Unmaking your mark: how to avoid scars, and how to minimize their appearance

Scars are kind of like tattoos you don't choose — like it or not, they stay with you forever, reminders of events long past.

There's that little divot in your forehead from when you had the chicken pox. That dimpled oval on your knee where you fell on some rocks. And, of course, that unsightly seam from your two caesarean sections.

Who knew so many of those old scars would still be around decades later?

Your doctor, that's who.

Dermatologists and plastic surgeons see dozens of scars every day on faces and bellies and legs. Most are almost invisible; others are pink and puckered and still angry.

Some people embrace their scars, including the celebrities listed below. Others go to great lengths to hide them or diminish their appearance as best they can.

The good news is it's never too late to try to minimize those marks if they bother you. "There's always something you can do about it," says Dr. Milan Lombardi of the Lombardi Institute of Dermatology in Tampa.

The depth, size and type of wound will determine what kind of scar you get, as will your age, genes and ethnicity. And they'll factor into your treatment as well. Just as important, though, are the steps you take to care for your cut, burn, incision, abrasion, bite or puncture as soon as you get it.

When the dermis, the deep, thick layer of your skin, is damaged in some way, your body goes to work forming new collagen fibers to fix it. Normally, those fibers line up in a nice parallel fashion, forming a bridge across the wound that will slowly contract and pull the edges together, resulting in a scar that is flat, thin and eventually pale.

But if your body gets too aggressive with that collagen, the scar can be red or raised. These hypertrophic scars, or more severe keloid scars, are more common in younger people and those with darker skin, whose repair systems sometimes go into overdrive.

Some scars can be painful. If you're burned, you may get a contracture scar that tightens your skin and can affect your muscles and nerves. Others just hurt to look at: those deep acne scars you have to face every day, for example, or the surgery scar that no amount of makeup is going to mask. These atrophic scars form a depression because of damage to the collagen, fat or other tissues below the skin.

Of course, some scars are unavoidable, and because everybody is different, what works for one person won't necessarily do the trick for another, says Jennifer Hickman, a nurse practitioner with Tampa Bay area Suncoast Skin Solutions. People with diabetes or some other chronic illness may need extra care, as will children and older adults.

If the breach is larger than a centimeter, head to the doctor, says Lombardi, a fellow of the American Academy of Dermatology. You may need a tetanus shot, and you could require stitches or some other specialized care. People always worry about how many stitches they'll get, he says, "But sutures are great for wound healing. The more sutures, the less tension, and the better the wound will stay together and heal."

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If it's an injury you can treat yourself, make sure you've flushed it clean with antibacterial soap and water, and cover it with a light bandage. If you have sensitive skin, choose a cover that won't pull when you remove it. Lombardi recommends a nonstick bandage and surgical paper tape; gauze can stick to the wound.

After that, it's pretty basic. Clean it once a day with soap and water, moisturize it (petroleum jelly will do), put on a clean bandage and leave it alone. Hickman advises using your shower or bath time as an opportunity to loosen the bandage with water, clean the wound and treat it.

Whatever you do, don't pick at it. This can delay healing, and it increases the risk it will become infected and you'll get a scar. "There's nothing you can do with your hands to make it better," Lombardi says. And stay away from Neosporin, he cautions. Many people are allergic to neomycin, one of the antibiotics in Neosporin, and can have a bad reaction.

Forget what you've heard about "giving it air" or getting a "good" scab, he says. Keep your wound covered and avoid exposing it to the sun for the first 30 days as it heals. If you feel pain or you see redness spreading, or if it fails to heal after a week to 10 days, see a doctor.

Keep in mind that the location of your wound also will affect how it heals. Women with heavy breasts often have trouble with an incision on their chest, Hickman says, because the weight pulls it open. Heel wounds also are especially challenging, because you have to stay off your feet, there's minimal blood flow and the bone is close to the surface.

Once your wound has healed, you can start working on minimizing any scarring, and there are dozens of over-the-counter creams, ointments and gels that may help with small or newer scars. Lombardi tells his patients to stick to products that are silicone-based, including the silicone gel sheets that are popular with plastic surgeons, because they hydrate and protect.

As for secondary ingredients — rose hip oil or the onion extract found in Mederma, the most popular scar product — a 2009 study in the Journal of the American Academy of Dermatology found some big disparities between what is advertised and clinical evidence that shows they do any good. "It's all anecdotal," Lombardi says. "Your cousin tried it and it worked. That sort of thing." Consumer advocates advise buyers to always look for a money-back guarantee.

Go with the timing and products your doctor recommends, not the internet, Hickman says. And don't rush it, she warns.

When scars are visible, such as acne marks, patients are often eager to start treatment. "But we really have to wait until the acne is stable," Hickman says. "I don't want to treat something that would have faded on its own."

If topical treatments don't work, you may have to move on to other therapies.

Your doctor might suggest steroid injections to treat thick or raised scars. And collagen or other fillers may work for some types of pitted scars. Creams containing retinol, vitamin C or glycolic acid can help reduce the appearance of acne scars, according to the American Academy of Dermatology. If the scars are especially deep, though, your doctor will probably prescribe a retinoid, or discuss chemical peels, microneedling to stimulate collagen, or lasering.

Lasers also can be used to mitigate thick scars, especially if they're used early to destroy the blood vessels feeding the scar tissue, Lombardi says. "They work to make the scar less red, smooth it and bring it back to normal."

With surgical scar revision, the scar is removed and replaced with something smaller or narrower. A zigzag can become a straight line. A red scar can fade to one that's smooth and white. And that C-section scar you hate can be turned into a tummy tuck.

Prices vary depending on the treatment, who provides it and how many treatments you require. If you're correcting your scars for cosmetic purposes, you'll probably end up paying for it yourself, but it never hurts to check. And if your scar causes a physical impairment (with your doctor verifying that it's limiting your motor function or causing pain) your insurer will likely work with you.

Your scar may not ever fully fade away, and it may take several different treatments before you find the one that works, Lombardi says. But if you're looking at it every day as a defect that's killing your confidence, you have nothing to lose by asking your doctor what he or she can do to improve a scar's appearance.

Contact Kim Franke-Folstad
at kffolstad@gmail.com.