Many misconceptions circulate about (over the counter) scar treatment. I know from experience it can be very hard to find the information you need. Both online and offline.
Emblematic for this segment of health care is the lack of knowledge of both medical professionals as well as among patients. This often leads to inappropriate choices of treatment which may, in some cases, worsen scar appearance.
I did a lot of research when I wanted to treat my own scars which, eventually, led to a rather successful treatment. Had I known then what I know now I could have gained better results in the end.
Another reason I deliberately use the word ‘rather’ is because scars will almost never disappear. Their appearance can be made less prominent though. And problematic scars can be avoided and treated.
This article is about what I know about scar treatment. With appropriate, unbiased, information at hand, and if necessary, consulting a good dermatologist who can offer support and, possibly, more invasive treatment, various things can be done to improve scar appearance.
Why Scar Treatment?
How a scar looks depends on a number of factors, including the type of trauma/ injury causing the wound, the wound site, the primary treatment and possible complications later on.
In an ideal situation a healed scar is flat, even with its environment, shows no difference in color and runs in relaxed skin lines or natural anatomical transitions. The optimal scar is also short and without unnatural straight sections.
In reality though many scars do not form this way. The skill of the surgeon, whether or not the surgery is performed under stress and hurry in case of emergencies, the overall health and lifestyle of the patient, genetic predisposition, and other factors all play a role in how a scar will form.
Apart from these aspects a scar is more or less likely to form excess scar tissue. Such scars are called problematic scars and a common reason for scar treatment.
Over The Counter Scar Treatment vs. Invasive Scar Treatment
Scar treatment can be divided into two areas. The first is non-invasive scar treatment also referred to as natural scar treatment.
It is strongly recommended to indulge in this type of treatment first. This because, as the word says it already, it’s non or less invasive. Over the counter scar treatment which is another denotation has little to no risks on side effects and worsening scar appearance.
This in contrary to invasive scar treatment. Effective non-invasive scar treatment exists of:
- pressure therapy (compression)
- silicone therapy
- scar massage
- hydrating ointments
Scar surgery, laser therapy, steroid injections, cryotheraphy (freezing), and radiotherapy are lined among invasive scar treatment.
Only opt for these kinds of treatment if non invasive treatments have no or not sufficient effect. This because there are risks of worsening scar appearance but also because in general this kind of therapy is far more expensive. Examples of invasive treatments:
- laser therapy
- steroid injections
- cryotherapy (freezing scars)
- radiation therapy
Effective Topical Scar Treatment
first line scar treatments backed by science
Evidence supports silicone sheeting, silicone gel ointments (several studies indicate ointments to be less effective than sheets) pressure dressings, and corticosteroid injections as first-line treatments.
Cryotherapy may be useful, but should be reserved for smaller lesions. Imiquimod cream, and ointments based on the the herb Centella asiatica (also known as Gotu kola) have demonstrated some benefits but more research is needed.
These are the only proven effective scar treatments. There is no evidence creams based on onion extract (such as Mederma), calendulan, vitamin E, or Palmer’s Cocoa butter are effective.
The popular and widespread topical use of vitamin E is discouraged by many dermatologists because this use has shown to cause side effects such as skin irritation and did worsen scar appearance in some cases.
Types of Scarring
different scar tissue types and their characteristics
In order to determine the appropriate treatment for certain scar tissue it is necessary to be aware of the type of scar. A description of the various scar types:
Flat, Pale Scars
This type is most common and these scars are the result of the natural healing of the body. In the beginning it is possible that they are red or dark and that they protrude above the normal skin level. Over time, these scars paler and thinner until finally a white, flat scar remains. This process can take up to 2 years and almost always a visible “memory” of the wound will remain.
Red, Raised Scars – Hypertrophic scars
Hypertrophic scars are red and thick/ raised and may itch or hurt. These scars generally from relatively quick after the skin trauma. They don’t extend beyond the injured site. If situated near a joint, they might hinder movement.
Young people (below 30 years of age) and people with dark skin are more susceptible to this kind of scars. Inherited factors determine whether or not people are prone to developing these scars.
It is not possible to completely prevent these scars but treatments such as silicone sheeting, and in lesser amount compression, ensure a hypertrophic scar to be converted into a flat, white scar faster.
