Caring for pediatric scars

By Valerie B. Lyon, MD

Questions from parents about scars and scar care are common. Physicians should understand the best protocol for scar care.

In general, any scar can benefit from avoiding sunlight the first year. New skin is more susceptible to sun damage than older skin, and new scars are easily sunburned. Sun damage can contribute to formation of superficial telangectasia and skin pigmentary changes, making scars more obvious.

Most scars benefit from gentle massage several times a day with thick ointment. Gentle circular motion over the scar with light pressure, starting one month after the wound is healed, will help continue wound remodeling. Aquaphor Healing Ointment is an over-the-counter product that can be found in most drugstores, and it is particularly suitable for scar massage.  

Keloid on the posterior thigh before treatment.

Keloid on the posterior thigh after treatment with intralesional steroid therapy, occlusion with silicone sheet and laser therapy.

White petrolatum is an equally beneficial product that may serve as a less expensive alternative. Many of the commercially available scar gels that are marketed to consumers show no real benefit over either of these agents.

In order to provide further scar advice, know the answers to the following questions:

• What is the age of the scar?
  
• What is the location of the scar?
  
• Is the scar symptomatic: itchy, painful, growing?
  
• What is it about the scar that is most obvious, for example: color, height, texture, tension on surrounding skin or structures?
  
• What are the parents' expectations regarding the scar?

Age of the scar

Scars mature the most in the first year. Invasive treatments to improve scars often can be avoided as they will improve with time. The first part of the scar to improve is the coloration. In lighter-skinned individuals, the scars often will look pink for the first several months and later become white. In darker-skinned individuals, scars often will be hyperpigmented or lighter centrally with darker borders. The darker color takes many months to fade, sometimes even years. Scars on the face fade more quickly, scars on the leg fade more slowly.

Explanation of the natural maturation of scars helps remind parents what to expect.

Location

The "v" of the chest, the upper back extending over the shoulders and the jaw are prone to keloid formation. Wounds in these anatomic areas should be monitored for becoming thicker over the first year, rather than flattening. Keloids are scars that overgrow the original incision size, becoming thick and occasionally quite large and are more common in African-Americans. They can be itchy, painful, unslightly and inhibit function when located over a joint. Curad® Scar TherapyTM and Neosporin® Scar SolutionTM are   over-the-counter bandages that have a thin silicone pad. These bandages can be helpful to prevent keloids in keloid-prone individuals or anatomic locations. They also can help soften and flatten an existing keloid. The bandages need to be worn for several months for the full benefit to be observed. A dermatologist or other surgeon trained in keloid care should help manage these wounds if they continue to progress. Intralesional therapy with steroids, laser therapy and occlusive dressings can be used, and often a combination of the above is needed.

Character

Often what is bothersome to the patient or parent about the scar may not be intuitive to the physician. Understanding the character of the scar that is problematic to both your eye and the patient's eye is essential to arrive at a treatment plan. Many times the patient is unaware of why he or she dislikes the scar. Often, the most obvious feature of the scar is the pink color, which normally fades with time.

Expectations

Expectations regarding scars are best addressed by the surgeon preoperatively, in the case of an elective procedure. A common scar myth is the notion that scars in a child vanish over time. Anticipation of a scar that is smaller than is reasonable for the surgery required is almost universal unless a discussion takes place between the surgeon and the patient or parent preoperatively. An outcome that is different from that discussed prior to the procedure is frequently not appreciated by the parent or patient and can be an area of significant dissatisfaction with the surgeon and the procedure.

Camouflage

Glominerals®, Covermark® and Dermablend® are brands of makeup designed to cover scars. New technology has made them very effective cover-ups, and they even can be waterproof. Generally this makeup is best applied in layers. Someone with experience is needed to demonstrate the best way to apply these products to achieve the desired affect. This makeup can be found in some higher-end department stores and selected skin specialty offices.

Valerie B. Lyon, MD, is a pediatric dermatologist at Children's Hospital of Wisconsin. She also is an assistant professor of Dermatology at the Medical College of Wisconsin.

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