Not all scars are created equal. And some scars aren't even scars at all. But it's amazing how the most minor skin flaw can become labeled a "scar." You won't get rid of an ice pick scar if you are treating it like it's a keloid. And you won't resolve the residual discolored aftermath of a blemish using a "treated" bandaid. The best way to try to erase a scar is by understanding your scar.

What is a Scar?

Technically, a scar is the reaction of the skin to a trauma; minor or severe. Scars come in a variety of types. There's keloidal overgrowth of scar tissue, pock or ice pick types of depressed scars, stretchy scars similar in appearance to a stretch mark and your garden-variety straight-line style of scar.

• Keloid

  Keloids and hypertrophic scars are excessive tissue growth in response to skin trauma. You don't have to have a large wound in order to form a keloid. It takes just a minor scratch, acne bump or pierced ear for a keloid to form. The main difference between a keloid and hypertrophic scar is size. Keloids can be overwhelmingly large occasionally becoming baseball size. Fortunately this excess is not the norm. Keloids are thick, raised and rubbery.

  While keloids have been stereotyped as only affecting people of color, anyone can develop a keloid. Men more commonly make keloids than women. And the upper body especially the back and chest may form thickened raised scars. Just visualize the type of scar you may see on someone you love who's had bypass surgery. Again, these are generalizations, and like everything else in medicine, anything can happen.

  It's unfortunately, not how to get rid of a keloid, as opposed to how can you minimize its appearance? One of the most effective treatments is to inject a concentrated steroid solution directly into the scar. Usually treatment is repeated every few weeks. Plan on at least 3 round of injections. While the steroid solution doesn't erase the scar from view, the keloid does shrink down and flatten. Any pain that may accompany the scar often resolves with treatment. A real slap in the face, medical insurance often does not cover keloid treatments, referring to scars as "cosmetic." Some patients try to get around this by requesting potent prescription topical steroid preparations. To be honest, I have never been impressed with the results of these creams or ointments. They just cannot penetrate deeply enough to be therapeutic. Steroid impregnated tapes, such as prescription Cordran, can be more helpful. However, the ideal approach is through local injection.

  What if steroid injection isn't successful? There is an array of various silicone sheeting and gels that claim to shrink the keloid. Personally, I wouldn't want a thick sheet of material attached to my skin, especially in a highly visible location. Berman and Flores published a study in the Journal of Dermatologic Surgery in June of 1999 that found that there was no difference in the clinical results between using silicone gel or sheeting when it came to treating keloids. Gold in January of 2001 published a study in the same journal again supporting the effectiveness of silicone in the treatment of keloidal scars. To be honest, the exact reason why silicone helps reduce keloids is still uncertain. Perhaps there is something to the maceration ability of the ingredient. Theories also exist that static electricity generated by the friction of the silicone against the skin may result in anti-scarring effects.

  If you are considering trying a silicone product for a recalcitrant keloid or hypertrophic scar, you may want to consider Kelo-cote Advanced Formula Scar Gel or Dermatix Ultra Advanced Scar Treatment. Applied once or twice daily, it has been shown to help reduce the appearance of these scars. Both are considered safe to use on children.

  Some plastic surgeons and dermatologists will remove unsightly keloids with laser surgery, and then either locally inject the area with steroid or use the silicone sheeting to prevent the reformation of these lesions.

• Ice Pick, Pock Marks, Saucer Shaped and Depressed Scars

  Deep jagged ice pick scars are often the result of severe cystic acne. While acne can result in more saucer shaped depressed scars, ice pick scars are going to be different in management.

  Most depressed scars will respond to one of several methods of treatment. They can be filled with a human derived collagen material known as Dermalogen or Cymetra; they can be filled with another injectable tissue known as Fascian. Yet to be approved in the U.S. is Restylane, a hyaluronic acid filler agent used in Canada and Europe. A series of N-Lite laser or IPL treatments can stimulate fibroblasts to make collagen. Keep in mind it takes several sessions to see results.

  Spot laser resurfacing for an acne or chickenpox scar may not result in even skin tone. I am personally not a fan of generalized laser resurfacing which literally burns off the entire epidermis leaving the underlying tissues exposed. However, there are always more severe cases when such aggressive treatments may be in order. Be aware that such an invasive technique may have permanent skin discoloration, infection and rarely even worse scar formation associated with it.

