The scar is the end result of the wound healing process.
How does this work exactly?
What types of scars can arise?
And what does the cosmetic and medical treatment look like?
After an injury to the skin that extends into the dermis, a scar represents the final state of wound healing . The causes can be, for example, surgical interventions, burns, tattoos or other injuries. Only injuries to the epidermis such as abrasions heal without scars. Wound healing can be broken down into four phases split up.
It takes about eight to ten days for a wound to heal, but it takes about three weeks to fully cope with stress. It should be noted that the scar tissue is a substitute for connective tissue and in no way has the functions and properties of normal skin. The collagen fibres are no longer intertwined, but arranged in parallel, and there is a lack of elastic fibres. As a result, the scar tissue lacks elasticity and there is also a lack of hair, sebum or sweat glands and the melanocytes responsible for pigment formation. This also explains why a scar looks different than normal skin.
After the wound has healed, further remodelling processes take place in the scar: collagen fibres multiply and contract, the scar can shrink and harden, and the number of blood vessels decreases. The scar, which initially appears red, fades over time and becomes whitish.
What types are there?
There are a variety of types of scars. In daily practice, a distinction is mainly made between immature, mature, sunken (atrophic) scars, scar growths (hypertrophic scars) and keloids.
Immature scars are seen at the beginning of every scar healing process. They are often reddened, slightly raised and accompanied by itching or some pain. After the remodelling processes of the tissue are complete, they turn into mature scars that are pale, depigmented, and largely without pain or itching. Mostly they are at the skin level or slightly below. Depending on the visibility of the scars, they can still be very stressful for the patient.
Atophic scars are typically below the skin level because not enough collagen fibres were formed during wound healing. This happens when tensile forces have acted on the wound or, for example, the wound has not been adequately supplied with blood and supplied. Well-known examples are acne scars on the face, especially on the cheeks, but also on the décolleté or back. A distinction is made between ice pick scars or “ice-pick” scars (narrow and deep), “boxcar” (as punched out) and “rolling” (U-shaped) scars on the basis of their optics. Another example of atrophic scars are chickenpox scars.
Hypertrophic scars are more pronounced, bulge-like and protrude above the skin level, but are limited to the location of the injury or the wound. They often appear reddish and partly hardened. Itching or scarring may occur. In addition to the aesthetic aspect, hypertrophic scars in the area of joints can interfere with the movement and lead to functional restrictions.
The reasons for the development of hypertrophic scars are tension forces that act on the wound during the healing phase. For protection and stability, the wound works against it and produces more collagen fibres.
Keloids are often mistaken for hypertrophic scars. An important distinguishing feature is that keloids grow beyond the actual area of the injury. Keloids are hemispherical, bulging, rough, reddened skin changes that are often accompanied by itching and pain. Even minimal injuries, such as insect bites, can lead to keloid formation, and often only months to years after the injury.
The development of keloids appears to be genetically influenced (familial clustering) and is more common in patients with darker Fitzpatrick skin types. The associated overgrowth of the scar is an overproduction of connective tissue and collagen fibers. The anatomy also plays a role: it is noticeable that keloids form on the upper half of the body, especially on the décolleté, back, upper arms or earlobes.
Limits in cosmetics
An important focus of cosmetic scar treatment is optical coverage. The products used (blemish balms or camouflage make-up) should have good, proven compatibility and have a slightly occlusive effect. This offers the fabric protection and improves moisture retention. In addition to lamination, cosmetic treatments are also available, the success of which depends largely on the age of the scar. As a rule of thumb, the older the scar, the more difficult it is to treat. However, cosmetic scar treatment should only be started after the wound has healed, when the tissue is sufficiently firm. Keloids always belong in the hands of dermatologists!
Cosmetic treatments
First and foremost are peeling treatments such as plant-based treatment cures ( Green Peel) . Scar tissue and superficial indurations are gently removed, the regeneration of the tissue and the absorption of active ingredients are supported. Mechanical ablation makes scars flatter, softer and less visible. But not all peeling methods are suitable for scar tissue. Fruit acid peelings or medicinal trichloroacetic acid are effective, but not a means for long-term use, as the skin is stressed.
Other superficial procedures, for example microdermabrasion , can also be used by the beautician to visually improve especially superficial, atrophic scars. Repeated treatments are required depending on the initial condition. With microneedling, the new synthesis of collagen is stimulated by pinprick-induced small injuries in the skin. Especially with sunken scar tissue, an adjustment to the surrounding skin level can be achieved.
