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July 13, 2020  
WOUND NEWS: Feature Story

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    Scar Healing: The Final Step in Wound Care


    January 21, 2010

    By Dr. Minas Chrysopoulo for Body1


    Scar Healing is the result of biologic wound repair and is a complex process.

     

    With the exception of minor lesions, every skin wound causes some degree of permanent scarring. The word scar comes from the Greek word eschara, meaning “place of fire.”  Scar tissue is different from normal skin. It is inferior in appearance and function. Scars are less resistant to ultraviolet rays and more prone to sunburn. Scars also lack a blood supply or sweat glands, and they never grow hair.

     

    Complete scar healing can take up to 2 years. Scars continue to soften, flatten and fade throughout this time. Unfortunately, some scars become more problematic over time by:



    • Growing larger or more raised

    • Causing itching

    • Becoming painful

    • Becoming permanently pigmented (dark red/brown)

    • Restricting motion




    There are various factors influencing scar appearance:





    Age – younger skin is more prone to abnormal and exaggerated healing. This can lead to hypertrophic or keloid scars. Older skin takes longer to recover.

    Skin type – scar healing is typically worse in people with darker skin types. African and Hispanic ancestry is associated with a higher risk of developing hypertrophic or keloid scars.

    Genetics – abnormal scarring can be inherited.  

    Location – Movement of scars over joints can make them wider.  

    Infection – Infected wounds do not heal well. The final scar may be raised, wide, uneven and abnormally red or dark.

    Poor nutrition – Not eating healthily deprives the body of nutrients (like protein), vitamins (like vitamin C) and minerals (like copper and zinc) that are needed for optimal wound healing.

    Smoking – Cigarette smoke causes blood vessels to clamp down and decrease blood flow. Wounds that do not receive enough blood are more prone to poor wound healing and worse scarring.  

    Sun exposure – Exposing fresh scars to the sun causes permanent redness.


    We can improve the final scar in the following ways:



    Inflammatory Phase


    Inflammatory Phase


    Dilation of blood vessels causes leakage of fluid that contains enzymes, growth factors and cytokines (inflammation cells) including MMPs *, TGF **, and TNF ***. The wound uses this fluid to break down the collagen damaged by the injury.Unfortunately, the skin is not efficient at controlling the amount of these healing factors. This causes an “over-breakdown” of collagen and contributes to a larger, less cosmetic scar. We have found that certain scar treatments work together to decrease this excess breakdown of collagen at the wound area. These include stable forms of vitamin C (that don't oxidize and become unstable on exposure to air), dimethicone silicone gel and certain botanicals (natural plant extracts ) like licorice, aloe vera and oils rich in n3 and n6 essential fatty acids (like sunflower and safflower seed oils).




    Proliferation Phase
     


    Proliferation Phase


    After the inflammation, the body replaces the damaged tissue with new collagen. The skin builds this new collagen very quickly and may produce abnormal collagen. The build-up of abnormal collagen can lead to hypertrophic scarring and even keloid scars. Stable vitamin C complexes and dimethicone encourage production of normal, “healthy” collagen while also limiting production of abnormal collagen.



    Epithelization Phase 


    Epithelization Phase


    The top layer of skin conserves water and serves as an infection barrier. Skin injury severely disrupts this function.


    The next phase of healing is formation of new top skin (epidermis). Replenishing water content of the skin is essential during this phase.  Essential fatty acids restore the lipid biolayer and provide moisture to the developing epidermis. Dimethicone also traps water. The resulting increased moisture encourages faster and improved scar healing.


    Scar treatments containing alcohol should be avoided. Alcohol can dry the skin which worsens scar healing.



    Maturation Phase 


    The newly formed scar now starts to mature. This final scar healing phase can last for 2 years. Collagen fibers reorganize for a stronger and durable scar. This can cause scar hardening and loss of elasticity. The scar may also become red, which can take up to several years to improve.


    Stable forms of L-Ascorbic acid (vitamin C) and certain vitamin C esters aid in decreasing scar pigmentation by over 80%. Botanicals like licorice extract also helps decrease hyper-pigmentation. Essential fatty acids are vital for restoring normal skin elasticity during this phase.

     


    * Matrix Metalloproteases (MMPs) are zinc-dependent enzymes capable of degrading all forms of extracellular matrix proteins contained in the skin, including collagen. They are also involved in cell proliferation, migration, differentiation, angiogenesis and apoptosis (cell death).

     

    ** Transforming Growth Factor Beta (TGF) exists in humans in three known subtypes:, TGFbeta1, TGFbeta2, and TGFbeta3. Silicone gel inhibits the release of TGFbeta2. All TGF subtypes play critical roles in tissue regeneration and modulation of the immune system. Increased TGFbeta activity is associated with some human cancers.

     

    *** Tumor Necrosis Factor Alpha (TNF) is a member of the Cytokine family. The primary role of TNF is in the regulation of immune cells. TNF is also able to induce cell death and inflammation, and to inhibit tumorigenesis and viral replication. Overproduction of TNF is associated with a variety of human diseases including various cancers.


    **** Images borrowed from Elastoplast


     


    Discuss Scar Treatments in our Forums






    Dr. Chrysopoulo is a Board certified plastic surgeon specializing in breast cancer reconstruction and scar healing. He is Chief Science Officer of InviCible Scars.


    Read his interview with Scars 1

    Last updated: 21-Jan-10

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