What cream is recommended for treating scars, including keloid, hypertrophic, and atrophic scars?

Management of Scars: Evidence-Based Recommendations

Silicone gel or silicone gel sheeting is the first-line topical treatment for preventing and treating hypertrophic and keloid scars due to its proven efficacy and safety profile. 1, 2

Types of Scars and First-Line Treatments

Hypertrophic Scars

• Silicone-based products have been used successfully for more than 20 years in scar management with high efficacy for both prevention and treatment 1, 2
• Silicone gel forms a thin flexible sheet over newly epithelialized wounds or mature scars, providing occlusion and hydration of the stratum corneum 1
• Silicone gel sheeting should be worn for at least 12 hours per day for optimal results 3

Keloid Scars

• For keloid scars, silicone products are effective but often need to be combined with other treatments 2
• Effective adjuncts to surgical excision of keloids include corticosteroids, mitomycin C, bleomycin, and radiation therapy 2
• Corticosteroid injections administered 10-14 days after surgery are superior to injections given before or during surgery for keloid prevention 4

Atrophic Scars

• Limited evidence exists for specific treatments of atrophic scars, but silicone-based products may still provide benefit through improved hydration 2

Mechanism of Action of Silicone Products

• Silicone works through occlusion and hydration of the stratum corneum 1
• This hydration leads to cytokine-mediated signaling from keratinocytes to dermal fibroblasts, which helps normalize collagen production 1
• No silica from the dressing is found at the wound site, confirming safety 3

Alternative and Adjunctive Treatments

• Tretinoin cream has shown efficacy similar to silicone gel in preventing hypertrophic scars and keloids after surgery 5

• For established hypertrophic scars, additional effective treatments include:

  • Pulsed-dye laser and CO2 laser 2
  • Corticosteroid injections 2, 4
  • 5-fluorouracil and bleomycin injections 2
  • Scar massage 2

• For keloids resistant to first-line therapy:

  • OnabotulinumtoxinA appears superior to both fluorouracil and corticosteroid injections 4
  • Intralesional cryotherapy with liquid nitrogen shows benefit 4

Treatment Protocol

1. Begin treatment as soon as possible after wound closure or when an itchy red streak develops in a maturing wound 3
2. Apply silicone gel twice daily to clean, dry skin 1, 5
3. If using silicone gel sheets, wear for at least 12 hours daily 3
4. Continue treatment for at least 2-3 months for optimal results 5
5. For resistant or severe scars, consider adding corticosteroid injections or other adjunctive therapies 2, 4

Common Pitfalls and Caveats

• Delayed initiation of treatment reduces efficacy - start as soon as the wound is fully epithelialized 3
• Inconsistent application leads to suboptimal results - patient adherence is crucial 1
• Silicone products work best when combined with tension reduction across the wound 2
• Patients with darker skin tones or personal/family history of keloids require more aggressive preventive measures 4
• Avoid elective procedures in high-risk anatomical locations (chest, shoulders, earlobes) in predisposed individuals 4

Special Considerations

• For pediatric patients or those with sensitive skin, silicone gel may be better tolerated than silicone sheets 1
• For scars in mobile areas (joints), silicone gel provides better flexibility than sheets 1
• For very large scars, consider combination therapy with silicone plus other modalities for optimal results 2, 4