4 days ago

Scar Team

We have discussed the delivery of potent anti-scar drugs into the depths of hypertrophic scars with lasers and radiofrequency devices. The machines make hundreds of small channels through which medications may be administered directly. Drugs that have been given in this way include steroids such as triamcinalone acetate, 5-fluouracil, collagenases and platelet-rich plasma. Now, ultrasound energy has been used to push such drugs more deeply into the skin. In an article in the journal Lasers Surgery and Medicine, Trelles and colleagues showed that after holes had been created deep within the skin - in this case by using radiofrequency energy - ultrasound results in an effective and simple way of driving medications more deeply for problematic scars. ...

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1 week ago

Scar Team

What guides our treatment of burns scars? Mieke Anthonissen and colleagues undertook a thorough review of the literature in 2016. Their systematic review in the journal Burns found that there is surprisingly little top quality evidence that a given treatment is beneficial. Only twenty-two articles were found that relayed reliable findings from, for example, a 'randomised controlled trial' where a treatment is compared with a control such as no treatment. The results were fascinating. Pressure and silicone appear to be beneficial producing improvements in scar thickness, redness and pliability. Massage had some credible benefit on scar pliability, pain and itch, but not as convincing in effect as pressure or silicone. The use of moisturisers and lotions may have an effect on itch, but the findings of multiple studies were contradictory. For all other forms of 'conservative' treatment, there was no consensus in the literature. ...

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2 weeks ago

Scar Team

Does taping a maturing, incisional scar improve its appearance? Increasingly, the answer evidence suggests 'yes'. Helena Rosengren and colleagues published rigorous research on this in 2013. 195 Australian patients having skin lesions removed were randomised to either taping or the traditional treatment for three months. Of the 136 patients who taped, a blinded assessor found that their scars were on average 1mm less stretched than the scars in the 73 control patients. Moreover, the effect seemed to be gender-dependent: everyone benefited, but the mean benefit for male subjects was a scar that was 3mm less wide than the control group. This effect seemed to be conserved up to six months. ...

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2 weeks ago

Scar Team

We often get asked, "How long until my scar fades?" The common cause of colour change in a normal scar is the redness associated with altered blood flow. In a comprehensive study of very similar wound images from 103 volunteers, Bond and colleagues made a number of useful findings back in 2008. Most normal scars fade - go from red to pale - at around seven months after injury. Some 'normal' scars remained red at one year. However, the researchers found some interesting trends. Scars made from incisions - where no tissue was taken - became pale more quickly than those in which tissue was taken away ('excisions'). Also, scars on the front of the body seemed to lose redness more quickly than those on the back of the body. Microscopic examination of samples seemed to show that the redness of scars was related to the overall number of blood vessels within a scar. ...

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2 weeks ago

Scar Team

History teaches us some salient lessons derived from practice and meticulous observation. Nature still holds that, "...a keloid should not be operated upon: it will only return, and will also recur in the stitch-holes." A quote from Professor John Da Costa in his 1894 text, 'A manual of modern surgery.' ...

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2 weeks ago

Scar Team

For difficult scars, sometimes multiple approaches are necessary. Severe acne scars are a good example. Garg and Bajeva in 2014 described a multi-pronged approach to significant acne. Subcision, microneedling and a trichloroacetic acid (TCA) peel were combined for fifty patients. The types of treatment were varied and notably, all patients needed a minimum of six treatments. 63% of patients with the most severe form (grade 4 on the Goodman and Baron scale) improved to grade 2. There was high patient satisfaction and in a minority patients, it was reported that there was no visible scarring at one month. This study demonstrates something that we constantly emphasise to patients - for the majority, there is no magic solution that will give immediate results and the best strategy is to work on gradual but durable improvement. Having realistic expectations leads to a better adaptation. Often, multiple different treatment approaches are required and this may entail changing techniques as a scar matures. ...

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2 weeks ago

Scar Team

How might pressure garments work in terms of the improvement of scar tissue? We have used them for decades, but we have never really had much of an insight about how pressure improves hypertrophic or keloidal scarring. An article in the journal Wounds in 2018 shed some light. Alkhalil and colleagues had used a model that mimics human skin to establish the effect of pressure. A global screening approach (gene array) to look at all the messenger RNA - the product of the genes - which were activated by pressure, revealed some novel findings. Multiple pathways were changed by pressure. These included those involved with acute inflammation, calcium signalling and cholesterol utilisation. Key genes were identified such as CYP51A1, which may be a fruitful target for future anti-scarring treatments. This paper offered some fascinating insights into a widely used clinical treatment that may bridge the gap in our understanding about how cells within scar tissue interact with their environment. ...

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3 weeks ago

Scar Team

Can laser be used in children with significant scarring? The answer is yes, and with good effect. Zuccaro and colleagues published last year about their experience with combined ablative, fractional CO2 laser and pulsed dye laser in children. They had undertaken treatments with either laser or both in combination in 125 children with burn scars, half of whom were under 5 years-of-age at first treatment. Average Vancouver Scar Scale score went from 7.4 to 5.8. Usually in younger children, a general anaesthetic is required for shorter treatment. We work closely with the laser services in Bristol and Salisbury to provide laser - mainly for hypertrophic burns scars - to the paediatric population. ...

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3 weeks ago

Scar Team

Deliberate self harm scars can be very debilitating. There are few options for the improvement of scars which may often show features of colour mismatch, stretching, atrophy and occasionally, adherence. One of the most drastic approaches to changing appearance was described by Ismail and colleagues in 2008 in the journal JPRAS. Surgically, they removed all of the skin of the forearm and resurfaced the area with an artificial bottom layer of the skin ('Integra' - a dermal substitute) and the patient's own top layer of the skin over this. This procedure,which can be done in one or two stages, requires a general anaesthetic, significant time away from activities and prolonged dressings. If it works well, the operated area no longer has stigmatising marks for which the regularity and direction can be obvious. The operated area clearly looks different from surronding skin.
If the technique does not work perfectly, there can be significant problems with wound healing, infection and altered sensation. A challenging and major approach to a increasingly common problem.
...

