How should I manage a post‑inflammatory scar resulting from eczema?

Management of Post-Eczema Scarring

Understanding Post-Inflammatory Changes After Eczema

Post-eczema scarring typically manifests as post-inflammatory hyperpigmentation or textural changes rather than true hypertrophic scars, and the primary treatment strategy focuses on preventing new inflammation while addressing residual pigmentary changes. 1

The key distinction is that eczema rarely produces true hypertrophic or keloid scars unless there has been severe excoriation, secondary infection, or repeated trauma to the same area. 1 Most "scars" after eczema are actually post-inflammatory dyspigmentation that will gradually fade with proper management. 2

First-Line Strategy: Prevent Further Inflammation

• Continue aggressive emollient therapy even after the eczema has cleared to maintain barrier function and prevent recurrence that could worsen pigmentary changes. 1, 3
• Apply fragrance-free emollients containing petrolatum, mineral oil, urea (~10%), or glycerin within 10-15 minutes of bathing to damp skin. 3
• Reapply emollients after each hand-wash and every 3-4 hours throughout the day. 3

Addressing Post-Inflammatory Hyperpigmentation

• Azelaic acid is specifically recommended for treating post-inflammatory dyspigmentation following acne and can be applied to areas of residual pigmentation from eczema. 2
• Use sun protection religiously: apply hypoallergenic sunscreen daily (minimum SPF 30, broad-spectrum) containing zinc oxide or titanium dioxide to prevent darkening of pigmented areas. 2, 3
• Avoid all potential irritants—harsh soaps, alcohol-containing products, perfumes—that could trigger new inflammation and worsen pigmentation. 1, 3

For True Hypertrophic Scars (If Present)

If the patient has developed actual raised, hypertrophic scars from severe excoriation or secondary infection:

• Silicone-based products (sheets or gels) are the gold standard, first-line, non-invasive option for both prevention and treatment of hypertrophic scars. 4
• Silicone gel is preferred over sheets for facial areas, scalp, or joints where sheets are difficult to apply or cosmetically undesirable. 5
• Apply silicone gel twice daily to the scarred area after the skin has fully re-epithelialized. 6, 5
• Continue treatment for at least 90 days, as studies demonstrate progressive improvement in scar color, size, erythema, pliability, pain, and itching over this period. 6, 5

Maintenance to Prevent Recurrence

• After clearance, implement proactive maintenance by applying a low-potency topical corticosteroid (hydrocortisone 1-2.5%) twice weekly to previously affected sites to reduce the risk of flares that could worsen scarring. 1, 3
• Keep fingernails short to minimize trauma from scratching. 1, 3
• Wear smooth cotton garments and avoid wool or synthetic irritants. 1, 3

Common Pitfalls to Avoid

• Do not use topical retinoids or acne medications on post-eczema skin—they will irritate the area and potentially worsen pigmentation. 2
• Avoid greasy or occlusive creams that may promote folliculitis. 2
• Do not apply medium- or high-potency corticosteroids to facial post-eczema changes, as they cause atrophy and telangiectasia without benefit for pigmentation. 1, 3
• Patients often confuse post-inflammatory pigmentation with active disease—educate that pigmentation will fade gradually (months) with sun protection and barrier maintenance, not with more aggressive anti-inflammatory treatment. 2, 1

When to Refer

• Refer to dermatology if true hypertrophic or keloid scars develop and do not respond to silicone therapy after 3 months. 4
• Consider referral for persistent, disfiguring post-inflammatory hyperpigmentation that does not improve with azelaic acid and sun protection after 6 months. 2
• Seek specialist input if diagnostic uncertainty exists about whether the changes represent scarring, active eczema, or another condition. 1, 3