Scar solutions
Experts discuss current approaches to scar management.
Feature
By Emily Margosian, Assistant Editor, January 1, 2025
Every scar has a story. However, for millions of people worldwide, scars may negatively impact their quality of life, causing psychological distress along with physical discomfort.
While therapeutic approaches to treat scars abound, each patient requires a tailored approach, experts say. “I try to educate people that the best treatment plans are multi-modality. It’s a rehabilitation of the scar. For example, when you have a knee replacement, you need to go to physical therapy. It’s the same thing with a scar,” said Chad Hivnor, MD, FAAD, chief of dermatology at South Texas Veterans Health Care System. “You’re not going to institute normal skin; that’s just not feasible. So how can you make the scar healthier, better-looking, and more functional for the patient?”
This month, experts share their insights on the nuances of scar management and the need for expanded patient access to treatment.
Short on time?
Key takeaways from this article:
Scarring is ubiquitous and can have a physical and psychological impact on patients.
Often, scar treatments are not covered by private insurers.
The use of ablative and non-ablative fractional lasers can be used to significantly improve scar appearance, function, and mobility.
Other treatments include injectable treatments such as corticosteroids, 5-fluorouracil, and topical fillers.
In some instances, scar surgery may be an appropriate treatment option, particularly in high-tension areas of the body.
Overall, experts recommend a multi-modality, multispecialty treatment approach for optimal results. This may involve a care team that includes occupational therapists and plastic surgeons, and the use of additional therapies such as microneedling and radiofrequency.
While regenerative medicine may show future promise in the treatment of scars, dermatologists should focus on familiarizing themselves with current treatments, experts say.
Impact of scarring: More than skin deep
While scarring is ubiquitous, its impact can be highly variable depending on the scar’s origin and location, and the patient’s age and any associated injuries. “Some scars may be a positive badge of honor and a reminder of an individual’s bravery, service, and sacrifice, or they may be a constant reminder of a traumatic event that can trigger symptoms of PTSD,” explained Peter Shumaker, MD, FAAD, chief of dermatology at the VA San Diego Health Care System. “Disfiguring scars may lead to social disengagement and depression, and a scar’s psychological impact may not necessarily be proportional to its size. Likewise, scar-associated pain and itch can be all-consuming, and symptomatic scars in children can lead to issues with growth and development. Scarring’s impact on quality of life can be devastating.”
“Scarring’s impact on quality of life can be devastating.”
According to Thomas Beachkofsky, MD, FAAD, director of the Dermatology Laser Surgery and Cutaneous Rehabilitation program at the James A. Haley Veterans Hospital in Tampa, Florida, the true impact of scarring on a patient may not always be outwardly visible. “You can’t see someone’s pain, you can’t see someone’s discomfort, and you can’t see their itching. You can just see what the scar looks like from an appearance standpoint. Many patients live with some degree of symptoms because insurance often doesn’t cover treatment for scars.”
For some patients, the psychological burden of a scar may be more painful than its physical effects. “I had a patient who was randomly attacked outside his gym. It caused a scar that was just barely perceptible, but every time he looked in the mirror it reminded him of the incident. He wanted to go to all lengths to improve it to avoid reliving that trauma,” said Dr. Hivnor. “Every scar has its own story. You have to take an individual approach with each patient, because the mechanism of injury can be highly variable. Understanding that can help guide what you should do to help with appearance versus the functionality of the scar.”
Challenges in scar treatment and management
According to Dr. Shumaker, due to the unique nature of each individual scar, treatment plans must work around factors such as patients’ tolerance for discomfort and downtime, billing and insurance issues, and associated injuries. “Laser scar treatments should be widely accessible because many dermatologic surgeons already possess the requisite general skills and devices. However, experience in this niche is limited,” he explained.