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3 weeks ago

Scar Team

Experimental update: Michael Longaker's group in the United States have been undertaking some basic science work into the effects of an antibiotic, doxycycline, on wound healing. This drug, as well as it's effect on certain bacteria, has a number of beneficial effects on the formation of scar tissue (fibroblasia) without affecting the ability of wounds to repair. In a paper from the Annals of Surgery at the end of last year, the group found that a single of injection of the antibiotic just after a small wound could reduce the thickness of scars by about 25%. However, their model was pre-clinical in nature and we need to be sure that these effects are replicated in human skin under normal wound healing conditions. ...

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4 weeks ago

Scar Team

A recent paper provides some further support for the use of botulinum toxin in the treatment of symptomatic scars. Previous studies had suggested that the action of botox on nerves could be beneficial for symptoms such as irritation. An article in the journal Dermatologic Therapy from a collabortive of groups around the world indicates that they undertook a rigorous assessment of corticosteroid injection versus corticosteroid injections with botulinum toxin in 40 keloids across 20 patients. Each patient had two keloids, one of which had steroids and the other one had the combination of drugs. The botulinum toxin group had a markedly better outcome in terms of pain and itch. We have offered botulinum toxin injections for problematic scars for many years here at The Scar Team. We have found them to be a safe and effective way of breaking the cycle of irritation which leads to constant trauma to the site. ...

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4 weeks ago

Scar Team

There has always been a concern that aggressive resurfacing techniques in darker skin can result in complications such as permanently altered pigmentation. Ibrahim and colleagues in the literature this month report that three carbon dioxide treatments started one month after surgery and spaced monthly produced an improvement in the patients' scar ratings using the Vancouver Scar Scale. There appeared to be no complications in terms of pigmentation - pigmentation improved - and height and pliability of scars also improved. However, it is noted that the overall improvement in scars was not great and it is likely that to avoid hyperpigmentation, relatively low energy settings were used. Moreover, the follow up for patients was not particularly long. Studies of this type really need to review patients for a couple of years to ensure that the effects are durable. However, this study has demonstrated that some scar improvement is possible in darker skin with the CO2 laser and less powerful settings. ...

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4 weeks ago

Scar Team

How might we improve the colour of very pale scars? A quirky paper in this month's Aesthetic Surgery Journal gives one approach. In 38 patients, they undertook very small biopsy skin grafts and transplanted these to white or pale scars over one to three treatments. One year after treatment, the outcome in terms of pigmentation was judged to be vastly better by both the patients and independent observers. They have suggested that the improvement is due to the transfer of pigment cells (melanocytes) with the donor tissue to the pale scar. Scars are known to lack these cells. This approach is laborious but simple in concept - it may provide a permanent colour solution to normal or atrophic scars. ...

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4 weeks ago

Scar Team

Can microneedling be used for stretch marks (striae distensae)? Aust and colleagues in 2008 showed that in terms of patient perception, there was a great improvement with this approach. This general conclusion has been confirmed by subsequent studies by Fernandes and Signorini, Rezai and Park and colleagues. Moreover, Aust has gone onto show that there are improvements in skin structure, with tightening, an increase in collagen and elastin proteins, and new blood vessel formation. However, it is still possible to see striae at close quarters and in our experience, stretch marks never disappear completely. New approaches are being explored and over the coming months we will give our assessment on techniques such as the ablative lasers in this setting. ...

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4 weeks ago

Scar Team

When a keloid is injected with steroid, what is the success rate? Reviewing the literature, the best series indicate that only 9% of scars relapse and recur. In the worst reports, half of all keloids recur and some of these may become unresponsive to this form of treatment. This is why a multi-modal approach must be considered for these very troublesome skin growths. ...

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1 month ago

Scar Team

An interesting article in this month's literature compares corticosteroid injections and 5-fluorouracil (5-FU) in a Finnish population. Hietanen and colleagues indicated that in this randomised, controlled trial of injections in 43 patients (50 scars), both drugs produced clinical benefit for keloids over six months. However, there appeared to be less minor local side effects with 5-FU. Side effects with steroids included thinning of the skin and new, harmless but visible blood vessel formation ('telangiectasis'). However, there were rarer, but just as problematic side effects with 5-FU including ulceration and a change in pigmentation. Overall, 5-FU may be better for cosmetically-sensitive sites but, one of the drawbacks of this study was the short-term follow up. Keloids can certainly recur well beyond six months after treatment. Nevertheless, the authors should be commended for the rigorousness of this study. ...

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1 month ago

Scar Team

What does microneedling do to the thickness of the skin? Aust and colleagues in 2008 published the first in depth study on what scars look like under the microscope before and after microneedling. Twenty patients with matched samples from the same area were analysed. All showed a significant increase in the amount of the structural proteins - collagen and elastin - some six months after injury. Furthermore, the collagen seemed to show a normal lattice structure and not the parallel bundles of fibres that resemble thick ropes in mature, abnormal scars. As well as these changes in the bottom layer of the skin, the top layer also seemed to thicken by up to 40%. We use microneedling here at the scar team to normalise the texture and thickness of atrophic scars including stretch marks, some forms of acne scarring and more severe forms of deliberate self-harm scarring. ...

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1 month ago

Scar Team

When were corticosteroid injections first used therapeutically for scars? 1950 was the first year when steroids were applied topically to scars, producing thinning of the skin. We still do this in the form of corticosteroid tape with agents such as fludroxycortide. However, it was not until 1954 when Merton Griswold injected hydrocortisone into hypertrophic scars, that the first potential usage of an injectable agent was considered. There was minimal benefit, possibly because of the nature of the agent, its concentration or the site of injection. However, a few years later, a trial of hydrocortisone injected into vaccination sites on the arm or elsewhere demonstrated a high rate of scar regression: clinical benefit. Both topical and injectable corticosteroids are used by The Scar Team to reduce angry, fibroproliferative keloidal or hypertrophic scars. ...

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2 months ago

Scar Team

How does a normal scar change with time? It would be slightly strange to put a normal scar under the microscope, but some groups have done this for reasons like scar revision operations or as part of a research study. The findings are fascinating. Normal scars are highly dynamic and change greatly with time. There are lots of inflammatory cells which are attracted into the wound in the early stages but if healing progresses normally, these disappear by about one month after injury. There is an increase in blood vessel number for anything up to three months. However, as blood vessel density goes down, the size of the remaining blood vessels may be relatively larger than those present beforehand. There seems to be a link between the overall vascularity and the tendency for scars to remain 'angry'; this underpins modern approaches with vascular lasers such as the pulse dye laser, in the first few months after wound formation. Ultimately, in a normal scar, the top layer of the skin (epidermis) reforms, but its junction with the bottom layer of the skin (dermis) remains abnormal. Equally, the structural proteins are changed for the long haul: collagen forms broader bundles and elastin is much reduced in quantity. Finally, skin appendages are usually absent in a normal scar. Clinically, this can be problematic with dryness due to sebaceous gland loss and alopecia due to hair follicle absence. ...