Thick, Lumpy Scars – Keloid scars
As hypertrophic scars, keloid scars also are the result of unbalanced, excessive production of collagen in a healing wound. Unlike hypertrophic scars, keloid scars grow out of the borders of the original wound and continue to grow indefinitely. That way relatively large areas of skin can get covered. They are thick and can be itchy and painful. It is even possible they will not improve.
Keloidal scars may result from any type of injury; scratches, injections, insect bites and tattoos included. Anyone can get keloid scars and they can exist anywhere on the body but are very rare on eyelids, penis, and breast areola.
Yet young and people with dark skin are more sensitive to these scars. Especially the skin above sternum (chest), abdomen, shoulders, upper arms, back, earlobes, the neck and face are most susceptible to developing these scars.
Indented, Depressed, Sunken Scars – Atrophic scars
In these scars, there is a very thin layer of scar tissue. The scars are sunk into the skin also referred to as a “cigarette paper’ texture. They arise when the healing process of the skin is broken and as such lack of new skin fibers are formed.
They can also be caused by the skin itself. By the loss of underlying fat, but are generally the result of skin lesions after viral or fungal infection (Viral, fungal), immunity diseases (such as lupus erythematosus) and radiation therapy.
Scars after Acne or Chickenpox
Acne and chicken pox are often the cause of depressed/ sunken scars. This often results in deep wells in the skin. It is important to know that these scars can develop to keloid scars. These scars are not always atrophic.
These scars form when the skin surrounding the scar has been under tension. In the beginning the scar is similar to a normal scar, but the constant tension the scar expands and dilutes it for the next weeks or months, until a stretched scar is formed.
This happens for instance when the scar is close to a joint is located and is tensioned during movement. Once stretched will the scar never narrow. The most common causes are injuries and operations. Another cause is the poor healing due to a poor general health or poor nutrition.
These scars occur in case of large wounds. The skin quickly heals up and uses an inelastic tissue instead of normal skin tissue to close the gap. These scars can even deform the underlying muscle impeding movement.
Sometimes they even attack the nervous system. This type of scars can be very severe and difficult to treat. Many can only be improved by surgery.
This type of scarring occurs when the skin is stretched rapidly, e.g during pregnancy or sudden rapid growth of an adolescent. Also hormonal changes seem to influence the formation of stretch marks. In the beginning, these stripes appear red or purple, but they get paler over the years.
Raised, Hypertrophic Scar Treatment
In general, hypertrophic scars develop soon after the trauma or surgery. A distinction between linear hypertrophic and widespread hypertrophic scars is made.
This type of scarring is the result of an overproduction of collagen which leads to the raised appearance of hypertrophic scars. Other characteristics are redness, itch, and sometimes pain.
Widespread scars commonly develop after burn wounds. They are also red and elevated but are wider. Also overstretching can result in widespread scarring.
“Hypertrophic scars may increase rapidly in size for 3-6 months and then, after a static phase, begin to regress. Mature to have an elevated, slightly rope-like appearance with increased width. Full maturation can take up to two years.”
Recommended treatment: silicone sheeting, possible in conjunction with steroid injections when sheeting doesn’t have effect.
Red, Purple Scars
Fresh or immature scars generally are red or purple colored. Causes for this hyperpigmentation are increased blood flow, inflammation, and the presence of broken blood vessels. Mature scars commonly are paler than the surrounding skin because of limited blood circulation and pigmentation.
Keloid Scar Treatment
benign scar tissue treatment and side effects
Contrary to hypertrophic scars keloids may not develop for many months after after initial trauma ( injury or surgery). Keloids are more prevalent in individuals with darker skin.
Data from the National University of Singapore indicate that keloid scars are three times more common in Chinese patients than among Caucasian patients. Healthcare professionals make a distinction between minor and major keloids.
A minor keloid is a focally raised, itchy scar that extends over normal tissue. It may develop up to one year after injury and does not regress without treatment. A major keloid extends over normal tissue and can continue to spread over many years. In general, keloids are less responsive to treatment than hypertrophic scars.
Results of silicone sheeting treatment are variable. Some keloids are reduced in size while in other cases silicone sheeting has little to no effect on keloid scars.
In those cases (cortico)steroid injections (also referred to as intralesional steroids) might offer a solution. Although this treatment is relatively safe it can be slightly painful. There are also some possible side effects.
