Many patients seek out their local Emergency Department across the country on a daily basis for management of open wounds that usually include primary closure with either sutures or staples. Open wounds make up approximately 4.5% of ER visits annually. We see the bulk of this volume in the warmer months of the spring and summer when people are spending more time outside.
Wound management for my patients involves a lot of complex choices. In the ER, I have to decide which type of wound closure material to choose – steri-strips, glue, staples or sutures – based on the wound location, size and level of contamination. If I choose sutures, there are additional options including size, thickness and absorbability. Patients are then instructed to return to the ER at a later date – again, depending on the location of the wound – to have the suture material removed.
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These are all very important steps in wound management in the ER. But perhaps an equally important step, and one often overlooked, is prevention and treatment of scar formation.
How do scars form?
Skin is the largest organ in the body and an important part of the immune system as a protective barrier against germs such as bacteria. When it is damaged, our body generates collagen protein to close the wound and protect us from infection.
While aesthetically unpleasing, a scar is the body’s natural way of healing and replacing lost or damaged skin. Scarring does not always occur and is dependent on several factors:
- Size, severity and the location of the initial wound
- Whether you received prompt care including stitches for the wound or let it close on its own
- Presence of infection
- Age, genes, ethnicity and overall health or presence of other medical problems like diabetes and high blood pressure
The primary difference between a scar and the tissue it replaces is the alignment. While both feature collagen, scar tissue collagen is less organized in a single direction whereas the original tissue had a more complex basket weave-type formation. Scar tissue collagen is also thicker and discolored.
How to prevent scars
First and foremost, clean the wound when the injury happens. Tap water by itself is sufficient to clean the wound. Avoid more toxic, tissue-damaging antiseptics like hydrogen peroxide or alcohol.
Everyone puts hydrogen peroxide on their wounds:They really shouldn’t.
Second, seek medical attention. Sutures, or stitches, to close larger wounds can minimize the risk of scar formation. As will treating with oral antibiotics if your doctor thinks the wound was contaminated and prone to infection. I like to avoid topical antibiotics like Neosporin in my patients given that a not insignificant number of them develop allergic contact dermatitis from its use.
Scar treatment: What’s the latest?
So, you sought immediate medical attention, got some sutures and your wound is healing well without infection. But it looks like there’s a scar forming. Or you suffered a wound injury months ago and there’s still a scar. What can you do?
First, remember that scars can continue to fade for up to two years. After that time, unfortunately though, it’s unlikely there will additional natural change in scar appearance.
Avoid products containing topical vitamin E. Long-considered a popular addition to topical creams to treat scars, multiple studies have consistently demonstrated that topical vitamin E is ineffective and can cause contact dermatitis – irritation and itchiness at the scar site – in approximately one-third of people who use it and may end up worsening the scar appearance.
Keep it simple and apply Vaseline with sunscreen. Scar tissue is more susceptible to alterations in appearance by UV light than normal skin tissue so sunscreen is a must if you are concerned with the scar’s appearance. Both Vaseline and Aquaphor will protect the skin and keep the scar tissue hydrated.
It’s impossible to remove scars completely without more advanced surgical techniques. But there are many so-called scar creams to consider on the market that can help minimize the appearance of a scar. There is a shortage of high-quality studies to independently evaluate these creams, but anecdotally products with some of the following active ingredients have garnered a lot of positive reactions:
Silicone dioxide sheets soften and flatten scars and do have consistent support in the research literature. These sheets mimic the natural skin barrier to trap moisture against the skin’s surface. This hydration, in turn, reduces the itching associated with scars.
More intense treatment options include dermabrasion, corticosteroid injections, laser treatment, cryotherapy, dermal fillers or scar-revision surgery. Consider a consult with a dermatologist to explore these more advanced alternatives.
The bottom line? Scar formation is a natural process to replace damaged tissue. Scars can continue to fade over years. Stick with a combination of plain Vaseline and sunscreen or silicone sheets to keep scar tissue hydrated and protected from UV rays that can further alter its appearance. Avoid products with topical vitamin E – there’s no evidence it works and may cause contact dermatitis at the site. Consult your dermatologist for more advanced treatment options.
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Michael Daignault, MD, is a board-certified ER doctor in Los Angeles. He studied Global Health at Georgetown University and has a Medical Degree from Ben-Gurion University. He completed his residency training in emergency medicine at Lincoln Medical Center in the South Bronx. He is also a former United States Peace Corps Volunteer. Find him on Instagram @dr.daignault