Best Scar Treatment
For atrophic/acne scars, microneedling combined with platelet-rich plasma (PRP) or platelet-rich fibrin (PRF) is the most effective treatment, while for hypertrophic scars and keloids, topical silicone gel sheets applied at least 4 hours daily represent the gold standard first-line therapy.
Atrophic Scars (Acne Scars, Depressed Scars)
Primary Recommendation: Microneedling + PRP/PRF
Microneedling combined with autologous platelet concentrates demonstrates superior outcomes compared to any single modality, with the combination showing 70.43% mean improvement versus 48.82% for PRP alone and 39.71% for microneedling alone 1.
Treatment Protocol
- Three sessions spaced one month apart 1, 2
- Needle depth: 1.5 mm 1
- Critical technique: Apply PRP/PRF BEFORE microneedling (not after) to allow the needling effect to push platelet concentrates deeper into the skin 1, 2
- Maintenance treatments every 6 months 1
PRF vs PRP Considerations
PRF may be even more effective than PRP, showing 3-fold higher excellent outcome rates when combined with microneedling 3, 2. PRF demonstrates superior improvement whether used alone or combined with microneedling 1.
Expected Outcomes by Scar Type
- Rolling scars: Best response 3, 2
- Boxcar scars: Good response 3, 2
- Ice pick scars: Most resistant 3, 2
Clinical Results
- Goodman and Baron scar grade reduction from 3.45 to 1.47 with microneedling plus PRP 2
- 43% excellent response rate with combined treatment versus 20% with single modality 1
- Patient satisfaction significantly higher (5.95 vs 5.35) 2
- Significantly shorter downtime with PRP-enhanced treatments 2
Treatments to Avoid
Q-switch lasers are inappropriate for atrophic acne scars 3. These lasers deliver nanosecond pulses at extremely high temperatures (up to 900°C) designed to fragment pigment particles, not to stimulate the collagen remodeling needed for scar improvement 3.
Hypertrophic Scars and Keloids
Primary Recommendation: Topical Silicone
Silicone-based products (sheets and gels) are recommended as the gold standard, first-line, non-invasive option for both prevention and treatment of hypertrophic scars and keloids 4.
Application Protocol
- Apply at least 4 hours per day for optimal results 5
- Can be used on scars ranging from 2 weeks to 62 years old 5
- Treatment duration typically 1-16 months depending on scar severity 5
Clinical Evidence
- All scars improved significantly in color, thickness, and elasticity regardless of scar type and maturity 5
- Mean scar thickness reduction of 37% (range 20-54%) after 6 months of twice-daily silicone gel application 6
- Effective for both hypertrophic scars (205 patients) and keloids (19 patients) 5
Silicone Gel vs Tretinoin
Both silicone gel and tretinoin cream (0.05%) applied twice daily effectively prevent hypertrophic scars and keloids compared to no treatment, with no significant difference between the two agents 7. However, silicone has broader guideline support as first-line therapy 4.
Secondary Treatment Options for Resistant Cases
When silicone therapy alone is insufficient, the following have high efficacy for existing hypertrophic scars 8:
Invasive Options with High Efficacy
- Intralesional corticosteroids 4, 8
- 5-fluorouracil injections 4, 8
- Bleomycin injections 8
- Pulsed-dye laser 8
- CO2 laser 8
- Scar massage 8
For Keloids Specifically
Effective adjuncts to surgical excision include 8:
- Corticosteroids
- Mitomycin C
- Bleomycin
- Radiation therapy
Low Efficacy Treatments to Avoid
- Onion extract has low efficacy for both prevention and treatment 8
- Pressure garments have low efficacy for prevention 8
Prevention Strategies
High Efficacy Preventive Measures
General Preventive Measures
Clinical Monitoring
Re-evaluate patients every 4-8 weeks to determine whether additional treatment is warranted 4. The amount of scar management measures applied should depend on the patient's risk of developing a scar and their level of concern about appearance 4.