Ken Glasser, a 39-year-old Billerica man who works as a buyer of components for aircraft instruments, has been through hell trying to get rid of the stubborn scars on his chest.
He tried laser treatments, which reduced the thick, ropy scars, called keloids, for a while. But when the treatments ended, the scars – which often occur after injury, vaccinations, or even an infected hair follicle – got itchy again and started growing again.
He tried freezing, including one memorable session in which, he says, the doctor “took the safety nozzle off the liquid nitrogen gun and blasted the scars big time.”
His physician, Dr. Kenneth Arndt, chairman of the dermatology department at Beth Israel Medical Center, puts it more delicately. There’s no safety nozzle, he says, but he did switch attachments to get a thick spray – “more like a fire hose” – in order to penetrate the scars more deeply.
That hurt – more than either Glasser or Arndt expected – but helped enough that Glasser was game for more. In later visits, Arndt anesthetized the area, froze the scars with liquid nitrogen, waited until they turned spongy, then injected them with steroids to cause atrophy. That worked, but not enough to make the scars go away.
So Glasser’s at it again, this time with the addition of a cancer chemotherapy drug called 5-FU that’s injected into his scars in hopes of preventing excessive division of skin cells.
Glasser’s battle with scars is unusually dramatic, but we’ve all got them to some degree – “ice pick” marks from acne, craters from chicken pox, old badges of courage from sports. And while many scars become invisible with time, others – depending on where and how bad they are – can be a source of embarrassment.
But in recent years, doctors have been finding better ways to attack scars, even old, stubborn ones. Usually, they can’t banish them totally, but they can often make them look better.
Scars are “nature’s repair” system, says Dr. David Alkek, clinical professor of dermatology at the University of Texas Southwestern Medical Center in Dallas.
If you injure just the outermost layer of skin, the epidermis, you won’t get a scar, notes Dr. Brett Coldiron, a dermatologist at the University of Cincinnati. But when the injury extends into the dermis, you form a scar. It’s the job of fibroblast cells in that layer to do just that – pump out collagen, the glue-like tissue that helps hold wounds – and other parts of the body – together.
Sometimes, collagen does its work, then stops. But if the body makes too much, the result is a big, “hypertrophic” scar that may take a year or more to diminish. In 1 percent of people, scarring is abnormal and results in keloids, like Glasser’s, that well spread beyond the initial injury.
Scars form differently on different parts of the body because the skin varies so much, with the worst scarring usually on the chest, shoulders and upper back. You can get a scar from “the least little cut on the hand,” notes Alkek, but the same injury on the face won’t cause one.
In fact, the face is the “most forgiving area,” says Dr. Robert Stern, a Beth Israel dermatologist. “Healing times are very different. On the face, we leave stitches in for five to seven days; on the trunk, 10 to 14.”
So what can you do to help prevent scars in the first place and to minimize those that do form? Plenty, as it turns out.
With a new scar, the key is to keep the area moist and free of infections, with unguents like Aquaphor Healing Ointment. If the injury is deep, you should see a doctor for stitches or a new product called “skin glue,” a high-potency adhesive that holds the edges of the wound together as it heals.
Pressure bandages can also help prevent bad scars, by forcing collagen to be “laid down” properly; compression of the area can even help rearrange collagen in some old scars.
Over-the-counter strips of Silastic or silicone also help make scars – even some old ones – become flatter and turn white faster. No one knows why, but the strips may keep moisture in.
With immature scars – six to eight weeks old – dermabrasion can make a potentially bad scar less unsightly. The skin is “sanded,” under local anesthesia, with a diamond wheel or rapidly-rotating wire brushes, to grind the epidermis down to the level of the scar. The epidermis then regrows, hopefully hiding the scar.
Dermabrasion is often used on acne scars, and works best on faces. But the procedure sprays blood around – not a good idea in the age of AIDS – and it takes a trained eye to gauge depth. Chemical peels do much the same thing, but again, it takes a trained hand to avoiding burning or otherwise damaging the skin.
An increasingly popular alternative is laser skin resurfacing, which, like dermabrasion, works best on faces, not torsos. Usually, CO2 lasers are used for deeper skin problems and Erbium:YAG lasers, for more superficial problems. For scars that are red or purple from blood vessels, pulsed dye lasers can decrease color and flatten the scar.
Lasers convert light energy to heat that strips away thin layers of skin cells bloodlessly and with great precision. The disadvantage of laser resurfacing is that skin can stay red for weeks, longer than with old-fashioned dermabrasion.
To get rid of deep pits from acne, doctors often “punch” into the scar with a surgical instrument, take out old scar tissue, then bring the edges of the hole together with stitches. Another option is to dig under the pit with a sharp instrument to loosen it and make it shallower. The cosmetic result from this process can then be improved by skin resurfacing.
For some scars, especially long ones, the problem is partly perceptual. The human eye fixes on unbroken scars, but may barely notice one that zig-zags. For that reason, dermatologic or plastic surgeons cut open a long scar, then stitch the skin together again in stair-step fashion to make it less visible.
The direction in which a scar lies is also key, says Dr. Paul R. Weiss, a New York plastic surgeon. On the forehead, “it’s hard to do anything” for a vertical scar. But if a scar is horizontal or oblique, a surgeon can re-position it so that it is hidden by natural creases in the forehead.
The most difficult scars are keloids like Glasser’s. Though these scars can get huge, the cause is sometimes elusive. Often it’s surgery or an injury, but it can be something as minor as an infected hair follicle that the patient doesn’t even remember.
Weiss says he’s had “wonderful successes with surgery” for keloids, provided surgery is followed by steroid injections into the scars and radiation therapy to stop cell division.
But many dermatologists disagree, arguing that cutting out keloids may create worse keloids afterward. The exception to the no-cutting rule are keloids on earlobes – often from ear piercing – which can often be trimmed away successfully.
Many people, of course, simply live with their scars, figuring that beauty is more than skin deep. But some, like Glasser, keep seeking treatment in hopes of getting the skin back to normal.
Glasser says his keloids itch and are “a tremendous nuisance.” And they’re sensitive, especially when he wrestles with his two “little guys,” aged 1 and 3. “My one- year-old sits there and it hurts,” he says. Besides, he adds, he just doesn’t “want to drag this ball and chain around.”
Some home remedies
There are numerous over-the-counter products to improve the appearance of scars, though data to back the claims are scarce.
Silicone sheets – such as ReJuveness, Sil-K, Silastic Gel Sheeting and Cica-Care – often work, dermatologists say, though nobody knows why. One theory is that they may prevent water loss through the skin. Another is that they may change the skin in a way that nudges collagen – the fibrous protein that scars are made of – to re-align in a more orderly fashion. Or perhaps the slight pressure from wearing a silicone bandage may itself help a scar remodel.
These products can be expensive – $40 for a small sheet.
Other products, such as Mederma or Kelocote, are gels that are spread on scars. Mederma, made from onion extracts, may decrease the thickness of some scars, but again, the evidence is sketchy and nobody knows why it would work. Kelocote is a silicone gel that presumably acts somewhat like silicone sheets.
Many people swear by vitamin E for scars, but dermatologists say there’s little evidence for this. There’s even less for another popular remedy – emu oil.
If your scar is recent and healing well, these do-it-yourself remedies may help. If you have a thick, old scar that you want to treat, you should probably see a dermatologist.