Scar Wars: How To Treat Every Type Of Scar

All scars form for the same reason — a surgery, burn, cut, acne spot, or trauma of some sort occurs, which signals a dermal healing response that recruits inflammatory cells. “Living animals all have a natural ability to attempt restoration of function and repair damage to the body after an injury.” explains James Beckman, MD, a board certified plastic and reconstructive surgeon and founder of Therapon Skin Health. “Whether it is skin, other tissue, or even entire organs, scar formation is the first step.” The purpose? “It serves to cover open areas, preventing bacteria from entering and keeping tissues from drying out,” he says.

When you consider the state our bodies would be left in without the ability to scar, it’s a pretty remarkable phenomena. “If our skin would not scar, we would be walking around with big open wounds, which is why scarring is a necessity,” says Gregory Buford, MD, a board certified plastic and reconstructive surgeon in Englewood, CO. “It’s just that society has determined that it’s not pretty.” He likens scars to a kind of biological glue.

With that said, there is no rhyme or reason to how the body responds to injury, which means you can be left with some pretty unique scars. If you are unhappy with the appearance of a scar — no matter where it came from — there are ways to minimize it. Read on for both at-home and in-office scar solutions.

What Determines the Appearance of a Scar

Even on the same person, no two scars heal the same. As Jessica Weiser, MD, a board certified dermatologist in New York City, explains, there are several reasons why scars settle uniquely, including:

• Extent of the injury
• Location of the wound
• Genetics
• Body’s collagen response (i.e. how much of the protein, which is like the building block of skin, is made)

“When new collagen forms, the bundles fill in a wound in the dermis (the second layer of skin),” she says. When just the right amount of collagen is produced, the scar is flat; too much collagen leads to thick, rope-like raised scars and keloids. All scars start red and, as they mature, transform to pink and then white.

Like a good piece of real estate, the end result is all about location, location, location — certain parts of the body are better equipped to handle the formation of a scar than others. “Luckily, on the face, there is a good blood supply, so the area tends to heal more readily there,” says Amanda Doyle, MD, a board certified dermatologist at Russak Dermatology Clinic in New York City. The same cannot be said the further south you go. “As you get towards the waist and further down, the blood supply is farther from the heart, so it takes a lot longer to heal because of the location,” she shares.

Another factor that affects scarring is tension. “In areas like the shoulder or the back, there is a lot of pulling and tugging, and that can lead to a wider-looking scar because of constant tension in that location,” Dr. Doyle adds.

Types of Scars

Scars are like snowflakes — no two are identical. At the most macro level, scars can be classified into two categories:

1. Sunken (a.k.a. atrophic): “Sometimes, there is an absence of fat or other underlying structures that the body cannot fill in and scars end up atrophic or indented,” Dr. Doyle explains.
2. Raised (a.k.a. hypertrophic): “In other circumstances, the body stimulates an overly exuberant response that causes excess scar tissue clinically appearing as raised or keloid-type scars, which are typically the most challenging ones to treat,” she says. “Even with treatment, they may recur or may not respond as readily.”

Moving to a more micro level, there are specific types of scars within those initial classifications:

Atrophic Scars

• Ice Pick Scars: Deep and narrow but small, ice pick scars almost always have a tie to nodular or cystic acne. Resembling a puncture wound of sorts, ice pick scars are commonly categorized as indented skin and occur on the cheeks.
• Boxcar Scars: Rounder in shape and resembling more of a crater, boxcar scars are wider than an ice pick scar but not as wide as rolling scars. They are often due to acne, and the deeper they are, the harder they are to treat.
• Rolling Scars: Reminiscent of a pit but with undefined edges, the more common rolling scars give the area an almost wavy texture and can worsen with age due to a loss of elasticity and collagen in the skin.

Hypertrophic Scars

While not all hypertrophic scars are keloid scars, keloids are perhaps the best known raised scars. They are also considered among the most difficult to treat. Keloids tend to be wide, large, and puffy and occur after a surgery, cut or wound, or even piercing. As Dr. Buford explains, keloids grow outside of the boundaries of the scar and are technically tumors (tumors, by definition, are a growth in the skin and can be noncancerous).