Supportive cosmetic procedures for scar treatment are massages and ultrasound . With regular use, the scar structure can be significantly improved and active ingredients can also be smuggled into the tissue.
Medical treatments
Different therapies can be used depending on the type of scar. Surgical therapy can improve “problem scars” near the joints, for example, or hypertrophic or cosmetically disturbing scars. However, the doctor should always carefully consider whether the planned intervention can significantly improve the functional or cosmetic result.
Another medical treatment is to inject cortisone (glucocorticoids) directly into the scar. This inhibits the production of collagen fibers and the scar becomes flatter. The therapy works particularly well with hypertrophic scars and active, bright red keloids. In the case of keloids, injection treatments are often combined with freezing (cryosurgery). If there is no improvement, then surgical removal of the keloid can be considered, although there is always the risk of a new keloid.
A treatment by means of pressure takes the form of compression bandages that must be worn by the patient for months to years - hence the involvement of the patient is very important! Areas of application are large-scale hypertrophic scars, for example after burns or scalds.
Lasers are playing an increasingly important role in scar therapy. They make use of various functional mechanisms and can therefore be used very specifically depending on the type of scar. The laser treatment of scar tissue always belongs in the hands of experts, because an aggressive approach can also lead to a deterioration of the scars with all technologies and scar types.
Scar care
As long as no permanent scar with a dry surface has formed and there is still moist granulation tissue, panthenol supports the wound healing process and the moisture balance in the scar tissue. To restore maximum skin elasticity, the scar tissue should be supplied with natural oils so that it remains soft and does not dry out.
In scar care, silicone is also very important. It can be applied in the form of plasters, gels or creams. It should be used regularly every day and for at least three months to get a good effect. The mechanism of action has not yet been finally clarified, but it is known that the occlusive effect of the silicone increases the moisture penetration of the scar. In addition, signals to the fibroblasts should result in good structuring within the scar.
Another active ingredient that is often used for scar care is onion extract . It has anti-inflammatory, germicidal and inhibitory effects on the multiplication of connective tissue cells. This can counteract the development of bulging or hypertrophic scars.
Since there are no pigment-forming cells in the scar tissue, every fresh scar should be protected with a high level of light protection (SPF 50) in the first three months in order to avoid sunburn and consequent complications (hyperpigmentation, development of skin cancer).
Professional tip : The all-rounder urea helps with itchy keloids, among other things.
The 4 phases of wound healing
1. Exudation phase (exudation phase): Immediately after the injury, blood escapes from the damaged vessels and collects in the wound with tissue water. This flushes out the wound and cleans it. The blood flow is stopped as part of the coagulation, which also initiates the regeneration process at the same time. In the process, a special protein (fibrin) is formed which, like a kind of "glue", seals the wound like a net - a natural, temporary wound closure is created.
2. Cleaning phase (resorption phase ): In this phase, special phagocytes (macrophages) ensure that debris is cleared away. The cells of the body's own defenses fight against invading pathogens such as bacteria. At the same time, substances are released that attract cells to repair the tissue defect.
3. Multiplication phase (proliferation phase): Special connective tissue cells (fibroblasts) migrate into the wound and start collagen production. The fibrin network serves as a kind of scaffolding during the first phase of wound healing. At the same time, new, small vessels sprout. The result is a cell-rich, well-perfused defect covering - the granulation tissue is formed. The edges of the wound are approaching again.
4. Repair phase (epithelialization phase): The granulation tissue matures into tear-resistant connective tissue, whereby the collagen bundles align themselves along the direction of stress. The surface of the wound is now also closed by new epithelial cells. A connective tissue scar has emerged as the final stage of wound healing.
Dr. med. Christine Schrammek
The managing director of Dr. med. Christine Schrammek
Kosmetik GmbH & Co. KG is a dermatologist and allergologist. As an anti-aging expert, she develops treatment methods such as the GREEN PEEL® herbal peeling treatment and dermatological care products.
Christina Drusio
is part of the Dr. med. Schrammek owner family and management of Dr. med. Christine Schrammek Kosmetik GmbH & Co. KG. As an expert of sensitive skin, the Medical Specialist for Dermatology and Venerology is a valued speaker at international lectures and seminars.