Scars and Scar Treatments, Part 2

Henderson Plastic Surgeon Serving Las Vegas and Nearby Areas of Nevada

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Why does everyone want to put Vitamin E, Neosporin, or Mederma on their scars?

The Vitamin E myth has been passed down from generation to generation, and the Mederma and Neosporin marketing teams are doing a fabulous job.

Despite all the great ads and commercials for Mederma-IT HAS NO PROVEN BENEFIT for improving scars. Do you know what Mederma is? Onion extract! The manufacturer recommends you apply it three times a day for 8 weeks. Did you know that if you apply lotion or Vaseline on a scar three times per day and 8 weeks pass, your scar would look better than if you use Mederma? Three major controlled scientific studies have shown this! Save your money.

Now, what about Vitamin E? Vitamin E is an antioxidant and has anti-inflammatory effects, and adversely affects platelet function. (So be sure and stop Vitamin E supplements before a surgical procedure as it can increase your risk for bleeding) Scientific studies have shown that there is no benefit in scar quality by twice per day application of Vitamin E compared to Vaseline or Aquaphor. As a matter of fact, the scars can look worse due to the high risk (30%) of allergic contact dermatitis, which causes a horrible rash and inflammation affecting the healing scar.

Neosporin is the most heavily advertised and most popular topical antibiotic in the country. It has three active antibiotic ingredients in a petroleum jelly base: neomycin, polysporin, and bacitracin. “Triple Antibiotic” has the same ingredients. Both products are sold over-the counter. Immediately after a surgical procedure or injury, Neosporin will speed healing while reducing infection rates and scarring. But you need to stop using it once the wound is closed and healed. The problem is that about 25% of patients who continue to use the product will develop ‘contact dermatitis’, usually from the Neomycin component in the product. The rash and reaction from allergic contact dermatitis can range from mild to severe. I have seen several cases of severe reactions to Neosporin with resulting rash and inflammation to the scar and surrounding skin, having a deleterious effect on the final scar. I even had one patient in my practice end up in the emergency room with a severe allergic reaction requiring hospitalization and IV steroids. These patients subsequently required scar revisions. I do frequently recommend topical antibiotic ointment for the first 1-2 weeks or so after a procedure, however I recommend that the product is discontinued once the incision is completely healed and for users to monitor for signs of a rash, redness, or itching which would require immediate cessation of the product.

Conclusion: DO NOT USE VITAMIN E OR MEDERMA on your scars. Do not feel the need to self-treat. In the majority of patients, the best course of action is keeping the incision clean and moist. After incisional healing, lotion or Vaseline, keeping the scar soft and supple will provide you with the best quality scar. I advise Cetaphil lotion, Aquaphor or Vaseline, which is well tolerated by patients with low risks of allergic reactions, rashes, or breakouts.

Here’s what works in reducing the appearance of scars:

1. Hydration. It is widely recognized that wounds heal best under moist conditions — the skin fills in faster and scars are less visible. So after complete incisional healing, in 1-2 weeks, I recommend Cetaphil lotion to keep the scar soft and supple. Aquaphor or petroleum jelly is fine too. But beware of too moist… to avoid maceration of tissue and infections. It’s a fine line!

2. Massage also helps in softening and smoothing scar tissue.

3. Sunscreen is required to prevent darkening and persistent redness of scars. It should be used for at least one year on sun-exposed scars. Scars and surrounding skin after a surgical procedure can be very sensitive and can burn during the normal Las Vegas summer temperatures. Avoid black clothing or swimwear when spending significant time outside in the summer to avoid the absorption of too much heat that can burn sensitive skin, and redden scars.

4. Silicone Gel Sheeting. Silicone sheeting is available at my office or over-the-counter. Neosporin scar strips are silicone sheets. Consistent use of this product has been proven to improve scar quality. This is the only over-the-counter scar therapy that works. The mechanism by which it works is unclear, but we think it is a combination of pressure, hydration of the scar, and a change in the electromagnetic energy within the scar. The problem with this product, however, is compliance. For the product to be effective, the silicone sheet needs to worn on the scar the majority of the time for months.

5. Pressure. Pressure may theoretically break up collagen bundles and soften the scar mass; however, therapy must be instituted for long periods (>23 h/d for 6 mo) before significant effect can be achieved. Burn scars are typically treated with pressure garments.

