Correcting scars requires careful planning

She says careful planning reduces scarring and so does good surgical technique - orienting scars along wrinkle lines, installing deep sutures to relieve tension and using occlusive dressings.

"It's helpful to see how a patient has handled previous surgeries. If a keloid scar developed on the stomach after abdominal surgery, she or he needs close follow-up," she noted at the Dermatology and Cosmetic Conference here.

"Sometimes you need to wait and see. Scars can remodel and improve with time," she says.

However, if a patient has a history of bad scarring, or if a particular scar appears to be heading in the wrong direction, she does step in. Several products are available for early intervention. Scarguard (Red Rock Laboratories) is a clear liquid that dries to a transparent protective film; it contains a 12 percent silicone gel to decrease scar formation, 0.5 percent hydrocortisone to inhibit fibroblast proliferation, and vitamin E as a lubricant and collagen inhibitor.

Worn continuously for eight weeks to reduce raised, pigmented hypertrophic scarring, the Scar Therapy Cosmetic Pad (Curad) containing polyurethane and sodium acrylates is another option.

Topical corticosteroids are an effective treatment for young hypertrophic scars. Potential adverse effects include pain, atrophy, pigment alterations, telangiectasias and ulcers. Another alternative is 5-fluorouracil, which inhibits fibroblast proliferation. Potential adverse effects include hyperpigmentation, purpura at the injection site, and pain.

To avoid keloid development, she says, try immune modulator therapy - postoperative use of imiquimod 5 percent cream. Begin treatment the night after surgery and continue for eight weeks. This induces local production of interferons. The recurrence rate is only 15.4 percent. Potential adverse effects are pruritis and erythema.

Scar treatment modalities If preventative efforts, early intervention and time fail to optimize wound healing, she says there are many options.

"If the tissue has thickened, I might use triamcinolone, a steroid analog. If it's persistently red, I might treat it with a laser or a hyfrecator. Depressed scars can be corrected with a number of new fillers."

Cryotherapy is a good treatment for small keloids. Freezing induces tissue hypoxia that leads to necrosis and scar reduction. On the downside, it can delay healing or cause pain or atrophy.

Intralesional injection of interferon is a promising new approach to keloids. The drug decreases collagen types I, III and IV and synthesis of glycosaminoglycan. The only known side effect is the pain associated with injection.

Scars can be excised, but the recurrence rate is 40 percent to 100 percent. Pulsed-dye lasers may improve the vascularity, color, height, texture and pliability of hypertrophic or keloid scars, but the response rate is slow.