Keloids tend to be more common in people with darker skin (but any skin tone can develop them). “Although keloid scarring generally tends to happen in Asians and African Americans, we don’t fully know why it affects certain skin tones,” Dr. Doyle says. “It’s related to the whole inflammatory process and collagen being re-formed in those areas of injury.” For whatever reason, some people experience that inflammatory response a little more robustly than others, and, “particularly in those two populations, we see it more frequently,” she adds.

At-Home & In-Office Scar Treatments

Scars don’t subscribe to a one-treatment-fixes-all method. Each class of scar responds differently to treatment, which is why picking the right procedure is important. To get the best result, Dr. Doyle recommends an in-person evaluation so your doctor can fully evaluate the size, color, and texture of the scar. Most scars can show improvement, even if that means taking a mix-and-match approach. “There’s no silver bullet or monotherapy that makes scars look perfect,” Dr. Buford cautions. “We can’t always remove a scar in its entirety, but we can take the red out, modulate the scar, and make it thinner.”

Whether your scar is fresh or more mature, the first rule of scar care is to make sure to always protect it from the sun with sunscreen to prevent discoloration and improve its appearance. From there, below are the most effective treatment options for each scar type:

1. Topical Scar Gels

• Best For: Scars that are less than six months old
• The 411: If a scar is newer, faint, and pretty small, you may be able to treat it with a cocktail of over-the-counter topical ingredients like vitamin C, retinol, and hydroquinone or a specifically formulated scar cream, which contains a cocktail of effective ingredients.
• Find It In: Avène Cicalfate+ Scar Gel & Visha Skincare Advanced Correcting Serum

2. Silicone Gel Sheets

• Best For: Minimizing closed, raised surgical scars
• The 411: These specially designed self-adhesive sheets (they’re somewhat reminiscent of a mega bandage) work well for pretty much all types of scars. Not only do they act as an occlusive dressing (read: seals in moisture by creating a barrier), but they also regulate pressure on the scar. Dr. Beckman says that silicone gel sheets have an unexplained effect to keep both the scar and skin surfaces from becoming raised, unsightly, or painful.
• Find It In: Embrace Scar Sheets & Aroamas Professional Silicone Scar Sheets

3. Polyurethane Dressing

• Best For: Hard, red, & raised scars
• The 411: A flexible, waterproof pad of sorts, “polyurethane dressings, while initially used for wound healing, have been shown in a few smaller studies to positively impact the scar surface, improve the microcirculation and improve scar color, firmness, and thickness,” Dr. Weiser says. As she explains, polyurethane is “an alternate ingredient to silicone but behaves in the same way as an occlusive dressing.”

4. Steroid Injections

• Best For: Keloids & thick, raised, itchy, or painful scars that are fully healed
• The 411: Performed by your dermatologist or plastic surgeon, steroid injections use cortisone to take down scar thickness. Some even contain very small amounts of 5-fluorouracil (5-FU), a cancer drug that reduces fibroblast activity and, in turn, hinders the progression of scar tissue. There is the potential for the injection site to darken, but, when cortisone is injected into a keloid, Dr. Beckman says that the steroid softens and weakens the scar.

5. Hyaluronic Acid & Biostimulatory Fillers

• Best For: Sunken & indented scars, like ice pick acne scars
• The 411: For the past few years, doctors have been injecting fillers like Juvéderm® and Belotero® Balance to treat scars. “Dermal fillers help add volume to level a sunken scar with the surrounding tissue,” Dr. Weiser says. Depending on the patient’s preference, “hyaluronic acid fillers can be used for immediate improvement or biostimulatory fillers can be used to stimulate collagen production around the scar like a scaffold,” she adds. Some doctors, like Dr. Buford, pair hyaluronic acid filler with platelet-rich plasma (PRP) to level up the scar and change the character of the overlying skin. Just like using filler in the face for aesthetic and anti-aging purposes, the results are not permanent and need to be repeated.