The scar may become depressed (skin atrophy), discolorization, and increased scar redness might occur. Steroid injections are usually given each 4 to 6 weeks until the desired appearance (flattening of the keloid)
Sometimes steroid injections are administered in conjunction with laser treatment and cryotherapy (freezing). Cryotherapy is done with liquid nitrogen. This treatment may flatten keloid scars but often darkens the tissue.
“Citrus limon (lemon). Lemon’s role as an antimicrobial agent has been widely reported. However, despite numerous anecdotal reports, there is only one case report in the medical literature involving the use of lemon juice on keloids.”
(Rueter, G. Treatment with lemon juice in the prevention of recurrences of keloid. Zentralbl Chir. 1973;98(16):604-6. )
Also see Aldara iquimod cream further on this page. It has shown to be effective in reducing keloidal scar tissue in some cases.
Surgical keloid treatment involves risks because the incision can cause the keloid to grow back (est. 80%) and the operation might cause an even bigger keloid scar to form. In some cases the surgery is combined with steroid injections, radiation, and pressure dressings immediately after the surgery. Surgical excision is often followed by recurrence.
“When used in combination with steroids the recurrence rate is much better – less than 50%.” (Berman and Bieley, 1995, Urioste, Arndt and Dover, 1999).
Here’s good keloid treatment info based on a study on earlobe keloids but provides good info on general treatment as well.
Painful and Itching Scar Treatment
Additonal positive effect of silicone sheeting is that is prevents and reduces pain and itching in hypertrophic and keloid scars.
Other ways to reduce pain and itching are massage, and the use of anti-itch creams such as antihistamine cream, and creams containing hydrocortisone which is a type of steroid.
All OTC anti-itch creams contain 1% hydrocortisone, also those labeled as maximum strength. Prescription creams may contain more.
Old Scar Treatment
Although over the counter scar treatment works both on and new scars it is recommended to start treatment as early as possible. Older scars will generally take longer to improve. Scar treatment with the use of aforementioned measures can be started right after the wound has closed but certainly not before. There must be no open areas, scabs, or oozing.
Contracture Scar Treatment
Scar contractures cause a permanent tightening of the skin (tissue shrinkage) and are generally the result of burn wounds. Contractures may hinder movement of joints and muscles. These are very problematic scars which generally need intensive treatment in order to achieve improvement. Some studies indicate silicone sheeting treatment improves contracture scars.
Evidence That Use of a Silicone Sheet Increases Range of Motion Over Burn Wound Contractures. Wessling N, Ehleben CM, Chapman V, May SR, Still JM Journal of Burn Care and Rehabilitation 1985/6, p503-5
Silicone Gel: a New Treatment for Burn Scars and Contractures. Perkins K, Davey RB, Wallis KA Burns 1982; p 201-204
Types of Treatments
Silicone Gel Scar Treatment
topical treatment and prevention of problematic scars
Silicone gel sheets were developed in the 1980's. Initially used exclusively by hospitals, burn centers, and other medical practitioners they are now used worldwide as the most effective over the counter scar treatment available.
It is a painless method of treatment and is now routinely used to treat hypertrophic and keloid scars that arise from thermal burns, surgical procedures and traumatic events (Perkins, Davey and Wallis, 1983, Sawada and Sone, 1990, Carney et al., 1994).
This over the counter scar treatment works both curative as well as preventive. It has demonstrated to prevent problematic scars such as hypertrophic and keloid scars from developing. For an optimal preventive effect in surgical scars the sheets should be applied right after the sutures/stitches are removed.
Silicone gel sheets are both waterproof and flexible and look and feel like transparent gelatin. They can be cut into the shape of the scar and are marketed as comfortable and easy to apply even in difficult places. But in reality this isn’t always true. Although they are sticky they can be hard to keep attached. Many times additional tape is necessary to keep the sheets sticking. Especially on moving parts of the body or on the face it can require some dedication to keep wearing the sheets.
The exact mechanism remains disputed but research suggests that silicone gel sheets work by hydrating the scar area and the exit. Researchers also think the gel sheets decrease fibroblast activity (the process responsible for excessive scar tissue growth.) This helps reduce the scar and the color and improve its elasticity. Research also indicates that these improvements are permanent.
