2013 Wound Care People Ltd - Journal of Community Nursing
W ound H eAling
Abnormal scarring: an overview
first used in an attempt to illustrate the
way the lesions expand laterally from the
original scar into normal tissue. Keloids
are dermal fibrotic lesions that are raised,
reddish-purple, nodular scars that are
firmer than hypertrophic scars (Figure 2).
They have a prolonged proliferative
phase due to an inherited metabolic alteration in collagen. Keloids continue to
grow indefinitely and may become
uncomfortable and restricting, itchy or
painful. Formation may occur weeks or
years following the initial trauma.
Keloids arise due to trauma or injury to
the skin such as scratches, injections,
insect bites, ear piercing and tattoos3.
Young people with darker skin are more
prone to this type of scarring; keloids are
between five and 15 times more common
in black people than white people6,
suggesting a genetic basis. Additionally,
they are more common on certain parts of
the body for example ears, chest, shoulders and back.
Both keloid and hypertrophic scars
have many features in common, they are
both raised; initially pink to purple
lesions that are often painful, pruritic or
both3. Table 1 outlines the clinical
features of each.
Hypertrophic scars and keloids usually
form7: in body areas that exhibit slow
wound healing; in pressure dependent
or movement-dependent areas; in areas
of tension that are particularly prone to
abnormal scar formation.
Hypertrophic scars have a good
scar is an essential part of the
natural healing process subsequent to an injury to the dermis or
the epidermis1. Scars are thick mounds of
scar tissue, characterised by excessive
amounts of collagen deposition2. The
type of scar that forms can depend on a
variety of factors3: the nature of the
injury; part of body injured; size and
depth of the wound.
Scar classification is therefore important as subtle differences in clinical
characteristics can indicate the diagnosis
and treatment protocol required3.
An estimated 23 million adults in the
UK have some sort of scar. Normal
scars are preceded by injury, immediate
in onset, flat and asymptomatic. These
are the most common type of scar and
are a result of the body’s natural
healing process. Hypertrophic and
keloid scars occur when the healing
process is deranged.
This article, abridged and amended
from an article previously published in
JCN, outlines the differences between
these latter types.
Normal scars, the most common, are
immediate in onset, flat and asymptomatic. They form when a skin defect
heals without excessive quantities of
newly synthesised collagen. Initially the
scar may be red or dark and raised, but
will become pale and flat over time; this
may take up to two years4.
Abnormal scar formation is unique to
humans; the range of suggested aetiologies and treatments for abnormal wound
healing indicate that our understanding
of these processes is incomplete.
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Hypertrophic scars are caused by
overzealous collagen synthesis coupled
with limited collagen degradation
during the remodelling phase of wound
healing. These scars occur within weeks
of the initial trauma and have a tendency
to remain stable or regress with time;
while they remain confined to the
boundary of the original injury, they may
continue to thicken for up to six months5.
Hypertrophic scars are pink, raised, firm
erythematous scars characterised by a
decrease expression of collagenase (Figure 1).
Hypertrophic scars are more common
in young people and people with very
pale or very dark skin. Despite numerous
studies, however, there is no uniformly
accepted theory or explanation which
indicates which factor initiates hypertrophic scar formation. Almost all
hypertrophic scars are associated with an
assault or injury to the skin, in addition
factors such as skin tension, wound
infection, and prolonged inflammatory
response, have all been implicated5.
Figure 1: A hypertrophic scar.
The term keloid, meaning “crab claw” was
Journal of Community Nursing May/June 2013, volume 27, issue 3
Figure 2: Keloid scarring.
W ound H ealing
Less familial incidence predilection
Blacks more than Caucasians
Less race related
Females more than males
Equal sex ratio
Most common in 10 to 30 year Any age but more common in
younger age groups (under 20yrs)
Overgrows wound border
Develops months after injury Develops soon after injury and
and rarely subsides
subsides with time
High predilection for the face, Across flexor surfaces
earlobes, pre-sternal area and
The prevention of scar formation is
important for physical and mental wellbeing; teaching patients to massage their
scars will have a significant effect in
preventing the scar to form. Appropriate
management of the scar will ensure that
the wound remains healed and that the
patient is happy with the outcome.
No scar can ever be removed completely,
although they may improve naturally
over time. Their appearance can be
improved by surgical removal, silicone
gels, and laser therapy. Generally,
conservative non-surgical methods are
applicable as a primary treatment option.
Choice of treatment will depend upon
anatomical location of the scar and
Massage and creaming
Massage can help prevent abnormal scar
formation; it breaks up the collagen fibres
to soften, flatten and fade scars. While
evidence is unsubstantial, it correlates
with the evidence for the use of pressure
therapy8. Any type of emollient cream
can be used, but not oil or petroleum
based if having pressure therapy.
