reducing itching associated with the scar.

  2. Onion Extract-Based Gel: Quercetin is weirdly found in onion extract – and the main ingredient in Mederma, which also can be purchased over-the-counter. Quercetin has anti-proliferation and anti-inflammatory effects, helpful in stage one and two of healing. While it may sound counter-intuitive, sometimes the body overreacts during these stages. Recently, a couple of studies showed that even though Quercetin helped collagen organization, it did not improve scar appearance or symptoms when compared with use of a standard petrolatum ointment. 

  3. Vitamin E: Vitamin E is believed to reduce the amount of reactive oxygen available during the inflammatory stage of healing. Many of our patients have noted improved scar appearance when cracking open a vitamin E capsule over their scar once a day during the healing process, but some studies have found no benefit from using vitamin E. 

  4. Limit Scar Stretching During Healing: Keloid and hypertrophic scars usually occur in areas of the body frequently stretched during natural daily movements, like the front of the knee. This can be a catch-22 because your physical therapist will usually encourage you to bend the knee often, which is also very important. If you’re concerned about a scar becoming abnormal, talk to your physical therapist about taping or using silicone gel sheets (see above).

  5. Compression: If you experience more widespread hypertrophic or keloid scarring, pressure garments can be worn while your incision is healing. Compression over the scar can decrease the production of collagen, decrease swelling and even reduce itchiness and pain. It's been reported that a minimum of 15 mmHg is needed to promote scar maturation (3rd stage). If you have ever worn compression socks, it feels about that tight.

  6. Massage: Massage therapy can disrupt fibrotic tissue and increase the pliability of the scar. It can also improve swelling, thickening, and hardening of the scar tissue. Your physical therapist can show you how to properly massage your scar, but here is a good reference on deep friction massage. However, you should wait about 10-14 days before starting massage or after the incision is closed, as starting too soon can actually promote hypertrophic scarring.  Lastly, make sure your hands are clean and sanitized before starting massage.

  7. Sunscreen: Be sure to keep your scar out of sunlight as much as possible until the scar has matured. UV radiation has been shown to increase scar pigmentation, making its appearance worse.

Rather than waiting until a scar becomes either hypertrophic or keloid, early treatment aimed at prevention is key. If you have any questions about your particular scar, reach out to your physical therapist, as they have seen a lot of them. If you are ever concerned about your scar becoming infected, call your surgeon immediately.

Be well!

-Tucker Schonberg, PT, OCS