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2 months ago

Scar Team

One of the great enigmas of wounds and scarring is why in certain situations, healing results in no visible scar. This has been termed 'regenerative wound healing'. There are some classical examples in the animal world. The Mexican axolotl can regenerate a whole limb including skin and soft tissue. No scarring is visible. Similarly, deer discard their antlers every year and regrow a new set. However, in adult humans, it only appears that certain tissues such as the liver, kidney and lining of the womb can regenerate when injured. Much interest has focused on embryonic wound healing and there is some evidence that in the early stages of pregnancy, wounds or operations appear to heal without evidence of visible scarring. Genetically, we are just starting to get a flavour of which genes might be involved in the process of regenerative wound healing. The Lin28a gene is a prime target. When this gene is knocked out by genetic engineering approaches, certain rodent species seem to produce scarless healing of skin wounds. This gene may be involved in the stimulation of stem cell activity. However, we suspect that the restoration of a regenerative state in humans will take far more than the manipulation of one or a few isolated genes. ...

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2 months ago

Scar Team

Which were the first groups to investigate the use of microneedling for scars? Orentreich and Orentreich in 1995 demonstrated that repeated piercing of a scar with a needle activated wound healing. Subsequently, Camirand and Doucet in 1997 used a tattoo gun without pigmentation to treat scars. Both studies hinted at the modification of scars with time and the formation of the body's own, injury-induced collagen. ...

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2 months ago

Scar Team

Prof Geoffrey Gurtner provided a fascinating talk at The Scar II Conference in Israel. Currently, there is great excitement as to whether we can regenerate tissues such as the skin. It is known that certain amphibians such as the salamander can completely regenerate an amputated limb, seemingly without scarring. Can we recreate scarless healing in human skin. Prof Gurtner described his work at Stanford where both the seeds (cells) and the soil (cellular surroundings) have been optimised to produce a model of scarless healing. This is a fiendishly difficult process to simulate as the stem cells required need very specific signals (cues) that change with position across the wound and with time. He suggested that mature scars will not be the first to benefit from this approach, but rather open, non-healing wounds such as those caused by poor blood flow or diabetes. ...

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2 months ago

Scar Team

Dr Ardeshir Bayat made some interesting observations about keloids at The Scar II Conference. There has long been a parallel between these pronounced proliferative scars and cancer. Although keloids are not dangerous and do not spread to distant sites, they can invade locally and are resistant to many forms of treatment. Dr Bayat focused on the science of how the environment in a keloid mirrors that of a cancer. Both have a relative lack of oxygen. Keloid fibroblasts grown outside of the body on a culture plate spread and grow in a manner that is not dissimilar to cancer cell lines. Moreover, many keloid cells have increased levels of chemicals internally which mirror signalling pathways that go wrong in cancer. These include those related to TGFbeta, notch and mTOR. ...

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2 months ago

Scar Team

Dr Ganesh Pai described a bespoke approach to acne and 'chicken pox' scarring at The Scar II Conference. He used a combination of lasers and dermal filling to change the texture of the skin, reduce pits and reduce inflammation. His preferred lasers were the fractionated erbium:YAG laser for deep pits and thick nodularity. For more superficial scars, he tended to use the 1540 erbium glass laser with several passes over the same area. Any deficiency of volume of the skin after laser release was treated with the injection of a filler - chondroitin sulphate gel. Again, it was emphasised that in pigmented skin, there is a risk of inflammatory over-pigmentation that is difficult to treat. ...

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2 months ago

Scar Team

What is the best way to treat post-inflammatory excessive pigmentation in scars, particularly in darker skin types? At Scar II, Henry Chan argued that it is a combination approach. Specific lasers on low settings may be advantageous. Equally, bleaching agents in combination with other topical agents may be useful: steroids, hydroquinone and retinoids. ...

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3 months ago

Scar Team

Dr Amir Koren described an interesting approach to treating acne scars at The Scar II Conference. He looked at the records of 352 patients in his department who had been treated with a variety of techniques over three years. A filler injection followed by an ablative (destructive), fractionated carbon dioxide laser seemed to give the best global improvement. It gave a better overall outcome than non-ablative laser treatments and radiofrequency devices. The addition of the filler also appeared to be essential. However, this was a retrospective review of results and it may just have been that the team were more able to optimise the settings for the CO2 laser with time. Moreover, the CO2 laser appeared to have a longer 'down time' - time spent away from being socially visible - than the other treatments. The more aggressive approach took longer to heal. ...

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3 months ago

Scar Team

Atrophic scarring is one of the most difficult types to treat. It is characterised by thinning of the bottom layer of the skin (the dermis), reduced volume of the tissue beneath the skin and often, inflammatory redness. Daniel Friedmann at The Scar II Conference described a combined approach to this problem. First, he treated patients with intense pulsed light (IPL). This seemed to reduce inflammation. Then he improved the thickness and texture of the skin with a carbon dioxide laser. Finally, he improved the volume of the tissue beneath the skin by the injection of a filler, poly-L-lactic acid. He presented some very nice results with this approach but it was noted that many cycles were necessary before a significant difference was visible. ...

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3 months ago

Scar Team

One of them more experimental but fascinating developments at The Scar II Conference came from Dr Daniel Cassuto from Italy. He described a device that had been used to treat atrophic scars. Atrophic scars, as occur in pregnancy, after some forms of acne or when normal scars are weak as they mature, are characterised by being thin, stretched and shiny. They are notoriously difficult to treat. Dr Cassuto's device both provides a physical stimulation to the skin and the injection of a solution of hyaluronic acid. Combined, he had shown that this 'Jet Volumetric Remodeling' resulted in a thickening of the skin that seemed to be sustained for at least 24 months; this seemed to be longer than the volume provided by traditional skin fillers alone. Moreover, the procedure could be carried out with local anaesthetic. ...

