How a wound heals and where the scar comes from
Healing goes through several natural stages. First, the bleeding stops and inflammation starts - cells come into the wound and cleanse it of damaged tissue and microbes. Then the recovery phase begins: special cells, fibroblasts, actively produce collagen, which fills the defect. The new tissue is initially redundant and chaotic - this is why a fresh scar is red, raised and dense. Next comes the longest phase - restructuring: excess collagen is gradually absorbed, the fibers line up in ordered bundles, the vessels become empty, and the scar turns pale, softens and flattens. This process takes from six months to one and a half years, and that is why it is pointless to evaluate the final appearance of the scar before a year.
Problems arise when the balance between collagen formation and breakdown is disrupted. If fibroblasts continue to produce collagen longer than expected, the tissue grows excessively - this is how hypertrophic and keloid scars are formed. If there is not enough collagen produced or the underlying tissue is destroyed, the scar becomes retracted - atrophic. What exactly happens depends on the depth and location of the wound, skin tension, the presence of infection, but to a large extent - on the individual characteristics of the body, which cannot be influenced.
- The first 3-7 days - inflammation and cleansing of the wound, primary fusion of the edges is formed
- From a week to a month - active collagen production, the scar turns red and rises
- From 1 to 6 months - the period of maximum activity, when excess growth most often begins
- From 6 to 12-18 months - restructuring: the scar turns pale, flattens, becomes softer
- After a year and a half, the scar is considered mature, and its properties change extremely slowly
- Wounds in areas of constant tension - chest, shoulders, back, joints - heal with a rougher scar
Types of scars: the difference determines the treatment
In medicine, there are several types of scars, and they are treated in fundamentally different ways. There is no universal “ointment for scars” precisely because the tasks are opposite: in one case it is necessary to reduce excess tissue, in the other it is necessary to compensate for its deficiency.
- Normotrophic - light, flat, at skin level, elastic. This is the optimal outcome; correction is usually not necessary
- Atrophic - retracted, below the level of the skin. A typical example is scars after acne and chickenpox; here the fabric needs to be increased, not removed
- Hypertrophic - raised, dense, red, but strictly within the boundaries of the former wound. Over time, it often flattens and brightens on its own.
- Keloid - extends beyond the wound onto healthy skin, grows for months and years, itches and hurts, does not regress on its own
- Scar contracture is a tightening of tissue that limits movement; develops after deep burns and wounds in the joints and neck
- Stretched scar - wide and flat, occurs where the edges of the wound diverge under tension
There is another reason why the type of scar is determined before the procedures begin. Some methods that are useful for one type of scar are harmful for another. For example, aggressive resurfacing or medium peeling in a person with a tendency to keloids can provoke a new keloid at the site of impact. Dermabrasion, deep mechanical injuries and even too active work with the scar with needles in such patients require caution. Therefore, the doctor does not ask the question “have you had rough growing scars in your family or have you yourself” for the sake of formality - the choice of method and even the very admissibility of planned intervention depends on the answer.
Keloid: the main difference and why it is not excised
Distinguishing between a keloid and a hypertrophic scar is more important than it seems, because the prognosis and tactics are different. A hypertrophic scar is a local excess of tissue in response to a specific injury: it remains within the boundaries of the wound and usually partially flattens on its own within one to two years. A keloid is a tumor-like growth of scar tissue that behaves autonomously: it spreads onto intact skin, continues to grow months after the wound has long since healed, and never goes away on its own.
- Borders: the hypertrophic scar follows the contour of the wound, the keloid extends beyond it in the form of processes and “claws”
- Timing of appearance: hypertrophic forms in the first weeks, keloid can begin to grow 3-12 months after injury
- Dynamics: hypertrophic becomes pale and flattened over time, keloid grows or remains stable for years
- Sensations: keloid often itches, hurts, responds to touch and clothing
- Size in relation to injury: A keloid can grow many times larger than the original injury, including a tiny puncture or insect bite
- Localization: keloids prefer earlobes, sternum, shoulders, upper back, lower jaw area
This leads to a key practical conclusion that many learn too late. Simple surgical excision of a keloid without accompanying treatment leads to relapse in the vast majority of cases, and the new keloid often turns out to be larger than the removed one - after all, the incision itself is a new injury to the same skin. That is why surgery for keloids is never used in isolation: it is combined with injections into the scar area, compression, silicone coatings, and in some stubborn cases - with radiation therapy to the suture area on the first day after surgery. The decision on such treatment is made jointly by several specialists and only with clear indications.