Laser scar treatments can often occupy a hazy space between cosmetic and medical in the eyes of private insurers, limiting patients’ access to them. “One of the challenges with scar therapy is that it’s expensive and it requires experience and training,” said Dr. Beachkofsky. “A lot of these devices are marketed for aesthetics, but their benefits to patients are far-reaching. Despite decades of studies demonstrating their efficacy, they’re often not reimbursed by medical insurance.”
AAD resources on scar prevention and treatment
Share AAD resources with your patients, including dermatologist-approved information about scar type, treatment, and management as well as wound care tips for scar minimization.
Lasers and light treatments
Among recent advances in scar management, none have moved the needle as much as lasers, experts say. “Lasers have become essential and are probably the single-most-important development in the last several decades,” said Dr. Shumaker. “They fill an important gap between conservative measures, such as massage, pressure, physical therapy, and more invasive procedures like surgical revision. However, it’s important to emphasize that they are an important addition to standard therapy and not necessarily a replacement.”
Laser therapy can be used to improve scar appearance and range of motion, as well as address issues related to the fit and comfort of prosthetic devices for amputees via the removal of unwanted hair. “Many of us have observed countless small victories and occasional minor miracles,” noted Dr. Shumaker. “In a recent commentary on laser scar treatment, I — along with my colleagues Drs. Nathan Uebelhoer, Chad Hivnor, and Jill Waibel — was among the first to apply novel ablative fractional laser technology to traumatic scars and other scar types and document the impressive improvements in function, appearance, and symptoms” (Lasers Surg Med. 2023 Jan;55(1):9-11).
Ablative fractional lasers
According to experts, ablative fractional lasers are one of the most effective tools in treating prominent scars due to their depth of penetration within the skin. “This is my go-to device for the thickest scars with any associated contracture, or for scars associated with open wounds,” said Dr. Shumaker.
The use of ablative fractional lasers is often ideal for treating keloidal and hypertrophic scars, agreed Dr. Beachkofsky. “Micro fractional ablation involves very small beams, on the order of 120 microns. There are pretty good historical data showing that if you can create an injury to the skin that’s smaller than 500 microns — or half a millimeter — it heals without scarring. That’s critical, because essentially if we make a lot of these small injuries to the skin, they heal as normal tissue as opposed to the scar tissue that we are treating.”
The use of fractional ablative resurfacing can be used to provide immediate relaxation of tissue tightened by scarring, and present channels for the delivery of topical medication to further assist with the healing process. “We call this laser-assisted drug delivery, which has been well-documented as efficacious,” explained Dr. Beachkofsky. “Once you create small holes in the skin, you’re able to more evenly deliver medication. Steroids, for example, are traditionally injected within scar tissue. However, that can be associated with side effects from uneven distribution such as tissue atrophy, hypopigmentation, and systemic absorption. Through topical delivery, we can use less product and get a more even delivery throughout the treatment zone.”
Drawbacks to ablative resurfacing include more downtime compared to other laser and light treatments, and the potential for pigment changes in patients with skin of color. “Treatments tend to be more uncomfortable and there’s sometimes some bruising or bleeding,” said Dr. Beachkofsky. “In patients with darker skin, there’s a higher chance of post-inflammatory pigment alteration, including hyper- and hypopigmentation. Depending on the anatomic location of the scar, if it’s in a cosmetically sensitive area, we might consider the use of non-ablative lasers.”
Non-ablative fractional lasers
Non-ablative lasers still deliver fractional injury to skin, but do not provide an ablative injury. As a result, they are associated with less pain, downtime, and other side effects. However, they may not provide results as quickly or dramatically.
“Over the years, I’ve noticed that non-ablative lasers can do just as much good without the post-treatment redness and inflammation,” said Dr. Hivnor.
“What we’ve seen with the use of non-ablative devices over time is that we can still get significant improvements in all the same areas, but not as rapidly as an ablative device,” added Dr. Beachkofsky. “To that end, there are many different types of non-ablative lasers on the market. I’m not aware of any research indicating one is significantly better than another.”