  Fairly superficial depressed scars may also respond to a series of microdermabrasions or chemical peels.

  Ice pick scars often have to be surgically cut out and stitched back together leaving a fine line scar instead of the deep, thickly walled jagged skin defect. These are relatively small excisions, just large enough to get around the scar. Then microdermabrasion or another procedure can be used to make the linear scar less visible if necessary. Ice pick scars do not tend to fill well due to the continued visibility of the edges.

I like trying to use topical products that are known to help stimulate fibroblast activity and boost collagen production. Vitamin C as found in Cellex-C High Potency Serum and Cellex-C Advanced-C Serumhas these wound healing, rejuvenating qualitities. I wouldn't call Vitamin C, "scar" therapy products, but I do think that if you are looking for all options to try to help improve the appearance of a scar, you may want to consider trying it.

• Skin Discoloration

  Skin discoloration is not a scar. Medically termed post inflammatory hyperpigmentation (dark skin stains) or post inflammatory hypopigmentation (lighter than normal skin discoloration), PIH is simply discoloration. It it's dark, you need to bleach it. If light, give Mother Nature time to try to re-pigment the area. As long as it's not porcelain white due to a complete loss of pigment producing cells, you stand a good chance of regaining at least some skin color over time. In either situation, wearing a sunscreen daily is very important for obtaining your best results.

  Now most skin trauma may have some discoloration associated with it. That is why a good surgeon/dermatologist will tell the patient to keep the newly healing wound from getting sun exposure that may exaggerate the natural skin discoloration that accompanies wound healing. Use an SPF 30 or Total Block to help protect the area.

AVOIDANCE OF SCAR FORMATION

Wouldn't it be easier if you didn't get the scar in the first place? Then you wouldn't have to worry about how to fix it.

Let's begin at the beginning. How do you care for a wound? Whether it's a scrapped knee on the playground or a skin biopsy at the dermatologist's office, a cut can result in a scar. Infection is a major contributor to increasing your chances for developing a bad scar. All open wounds should be cleansed with hydrogen peroxide and a topical antibiotic ointment like Polysporin First Aid Antibiotic Ointment applied twice daily.

Neosporin, a brand of antibiotic ointment, has been marketed as a scar prevention treatment. However, what you may not glean from the commercials and ads is that there is no reason other brands of topical antibacterial ointments shouldn't accomplish the same outcome. Neosporin is a brand that has been around a long time and has a good track record, but I would be remiss as a dermatologist if I didn't share with you that who can develop serious allergic skin rashes to the use of neomycin, the active ingredient in Neosporin. The same is true for any first aid cream containing neomycin, particularly those labeled "triple" antibiotic ointments. If your cut is worsening, swelling, turning red, blistering or oozing, you may have an allergic reaction to your antibiotic ointment instead of an infection. Only your doctor should make that determination, so make the phone call.

Next, you've heard it time and time again. Don't pick at your skin! This includes squeezing your acne bumps, popping your chicken pox, scratching open your mosquito bites and digging at those ingrown hairs.

So now you've treated the open wound and the skin looks intact. Did you know that it still takes at least 6 months for the collagen within the dermis to be fully healed? Now is the time to take steps to helping normalize the healing process.

Mederma has continued to show excellent results in helping prevent freshly healed wounds from scarring badly. In addition, it also helps the areas resolve quicker. The wound must be healed, without raw, open areas before Mederma is started. As Mederma is derived from onions, it is safe to use even if pregnant, nursing and OK for the youngest of children. In fact, I used it successfully on an infant in the neonatal ICU who was prone to developing scars from the electrode patches used to monitor his condition.

Mederma is usually applied 3-4 times a day for anywhere from 8-12 weeks.

Needless to say, avoidance of conditions that lead to scar formation is important, such as treating acne or starting appropriate therapy for your chickenpox or eczema can help prevent future long, drawn-out scar treatments.

As you can see, there are numerous options for those interested in the treatment of scars, so hopefully you won't have to look at them for the rest of your life!

Thank you for taking your time to read my newsletter. As always, I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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