New Hope for Old Wounds

Heal, Fall 2007, Volume 1, Issue 2

A variety of techniques can help minimize the appearance of surgical scars.

An ugly, visible scar can be a difficult reminder of a cancer surgery. But even a hidden scar can be itchy, painful, or tight.

Fortunately, surgical scars can be reduced or revised in a number of ways, from laser treatment that can reduce a scar, even years after it has formed, to effective over-the-counter therapies that are especially helpful in the early stages of scar formation.

“Scars can be an unwanted reminder to the person of the cancer that used to be there, opening up lingering questions for [a survivor] and adding to fears of a possible recurrence,” says dermatologist Rebecca Tung, MD, of the Cleveland Clinic. “That’s where dermatologists come in, to help alleviate these scars and remove any sort of stigma that they may have with them.”

The mode of treatment a dermatologist or plastic surgeon might select to improve a bothersome scar depends greatly on the age of the scar and what type of scar has formed, Tung says.

The most cosmetically disfiguring scar, Tung says, is called a keloid—a firm, raised, red scar, resembling a cauliflower floret, which extends beyond the area of the original incision. These scars often itch and can be painful. Keloids can form anywhere on the body but are most common on the earlobes, chest, back, and shoulders, and occur more frequently on darker-skinned people. They can form weeks or even years after an incision.

Another, less disfiguring type of scar is a hypertrophic scar, also usually a red or raised scar, but one that doesn’t extend beyond the border of the incision. Just like a keloid, it can be itchy or painful.

Both of these types of scars have too much scar tissue, which results from a healing response stuck in overdrive. The normal healing process brings inflammation along with extra blood vessels to a wound, and new cells that produce collagen to replace lost skin. But a hypertrophic or keloid scar develops when there’s too much collagen, “and then those initial inflammatory cells and blood vessels that come into play continue to hang around,” says dermatologist Tina Alster, MD. “You have all the troops in there, and then they just don’t clear out.”

Alster, who heads the Washington Institute of Dermatologic Laser Surgery and is a clinical professor of dermatology at Georgetown University in Washington, D.C., often uses laser treatment for hypertrophic or keloid scars. Lasers cause “just enough injury to get the process maturing in the way it should have normally,” she says, “to clear out those blood vessels, to cut down on the inflammation and to exert a negative effect on collagen growth.” Excess collagen contributes to the tightness of the scar.

The laser used to treat these types of scars is called a pulsed dye laser and emits light at a specific wavelength (585 nanometers) that is absorbed by the hemoglobin in red blood cells. The laser doesn’t cut or abrade the skin. “This laser treatment is really not uncomfortable at all,” says Alster. “During the treatment, there’s a bit of a snapping sensation, followed by the feeling of a sunburn. And right afterward, it may look a little pink and swollen, but there is no crusting, scabbing, or oozing.”

The treatment lasts only a few minutes, depending on the size of the scar, and then it takes about six to eight weeks for the area to fully heal, although it may only be slightly reddened for a few days. Most people need two or three treatments, two months or so apart, before they see significant improvement in a scar. “Two to three treatments,” says Alster, “will improve a scar an average of 50 to 80 percent.”

Of course, patients can keep getting laser therapy if they want to see scars improve even more, but the last 20 to 50 percent is harder, she says, and no one will ever have a scar disappear. But because laser light is non-ionizing radiation, “it does not change cell structure in any malignant way. It’s safer than going out in the sun for half a day,” she says. The more laser treatments are performed, she adds, the better a scar responds. The scar continues to flatten, becoming more pliable with an improved surface texture.

Given everything else that cancer survivors go through, this is the easiest and probably the happiest thing that they do.

The Cleveland Clinic’s Tung says laser treatment is often combined with cortisone injections, which also help damp down collagen production and decrease blood vessel formation. Often the first thing patients notice is that their scars are less symptomatic, she says. “Itching is reduced, there’s less pain, so overall, they’re much happier.”

“Given everything else that cancer survivors go through, this is the easiest and probably the happiest thing that they do,” adds Alster. “It makes them feel better, and they see the results very quickly.”

For scars, especially keloids, that don’t respond to laser treatment, surgical scar revision—or cutting out the scar—is an option. Treating the site afterward with prescription imiquimod cream, which affects the skin’s immune response, can help prevent the keloids from returning.

Hypertrophic and keloid scars are treated similarly, but they’re not the only type of scar. A third type of abnormal healing response leads to an atrophic scar, where there is not enough collagen in the area. The scar appears sunken or dimpled.

Laser treatment for these scars is more invasive. There are two lasers used to treat them, either erbium or CO2. These lasers both emit light at wavelengths that are absorbed by water and ablate, or shave, the tissue. “They actually reduce the step-off from the scar border to the normal skin, and they promote some new collagen growth right in the area where there is a little dell [indentation] in the scar,” says Tung. Because they break the surface of the skin, “these do have some healing associated with [them].”

Non-ablative lasers can also be used on atrophic scars, although generally three to five treatments are necessary. But unlike with the ablative treatment, Tung says, “patients can go back to work, they can apply makeup right after the procedure, and carry about their normal day.”

For people who aren’t willing to undergo surgical scar revision but have a sunken scar, a dermatologist can inject a soft-tissue filler, such as collagen, to plump up the area. But collagen injections aren’t permanent and often need to be repeated.

An individual laser treatment generally costs $200 and up, depending on the size of the scar. The expense may be covered by insurance, especially if the scar has created a clear functional problem, such as preventing someone from opening the mouth fully. Both Tung and Alster say they often write letters on patients’ behalf to insurance companies.

Laser scar therapy can be done at any time, although usually after the incision has healed for six to 12 months. But “if someone is developing an abnormal scar response,” says Tung, we would like them to be referred as soon as possible so we can do something to improve that quickly.”

Earlier and less expensive therapies include over-the-counter silicone sheeting, which may work by hydrating the wound and reducing some of the new blood vessel formation. The sheets are worn over the scar for 12 to 24 hours a day, two to four months, beginning as soon as the wound heals over.

Products like Neosporin Scar Solution start around $30. “If you can treat the scars very early on, you can notice good improvement. It minimizes the size of the scar, reduces the firmness, also causes the redness to settle down, as well as minimizes some of the itching,” Tung says.

“You’re not going to get as profound effects with these topical therapies as you might with in-office procedures,” she says, “but definitely they’re nice adjunctive products.”

People who have a history of developing keloid or hypertrophic scars may be able to prevent abnormal scars from forming in the first place by working with a dermatologist or plastic surgeon shortly after surgery. The most common treatment is one or more steroid injections at the surgical site in conjunction with the use of silicone sheeting. Treatment length may vary, depending on whether the developing scar is hypertrophic or keloid.

Tung always advises her patients to keep checking their scars for new bumps or nodules, since some types of cancers can metastasize to the skin. “If there is something new on your skin,” she says, “we’d like to have you come in and we can look at it and see if something needs to be addressed.”