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3 months ago

Scar Team

What place do chemical peels have in the treatment of acne? Dr Marina Landau from Israel gave her perspective at The Scar II Conference. For mild acne, she used a combination of the chemicals salicylic acid and retinoic acid. She found this beneficial for pigmentation and redness. However, for more significant acne, typically she would use a high concentration of trichloroacetic acid in her peels. This had the benefit of improving texture and, for older patients, tightening the skin. ...

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3 months ago

Scar Team

According to Henry Chan at The Scar II Conference, fractional lasers - in which the laser beam is split to create many tiny injuries - have greatly improved the treatment of acne scarring. However, among darker skin types, there is a concerning issue that there can be excessive pigment produced at the site of each tiny injury. This can leave an odd, 'leopard skin' type pattern. Dr Chan described a way of limiting this complication by careful selection of the laser settings and skin bleaching agents including combination steroid, hydroquinone and retinoids. ...

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3 months ago

Scar Team

One innovation presented at The Scar II Conference was a heating device that targets the bottom layer of the skin (dermis). Professor Woraphong Manuskiatti from Thailand had created a radiofrequency device that caused minimal epidermal injury but made small volumes of dermal injury. Around each tiny target area, the dermis remodelled to produce new molecules including collagen, elastin and hyaluronic acid. The technique creates 'radiofrequency thermal zones' of injury that heal with increased skin thickness and tightening. Professor Manuskiatti showed some results indicating that this device may have a role in treating atrophic and acne scars. ...

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3 months ago

Scar Team

Isotretinoin is a vitamin A derivative that is very effective for severe acne. Many patients we see in clinic have been on this strong medication for their acne for prolonged periods of time. How long after isotretinoin is stopped can interventions such as surgery or microneedling be undertaken? Peter Shumaker at the Scar II Conference had reviewed the literature. He commented that it was conventional to wait at least 6-12 months after Roaccutane (Isotretinoin) had stopped before commencing other interventions. However, he felt that the literature did not show overriding evidence for waiting too long and he suggested that it was probably safe to commence other treatments at an earlier stage. Here at The Scar Team, we tend to wait at least six months and certainly until any inflammation or local infection has settled. ...

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3 months ago

Scar Team

At Scar II, Greg Goodman spoke about his graded approach to the different types of acne he encounters. Mild, flat disease (grade 1) is treated with light skin peels, microdermabrasion, vascular lasers or light therapy. Mild grade 2 disease is treated with non-ablative or fractional laser resurfacing along with microdermabrasion or fillers. Grade 3 disease requires ablative or fractional lasers, strong chemical peels, skin microneedling, dermal filling or subcision. If the scars are hypertrophic (red and raised) they may require intralesional steroids or cytotoxic medications such as 5-fluorouracil. The worst form of acne (grade 4) may require components of all the techniques above and surgical approaches including lipofilling, floating or excision grafting. He has found this last group to be particularly well-served by the CO2 laser. ...

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3 months ago

Scar Team

How should you grade acne scarring? According to Professor Greg Goodman from Australia at The Scar II Conference, there are four different grades according to the 'burden of disease'. Grade 1 patients have red, white or brown flat marks that are visible only because of a colour mismatch. Grade 2 patients have mild acne that is not obvious at usual social distance, but may become more visible in tangential light. It is relatively easily covered by make up or in the right area in a male patient, by facial hair. There is a mild contour deformity. Grade 3 patients have moderate disease and this is the most common type. There is a moderate contour or textural deformity that is obvious at 50cm distance or more. However, with manual stretching of the skin, this type of acne becomes less obvious. Type 4 acne is the most severe type and is conspicuous in most settings. It cannot be improved by manual stretching of the skin. This form has punched out, pitted or 'ice pick' scars in atrophic areas, and raised or red fibrous growths in hypertrophic or keloidal areas. ...

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3 months ago

Scar Team

What symptoms might improve after a laser treatment for a hypertrophic scar? Jon Friedstat from Harvard Medical School talked about this topic at The Scar II Conference. His team used a fractional CO2 laser to 272 patients with hypertrophic scars. Patients received an average of 2-3 treatments. Most treatments were undertaken in the first 12 months after injury. Almost all patients improved in terms of pain, itch and tightness. However, the study was not ideal as other treatments were undertaken on the same group including topical or injectable steroid application. It is difficult to establish absolutely how much of the response was attributable to the laser. However, there appeared to be no infections or other complications. ...

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3 months ago

Scar Team

At The Scar II Conference, Jung hwan Lee from Seoul described his study to see how different thicknesses of hypertrophic scar responded to laser. He defined hypertrophic scars into four groups: less than 1mm in thickness; 1-4mm in thickness; and greater than 4mm in thickness. He adjusted his strategy for laser according to the thickness of the scar. The thickest scars were the most difficult to treat, but he found a successful technique using a CO2 laser and creating individual 'pinholes' of laser scar damage. ...

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3 months ago

Scar Team

What is the optimal dose of radiotherapy to prevent keloid recurrence after surgery? Rei Ogawa and colleagues have investigated this topic in a large study of scars in an oriental population. Across 370 scars over 18 months, his team found that the amount of radiation sufficient to provide an optimal response was dependent upon site. For the chest, shoulder and scapular areas, 20 Grays' dose of radiotherapy was given in four fractions over four days. However, for the earlobe, only a 10 Gray dose was necessary in two fractions over two days. For other sites, 15 Grays in three fractions over three days was best. In essence, this work has provided an indication that smaller amounts of radiotherapy than traditionally described can be effective for preventing keloid recurrence. Also, there appears to be some site-dependency in terms of dose - all body sites must be treated in a bespoke manner and several treatments are necessary. ...

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3 months ago

Scar Team

After surgical removal of an ear keloid, what is the best way to prevent recurrence, injection of corticosteroid or radiotherapy? A rigorous systematic review and meta-analysis in the journal Plastic and Reconstructive Surgery in 2016 looked at this issue. Twenty-five relevant studies were identified. The recurrence rate for an ear keloid that was removed and then injected with triamcinalone, a corticosteroid, was estimated at 15.4%. The same figures for the surgery then radiotherapy group was 14.0%. The main issue with this review was that the data from the studies analysed was retrospective. There may have been hidden biases or other issues with the work. However, the chances of this were small and it is likely that both approaches are powerful and roughly equivalent for reducing the tendency for ear keloids to recur. We now have to confirm this work with a study where both treatments are compared side-by-side in what is called a 'prospective study'. ...

