What is the best treatment for skin scars?

Best Treatment Options for Skin Scars

The combination of microneedling with platelet-rich fibrin (PRF) or platelet-rich plasma (PRP) is the most effective treatment for skin scars, particularly for atrophic acne scars. 1

Types of Scars and First-Line Treatments

Scars can be categorized using the S.C.A.R. classification system 2:

• Stretched (flat) scars
• Contracted scars
• Atrophic scars (depressed, common with acne)
• Raised scars (hypertrophic and keloid)

First-line treatments by scar type:

1. For hypertrophic and keloid scars:

   • Silicone-based products (sheets or gels) 3, 4
   • Apply silicone sheets for at least 4 hours per day for optimal results 3
   • Silicone products work by occlusion and hydration of the wound bed, suppressing overactivity of scar-related cells 4

2. For atrophic scars (including acne scars):

   • Microneedling combined with PRF or PRP 1
   • This combination shows significantly higher patient satisfaction (75% satisfaction rate) compared to microneedling alone (3% satisfaction rate) 1

Evidence-Based Treatment Algorithm

Step 1: Assess scar type and severity

• Determine whether the scar is stretched, contracted, atrophic, or raised
• Evaluate scar age, location, and symptoms (pain, itching, functional limitation)

Step 2: Select appropriate treatment based on scar type

For raised scars (hypertrophic/keloid):

1. Silicone-based products - First-line therapy 3, 4, 5

   • Silicone sheets: Apply for at least 4 hours daily (optimal results with longer wear time)
   • Silicone gels: Apply twice daily to clean, dry skin
   • Continue for at least 2-3 months

2. If inadequate response after 2-3 months:

   • Consider intralesional steroid injections (triamcinolone acetonide) 1
   • For resistant cases, consider 5-fluorouracil or combination therapy 1

For atrophic scars (including acne scars):

1. Microneedling with PRF or PRP 1

   • Protocol: 3-4 sessions, 1 month apart
   • Maintenance: One treatment every 6 months

2. Alternative options if above not available:

   • Microneedling alone (still effective but less than combination therapy) 1
   • Laser therapy (particularly pulsed-dye laser after paring/salicylic acid pretreatment) 1

Important Clinical Considerations

1. Timing matters:

   • Early intervention is crucial, especially for patients prone to abnormal scarring
   • Preventive measures should begin as soon as wound healing occurs

2. Combination therapies often yield better results:

   • The combination of microneedling with PRF showed 3-fold better therapeutic response than PRP alone 1
   • Rolling scars respond best to treatment, followed by boxcar and ice pick scars 1

3. Patient adherence is critical:

   • For silicone products, consistent application is essential
   • Patients often discontinue silicone sheets due to discomfort, irritation, or maceration 6
   • Liquid silicone gels may improve adherence but have limitations (long drying time, shiny appearance) 6

4. Cost considerations:

   • Moisturizers may be a cost-effective alternative to silicone gels for scar hydration 6
   • PRP/PRF treatments typically require multiple sessions and specialized equipment

Pitfalls and Caveats

1. Avoid excessive occlusion with silicone sheets:

   • Can lead to skin maceration, irritation, and pruritus 6
   • May limit patient adherence

2. Be cautious with steroid injections:

   • Can cause skin atrophy, telangiectasia, and hypopigmentation
   • Should be used judiciously and at appropriate concentrations

3. Set realistic expectations:

   • Complete scar resolution is often not achievable
   • Multiple treatment sessions are typically required
   • Some scars may be resistant to treatment

4. Consider scar maturity:

   • Immature scars (<1 year) may respond better to treatment
   • Mature scars often require more aggressive intervention

The evidence supporting silicone products for scar management is considerable, though the exact mechanism remains under debate 4, 5. For atrophic scars, particularly acne scars, the evidence strongly supports combination therapy with microneedling and platelet concentrates 1.