What to do about an inflamed, raised, hard scar

Question: I had an injury to my shoulder earlier this year and while the wound has mostly healed and is no longer scabby, the resulting scar is still painful, raised, hard and lumpy. It’s bigger and uglier than the original wound. What can I do?

Answer: There are two types of scars that resemble what you describe and there’s a lot we can do in the dermatologists office to help them look and feel better.

Keloid scar

Keloid scar

Keloids and Hypertrophic Scars

This type of scarring is usually after local skin trauma (e.g., laceration, tattoo, burn, vaccination or surgery) or as a result of an inflammatory skin disorder (e.g., acne, bites or abscesses).

Scars are composed of new connective tissue that replaces lost tissue in the dermis or deeper parts of the skin, as a result of injury. Their size and shape are determined by the form of the previous wound. The process of scarring is characteristic of certain inflammatory processes. A resulting scar can be thin (atrophic) or thickened, fibrous and overgrown. Some individuals and some areas of the body (e.g., anterior chest) are especially prone to scarring. Scars may be smooth or rough, pliable or firm, they can be pink or violaceous or become white. They can also be hyperpigmented (darkened). Scars are persistent and normally become less noticeable in the course of time.

At times though, and in certain anatomical locations (e.g., shoulders, sternum, mandible and arms) they can grow thick, tough and corded forming a hypertrophic scar or keloid. Under normal circumstances,  wound healing takes place through the rapid and repeated reproduction of fibroblasts (the most common cells of connective tissue) at the wound site. But when fibroblast activity continues unchecked and excessive collagen (protein found in connective tissue) is deposited at the site of injury, the scar gets too big and a hypertrophic scar or keloid is formed.

Hypertrophic Scar remains confined to the borders of the original wound and most of the time, retains its shape. It is characterized by hardness, redness and irritation compared to the surrounding skin and can take the form of a firm papule or nodule.

Conversely, a Keloid is an overgrowth of dense fibrous tissue that you’ll notice extending beyond the borders of the original wound. Like a hypertrophic scar, a keloid can be hardened, raised and often darkly discolored. Keloids do not regress, appear to get better or shrink over time on their own. Instead they grow in a pseudo tumor fashion and distort the size and shape of the original lesion.

If you know you have a hereditary predisposition toward keloid scarring, mention that to your dermatologist because then we will not try to surgically remove them (called excision) because keloids tend to recur.

The differences… A hypertrophic scar can occur at an any age and usually stays within the borders of the original wound, whereas a keloid commonly occurs in the third decade and enlarges beyond the area of the initial wounding with web-like extensions. Keloidal growth can also be triggered by pregnancy and compared with hypertrophic scars, a keloid can often be painful and super-sensitive.

How we treat stubborn keloids and hypertrophic scarring

We often use a 3-step process in the office to attack raised, hardened scars as soon as we notice a scar is exhibiting signs of hardening, as early as one month-post op, in the case of a scar due to surgery.  The earlier you treat a keloid or hypertrophic scar, the better your results will be.

We inject  5-fluorouracil “5-FU” (used primarily as an anti-cancer drug but also used for the prevention of scars in glaucoma surgery for at least 15 years) combined with a specific low-dose corticosteroid (to reduce further inflammation and any pain) along with Pulsed Dye Laser treatments.

5-FU works to reduce skin’s metabolism rate and inhibits the over-production of the fibroblasts building up on and around the wound. We combine that with Kenalog (triamcinolone), the low-dose corticosteroid, and perform injections one to three times per week, at regular intervals such as Monday, Wednesday and Friday, depending on how red, hardened and inflamed the scar is.  Once the scar softens, injections can be reduced to two times per week, once a week and then every other week, monthly and finally, every six months. The Pulsed Dye Laser is used to decrease any redness, to normalize the wound surface and improve skin texture at the scar and to further blend scar into surrounding skin and we perform those treatments in intervals of four to eight months apart.

While any keloid or hypertrophic scar can be treated with this technique,  you’ll get the best results the younger the scar is. The more inflamed and symptomatic the scar, the better the response to treatment. Older scars that have been hardened for many years and are not inflamed, red, itchy or painful, will not respond as quickly or as thoroughly. Hypertrophic scars respond better than keloids, which frequently recur, although small isolated keloids (less than 2 cm in diameter) usually completely resolve with this technique without recurrence.