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3 months ago

Scar Team

Can a light treatment that is not laser be beneficial for scarring? At Scar II, Cheuk Hung Lee from Hong Kong described a small case series of different types of scar that were treated with intense pulsed light (IPL). The wavelength of light was 515-755nm and all of the patients had a larger number of treatments (10-18 range). Scars were assessed in a blinded manner and pre- and post-treatments photographs were compared. In all patients there appeared to be an improvement in pigmentation, thickness, hardness and redness of scars. The effects were thought to be long-lasting and 'excellent' in most cases. Patient satisfaction was high. However, is this technology only beneficial in Oriental skin: more work needs to be done in a variety of skin types and a bigger case series. ...

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3 months ago

Scar Team

When is the ideal time to start laser treatment for problematic hypertrophic scarring of the skin? Matteo Clementoni at the Scar II Conference felt it was as early as possible after injury. He reported that some practitioners were even commencing treatment within the first week after injury. However, it is still not clear about the criteria for commencing treatment. He felt that clinical features were the overriding triggers: scar thickness, redness and pigmentation. ...

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3 months ago

Scar Team

Scar pain and itch are intensely debilitating concerns after major scarring. William Norbury from Texas gave a talk on these symptoms as The Scar II Conference. In essence, he reported that there are both pharmacological and non-pharmacological approaches to treatment. The mainstay of drug treatment remains opioid analgesics and drugs such as antihistamines. However, there is an increasing body of work showing that drugs such as gabapentin and pregabalin are very useful for overwhelming itch. Moreover, he emphasised that there may be underlying issues of a psychological nature that may colour our interpretation of signals from a damaged area. These include anxiety, depression and post-traumatic stress disorder. If present, these issues must also be addressed if intractable pain or itch is to be reduced. Here at The Scar Team, we agree that such a multi-modal approach is vital for effective treatment. We already offer pharmacological treatment for these symptoms and moreover, psychological support through our team member, Becky Watkins. Moreover, we have a variety of cutting-edge approaches to break the cycle of itching including early pulse dye laser and intralesional corticosteroid injections. ...

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3 months ago

Scar Team

Uwe Paasch at The Scar II Conference gave details about how lasers can assist in drug delivery. The fractionated lasers create multiple temporary holes in the top layer of the skin - the epidermis. This provides an easy route for drugs to get to the bottom of a scar. Drugs can be applied topically after a fractionated laser treatment to immediately influence the cells at the bottom of a keloid or hypertrophic scar. The small areas of injury are called 'microscopic ablation zones.' ...

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4 months ago

Scar Team

At Scar II, Professor Woraphong Manuskiatti focused on the effect of lasers on skin. How do they improve scarring? The main lasers considered were the 595nm and 1064nm wavelength devices. He reported that the key effects were the selective destruction of blood vessels - reducing the blood flow to scars, reduced cellular activity possibly through a lack of oxygen, the breakdown of collagen and the stimulation of local chemicals which reduce inflammation. Combined, these tissue effects are thought to make scars softer, flatter and less inflamed. ...

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4 months ago

Scar Team

At The Scar II Conference, Uwe Paasch of the University of Leipzig talked about the alternatives to powerful ablative lasers. He described a range of devices which have mainly been used in the context of facial rejuvenation. These include the 'fractional non-ablative photothermolysis' devices with a range of wavelengths or q-switched lasers. An assessment of a range of scars treated with both ablative and non-ablative devices indicated that the former had the best impact on scar softening whereas the latter was good for redness and fixed pigmentation. ...

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4 months ago

Scar Team

What effect does microneedling have on the skin? Microneedling involves the creation of many hundreds of tiny holes in the skin that do not penetrate deeply. Microneedling is thought to alter the texture, thickness and density of the skin. At the Scar II Conference, the extent of this change was quantified by Peter Moortgat and the team from Oscare and the Antwerp Burn Centre. They undertook microneedling in 17 patients with hypertrophic scars at an average of 21 months after injury. They used a Dermaroller(R) device to make the injury with two treatments separated by three months. On average, they found the thickness of the dermis of a hypertrophic scar diminished whereas the density increased. These changes were deemed to be positive by the observers. ...

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4 months ago

Scar Team

How should we use radiotherapy for keloids? Brian Berman at The Scar II Conference described his experience with excision and radiotherapy as part of a multi-centre trial. 132 keloids in 104 patients were removed with an operation. On the first day after surgery, the wound and surrounding skin were exposed to radiotherapy. Some patients just had a (13 Gray) treatment on day one, but in other limbs of the study, smaller doses (8 Gray) were given on day 1 and 2 after surgery, or an even smaller dose (6 Gray) were given on days 1, 2 and 3 post-surgery in separate groups. The majority of patients were followed up for at least one year. Overall, they found a recurrence rate of 1.9% (two patients) within that time frame. The most common side effect was an increase in pigmentation. This reduction in recurrence compared to just surgically removing the keloid (a reported rate of 71% in the literature) sounds extraordinary, but the follow up period was not tremendously long. We know that keloids can recur very late after treatment. It will be fascinating to see the results of this group of patients at two and three years as if the recurrence rate stays low, this will become a favoured approach to keloids in particular settings. ...

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4 months ago

Scar Team

How does radiotherapy work for keloids? Professor Brian Berman of The University of Miami gave a fascinating talk on this topic at The Scar II Conference. He reported that a superficial treatment with radiation can stop the division of fibroblast cells which lay down the connective tissue of a scar. Further, it can cause cells that are not dividing to speed up their progression to death, a process called 'apoptosis'. In essence, the main cells responsible for scar formation are reduced in number in the bulk of a keloid scar. Prof Berman reported that without radiotherapy, the recurrence rates of keloid scars after different treatments can be as high as 71%. ...

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4 months ago

Scar Team

At The Scar II Conference, there was a talk by Aleksandar Krunic of the Northwestern University, Chicago. He described a multi-pronged approach to ear keloids. This included multiple rounds of Cryoshape, corticosteroid injections and surgical debulking. The overall conclusion was that more than a 90% response rate was possible for the first two years. However, once more recurrences can occur whichever modality is used. ...

