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

 

 

 

 

 

 

 

Can babies go in the sun?

Question:  I’ve heard conflicting opinions about what age babies can go in the sun. Is there a sun exposure rule for healthy skin for babies?

Always have baby wear a had to shade her face in addition to sunscreen in babies over 6 months

Always have babies over 6 months in age wear a hat plus sunscreen and other protective clothing

Answer:  I  second the advice of the The American Academy of Pediatrics, the U.S. Food and Drug Administration and the American Cancer Society: Keep babies under 6 months old out of the sun entirely and do not apply sunscreen on babies younger than 6 months.  Babies who are 6 months or older should be protected with clothing, hats, a broad-spectrum sunscreen and shade. Look for broad-spectrum formulations specifically for babies and toddlers who have more sensitive skin than adults. The time that they spend in the sun should be very limited.

Did you know? More than half of a person’s lifetime sun exposure occurs before age 20. Remember, skin keeps impeccable records, so every minute spent in the sun adds up as skin damage and possibly skin cancer. More than one million Americans develop skin cancer every year mostly from long-term exposure to ultraviolet radiation from the sun.

UV exposure makes you look old before your time and causes:

• Wrinkling

• Blotching

• Drying

• Leathering of the skin

Beginning with babies 6 months and older, limit time in the sun and protect skin with sunscreen and protective hats and clothing whenever exposed.

-Jodi

Should I be using a retinoid?

Question:  As I’ve moved through my thirties and into my forties, I’ve noticed a marked change in my facial skin. I have some dark spots and discolorations and my face seems thinner overall and a little more sallow. I’ve heard about using a Retin-A cream but I thought that is for acne or wrinkles. Is it for me?

Answer:  Actually Retin A is not just for acne or wrinkles. It is a simple, inexpensive topical cure-all for all pre-mature aging and photo-aging (skin damage caused by sun exposure).

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How your skin looks and feels as you age is influenced by many factors such as genetics, environmental exposure (sun, medication, mechanical stress), hormonal changes and metabolic processes. All of these factors, some of which have to do with your lifestyle and some  you have no control over, cause a change in skin structure, function, and appearance as you age. Although, we dermatologists have studied and seen first-hand that solar UV radiation (sun exposure) is the single major factor responsible for  the unwelcome, premature  effects of skin aging on face, neck or back of  hands such as:

  • Coarser, rougher skin feel and appearance
  • Sallowness
  • Wrinkles
  • Irregular coloration and discolored spots or patches
  • Discolored brown spots called lentigines
  • Telangiectasias (little red visible blood vessels)
  • Benign neoplasms (abnormal, yet non-cancerous, masses of discolored or raised tissue)
  • Pre-cancerous lesions called actinic keratoses and lentigo maligna
  • Cancerous lesions such as basal and squamous cell carcinomas and malignant melanomas.

So, what’s a “retinoid?”

First, a little science lesson.  You may hear or read about a lot of terms that all have “retin” in them. That’s because the retinoid family comprises vitamin A (retinol) and its natural derivatives such as retinaldehyde, retinoic acid and retinyl esters, plus many other synthetic derivatives. Vitamin A cannot be synthesized by our bodies, so it needs to be supplied and is naturally present in foods as the compound beta-carotene. Retinoids are required for a vast number of biological processes inside the body such as embryo development, reproduction, vision, growth, inflammation and cell differentiation, proliferation and apoptosis (naturally occurring cell death for normal cell growth stages).

Retin-A (tretinoin) is the most popular retinoid for facial skin and is also the retinoid most studied for the treatment of chronological or photo-aging. I have tracked numerous studies which have repeatedly shown clinical improvement in photo-damage with tretinoin treatment, as well as with some other topically applied retinols such as isotretinoin and retinaldehyde (which are not my favorites because they are not as potent or stable.) Longer-term studies (6-12 months) on tretinoin were carried out once short-term studies showed that patients’ skin condition continued to improve in appearance over time. Additionally, most of these studies compared the use of the various strengths of tretinoin to arrive at the optimal concentration for the treatment of skin aging.

How do retinoids work?

Retinoids are known to speed up the cellular processes such as cellular growth and differentiation. Retinoids work on the skin surface by prompting surface skin cells to grow and die quicker and slough off faster, making way for new cell growth underneath. In this way, they cause discolorations and spots to lighten and they hamper the breakdown of collagen and thicken the deeper layer of skin where wrinkles start.

Interestingly, current studies have found that the mechanism by which collagen and elastin are lost after skin is exposed to UV radiation may be blocked when topical tretinoin is applied before sun exposure. More studies are ongoing.

What about side effects?

The most common and frequent adverse effect of topical retinoids is called the “retinoid reaction” which you may or may not experience as burning, peeling, reddened or inflamed skin at the sites of application or in skin folds such as around the nose or lips where additional product might be deposited by accident. It’s this reddening and peeling that occurs within the first two weeks of use which cause many patients to give up therapy before realizing any of the benefits which can take two to three months or longer to see and feel. What most people don’t know (or wait for) is that the skin builds up tolerance to the retinoid treatment and side effects eventually subside. Also, you can reduce application amount and days or try a lower potency formula to start if you experience these side effects. The most important factor in success with tretinoin is to follow the entire course of treatment not to give up!

The other side effect associated with tretinoin therapy is photo-sensitization (you will be more sensitive to the sun’s rays and burn easier), which normally occurs at the beginning of treatment. I always advise patients on tretinoin therapy to avoid excessive sun exposure and use a broad-spectrum sunscreen of at least SPF 30 (and a hat).  Your skin’s response to UV radiation should also return to normal after a few months of treatment.

We love combination creams

I have found that the way to counter the side effects is to use a retinoid combination cream containing a corticosteroid to reduce inflammatory response and if discoloration or brown spots is one of your problems, you might want to add 4% hydroquinone (a known skin bleaching agent). We think that this combination may be even more effective than the individual components alone.

Has tretinoin worked for you? How long did it take?