“The results from a number of randomised, controlled clinical trials clearly demonstrate that silicone gel sheeting is a safe and effective management option for hypertrophic scars and keloids.” (Mustoe et al., 2002).
“The application of silicone gel improves the redness, itching, texture and thickness of hypertrophic and keloid scars in 60% to 100% of cases.” (Poston, 2000).
Medical Grade Silicone Scar Treatment
It is recommended to silicone strips as a first attempt at treatment. They are non-invasive so there are no side effects. The strips can be washed and reused, sometimes for an entire course of treatment which makes them relatively affordable.
Opt for well-reviewed, reputable manufacturer dimethicone silicone, medical grade, doctor approved products. Not all brands contain the same quality silicones.
Read this post to see which brands I recommend.
Scar Treatment Creams and Lotions
The only scar treatment creams with some data behind them as effective topical treatment options for scars are silicone gel creams and ointments containing the botanical ingredient Centella asiatica (Gotu Kola). The latter is not available in the USA.
Silicone Gel Ointments
“Silicone gel has also shown to soften and reduce hypertrophic scars much faster than pressure therapy without affecting pressure, temperature or oxygen tension. While silicone gel sheeting is suitable for some parts of the body, it cannot be easily used on the face and other places where the contours of the body make it difficult to ensure adequate contact and coverage.”
Creams vs. Dressings
Interestingly, the use of silicone cream alone compared with silicone cream with occlusive dressing showed 22% and 82% scar improvement, respectively, with respect to erythema, tenderness, pruritus, and hardness. These results supported that occlusion may be synergistic in wound healing and suggested that silicone gel alone may not be as effective as silicone sheeting.
Silicone gel in a tube makes it possible to use silicone gel on scar located on area’s where sheets are difficult or otherwise inconvenient to attach. For example on the face where the gel from tubes doesn’t appear as prominent as sheets.
This type of home treatment is relatively easy to use, sheets or gel are self-drying and can be used on old and new scars. Gel often dries to an invisible sheet and once dry will also accept cosmetics. It is particularly valuable in softening the skin and reducing the dragging sensation which many patients report following the removal of stitches after eye, lip or nasal surgery.
Scar Treatment with Hydrating Ointments
hydrating scar tissue with oils, creams, and lotions
Some studies show that scar hydration is beneficial to scar healing. They point out that keeping scars hydrated for long periods of time is what appears to improve the appearance of scar tissue.
Damaged skin will lose water more rapidly then healthy skin. Hydration is believed to reduce water vapor loss and to restore the homeostatic process in the scar.
“We have found that the provision of support and hydration and especially in addition with an enhanced wound healing constituent acts together to provide surprisingly improved scar management and maturation” source: patentstorm.us
Other clinical studies show that scar hydration is effective in decreasing scar symptoms (i.e., pain, itching, and tightening), but their efficacy in improving scar appearance (i.e., size, color, and texture) is unclear. One of theses trials involved hydrocolloid dressing treatment so a conclusion on hydrating ointments can’t be made based on this particular trial. Source:plasticsurgery.org
The notion that, according to the most recent scientific insights, the mechanism of silicones is assumed to be due to the control of scar hydration contradicts the theory that hydration only influences symptoms and not appearance.
Pressure (Compression) Scar Treatment
after-surgery and burn scar treatment
Scar treatment by compression has been used since the 1960's. This type of treatment is carried out either by using compression garments or by taping to reduce skin tension. These garments, a sort of elastic, tight fitting clothing need to be worn day and night for extended periods of time. Sometimes up to more than a year in case of burn scars.
Pressure speeds up the formation of collagen, flattens the scar, and reduces the number of cells in a given area. Compression therapy is commonly performed direct after surgery (e.g. tummy tuck surgery) to keep the pressure off the wound. In this case the tape and or garments are worn for several weeks or if necessary longer.
Scars older than 6-12 months do not respond to pressure therapy, or respond poorly. Pressure garments used in conjunction with silicone sheeting seem to be more effective.
Since silicone gel treatment has shown to soften and reduce hypertrophic scars much faster than pressure therapy this is the recommended therapy.
“Pressure therapy is used primarily to control hypertrophic scar formation after burns but can also be used to treat keloids.” (Rayner, 2000, Mustoe et al., 2002).