Who risks more and what is better not to do
The tendency to excessive scarring is largely innate, but the number of reasons for its manifestation is controlled by the person himself. Knowing your risk, it is wise to avoid unnecessary skin damage in hazardous areas.
- Swarthy and dark skin types have a much higher risk of keloids
- Ages from approximately 10 to 30 years are the period of greatest scarring activity.
- The presence of keloids in close relatives or your own keloid in the past
- Risk areas: sternum, shoulders, upper back, earlobes, lower jaw and neck area
- Pregnancy and adolescence - hormonal changes increase the tendency for scar growth
- Ear and cartilage piercings, tattoos, piercings in risk areas in predisposed people
- Severe acne on the chest and back left untreated
- Wounds healing with suppuration or under tension, as well as self-removal of sutures ahead of schedule
A practical lesson for people with an existing keloid: any planned intervention on the skin - from a cosmetic procedure to surgery - is discussed with a doctor and this feature must be mentioned. It is often possible to choose a different approach, a different incision location, or plan ahead to prevent scarring immediately after the procedure, and this changes the outcome. It also makes sense to avoid unnecessary punctures and tattoos in risk areas: a small puncture of the earlobe can turn into a keloid the size of a grape, which will require long-term treatment.
Treatment: what works and when?
- Силиконовые пластины и гели — метод первой линии при гипертрофических и келоидных рубцах. Работают за счёт создания замкнутой среды и поддержания влажности; применяются не меньше 12 часов в сутки на протяжении минимум трёх месяцев, а часто и дольше.
- Компрессия — постоянное давление на рубец. Для мочек ушей используют специальные клипсы, для обширных послеожоговых рубцов — компрессионную одежду, которую носят месяцами.
- Инъекции противовоспалительных препаратов непосредственно в ткань рубца — main способ уменьшить объём и снять зуд при келоидах; проводятся курсом с интервалами в несколько недель.
- Криотерапия — воздействие холодом, чаще в сочетании с инъекциями; применима при небольших плотных келоидах.
- Сосудистый лазер — уменьшает красноту и толщину незрелого рубца, ускоряет его созревание.
- Фракционный лазер и микроигольчатые методики — main инструмент при атрофических рубцах и рубцах после акне, а также для улучшения текстуры плоских рубцов.
- Хирургическая коррекция — иссечение, пластика встречными лоскутами, устранение контрактуры; при келоидах применяется только в сочетании с профилактикой рецидива.
Deadlines need to be understood realistically. The course of scar treatment is months, not one procedure: injections are carried out at intervals of 3-6 weeks, silicone is used for at least three months in a row, laser techniques are performed in series with breaks. It is impossible to completely remove a scar using any of the existing methods - the task is to make it flat, soft, close in color to the surrounding skin and invisible in everyday life. The promise of a scar disappearing without a trace should always be alarming.
Caring for a fresh scar: what you can do yourself
The first year after injury or surgery is a window of opportunity that will not be repeated. Simple actions during this period affect the final appearance of the scar more than complex procedures years later.
- Дать ране зажить без инфекции: чем спокойнее прошло заживление, тем тоньше будет рубец. Нагноение и расхождение краёв практически гарантируют грубый след.
- Не срывать корки: под ними идёт восстановление, а преждевременное удаление углубляет повреждение.
- Начать увлажнение и силиконовые покрытия примерно через две-три недели после полного закрытия раны, когда кожа восстановила целостность.
- Защищать рубец от солнца минимум 6-12 месяцев: одеждой, пластырем или средством с высоким фактором защиты.
- Уменьшать натяжение: специальные пластыри, фиксирующие края, ограничение резких движений в зоне шва в первые недели.
- Мягкий массаж зрелого рубца после разрешения врача — он улучшает эластичность, но не заменяет основное лечение.
- Показаться врачу, если через 4-6 недель рубец не бледнеет, а краснеет, растёт, зудит или выходит за границы раны.
