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Scars Content Supplied by NHS Choices
Introduction

A scar is a mark that is left on the skin after a wound or an injury to the surface of the skin has healed.

Scars are very common - most people have at least one on their body. They are a natural part of the healing process.

Scars can occur inside and outside the body. For example, they can occur on the internal organs where a cut has been made during surgery, and can develop after certain skin conditions, such as acne and chicken pox.

How do scars form

When the skin is wounded and there is a break in the body's tissues, the body produces more of a protein called collagen, as part of the healing process. Collagen builds up where the tissue has been damaged, helping to heal and strengthen the wound.

For a period of about three months or longer, new collagen continues to form and blood supply increases, causing the scar to become raised, lumpy and red. Some collagen then breaks down at the site of the wound, the blood supply reduces and the scar gradually becomes smoother, softer and paler.

Although scars are permanent, they can fade over a period of up to two years. It is unlikely they will fade any more after this time.

Skin wounds can be caused by many things, including:

  • accidental injuries
  • surgery
  • burns and scalds
  • intentional harm

Read more about the causes of scars.

Where do scars form

Scarring is unpredictable and varies from person to person. Certain areas of the body are more at risk of scarring, such as the chest, back, ear lobe and the shoulder.

Scars that form on the knees and shoulders can appear stretched or widened as a result of the healing process occurring over movable joints.

Types of scars

The different types of scars include:

  • Flat, pale scars - these are the most common type of scar and are due to the body's natural healing process. Initially, they may be red or dark and raised after the wound has healed, but will become paler and flatter naturally over time. This can take up to two years.
  • Hypertrophic scars - red, raised scars that form along a wound and can remain this way for a number of years.
  • Keloid scars - these are caused by an excess of scar tissue produced at the site of the wound, where the scar grows beyond the boundaries of the original wound, even after it has healed.
  • Pitted (atrophic or "ice-pick") scars - these have a sunken appearance.
  • Contracture scars - these are caused by the skin shrinking and tightening, usually after a burn, which can restrict movement.

Read more about the types of scars.

Treating scars

Depending on the type and age of a scar, a variety of different treatments may help make them less visible and improve their appearance.

Scars are unlikely to disappear completely, although most will gradually fade over time.

If scarring is unsightly, uncomfortable or restrictive, treatment options may include:

  • silicone gel sheets
  • pressure dressings
  • corticosteroid injections
  • cosmetic camouflage (make-up)
  • surgery

It is often the case that a combination of treatments can be used.

Read more about treating scars.

Emotional effects of scarring

Scarring, particularly when it is on the face, can be very distressing, especially if you feel you are being stared at. If you avoid meeting people as a result of your appearance, you may become socially isolated. This can lead to feelings of depression.

If you feel that your scars are making you depressed or affecting your daily activities, make sure you visit your GP.

Preventing or improving scars

It isn't possible to prevent scars from forming, but there are things you can do to help your scar be less visible and heal better, such as immediately cleaning dirt, objects and dead tissue from wounds.

Other ways to improve scarring include:

  • not scratching or picking at scabs and spots
  • covering wounds with a waterproof ointment (such as Vaseline)
  • using silicone gels or sheets to reduce redness and encourage healing
Types of scars

Scars on the skin may appear when a cut or other injury is in the process of healing. The different types of scars vary in appearance.

Flat, pale scars

The most common type of scar is the flat, pale scar that forms as a result of the body's natural healing process.

Initially, they may be red or dark and raised after the wound has healed, but will become paler and flatter naturally over time as the injury heals.

This process can take up to two years, and there will always be some visible evidence of the original wound.

If the skin at the edges of the wound has come together neatly, the scar will usually heal as a thin, pale line. In wider wounds, where more surface skin is missing and more scar tissue is needed to bridge the gap between the edges of damaged skin (such as a bad graze on the knee), the scar may be less neat and may take longer to heal.

These scars are not usually painful, although they may be itchy for a few months. They can also be quite dark in colour and unsightly.

If you have a darker skin type, scar tissue may fade to leave a brown or white mark. These are often permanent, but can sometimes improve over time. If your skin is tanned, the scar may appear more obvious, as scar tissue does not tan and remains pale.