Scar Massage Treatment
Scar massage is commonly used as an additional treatment. Goals are to increase scar pliability, suppleness, blood circulation and thus oxygen supply, and desensitization. Scar pain and itch can be reduced by regular scar massage.
Only a few limited clinical studies have been done but currently there’s no scientific evidence to proving the benefits of scar massage. Many anecdotal reports, as well as the fact that scar massage is commonly recommended by health care professionals, indicate the positive effects of massaging scar tissue.
Microporous, Hypoallergenic Paper Tape Treatment
Commonly used direct after surgery. Can also help reducing tension of the scar tissue and thus prevent scar widening. This type of treatment has modest evidence to support its efficacy.
Supposed mechanism of adhesive microporous hypoallergenic paper tape are semi-occlusion, hydration, and pressure.
Paper tape treatment is useful in treating fresh surgical incisions and scars several weeks out, but its efficacy was less than that of “more established treatments such as silicone gel.” (meta-analysis by Mustoe et al, source:Journal of American Society of Plastic Surgeons)
Non-Silicone Occlusive Scar Treatment Dressings
Various studies show silicone sheeting to be more effective than non-silicone sheeting. However, studies concluding the opposite also exist. Nonetheless silicone sheeting remains the most recommended and accepted treatment commonly referred to as the Golden Standard in Scar Treatment.
“Results from a meta-study of 27 separate trials indicate that silicone is more effective than other occlusive dressings such as polyethylene or polyurethane.”
Additional Scar Treatment Measures
pressure, oxygen, and warmth
Studies have shown that silicone sheets do not change pressure, temperature, or oxygen tension at the wound site. But, according to scientific research these factors seem to influence scar treatment in a positive way.
This leads me to think optimal scar treatment can be expanded by meeting this criteria. Application of pressure, raising temperature, and boosting oxygen supply e.g. by massage might be beneficial.
Invasive Scar Treatment
surgical treatments, laser treatments, steroid injections,
If over-the-counter treatments won’t work, surgical treatments might offer a solution. Collagen and steroid injections, as well as laser treatment, can all help improve the appearance of scar tissue.
When indulging in invasive treatments a dermatologist, cosmetic surgeon or other type of health care provider is the right person to help decide which invasive therapy is appropriate.
Surgical Scar Treatment
Scar surgery is also referred to as incisional scar revision or surgical excision. Its goal is to minimize scar tissue for cosmetic or functional reasons. For the most problematic scars which are hard to treat with other types of therapy surgical intervention will be the last solution. Examples of such scars are wide (widespread) scars, hypertrophic scars, and keloids.
Types of surgical intervention are excision, scar narrowing, and Z- or W-plasty (objective: change the tension of the scar). procedures.
Although surgery can remove the scar tissue recurrence occurs. Even worse, many times a larger keloid will form. Because of this counterproductive element scar surgery is often combined with silicone sheeting, surgical taping, compression, radiotherapy, and intralesional steroid injections.
“Surgical excision is the most longstanding, simplest, and only definitive way of removing keloid tissue and reducing the width of the scar. However, its effectiveness as a single mode of treatment is limited and sometimes counterproductive. In fact surgery for the treatment of keloid scars has been relegated mainly to a second-line therapy for lesions unresponsive to steroids or pressure, and for large lesions requiring debulking.” (Mustoe et al., 2002).
Redevelopment of keloids within the first two years after surgical scar revision (in case of single mode treatment) has been reported to be over 80%. (Berman and Bieley, 1996, Darzi et al., 1992).
When used in combination with steroid injections recurrence has shown to be significantly lower, (less than 50%). (Berman and Bieley, 1995, Urioste, Arndt and Dover, 1999).
Reduction of tension on the wound bed and scar tissue is recommended although the recurrence rate won’t drop considerably.
Surgical revision of hypertrophic scars consists of two approaches: excision and narrowing of scars, as is done for widespread scars, and Z- or W-plasty designed to change the tension of the scar.
Surgical excision combined with surgical taping and silicone gel sheeting can be successful for the treatment of hypertrophic scars resulting from excessive tension or wound complications.
More Info on Surgical Scar Treatment Techniques
A variety of different approaches exist to achieve cosmetic improvement for existing scars. While no scar can be completely erased, dermatologic surgeons can operate to achieve more esthetically pleasing scars. Classification of a scar abnormality guides the choice of surgical treatment technique.