No matter what, keep all scars out of the sun for best healing, at least until the “pink” of new skin is gone because exposure to the sun only makes scars darker.

-Jodi

 

 

 

 

 

 

 

How to avoid and treat dark spots

Post-inflammatory Hyperpigmentation

How a Dark Spot Forms

Question:  All I had was a simple pimple – why did it leave such a dark spot and how can I get rid of it as quick as possible?

Answer:  Of course the answer’s not that simple! Everyone’s propensity to form a dark spot in response to anything that causes skin redness and swelling,  (medically called post-inflammatory hyperpigmentation) varies depending on skin type, ethnicity and racial group as well as the severity of the inflammation and its duration. That’s because the amount melanin (light-absorbing pigment) and type of melanosomes (pigmented skin cells)  have a significant impact on the formation of a dark spot in your skin.

To avoid dark spots from forming at all costs, it’s a good idea to first know what skin type you have. Your Fitzpatrick Skin Scale type depends on genetic disposition and your skin’s reaction to sunlight and tanning. Dark spot intensity and duration is linked to skin hue and more pronounced in skin of color, especially phototypes IV-VI. Click the link above to take the quiz and find out if you’re more at risk for developing dark spots, then read on.

What causes dark spots?

  • Any skin disease, infection or injury-producing inflammation
  • Acne
  • Insect bites
  • Razor bumps (pseudofolliculitis barbae or PFB)
  • Allergic or contact irritation (dermatitis)
  • Surgical or cosmetic procedures

Treat recurring conditions immediately!

The darkness, or intensity, of the spot, area or scar left behind depends on the duration of the inflammatory process underneath the skin and whether or not is has a chance to reach deeper tissues and cause damage. In response to a skin eruption or inflammation, melanin is over-produced at the site causing the skin-darkening. The longer the period of inflammation, the darker the postinflammatory hyperpigmentation response so action should be taken to avoid or intervene on any known causes of inflammation such as acne and PFB and treatment should be instituted as quickly as possible to stop the inflammation from damaging skin’s deeper tissues and causing the dark spot response. Skin conditions with a recurring nature such as acne or PFB intensify the hue of dark spots as do skin diseases that disrupt skin’s basal layer such as lichen planus, psoriasis eruptions and lupus)

Stay out of the sun!

In addition to any post-inflammatory response, UVA and UVB exposure also stimulate increased melanin production so limit sun exposure by walking on the shady side of street, wearing a hat, sunglasses and use sunscreen daily  on exposed, inflamed, irritated or healing areas. Sun exposure frequently darkens hyperpigmentation and chronic sun exposure may result in a longer resolution period of any dark spots.

Don’t let scabs form!

For any skin eruption (acne, insect bite), injury or surgery where the skin is open (no matter what the cause) never let a dry scab form and never pick at, squeeze or further exacerbate the inflammation! Acne surgery can be performed by medical professionals to  help acne heal faster to avoid skin damage and spots. Keep the area covered with antibiotic ointment until there is no crust at all and new skin is formed. And keep that area out of the sun the whole time it is healing and protected with sunscreen at all times until skin has returned to normal.

Rx for already-formed dark spots

Hydroquinone 4%:  This melanin-inhibitor is the most widley-used  active ingredient to fade dark spots. It is available at 4% strength by prescription only and at weaker concentrations (which you can try first) over-the-counter. Depending on the age and darkness of a dark spot, therapy may be required for 20 weeks, although you may see results much sooner than that.  If only used on one spot, sometimes a light ring of lighter skin surrounds the area like a halo, and this halo effect disappears when the hydroquinone is discontinued.  Do not use hydroquinone if it is a known allergen and watch out for any irritation or further discoloration (called exogenous ochronosis) in which case hydroquinone should be discontinued.

Azelaic acid:  An alternate, but slightly weaker ingredient for treatment if you’re allergic to hydroquinone. Similarly, kojic acid and glycolic acid are two more ingredients for hydroquinone-intolerant patients.

Combinations: We have even found that combinations, depending on your skin type and condition, including hydroquinone , and/or a corticosteroid, retinoid and Combinations are more effective than 4% hydroquinone alone. These can be prescribed if necessary by a dermatologic practitioner.

Chemical peels: Chemical peeling agents have been found effective in removing dark spots, but be mindful to start with the lowest concentration and then move upward because you want to avoid any additional postinflammatory hyperpigmentation caused by chemical peeling agents

Follow my advice and you will see spots fade and fewer spots form!