6. Neurotoxins

• Best For: Surgical scars & scars that occur in a bony area
• The 411: One of the newer ways to correct scars is with neurotoxin (think: Botox® or Dysport®), which can be injected into the scar to reduce muscle tension on scar tissue. “Using Botox® or other neuromodulators to reduce or eliminate muscle contraction in and around the scar has been shown to reduce hypertrophy and also to decrease fish-mouth or spread scars,” Dr. Weiser shares. Dr. Buford agrees. “Botox® is effective in a variety of scars,” he says. “When I place it in fresh scars all over the body, the scars tend to heal a little nicer.” But that doesn’t relegate the off-label use of Botox® just to body scars — it works on facial scars, too. “We know one thing that is consistent about scars is that they heal best under as little tension as possible,” he reiterates. “So, if you inject Botox®, you can relax the area to some degree. It’s a little trick, and it only works on certain areas.”

7. Laser & Light Treatments

• Best For: Acne scars, keloids, raised or flat scars, red & discolored scars
• The 411: Light-based and laser therapies stimulate new collagen to lessen the look of the scar. Light-based treatments, like IPL (intense pulsed light) and BBL (broadband light), work well on scars on lighter skin. Pulsed dye lasers (these target blood vessels in the skin) are best for reducing redness in scars, while resurfacing lasers can soften the scar’s appearance and coloration. “These lasers involve the creation of controlled microscopic wounds in a specified percentage of the skin, which induces a wound healing response,” Dr. Weiser explains.

8. Microneedling

• Best For: Superficial surgical & acne scars
• The 411: Perhaps the treatment du jour for unwanted scars, particularly acne scars, microneedling (a.k.a. collagen induction therapy) creates microscopic wounds in the skin to stimulate new collagen that, in turn, smooths out the skin and the surrounding scar. It can also be coupled with PRP to further enhance the results. “Microneedling — especially with PRP — does work, and there are studies that show its efficacy,” Dr. Buford says.

9. Subcision

• Best For: Acne scars
• The 411: One of the most reliable ways to pull a deep scar out from under the skin and make it more flush with the surface is with subcision. “This classic technique requires inserting a hypodermic needle into the skin directly beneath the scar to loosen and break the fibers that connect the scar to the tissue underneath it,” Dr. Weiser explains. “While this primarily helps to lift indented scars, it can also be helpful to release the collagen at the site of needle insertion to trigger a further healing response.”

10. Radiation Therapy

• Best For: Stubborn keloids
• The 411: One of the more under-the-radar scar treatments is radiation therapy, which, although promising, is strictly reserved for keloid improvement. “It’s used as a last resort for very challenging keloids,” Dr. Weiser says. If you are wondering how this therapy relates to cancer treatments, it is similar. “Radiation treatments entail the use of ionizing radiation — used for cancer/tumor treatment — usually externally applied to destroy existing collagen-producing cells and limit production of new ones,” she explains.

11. Scar Relaxation

• The 411: Performed using a digital rotary tattoo machine to safely injure the skin and then repair it, this unique scar reduction method gives up to 80 percent improvement over six to 12 months and transforms almost every type of scar into soft, smooth skin. Scar expert Linda Dunn Carter, who invented The DC Method over a decade ago, first abrades the skin down to the dermal layer to create new tissue while simultaneously forcing any dark pigment to purge. The tattoo machine breaks the bands of connective tissue that make up the scar to incite new, healthy tissue formation.

12. Scar Revision Surgery

• The 411: Usually performed as the result of a poor surgical scar (think: after a C-section), surgical scar revision works best when a piece of the original scar is excised. But here’s the kicker: anytime you treat a scar with surgery, it will result in another scar — albeit a potentially thinner and flatter one. “Remember, the only way to erase a scar is to cut it out and replace it for another scar,” Dr. Bufford cautions. “But, sometimes, we can replace the old scar with a better-hidden one.”

The Takeaway

Scarring is like a young child that you want to control but can’t. While scarless procedures sound promising, they’re far from reality, and you can’t do much to prevent occasional nicks and scratches. Fortunately, there are more treatment options to choose from than ever before for virtually every type of scar.

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