Examples of such techniques based on the classification: Geometric broken line closure (GBLC), punch excision, punch elevation, subcision, Z-plasty, W-plasty, fusiform/elliptical excision, and serial partial excision are all specific surgery techniques to reduce scar appearance.
More info on which surgery for which scar type is recommended here: Surgical Techniques for Scar Revision
Steroid Injection Scar Treatment
Steroid injections are either used alone or in conjunction with other treatments. (Mustoe et al., 2002). Corticosteroids are derived from a substance naturally produced in the human adrenal cortex. Topical use of steroids (e.g. creams) seems to be less or not effective. Depending on the strength of the ointment.
Steroid injections are a first-line therapy for the treatment of keloids and a second-line treatment for hypertrophic scars that have not responded to other treatments (Rockwell et al., 1989, Urioste et al., 1999).
Steroid injections reduce excessive scar tissue and offer relief from the pain caused by scar inflammation. Reports on the pain caused by the injection vary from minimal tot really painful. This has, for a large part, to do with the scar location and of course ones sensitivity to pain. Sometimes local sedation can be administered. Otherwise taking a painkiller previous to the procedure might help.
Steroid injections are an effective way of reducing excessive scar tissue. Recurrence rates after steroid injections vary from 10% to 50%. The injections are typically administered with intervals of 4 to 6 weeks depending on how well the skin responds. Some patients respond to steroid injections very quickly whereas others require more extended treatment.
Possible side effects are pain on injection, depression in the skin caused by thinning of one of the top two skin layers (skin atrophy), fatty plaque deposition, loss of skin color (hypopigmentation), and telangiectasia (small dilated blood vessels near the surface of the skin). Appearance of the latter complication can be diminished by laser treatment.
Hypopigmentation from Corticosteroid Injections
loss of skin color
Hypopigmentation is the loss, or lightening of skin color. (the opposite of hyperpigmentation where skin color gets darker) This lightening of the scar tissue and possibly surrounding skin can be caused by steroid injections. This results of this side effect can be hard to treat.
Laser Scar Treatment
The potential of laser therapy has always been confined by the limitations of laser technology. The past years technological advancement and refinements have resulted in more effective laser scar treatments with less adverse effects.
The principle of laser scar treatment is using high-energy light to reshape or remove scar tissue. Various types of laser treatment exist. Each individually suited for a specific type of scar.
Hypertrophic (raised and red), and keloid scars are best treated with pulsed dye laser. Laser treatment of hypertrophic scars typically takes about 2 to 4 sessions whereas improvement of keloids in general takes 2 to 6 treatments.
The chance on optimal results are generally higher if laser therapy is conducted in conjunction with other types of therapy such as steroid injections, cryotherapy, and or compression. Silicone sheeting is commonly used to reduce the risk of recurrence.
Dermabrasion can be administered by needling or chemical peeling. The purpose of (Micro)dermabrasion is to resurface the tissue by gradually peeling/ needling off the top layer of the tissue.
By applying a chemical solution to the skin, mild scarring may be treated. The procedure enables new, regenerated skin to appear, improving the appearance of the condition.
Chemical peels are generally recommended for discoloration, not for depressed scars. Commonly used chemical peels are glycolic and lactic acid, which are also available for home use.
Useful Scar Treatment Links
Postsurgical, traumatic, and burn scars can be painful, red, itchy, raised, and cosmetically unacceptable. Although a number of over-the-counter products are available to treat symptomatic scars, the peerreviewed data on the clinical efficacy of these products are limited and/or controversial.
Physician and patient choice of which product to use is often based on historical practice or anecdotal evidence. The aim of this review is to evaluate the evidence from published controlled clinical trials in humans on some of the most commonly used over-the-counter products for treatment of symptomatic scars.
Bottom line. What works? To summarize, silicone gel has the most data behind it as an efficacious topical, over-the-counter treatment option for scars, and is an option for patients who want something they can buy themselves.
Also, there is probably not any harm, and possibly some benefit, to rubbing honey onto healing wounds and scars. Further quality studies involving human subjects are needed for topical, natural preparations for scars, so in the meantime, encourage your patients to not waste their time or money on other natural products out there that claim to improve the look of their scars.