Massage should be started as soon as the
Silicone gels have been used for management of scars since the early 1980s.
Poston9 argues that it is a safe and effective management option; the gels adhere
and mould to any body contour and are
safely and painlessly applied and removed.
Their mechanism of action remains
unknown, but the moisture vapourisation rate has been found to be half of that
of exposed scar tissue10. The softening
and flattening effect of gel sheeting may
be due to hydration of the stratum
corneum and/or release of a low molecular weight silicone fluid. Poston9
suggests that application of silicone gel
improves the redness, itching, texture
and thickness of hypertrophic and keloid
scars in 60-100 per cent of cases. Results
from randomised, controlled trials
suggest that silicone gel sheeting is a safe
and effective management option for
both hypertrophic and keloid scars11. In
addition the International Clinical Recommendations on Scar Management state that
the only treatments for which there is
sufficient evidence to make evidence
based recommendation are silicone
gel sheeting and intra-lesional corticosteroids11.
The gels are self-adhesive or can be
held in place by bandages, tape, tubular
bandages or pressure garments. Patients
are advised to build up wear time until
patients can tolerate eight hours or more,
and ensure good hygiene of the product12.
Pressure therapy promotes: restoration
of function; relief of symptoms; prevention of recurrence; optimum aesthetic
Pressure garments are most useful
when the scar is still immature, either as
prophylaxis in individuals who are at
risk of developing abnormal scars, or
when there are early signs of abnormal
scarring. They are 85 per cent successful
in compliant patients, but the garments
are tight, often only available in one
colour and must be worn for 23 hours a
day for up to two years, so compliance is
often an issue5. Pressures should be
24mmHg or above and must be maintained for a minimum of 12 months. They
can be used in conjunction with silicone
gels, adding efficacy in areas that are
difficult to apply pressure such as the
sternum and joints11.
Related to tension and timing of
response to treatment, whilst keloids
seldom resolve spontaneously and have
a poor response to treatment3. Treatment
options outlined below refer therefore to
Remains within wound borders
Intra-lesional cortico-steroid injections of
triamcinolone are thought to be effective;
steroids restrict the blood flow locally in
the scar and inhibit protein synthesis5.
Corticosteroid treatment appears to
diminish tissue deposition and to soften
and flatten keloid scars; injections are
more effective in preventing hypertrophic scars than resolving them, and
are frequently administered in combination with surgery and pressure therapy to
Current laser technology permits
successful treatment of various types of
scars. Alster12 demonstrated clinical and
textural improvements in erythematous
and hypertrophic scars and keloids.
Table 1: Clinical features of keloid and hypertrophied scar tissue
1. Ladak A, Tredget EE. (2009) Pathophysiology
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3. Munro KJG. (1995) Hypertrophic and Keloid
Scars. Journal of Wound Care. 4; 3: 143-148
4. Juckett G, Hartman-Adams H. (2009) Management of Keloids and Hypertrophic Scars.
American Family Physician. 80; 3: 253 – 260
5. Pape SA. (1993) The Management of Scars.
Journal of Wound Care. 2; 6: 354 – 360
6. Bloemen MCT, Van de Veer WM, Ulrich MMW,
et al. (2009) “Prevention and curative management of hypertrophic scar formation”. Burns. 35:
7. Butler PD, Longaker MT, Yang GP. (2008)
Current Progress in keloid research and treatment. Journal of American College of Surgeons. 206;
8. Niessen F, Spauwen P, Schalkwijk J, et al. (1999)
On the nature of hypertrophic scars. Plastic &
Reconstructive Surgery. 104; 5: 1435 – 1458
9. Patino O, Novick C, Merlo A, et al. (1998)
Massage in Hypertrophic Scars. Journal of Burn
Care and Rehabilitation. 20; 3: 268-271
10. Poston J. (2000) The use of silicone gel sheeting
in the management of hypertrophic and keloid
scars. Journal of Wound Care. 9; 1: 10-16
11. Momeni M, Hafezi F, Rahbar H, et al. (2009)
Effects of silicone gel on burn scars. Burns. 35: 70-74
12. Mustoe TA, Cooter RD, Gold MH. (2002) International clinical recommendations on scar
management. Plastic & Reconstructive Surgery.
110; 2: 560-571
13. Fette A. (2006) Influence of silicone on
abnormal scarring. Plastic Surgery Nursing, 26; 2:
14. Alster T. (1997) Laser Treatment of Hypertrophic Scars, Keloids and Striae. Dermatologic
Clinics. 15; 3: 419-429
Journal of Community Nursing May/June 2013, volume 27, issue 3