Scar Management

Introduction[edit | edit source]

Scars are the normal and unavoidable outcomes of tissue healing where the fibrous tissue replaces normal tissue as a part of the remodeling phase of wound healing. The collagen synthesized initially is random and constituting bulky fibers, which eventually remodels along the lines of tension. As this normal process occurs there is a risk of adhesions in the adjacent tissues. Eventually, these collagen fibers are replaced with stronger and  more organized  collagen, representing a smoother and flat scar which is paler in appearance.[1]

A scar that stays within the boundaries of the original wound is a firm scar.

Keloid[edit | edit source]

Scars that progressively encroach on the surrounding area of skin tissue resulting in a cosmetic and emotional distress. They frequently develop in areas rich in blood supply like the ear lobe or the presternal area.

Hypertrophic scars[edit | edit source]

Prolonged inflammation causes excessive collagen deposition with an increased adhesiveness and contractility of the scar. The resulting scare is red, vascular, immobile and raised. This can adversely affect range of motion and cause functional limitations when present around a joint.[1]

Assessment[edit | edit source]

Objective measures:

Size: A scar usually undergoes a period of over growth before maturing and becoming flatter.

Method Use
Mark points along the scar and measure length, width, height and elevation with a ruler Easy method for rough quantification,
Photographing the scar or tracing it onto a piece of paper Easy, inexpensive in clinical use, however unable provide quantification
Negative impression made of the scar in a dental stone, used to later reproduce a positive impression of the scar. Objective and quantifiable, difficult to use in clinical setting
Ultrasonography of the scar Quantifies size of the scar both above and below the surface of the skin(depth of the scar), however this is time consuming

Color: This is a measure of vascularity as well as pigmentation (measure of the melanocytes, bile ad carotene pigments).

Method Use
Visual observation, photographic analysis Non standardized, rough method
Color control strips, computer packages like adobe allocate numerical values to colors Not validated, but convinient

Pliability: This refers to the extensibility or elasticity of skin

Methods Use
Range of motion assessment It however is an indirect assessment of function and not merely a measure of the scar
Vertical pressure tools

Cicatronometer: hand held tonometer that's held vertically on the skin, depressed is an indicator rod. The firmer the skin the higher the rod will move

Mdodified Shiotz tonometer: this device even gives a reading of the power required for a given deformation.

Properties good against the ultrasound, however not used frequently
Horizontal Stretch tools: These are the extensometer and elastometer The reliability of these tools is yet to be tested.
NK Derma Durometer: This is a computerised device that uses the pressure required to deform skin through the electric resistance of skin. Non invasive, esy to use, objective but expensive
Cutometer: Measures vertical deformation using a suction device Highly sensitive,

Temperature: The temperature of a scar is dependent o the vascularity and amount of metabolic activity.

Methods Use
Infrared camera or Infrared tympanic thermometer Non invasive method of assessing temperature
Biopsies to detect changes Histologic analysis

Transepidermal Water Loss and Transepidermal Oxygen: The water loss across the skin increases due to the destruction of stratum corneum. The deeper the wound the longer stratum corneum takes to normalize. Skin hydration also affects the skin elasticity, Scar maturity is related to the oxygen tension present transcutaneusly.[2]

Methods Use
Tewameter (Courage+Khazaka Electronic GmbH, Cologne, Germany) measures the skin hydration and rate of oxygen diffusion Useful in conducting research, however are noninvasive, commercially available.

Standardized outcomes[edit | edit source]

Burns scar index (vancouver Scar scale): Measures Pliability, pigmentation, vascularity and height

Hamilton scale: Proportion of irregular scar with its height, depth, color, vascularity and numerical scar rating scale

Numerical scar rating scale: Border height of the scar, scar stiffness, color difference and the thickness of the scar.

Scar Management[edit | edit source]

Aim: Altering the physical an mechanical properties of the scar by influencing the scar maturation process. Also promoting tissue strength and gliding by preventing adhesions.

Scar massage

During the proliferative stage massage has a beneficial role in collagen synthesis, as it prevents adhesions and helps in collagen synthesis. Also this mechanical stress when applied to the intermolecular bonds, helps in realigning collagen.

Splinting

Splinting can be used at all stages of wound healing, to immobilise at the earlier stages and with the aid of passive or active stretches to modify collagen alignment.

Pressure therapy

Silicon gel

Ultrasound therapy

Laser

Steroids

  1. 1.0 1.1 Jones L. Scar Management in Hand Therapy–is our Practice Evidence Based?. The British Journal of Hand Therapy. 2005 Jun;10(2):40-6.
  2. McOwan CG, MacDermid JC, Wilton J. Outcome measures for evaluation of scar: A literature review. J Hand Ther. 2001 Apr 1;14(2):77-85.