Pulsed-dye lasers
Other lasers can be effective in the treatment of scars depending on the type and symptom of concern. “Vascular lasers, such as the pulsed dye laser, target hemoglobin and can be effective in the presence of erythema,” said Dr. Shumaker. “Pigment-specific short-pulsed lasers can be used in the presence of hyperpigmentation or traumatic tattoos, while long-pulsed lasers can treat other issues that frequently accompany trauma, such as trapped or displaced hairs, or improve the fit and comfort of prosthetic devices.”
Navigating the acquisition process
Fact: Lasers are expensive. While laser devices can be powerful tools, experts say physicians should carefully consider the financial impact on their practice before acquiring a new device.
“Some of these devices cost hundreds of thousands of dollars and you really have to think about the return on investment,” said Dr. Beachkofsky. “Will you use it for a cosmetic or aesthetic indication, which are almost always cash pay? Are you just going to do pro bono work? For well-established dermatologists who are simply looking for a tool to provide better care, the cost may not be so important. For a new dermatologist just starting out, it’s a big problem.”
Choosing a laser
When assessing which laser is most appropriate for an individual scar, experts recommend asking several key questions prior to treatment.
“The first things to think about are: Where is the scar tissue? How thick is it? What type of device do you need to get into the scar tissue to provide an efficacious treatment? Non-ablative lasers, for example, simply don’t penetrate the skin as deep as an ablative laser. It’s a physics problem,” said Dr. Beachkofsky. “The wavelengths of energy they use can’t perform the same depth of treatment. However, if you have a superficial type of scar, or an atrophic scar, you don’t necessarily need to penetrate very deep within the skin. I think some practices try to get the most out of every single device they have. However, certain tools are required to do certain work.”
“The first things to think about are: Where is the scar tissue? How thick is it? What type of device do you need to get into the scar tissue to provide an efficacious treatment?”
In cases where a patient is greatly impacted by physical symptoms from their scar — pain, itching, or lack of mobility — a dermatologist may opt to use a fractional ablative device for speed of treatment. “We see benefits with fractional ablative resurfacing treatment within one or two treatments that you’re not going to see with non-ablative devices,” said Dr. Beachkofsky. “An exception might be if we’re trying to treat problematic scars in aesthetically concerning areas. Then I think discussion regarding the use of non-ablative lasers becomes a little bit more prominent. There’s no simple, straightforward answer. They’re both useful, and it’s up to the laser surgeon to curate the treatment plan that best suits the needs of their patients.”
Laser focus
Read more about recent advances in laser technology.
Intralesional and injectable treatments
In addition to laser treatment, scar management also includes the use of anti-inflammatories (corticosteroids) and antimetabolites (5-fluorouracil) injected intralesionally to reduce scar hypertrophy. Fillers may also be utilized to improve the appearance of atrophic or depressed scars.
“I feel that you often need to treat with injectable medicines such as triamcinolone and 5-fluorouracil in conjunction with lasers,” said Dr. Hivnor. “If you have a depressed scar, you can elevate it subtly with some fillers. All those things together can be very beneficial, because with a keloid or a thick scar, the laser can only penetrate so deep. If you can thin out that scar by pre-treating with injectable medicines, you’re going to get better results when you go in with your ablative or non-ablative laser.”
Scar surgery
In some instances, minor surgical procedures may be considered an appropriate treatment for improving scar mobility and appearance, particularly in high-tension areas of the body. “A Z-plasty is a procedure that rearranges the tissue to cause immediate reduction in skin tension,” said Dr. Beachkofsky. “One case example might be someone who has had significant skin cancer surgeries on their face. Unfortunately, that sometimes results in large tissue defects making it difficult for the patient to open or close their mouth or eyelids normally.”
While lasers can provide gradual improvement in scar tissue elasticity, in scenarios where there is a significant disruption to skin function, combination therapy with lasers and scar surgery can have a significant advantage.
