What is the appropriate management for a scar on the dorsal foot?

Management of Scarring on the Dorsal Foot

For scarring on top of the foot, apply topical silicone gel sheeting for at least 12 hours daily (ideally 12-24 hours) for a minimum of 2-3 months to improve scar appearance, texture, and elasticity. 1, 2

Initial Scar Assessment

Before initiating treatment, evaluate the scar characteristics to guide management:

• Document scar type (hypertrophic versus keloid), color, thickness, elasticity, and any associated symptoms such as itching or burning 1
• Assess scar maturity, as both new scars (as early as 2 weeks post-injury) and mature scars (up to 62 years old) respond to silicone therapy 1
• Examine for underlying complications that may require different management, particularly if the scar resulted from a diabetic foot wound, infection, or surgical procedure 3

Primary Treatment: Silicone-Based Therapy

Silicone gel sheeting represents the first-line treatment for hypertrophic scars and keloids due to its proven efficacy, safety profile, and ease of use compared to more invasive options like surgical excision, intralesional corticosteroids, or laser therapy. 2, 4

Application Protocol

• Apply silicone gel sheeting directly over the scar for a minimum of 4 hours daily, though best results occur with 12-24 hours of daily wear 1, 2
• Continue treatment for at least 2-3 months to achieve optimal improvement in scar color, thickness, and elasticity 2, 5
• Ensure good contact between the sheeting and the scar surface, as adequate contact is critical for therapeutic effect 6
• Begin treatment as soon as an itchy red streak develops in a maturing wound to prevent hypertrophic scar formation 5

Expected Outcomes

• Significant improvement occurs in 85-90% of cases, with reduction in scar bulk, improved color, decreased thickness, and enhanced elasticity 1, 5
• Symptoms such as itching and burning typically resolve within weeks to 6 months in approximately 63% of patients 6
• Both prevention of excessive scarring and improvement of established scars are achievable with consistent silicone therapy 2, 4

Alternative Formulations

Topical silicone gel applied from a tube (forming a thin flexible sheet) is equivalent in efficacy to traditional silicone gel sheeting but may be easier to apply, particularly over irregular surfaces like the dorsal foot. 4

Mechanism of Action

The therapeutic effect likely involves occlusion and hydration of the stratum corneum with subsequent cytokine-mediated signaling from keratinocytes to dermal fibroblasts, though the precise mechanism remains incompletely understood 4. Some evidence suggests negatively charged static electricity generated by silicone may contribute to scar involution 6.

Management of Recalcitrant Scars

For scars that show minimal response after 6-12 months of silicone therapy:

• Consider adding intralesional corticosteroid injections while continuing silicone gel sheeting, which can result in resolution over several months to one year 6
• Ensure compliance with wearing schedule, as inadequate duration of daily application is a common cause of treatment failure 1

Special Considerations for Diabetic Foot Scars

If the scar resulted from a diabetic foot wound or surgical procedure:

• Inspect the healed area and surrounding skin frequently for signs of breakdown, as scarred tissue on the foot remains vulnerable to re-ulceration 3
• Ensure proper footwear that does not create pressure over the scarred area, as the foot should never return to the same shoe that caused the original ulcer 3
• Include the patient in a comprehensive foot care program with lifelong observation once the wound is fully healed 3

Critical Pitfalls to Avoid

• Do not delay treatment initiation; early application (as soon as epithelialization is complete) prevents hypertrophic scar formation more effectively than treating established scars 5
• Do not discontinue therapy prematurely; treatment duration of less than 2-3 months yields suboptimal results 2
• Do not assume surgical scars on the foot are purely cosmetic concerns; in diabetic patients, scarred tissue represents a site of altered biomechanics and increased ulceration risk 3