Lumpy scars (keloid or hypertrophic)
Some scars become raised, lumpy and red, and may be itchy. These scars are called keloid or hypertrophic.
Keloid scars are more frequent at certain sites of the body, particularly the ear, over the breast bone and top of the arm. Keloid scars are also more common in darker skinned people. These scars may follow a minor wound to the skin, for example ear piercing, insect bite or spot. Keloid scars may continue to get larger over a long period.
Hypertrophic scars are the result of a wound or surgical incision that heals poorly. This may be a wound that takes a long time to heal, becomes infected or is not stitched well.
The treatment of keloid and hypertrophic scars is different. Keloid scars are most often treated with a course of steroid injections, done in the clinic, with local anaesthetic in some cases. The injections are repeated usually on several occasions with a period of 3-6 weeks between injections. Steroid injections reduce the lumpiness and itchiness, but will not make the scar vanish. Keloid scars that form large nodules (particularly on the ear) do not improve with steroid injections alone, and are treated with a combination of surgical excision and steroid injections. Unfortunately, excising a keloid scar is counter-productive; if this type of scar is excised, it is almost certain that it will recur, often larger than it was before. The surgical technique involves removing the bulk of the scar, but leaving a narrow rim around the edge, where the wound is stitched. This avoids stirring up further keloid scar formation. Steroid injection into the wound edges at the time of surgery is also performed.
There are other treatments for large keloid scars, including custom-made pressure garments, and surgical excision in combination with a single radiotherapy dose the day after the surgery.
The treatment of hypertrophic scars depends on how recent the scar is. Hypertrophic scars that have occurred within a few months will often improve with silicone gel treatment. Silicone gel helps scars settle down and mature and redness and itchiness improve as this occurs. Silicone gel preparations also may improve itchiness of keloid scars, and is helpful for scars in cosmetically sensitive areas.
Hypertrophic scars that remain red, raised and wide may be improved by surgical scar revision; this involves excising the scar and re-stitching the wound using meticulous plastic surgery technique.
Wide or unsatisfactory scars
Wounds that have taken a long time to heal, were poorly stitched or had an infection often go on to form a wide or cosmetically unsatisfactory scar. Poor scars may be improved by surgical scar revision; this involves excising the scar and re-stitching the wound using meticulous plastic surgery technique. If there is indentation or 'tethering' of the scar (it is stuck to tissues deep to it), there are several techniques that can be used to address these problems.
Acne scarring can be a difficult problem to treat. Specific indented acne scars ('ice-pick' scars) are very suitable for minor surgical treatment. This may involve subcision of the scar (releasing it from deeper tissues), often using injection with filler (Restylane) to correct the indentation. Excising the scar, or mini-skin grafts are also useful treatments for these scars. In cases where acne scarring is very widespread, laser resurfacing or acid peel may be appropriate treatments (I do not do laser treatments).