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4 months ago

Scar Team

A thought-provoking article by the dermatologist Michael Gold summarised with a practical point that most people working in the field of scarring appreciate. Whichever treatment is used for a scar in the first instance, there is always a risk of recurrence. This may be influenced by the site of the scar on the body or the type of scar. For example, an initially good response may yield to further growth or symptoms affecting all or part of a scar lesion. His strategy is to make patients aware of the risk, use a potent first-line therapy such as intralesional corticosteroids or fractionated CO2 laser, and to provide long-term, maintenance support with, for example, different forms of topical silicone. Sometimes, multiple treatments are required from an early stage such including superficial radiotherapy. ...

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4 months ago

Scar Team

A further addition to the debate about radiation for keloids has been provided by a dermatology team from Florida, USA. They have undertaken a case series on patients with large keloids that have been intransigent to other treatments. After first removing the keloid surgically, they undertook three treatments with radiation on consecutive days. Each radiation treatment was quite superficial and low dose compared to previous radiation treatments for keloids. The aim was to reduce high radiation exposure which can damage the surrounding skin. The long term benefit was to reduce the risk of malignant change in the keloid and surrounding tissue. The group found that there was a recurrence rate of less than 10% at one year. ...

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4 months ago

Scar Team

Radiation therapy is a long-standing treatment for keloid scars that have not responded to any other treatment. The literature is not decisive about the overall benefit, but some scars which have not responded to all other approaches seem to improve. Also, it is not something that we consider lightly as there is a small risk of malignant change when tissues are irradiated, usually many decades later. Our expert on the team at this specialist approach is Dr Amar Challapalli, a consultant clinical oncologist. At The Scar II Conference, Dr Mahmood Zidan described an unusual approach to using radiation for both hypertrophic and keloid scars. His team used external beam radiotherapy both the day before and the day after an operation to remove a problematic scar. They reported very good results. This is a topic we will be exploring over the coming months. We are hearing stories of excellent results with low dose radiotherapy used very soon after surgery for a significant scar. The doses of radiotherapy are such that it may reduce the long-term risk of malignant change. ...

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4 months ago

Scar Team

There has been a range of studies in recent years that have investigated how grafts of fat beneath the skin may improve the appearance of scars within the skin. This was a chance finding at first from the world of breast surgery. Patients who had their breast reconstructed with standard plastic surgical techniques often had the contours improved around the edges of the reconstruction by filling with fat removed by liposuction from a distant site. Completely unexpectedly, it was noted that some of the scars upon the reconstructed breast improved after this procedure. Geoffrey Gurtner at The Scar II Conference explained that we have still much to learn. The improvements in skin quality are unpredictable. We are still trying to optimise the procedure and there are key components of preparation that are still being investigated such as whether to wash the fat and how much to inject. A key area of interest is whether we should be aiming to graft the most potent cells within the fat - types of 'stem cells' - or whether we need all the components of the fat for an effect. ...

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4 months ago

Scar Team

At Scar II, Prof Yaron Har-Shai talked about intralesional cryotherapy (Cryoshape). A probe is inserted deep within to hypertrophic scars and keloids and there is gradual freezing with liquid nitrogen. His team have evaluated hundreds of patients after this treatment and noted a significant improvement in colour, hardness, pain and volume of scars. For example, for volume, they noted a 67% decrease for the ear, 60% for the shoulders and 50% for the chest. 3% of scars did not respond. They reported that not a single patients was made worse by the day case procedure. Here at The Scar Team in Bristol, we have been offering this treatment for three years and have one of the largest experiences of this technique in Europe. There has been an improvement with keloids of all sizes with a single treatment, but we have noted that about 5-10% of patients need two treatments to produce address more problematic lesions. ...

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4 months ago

Scar Team

Dr Ardeshir Bayat proposed an interesting new approach to keloid scars at The Scar II Conference. Photodynamic therapy (PDT) is already used for some forms of skin cancer and other skin lesions. In this standard technique, the patient is injected with a drug that sensitises the skin to light energy. After a period of time, that area is then illuminated with light of a particular wavelength. This activates the drug that was injected only at the site and as a result, kills only the local cells. Dr Bayat has proposed using the same technique for keloid scars. In several papers published in recent years, he has shown this approach to be beneficial in cells in the laboratory and has now advanced to treating patients. However, this work is still experimental in nature and importantly, he has shown that the benefit is dependent upon a range of factors including the type of photosensitiser drug injected, the amount of light energy hitting the skin and the part of the keloid in which the target cells reside. ...

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4 months ago

Scar Team

The dermatologist Michael Gold has an interest in lasers for early, aggressive scarring. Recent work with colleagues in China has focused on the utility of combining two laser types in the treatment of hypertrophic scars. Published in The Journal of Cosmetic Dermatology, their team made a rigorous attempt to undertake a controlled trial by assigning 56 patients to either a pulsed dye laser (PDL) or PDL followed by a fractional CO2 laser. Both PDL and fractional CO2 lasers are thought to work in different, but complementary ways on scarred skin. Using a Vancouver Scar Scale (VSS) and other parameters to assess outcome, they found that the combination of PDL and CO2 lasers was statistically better. There were some potential methodological issues with the work, not least the utility of the VSS to pick up change, duration of follow up and the issues of non-identical scars for both limbs. However, this piece of work was a useful addition to our understanding of the utility of lasers and we must now work on optimisation of the timing post-injury and settings of each laser to find the optimal means of treatment. ...

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4 months ago

Scar Team

Ardeshir Bayat of the University of Manchester gave a fascinating talk about the role of energy-based therapies in wound healing and scarring. It has been known for many years that a small electrical field exists across the skin and that on injury, a 'shock current' is passed between cells. Dr Bayat explained that within the epidermis of the skin the stratum corneum at the very top has a negative potential to the layers below. This field of charge is disrupted upon injury and a new 'endogenous electric field' is created which may have a role in repair. His group have modelled the application of external electric fields to the skin and shown that a particular current, voltage and waveform of electricity seem to stimulate wound healing in cell cultures. Moreover, the application of the same current to 60 healthy volunteers who had punch biopsies of their arms showed that certain beneficial chemicals (shown by a genomic mRNA screen) were stimulated by the electricity. These chemicals seem to be associated with reducing inflammation, increasing new blood vessel growth (angiogenesis), stimulating nerve growth (neurogenesis) and remodelling mature scar. ...