6. Bleaching creams. In patients predisposed to pigmentation of scars, I preventatively prescribe hydroquinone. This is a topical bleaching cream that needs to be applied twice per day to dark scars. Regular compliance is required for it to work, and it may take 4-6 months to see improvements, together with strict sun avoidance on the area being treated.

7. Steroid Injections are effective in treated hypertrophic and some keloid scars. I monitor all patients in my office until their scars are mature. Usually at around 6 weeks after surgery, the scar is the reddest and most inflamed. Patients with potential to form hypertrophic scars usually declare themselves at this time. A series of Kenalog (steroid) injections performed once every 6 weeks is usually an effective treatment for raised, thick, ropey scars. These scars can be tender and itchy as they secrete histamine, so over-the-counter antihistamines such as Benadryl can also help symptoms.

What about old or mature scars?

The treatments mentioned above are for immature scars, scars that are in the process of healing and remodeling. Usually after 1 year or longer, when the pinkness of the scar is resolved, the scar’s appearance is permanent. Here are options for improving scar quality in mature scars:

1. Surgery. Surgical scar revisions DO NOT remove scars. Plastic surgeons perform surgical scar revision to alter its size, make in narrower, reorient it so that it lies along natural skin folds and tension lines, and to improve upon depth and irregular texture. Surgery for hypertrophic or keloid scars has a very high risk for recurrence. Since the recurrence rate with surgical excision alone in keloid scars is about 50%, surgical excision is usually combined with one or more of the other listed techniques.

2. Injectible fillers. Injecting substances such as Juvederm or fat can immediately raise sunken scars. However, this treatment doesn’t last permanently and may need to be repeated.

3. Dermabrasion. This procedure uses special equipment to remove the surface of the skin, helping to reduce the look of raised scars. Basically you sand down the skin so it is more level. It works best on the face, but results can be subtle.

4. Laser resurfacing. This is done two ways: The skin surface is removed with lasers, or lasers are used to work on the collagen in the dermis without removing the upper layer of skin.

• Non-ablative lasers such as the 585 nm Pulsed dye laser, 1064 nm and 1320 nm Nd:YAG, or the 1540 nm Er:Glass are used as the standard laser therapy for hypertrophic scars and keloids. This therapy smoothes the skin by heating up and redistributing collagen while avoiding damage to the epidermis via contact cooling. Multiple sessions are usually required for a significant reduction in redness and improvement in the texture and pliability of hypertrophic scars and keloids. Treatments are expensive and results can be subtle. Lasers may help with scar color including redness or darkness of a scar.

• Ablative lasers such as the carbon dioxide laser or Er:YAG offer the best results for atrophic and acne scars. Like dermabrasion, ablative lasers work by destroying the epidermis to a certain depth. Healing times for ablative therapy are much longer and the risk profile is greater compared to non-ablative therapy; however, non-ablative therapy is also very expensive, and despite the downtime associated with recovery, offers only minor improvements in cosmetic appearance of atrophic and acne scars.

Conclusions:

So here is my opinion when it comes to scars and their treatment…First of all, ensure meticulous incisional closure by a board certified plastic surgeon. Second, keep the scar moist while it is healing. Neosporin is fine for the first 1-2 weeks but monitor for allergic reactions. If you have a history of a Neosporin allergy, there are alternative topical antibacterial creams you can use such as Bacitracin, Bactroban, or Silvadene. Once the incision is completely healed, switch to an emollient lotion such as Cetaphil, Aquaphor, or Vaseline. Massage regularly. For patients prone to raised or hypertrophic scars, use silicone sheeting or a topical silicone product regularly. For patients prone to pigmented scars, use prescribed hydroquinone bleaching creams. Follow up with me in the office regularly until your scars are mature. I will advise you on the best treatments for your healing scar and will start Kenalog injections or steroids if indicated. Use sunscreen and avoid sun-exposure on healing scars. BE PATIENT! As time passes, the scar will continue to improve! Avoid the temptation to self-treat your scar because you saw a great commercial on TV, or your mother said to use Vitamin E. Lastly, STAY HEALTHY AND AVOID SMOKING. Good nutrition is important for wound healing, and smoking has incredibly deleterious effects on wound healing and scar quality!

Dr. Hayley Brown MD, FACS
Las Vegas Plastic Surgeon
Desert Hills Plastic Surgery Center, Henderson and Las Vegas, Nevada

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