What is scar therapy?

Scar Therapy: Modern Approaches to Treatment

Scar therapy encompasses multiple treatment modalities including microneedling, platelet-rich plasma (PRP), silicone-based products, and manual techniques, with the combination of microneedling and PRP showing the highest efficacy for improving scar appearance and patient quality of life. 1

Types of Scars and Classification

Proper classification of scars is essential for determining the appropriate treatment strategy:

• Hypertrophic scars: Raised, red scars that remain within the boundaries of the original wound
• Keloid scars: Raised scars that extend beyond the original wound boundaries
• Atrophic scars: Depressed scars (commonly seen with acne)

Evidence-Based Treatment Options

First-Line Treatments

1. Silicone-based products

   • Considered the gold standard for non-invasive scar management 2
   • Available as sheets or gels
   • Mechanism: Provides hydration and occlusion to normalize collagen synthesis
   • Recommended for both prevention and treatment of hypertrophic scars 3

2. Microneedling

   • Creates controlled micro-injuries that stimulate collagen remodeling
   • Particularly effective for atrophic scars
   • Protocol: Typically 3-4 sessions at 1-month intervals 1
   • Needle depth: 0.25-2.5mm depending on scar type and location

3. Microneedling with PRP/PRF (Platelet-Rich Plasma/Fibrin)

   • Highest efficacy among combination treatments 1
   • Group studies show 70.43% mean improvement with combination therapy versus 39.71% with microneedling alone 1
   • Protocol: 3 treatments, 1 month apart, with maintenance treatment every 6 months 1
   • PRP applied before microneedling shows better results than application after treatment 1

Second-Line and Adjunctive Treatments

1. Corticosteroid injections

   • Highly effective for hypertrophic and keloid scars 3, 4
   • Often combined with other modalities

2. Laser therapy

   • Pulsed-dye laser: Effective for reducing redness and thickness 3
   • CO2 laser: Effective for remodeling scar tissue 3
   • Caution: Risk of hypopigmentation and persistent erythema, especially with ablative techniques 1

3. Manual scar therapy

   • Includes massage, manipulation, cupping, and taping
   • Improves scar pliability, reduces pain and pruritus 5
   • Protocol: Two 30-minute sessions weekly for 8 weeks 5

4. Pressure therapy

   • Indicated for widespread scarring, especially after burns 2
   • Requires consistent application (at least 23 hours daily)

Treatment Algorithm Based on Scar Type

For Hypertrophic Scars:

1. Prevention phase (immediately post-wound):

   • Tension reduction
   • Silicone sheets/gel
   • UV protection

2. Early scar phase (0-6 months):

   • Silicone sheets/gel (primary)
   • Manual therapy
   • Consider microneedling with PRP after 3 months

3. Mature scar phase (>6 months):

   • Microneedling with PRP (3 treatments, 1 month apart)
   • Corticosteroid injections for resistant areas
   • Consider laser therapy for persistent cases

For Keloid Scars:

1. Conservative approach:

   • Corticosteroid injections
   • Silicone sheets/gel
   • Pressure therapy

2. For resistant keloids:

   • Surgical excision with adjuvant therapy (corticosteroids, 5-fluorouracil, or radiation) 4
   • Post-excision microneedling with PRP may reduce recurrence

For Atrophic Scars:

1. First-line:

   • Microneedling with PRP (3 treatments, 1 month apart) 1
   • Depth: 1.5mm for optimal results

2. For resistant cases:

   • Consider fractional laser therapy
   • Dermal fillers for deep atrophic scars

Common Pitfalls and Caveats

1. Timing matters: Early intervention (within first 6 months) yields better results

2. PRP application technique: Apply PRP before microneedling, not after, for optimal results 1

3. Avoid aggressive treatments on high-risk areas: Lower legs, ears, and other areas with poor healing potential require gentler approaches 1

4. Patient expectations: Complete elimination of scars is not possible; focus on improvement

5. Combination therapy is key: Single modalities rarely provide optimal results 6

6. Follow-up and maintenance: Scars can continue to remodel for up to 2 years; maintenance treatments may be necessary

7. Risk of worsening: Overly aggressive treatment of keloids can stimulate further growth

By following this evidence-based approach to scar therapy, clinicians can significantly improve scar appearance, reduce associated symptoms, and enhance patients' quality of life.