“Other situations where we might consider surgery are for certain types of keloidal or hypertrophic scars. However, this is often a touchy situation, because although patients with keloidal scarring often want these scars excised, around 50% of the time, they will unfortunately recur and create a larger scar than the one that was replaced,” said Dr. Beachkofsky. “We do provide surgeries for patients with keloidal scars, but we try to tailor a multimodality approach within our clinic. So, if we’re going to use surgery to treat a hypertrophic scar, or a scar under tension, we keep these patients under close observation. If we see any signs or symptoms of early scar recurrence or keloidal scar formation, we like to intervene early before it gets out of control.”
Combination therapy
Ultimately, experts say combination therapy in conjunction with a multispecialty team produces the best results. “For example, after a major trauma such as an extensive burn, a multidisciplinary team might include an occupational therapist, plastic surgeon, and laser surgeon once the condition has stabilized. However, not every traumatic scar requires a team,” said Dr. Shumaker.
At his clinic, Dr. Beachkofsky often works closely with occupational, physical, and lymphedema therapists. “Depending on the anatomic location and range of motion impacted by a scar, we like to treat those patients in multidisciplinary combination therapy. For example, some of our cancer patients who have had significant surgeries on their head and neck have scar tissue that impairs their ability to rotate and extend their head normally. We use lasers to help stimulate healing in the character and quality of the skin. Then the therapists help improve range of motion through active stretching and strengthening.”
Dr. Beachkofsky also often augments non-ablative resurfacing with microneedling and radiofrequency-emitting devices. “Microneedling can be done manually or via several motorized devices. We also use red lights, blue lights, and infrared lights for photobiomodulation, which is another feature of the multi-modality care we provide.”
The many uses of microneedling
Read more about potential applications of microneedling.
Setting patient expectations
While current approaches to scar treatment offer promising results, it is still important to set patient expectations. “We cannot erase scars with lasers, but in nearly every situation we can improve characteristics such as the appearance, texture, pliability, and movement over a course of treatment,” said Dr. Shumaker.
Patients undergoing laser treatment for their scars should anticipate some discomfort, and multiple sessions at one-to-three-month intervals depending on the type of device used. “While improvements can be seen after one treatment, commonly three to five treatments or more — depending on the situation — might be anticipated,” said Dr. Shumaker.
While physicians don’t always tell patients what they want to hear, keeping them involved in the decision-making process often leads to better outcomes, advised Dr. Beachkofsky. “Our patients are appreciative of an honest assessment of what’s possible in terms of therapy and outcome. We give them the autonomy to choose between different therapies. They have to take into consideration things like: How does the procedure feel? What type of anesthesia is going to be provided? What is recovery like? How many treatments will it take to reach the point that I’m considered treated well or happy?”
Looking toward the future
Within the realm of scar therapy, while new advances on the horizon may show promise, the focus should remain on increased adoption of current therapies, said Drs. Beachkofsky, Hivnor, and Shumaker.
“As far as the future is concerned, I think regenerative medicine is a very exciting field,” said Dr. Beachkofsky. “It’s an area with a lot of new ideas like platelet rich plasma, exosome therapy, stem cells, and growth factors. However, I caution people regarding the use of these therapies too soon. There’s a lot of marketing around them, but I don’t know that the level of research is there to support applications for their use. We need to stay current with the literature and critically evaluate what’s being published and decide for ourselves. Are these therapies providing the outcomes that we want, safely? It’s exciting, but it’s not 100% there yet.”
“Targeted drug therapy at critical points in the wound healing cascade that eventuates in scarless wound healing is the ultimate goal,” added Dr. Shumaker. “Much work is ongoing but the best we can do now is avoid scarring in the first place, intervene early to mitigate scar formation, and increase awareness of the excellent treatments that are available right now.”
“I think the biggest thing is providing education to folks on what is currently possible,” agreed Dr. Hivnor. “There isn’t a ton of new technology out there that’s earth shattering or groundbreaking. We’re just continuing to tweak and refine our techniques to optimize our outcomes.”
*The views expressed are those of the participants and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States government.