Other scars

Keloid scars

A keloid scar is an overgrowth of tissue that occurs when too much collagen is produced at the site of the wound and the scar keeps growing, even after the wound has healed.

Keloid scars often have the following characteristics:

  • they are often raised above the skin
  • they can feel itchy
  • they can feel painful
  • they can appear much larger than the original wound
  • they can cause a burning sensation and feel tender to touch
  • they can restrict movement if they are tight and near a joint
  • they are raised above the skin
  • they are hairless and appears shiny
  • they feel hard and have a "rubbery" texture, although some keloids can form soft lumps (such as on the ear lobe after piercings)
  • a newly-formed keloid scar is red or purple, becoming paler with time

The areas of the body where keloid scars are more likely to form include:

  • the area around the breastbone (sternum)
  • the upper arms and shoulders (deltoids)
  • the upper back
  • on the ear lobes

Hypertrophic scars

Like keloid scars, hypertrophic scars are the result of an imbalance in the production of collagen in a healing wound.

Unlike keloid scars, they do not extend beyond the boundary of the original wound, but may continue to thicken for up to six months.

A hypertrophic scar is a red, raised scar that forms along a wound and can have the following characteristics for around two to five years:

  • it can restrict movement because scar tissue is not as flexible as the original skin
  • it heals within the size of the original wound
  • the healing tissue is thicker than usual
  • it is red and raised initially, becoming flatter and paler with time

Hypertrophic scars can have this appearance for many years.

Pitted or sunken scars (atrophic or "ice-pick" scars)

Some scars caused by skin conditions such as acne and chickenpox can have a sunken or pitted appearance.

They can also be the result of an injury, which may have included the loss of underlying fat.

Scar contractures

Scar contractures are commonly caused by burns. These occur when the skin "shrinks", leading to tightness and a restriction in movement.

 

 

Causes of scars

Scarring results from the body's natural healing process after body tissue has been damaged.

Tissue damage can occur for a number of reasons, including:

  • accidental injuries - such as cuts from falling off a bicycle
  • deliberate harm from a weapon or from self-harm
  • cuts made during surgery - such as a Caesarean section birth
  • bites and scratches from animals or people
  • burns and scalds from hot objects or liquids
  • body piercings - such as ear or nose piercings
  • injections - such as vaccination against tuberculosis (BCG vaccination)
  • tattoos

Scarring can also be a side effect or a complication of other conditions. For example, if you have a condition that causes a rash, such as chickenpox or acne, you may be left with scars where the rash was (this is more likely to happen if you scratch or pick at the affected areas).

It is thought that keloid scarring and hypertrophic scarring may run in families. This means you have an increased risk of developing keloid scarring or hypertrophic scarring if a member of your family has previously had these types of scars.

Internal scarring can be caused by injuries or surgery.

Treating scars

People seek help for scars if they are painful or itchy, if they are unsightly, or if they restrict movement.

Although scars cannot be removed completely, they can often be made less visible. However, more research is required to assess the effectiveness of the different treatments.

Your GP may refer you to a dermatologist or a plastic surgeon for treatment.

Some treatments - such as laser therapy - are not widely available on the NHS, so you will need to pay for them privately.

Corticosteroid injections

Corticosteroid injections are used to treat some keloid and hypertrophic scars.

Multiple small injections are made into the scar to reduce any swelling (inflammation) and to flatten the scar. Depending on the type of scar, these may need to be repeated. Injections are usually given on three occasions, at four- to six-week intervals, to assess your body's response. Treatment may sometimes continue for several months if the scar is improving.

This treatment cannot remove scars, but it can improve their appearance.

Silicone gels or sheets

Silicone gels or sheets are available from some pharmacies. They are used on healing skin (not open wounds) to reduce redness and to try to minimise hypertrophic or keloid scars.

To be effective, silicone gels or sheets should be placed over the scar for 12 hours a day, for at least three months.

You can ask your GP, dermatologist or pharmacist for more advice about a range of silicone-based scar treatments.