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4 months ago

Scar Team

What is new in the realm of silicone preparations? Silicone is thought to reduce inflammation within the epidermis of the skin and this, in turn, reduces inflammation in the layers of the skin below. The dermatologist Michael Gold has suggested that we should be moving beyond the traditional paradigm of placing silicone onto closed wounds and instead, looking at formulations which modulate the same effects on open wounds. Open wounds might include those that occur after chemical peels or laser treatment. Further, he has suggested using silicone formulations at an earlier stage in wound healing to pre-empt hypertrophic or keloid scar formation. Lastly, he has advocated using silicone formulations with added hypochlorous acid; this agent is thought to dampen down over-exuberant wound healing. Our thoughts are that silicone on open wounds needs to be examined in the context of a randomised controlled trial (RCT) to produce first rate evidence of its benefit. However, there is some evidence that for open wounds, an occlusive environment with increased moisturisation enhances epithelialisation (the regrowth of the top layer of the skin). If the trajectory of wound healing is improved, the late remodelling phase is likely to be less exuberant. In relation to hypochlorous acid, more evidence is required and it is useful that Dr Gold has recently published a treatment regimen with the new agent that could be one limb of an RCT (Journal of Cosmetic Dermatology, June 2017). ...

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4 months ago

Scar Team

At The Scar II Conference, Christine Dierickx presented a useful case series on how laser-assisted delivery can make a real-world benefit to problematic scars. 12 patients with 32 keloid or hypertrophic scars all improved rapidly with a fractionated laser and the application of traditional topical agents such as triamcinalone and 5-fluorouracil. The study only really qualified as 'proof of concept' given the small numbers recruited and the outcome measures involved. However, the presented work certainly raises the hypothesis that laser-assisted delivery can deliver potent drugs to the heart of a dense scar quickly and effectively. ...

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4 months ago

Scar Team

If we are going to deliver drugs to the bottom layer of the skin (the dermis), there may be a few problems inherent in the technique of using lasers to create multiple small, temporary tunnels in the skin. As surgeon scientist, Dr Josef Haik, reported at The Scar II Conference, it is all very well getting a laser to create a route for drugs to get to scars, but the laser may stimulate surrounding swelling and a physical block from burning, both of which prevent drug movement. His research team are getting around this problem by investigating how a unique device can create a physical pressure wave to drive drugs into the small holes that the laser makes and as such, improve the likelihood of therapeutic success. ...

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4 months ago

Scar Team

At The Scar II Conference, there was much talk about how we can get drugs deep into the skin to improve scarring. Normally the top layer of the skin provides a waterproof barrier to prevent loss of salty fluids and protein from the skin. This is a beneficial and vital role. However, the waterproofing of the epidermis can also prevent drug entry unless the chemical is adapted to make it favour the more fat-like epidermis (a 'lipophilic' drug). One way of allowing drugs to penetrate more deeply is to give them an artificial route into the bottom layer of the skin. Uwe Pasch from the University of Leipzig gave a fascinating talk on how lasers can help. The fractionated, ablative lasers create thousands of microscopic tunnels within the skin down to the dermis where scars are formed. If a drug is applied immediately after the tunnels are created, it enters and exerts its action after binding to the walls of each tunnel. This may be a future simple route for drug delivery which could be tailored to the nature of each scar. Thicker scars would necessitate a stronger laser energy and more tunnels on the surface to allow more drug to penetrate deeply. ...

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4 months ago

Scar Team

Michael Gold, a dermatologist from the United States, has carried out a number of studies to demonstrate the utility of silicone in the setting of hypertrophic scars. In 1993, he undertook a split-site study, where only one half of the scar was treated with topical silicone gel sheeting and the other was not. Only the treated side flattened and became less red. Since then, his group have undertaken experiments seemingly indicating that early topical silicone, immediately after a wound has been closed, has a similar benefit in so much as there was a lesser recurrence of hypertrophic scarring. We have long used topical silicone at the scar team and over the coming months, we will be exploring how it should be used and the potential mechanisms by which it is thought to work. ...

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5 months ago

Scar Team

How long does it take for a scar to a mature? In work at the University of Maastricht, the answer was found to be, 'surprisingly long'. In a review of 361 patients over five years, there was a clear difference with age and with treatment modality. Young subjects (<30 years) took longer for their hypertrophic scars to mature (average 35.6 months) compared to older patients (>55 years, average 22.5 months to mature). Treatment techniques seemed to expedite healing including: pressure garments (23.2 months average); silicone (35.5 months) and combination therapy (30.6 months). Although not entirely rigorous as an observational study of a cohort of patients, it still raises important questions about the trajectory of a scar and when to intervene. ...

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5 months ago

Scar Team

Pressure therapy has been used for decades to treat hypertrophic or keloid scars. Examples of its usage include pressure garments and clip earrings. However, to get exactly the right pressure (15-25 mmHg) takes a great deal of expertise. A recent paper in the journal Burns from an Australian group has shown that the pressure beneath a garment diminishes with time and can also be influenced by site. This reinforces the need for pressure garments to be fitted by an expert scar therapist and also to be regularly checked to ensure that they are exerting adequate force. Alison Guy on our team has vast experience in this field. She can measure, order and re-assess garments which are bespoke in nature. ...

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5 months ago

Scar Team

When should you use a laser to treat a maturing scar? According to Merete Haedersdal of the University of Copenhagen at the Scar II Conference, there is no clear consensus. Her team undertook a rigorous review of the literature - a systematic review - and found that there were few scientific studies which addressed how long after injury it is most advantageous to use laser treatment. Only 17 studies satisfied the very stringent criteria for analysis with comparison to an untreated scar. The types of lasers used included PDL, KTP, Er:YAG and fractional CO2. Treatments were given in different phases of wound healing: inflammation, proliferation and remodelling. Although there was no type of laser or time after injury that was most effective, a broad conclusion was that there was an overall benefit from laser application in terms of the severity of the final scar. ...

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5 months ago

Scar Team

A fascinating paper from the East Grinstead team in the journal BMJ Case Reports made an interesting finding about self-harm scars. A patients with such scars was assessed by a psychologist during their journey through surgical management. Although the surgery made the scar more conspicuous, there was a 'profound psychological benefit'. There is certainly a theory that a significant procedure can alter the perception of a stigmatising scar. We would advocate a multi-modal approach with every scar being taken on its merits. We are seeing a greater number of self-harm patients in clinic and there are a number of approaches to this difficult problem. ...

