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.
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.
A 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.