SCARRING is a natural part of healing, but there are several treatments available.
By Joanna Hall.

Centuries ago, scars were regarded as symbols of bravery.

Warriors wore them with pride, as visual evidence of the many physical dangers they had endured and survived. In Africa it wasn't uncommon for women to be purposely scarred after the birth of a baby - like getting a tattoo - to demonstrate their bravery in enduring the pain of childbirth. But today, scars are more likely to cause embarrassment than pride.

Most people have at least one scar somewhere on their skin. In fact, according to a 2003 clinical review in the British Medical Journal, around 100 million people each year acquire scars in the developed world. They happen for a variety of reasons: a bout of chicken pox, acne, a burn, an accident or surgery. But why do we scar? Dermatologist Dr Stephen Shumack, honorary secretary of the Australasian College of Dermatologists, says: "A lot of people think that if you have something cut off the skin, or injure your skin, that it's normal to have a scarless outcome. But scar formation is a natural part of the body's healing process."

Various factors influence how your skin scars. Aside from the depth, size and location of the injury, your age, heredity and ethnicity can impact on a scar's characteristics. "Some people are more susceptible to scarring than others, just as certain areas of the skin are more prone," Dr Shumack says. "People who are younger tend to have a more aggressive repair mechanism, so they usually end up with worse scars than older people. "Also, certain types of scars, including hypertrophic and keloid scars (see box), are more common in black and Asian skins. People with sensitive skin are also more susceptible to scarring, such as those with eczema."

Back to basics

A scar cannot be completely removed or avoided, but how you treat a fresh wound can impact on the outcome. "It's important that wounds are cleaned or washed with cool water," Dr Shumack says. "This removes dirt and foreign bodies, and avoids infection."

Over the past few decades, the process of wound care has also changed. "We've known for about 20 or 30 years that wounds that are kept moist heal better than wounds that are left open to dry," Dr Shumack says.

"The moist environment allows cells to migrate across the wound more easily, and the body also produces fluids which contain hormones and agents that help healing. If you have those on the skin, you get a better result."

A variety of topical applications claim to reduce scarring. One is vitamin E. "There's no real evidence that vitamin E has any benefit, but there's evidence that massage does," Dr Shumack says. "So the fact that you are rubbing something into the scar can help to smooth and soften it to a certain extent."

Silicone is a topical application known to help improve scarring. Scar tissue can also be removed surgically, especially if it is located on an area of mobility such as the knee, and thickened, itchy and keloid scars (see box) can be reduced using steroid injections.

Scarred for life?

One of the most common causes of scarring is acne. According to the Australasian College of Dermatologists, it affects 85 per cent of Australians at some time during their life, and can be severe in around five per cent of cases. Severe acne scarring can cause problems with skin pigment and leave contour scars indentations and bumps on the skin.

There are a number of ways to treat acne scars, including laser resurfacing, chemical peels and dermabrasion. But another, lesser known method promises similar results without the invasiveness, recovery time or expense. Called skin needling, or facial mesotherapy, the procedure was pioneered by Swiss-French dermatologist Dr Philippe Simonin in the early 1980s.

Skin needling involves "damaging" the skin with tiny puncture wounds caused by fine needles, to stimulate the production of new collagen. As it doesn't strip the healthy epidermis, the healing period is quicker than with other skin resurfacing techniques.

Dr Philippa McCaffery, a Sydney-based cosmetic physician, has been practising skin needling at her clinics (www.clearskincare.com.au) since 2002, and has developed her own skin rollers specifically for the procedure. "The skin roller facilitates skin needling by enabling multiple penetrations of the skin at an even depth, specifically targeting the upper dermis," Dr McCaffery says. Every consultation begins with a skin assessment. "I then usually supply the patient with prescription-strength vitamin A cream to begin the process of stimulating collagen production," says Dr McCaffery. "I also supply them with a home roller to use every night, to get them used to the sensation of needling. Then, every six or eight weeks, we get them into the clinic for a deeper needling session." Needling is performed under a local anesthetic and, depending on the size of the area treated, takes between 30 minutes to an hour. It costs around $300 per session. "We treat the skin quite aggressively," says Dr McCaffery. "The skin is red afterwards, and the person should rest."

Skin needling can also be used on surgery scars, burns and skin grafts. "It's also an antiageing treatment," says Dr. McCaffery. "It can help to reduce lines. I do a lot of treatments on areas prone to wrinkling, such as the upper lip."

Australia is at the forefront of wound care research. In 2006, Dr Shumack co-authored a paper, A Scarless Future, which explores the technological advances in wound care and future therapies that could eliminate scars forever.

One is the further development of the sprayon skin, pioneered by Perth-based plastic surgeon, Dr Fiona Wood. Microskin, based in Brisbane, is a simulated second skin designed to last for several days. Other innovations include biological wound dressings, the use of growth factors, the development of agents that can "turn off" the scar-producing process and stem cell therapy.

Dr Shumack says, "I think some of these things will be commonplace over the next 10 years, particularly in areas where major scarring is an issue, such as in burns victims. There's a lot of research being done, but there's also still a lot to do."

What's in a scar
Skin tissue repairs in a broad spectrum of scar types, from a normal fine line to a variety of abnormal scars.

Widespread scars
These usually appear when the fine lines of surgical scars gradually become stretched and widened. They are typically flat, pale, soft and symptomless.

Atrophic scars
These are typical of chicken pox or acne, and are flat indentations in the skin, which are usually small and round.

Scar contractures
Scars that cross joints or skin creases and are prone to develop shortening, and can be disabling. They are common after burn injuries.

Hypertrophic scars
These are raised scars that remain within the original boundaries of the wound. They are often red, inflamed, itchy and can also be painful, and typically occur after a burn.

Keloid scars
These scars are also raised, but they spread beyond the original boundaries of the wound.

Reproduced from The Daily Telegraph / Courier Mail Sunday 24 June 2007