Surgery for scars

Surgery can sometimes improve the appearance of scars, as it can be used to:

  • change the positioning of the scar
  • change the width or shape of the scar
  • release a tight scar that is close to a joint, to improve movement

Be aware that having surgery on your scar will leave a new scar that will take up to two years to improve in appearance. If surgery is used to treat a hypertrophic scar, there is a risk that the scarring may be worse after the surgery.

Surgery alone is not advised for keloids, as they tend to grow back larger. Surgery for keloids is often combined with corticosteroid injections at the site of the removed scar immediately after surgery. Some plastic surgeons also add other treatments, such as X-ray therapy and oral antibiotics, to try to minimise the recurrence of a keloid that has been surgically treated. You can talk to your surgeon about this treatment.

Pressure dressings for scars

The aim of pressure dressings is to flatten and soften scars. They are most often used for large burn scars or after skin grafts.

Pressure dressings are usually made from a stretchy, elastic material. They are worn over the scar 24 hours a day, for around 6 to 12 months. They can also be used in combination with silicone gel sheeting, to improve the appearance of scars over a long period of time.

Pressure dressings are usually used under specialist supervision.

Make-up for scars

Cosmetic camouflage (make-up) can help cover up scars and can be particularly useful for facial scars. Some are waterproof and can stay in place for two or three days.

Camouflage make-up that is specially designed for covering up scars is available over the counter at pharmacies. You can also ask your GP for advice.

Please note that camouflage colour testing (to get a good colour match for your skin type) can be a lengthy process, sometimes taking over an hour, and needs to be performed by someone who is qualified.

Laser therapy

Laser or light therapy (pulses of light) can reduce the redness in a scar by target=""=""ing the blood vessels in the excess scar tissue. For some pitted scars, laser surgery (laser re-surfacing) is used to try to make the scar flatter. This involves using a laser to remove the top layers of skin, which stimulates collagen production in the deeper layers.

However, there are very few long-term studies to prove the effectiveness and safety of this therapy. If you have laser therapy, it's important to make sure that the person carrying it out is a fully trained medical practitioner with experience in improving scars.

Dermal fillers

Dermal fillers are injections (often of a man-made acid) used to "plump up" pitted scars. Treatments can be costly and the results are usually temporary. Repeat treatments are needed to maintain the effect.

Skin needling

Skin needling, which involves rolling a small device covered in hundreds of tiny needles across the skin, is also reported to be helpful, but repeat treatments are often needed to achieve an effect, and results vary considerably.

Radiotherapy

Low-dose, superficial radiotherapy may reduce the recurrence rate of hypertrophic and keloid scars after surgery. It is effective in about 70% of cases but, because of the possibility of long-term side effects, it is only reserved for the most serious cases.

'Make-up is really good for hiding my scar'

Nicola, an office administrator from Newcastle, was involved in a bad road accident that caused serious facial injuries. Her four-year-old daughter escaped with a broken collarbone.

Nicola needed 158 stitches in hospital and, as she was eight months pregnant, she couldn't have any anaesthetic to ease the considerable pain.

She said: "I had to grin and bear it - I still haven't really recovered, even now. I felt really devastated when I realised that I would have a scar eight inches across one side of my face. One part is really bad, where the skin is more jagged than the rest."

Fortunately, the young mother gave birth to a healthy boy a month later. However, she was still upset by the prominent scar across her face. Nicola visited her doctor, who referred her to the Red Cross's skin camouflage service.

At the clinic, a Red Cross volunteer spent an hour showing Nicola how to use the camouflage creams, which are designed to cover disfiguring skin conditions.

Nicola remembered: "I just wanted to give it a try. I hadn't heard of anything I could use - normal make-up didn't hide the scar. After finding the right shade, the volunteer applied the cream for me. She then cleaned it off and I had to put it on myself, while she checked that I was doing it right. I was soon able to do it at home quite easily.

"I apply it every morning now before work - it takes 5-10 minutes to apply. It definitely makes me feel more confident than I did before. I'm looking forward to having an operation soon to correct the worst part of the scar, but when I go out the make-up is really good for hiding it. When I have the make-up on and pull my hair over that side of my face, you almost can't see it at all!"

 
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