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5 months ago

Scar Team

How might lasers work to improve scarring? One theory was put forward by Uwe Paasch of the University of Leipzig at The Scar II Conference this year. It is thought that the heating effect of certain lasers induces molecules called heat shock proteins (HSPs) within skin cells. HSPs are important for protecting proteins from permanent damage. In effect, HSPs bind to essential proteins within cells and sustain their function. Moreover, HSPs also enhance the suppress activity of certain immune cells called T regulatory cells. T regulatory cells may calm the immune response to injury within the skin. Therefore, there are at least two suggested ways by which the targeted heating effect of a laser is effective at changing the response to injury. ...

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5 months ago

Scar Team

The Imperial College team has found that by grafting hairs into atrophic or thinned scars, there is a remarkable transformation in the skin. Collagen thickness is increased, the collagen fibres are more aligned and the dermis is more dense. In essence, the bottom layer of the skin remodels to a structure that is more in keeping with normal skin. Looking at one form of messenger molecule in such skin using a global screening approach, it was found that over 200 genes were modified by the presence of transplanted hairs. This work reinforces one approach that The Scar Team take for visible scars in hair-bearing areas: hair transplantation to mask the scar and improve its structure. ...

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5 months ago

Scar Team

An interesting approach to remodelling an angry scar was described at both Scar II and ScarCon by Magdalena Plotczyk of Imperial College, London. She is using hair follicles to remodel stretched scars. Stretched, or atrophic, scars can be very difficult to treat as the bottom layer of the skin - the dermis - is thinned and disorganised. Often they occur after slow wound healing or at particular body sites. Ideally, we would remodel the dermis to produce a structure similar to uninjured skin. During hair follicle growth, the surroundings - termed 'extracellular matrix' undergo constant remodelling. Her hypothesis is that this natural phenomenon can be harnessed to stimulate thickening and re-organisation of the bottom layer of the skin. ...

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5 months ago

Scar Team

Prof Gurtner at Scar II indicated that his team had developed a dressing to shield a healing wound from stresses - mechanical forces across the wound. Clinical trials had shown reduced scarring. Modulation of the tension across a wound is an approach we have used for a long time at The Scar Team. Prof Gurtner emphasised that it seems to have benefit for both acute and, surprisingly, chronic wounds. ...

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5 months ago

Scar Team

Professor Geoffrey Gurtner addressed whether we can ever aspire to truly scarless wound healing at the Scar II Conference. His work has focused on whether the stresses across a wound can make the resulting scar at the site become more hypertrophic - abnormally red, raised and itchy. His team's initial work identified that an anchor molecule on the surface of cells, focal adhesion kinase (FAK), transforms any tension on the outside into an internal trigger that drives the production of lots of inflammatory chemicals. Ultimately, this leads to inflammation and fibrosis. This work is fundamental to lots of proposed treatment for hypertrophic and keloid scarring - does offloading tension on a scar in clinic reduce how angry it gets? It has relevance to a range of techniques, from massage to pressure garments. The field is termed mechanotransduction and it is one of the most exciting areas of current scar research. ...

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5 months ago

Scar Team

Prof Bayat reported at the Scar II conference that he has optimised a keloid model where cells are suspended in a collagen gel. This model does not use animals and can be tested for the response to interventions that we use clinically. Using this technique, the molecule PAI-1 has been identified as a potential target for anti-scarring drugs. ...

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5 months ago

Scar Team

Ardeshir Bayat noted at Scar II that artificial 3D models of keloids do not really match real scars. This has led researchers to look at models in which keloid tissue is transplanted onto mice. However, again this is not perfect as the transplant is attacked by the host’s immune system. It may also be altered by the hormones of the host. Not only may the results not reflect what happens to scars in humans, but there are also ethical issues of animal models. ...

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5 months ago

Scar Team

Ardeshir Bayat from The University of Manchester gave a comprehensive talk about the models and causes of keloid scarring during the Scar II Conference. He noted that most existing models of keloid scars rely upon single cell culture. This is very artificial. In real life, the fibroblast cells which drive collagen production are influenced by both the overlying top layer of the skin (epidermis) and the surrounding connective-tissue. In order to address this problem, groups around the world are starting to create artificial mixtures of cells in three dimensions. This is thought to better replicate the reality of keloid biology. ...

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5 months ago

Scar Team

At Scar II, Gerg Gauglitz, professor of dermatology in Munich, gave a comprehensive talk on the structure of scars. Hypertrophic scars are thought to have an excess of a certain type of collagen called ‘type III’. This collagen seems to line up parallel to the top layer of the skin. Hypertrophic scars seem to have large numbers of cells called myofibroblasts which lay down connective-tissue. In contrast, keloid tissue is mainly composed of type I and type III collagen which is organised in a more haphazard manner. There are also less myofibroblasts in a mature keloid. A key message from Prof Gauglitz’s talk was that abnormal scarring seems to be associated with a failure to resolve early wound healing. ...

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5 months ago

Scar Team

The Scar II Conference was held in Tel Aviv, Israel. There were a wide range of world famous researchers and scar clinicians who were giving updates on recent advances. Dr Ofir Artzi, The conference chairman, reported that there are an estimated 15 million people a year who sustained significant scarring from accidents, surgery or disease in the first world setting. ...

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5 months ago

Scar Team

Over the next few weeks we will be giving updates about the advances in scar management from the two leading international conferences, Scar II and ScarCon. ...

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4 years ago

Scar Team

The effect of a significant scar are devastating to the individual. Pain, itch and limitation of range of motion may make simple tasks impossible. Sleep may be disrupted. Moreover, the effects on appearance and perceived body image may make the sufferer withdrawn, cause flashbacks and even trigger clinical depression. Each problem cannot be dealt with in isolation - that is why we are here. ...

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4 years ago

Scar Team

Welcome to The Scar Team Facebook page. We are a multi-disciplinary team based in Bristol who focus on the treatment of scarring of the skin. ...

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4 years ago

Scar Team

The Scar Team were delighted to see a new consensus statement on scar management that was reached by a renowned international group. The review, published in the journal JPRAS, indicated the key strategies to reduce scar formation of limiting tension, avoiding excessive ultraviolet light exposure and keeping the early scar hydrated. Further, we offer the majority of the recommended treatments for developing scars, from topical silicone to pressure garments. We will be discussing the findings of this group, led by respected scar investigators such as Luc Teot and Esther Middelkoop, over the coming weeks. ...

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