Hypertrophic Scar: Causes, Treatment, and Prevention

Hypertrophic scars are a common and often distressing dermatological issue that occurs as an abnormal response to trauma or injury. Unlike their counterparts, these thick, raised skin scars remain within the original wound’s boundaries and do not spread to surrounding skin.

Distinguished by their red or pink hue, they often appear raised and lumpy initially but tend to flatten over time. Frequently associated with a history of burns, piercings, cuts, or surgical incisions, hypertrophic scars can cause discomfort, itchiness, and even pain. However, their most significant impact is often psychological due to their noticeable appearance.

Here, we’ll discuss the causes, treatments, and prevention tips for hypertrophic scars to help you better understand and manage this skin condition.

What are Hypertrophic Scars?

Hypertrophic scars occur when the skin’s healing process after injury is imbalanced. Wound healing involves inflammation, tissue formation, and tissue remodelling. During tissue remodelling, collagen, the main structural protein in our skin, plays a crucial role. Normally, collagen helps repair damage and is gradually broken down and remodelled to form healthy skin. However, there is excess collagen production in hypertrophic scars, resulting in raised, often red scars within the original wound boundary.

Over time, the scar may reduce in size or flatten as excess collagen degrades, but this process can take years. Understanding this biology is vital for treating and potentially preventing hypertrophic scars.

Hypertrophic Scar vs. Keloids

Both hypertrophic scars and keloids result from abnormal wound healing, but they differ in appearance, growth patterns, causes, treatments, and common locations.

Appearance: Hypertrophic scars are typically red or pink, raised, and remain within the boundaries of the initial wound, while keloids are often darker in colour, extend beyond the original wound boundaries, and can take on a bulbous, irregular shape.
Growth Patterns: Hypertrophic scars usually form within weeks to months after an injury and may gradually reduce in size over time. Keloids, on the other hand, continue to grow and expand for several months or even years.
Causes and Risk Factors: Both hypertrophic scars and keloids can result from various skin injuries, such as burns, piercings, surgical incisions, and severe acne. However, keloids are more likely to develop in individuals with darker skin tones and can have a genetic component.
Treatment Approaches: The treatment for both hypertrophic scars and keloids can include silicone sheets, steroid injections, and pressure therapy. More severe cases might require surgical removal or laser treatment. However, it’s worth noting that keloids have a much higher recurrence rate, even after surgical removal.
Common Locations: Hypertrophic scars typically form at the site of an injury or incision, while keloids tend to occur on the chest, back, shoulders, and earlobes, though they can develop anywhere on the body.

What causes hypertrophic scars to develop?

Several underlying causes can trigger the formation of hypertrophic scars.

Surgical Incisions: Post-surgical wounds are a common cause of hypertrophic scars. The severity of scarring may vary depending on the individual’s skin type, the location and depth of the incision, and the type of sutures used.
Trauma or Injury: Any skin trauma, including lacerations, puncture wounds, or abrasions, can lead to hypertrophic scars. The risk increases if the trauma is deep, extensive, or located in areas of high tension.
Burns: Second or third-degree burns often result in hypertrophic scars. The severity of the burn and the subsequent wound-healing process play a significant role in the development of these scars.
Acne: Severe acne, particularly cystic acne, is another common cause of hypertrophic scars. When inflamed acne lesions rupture, they can damage the surrounding skin, leading to scar formation.

The development of hypertrophic scars is not exclusive to these causes. Various other factors, such as skin tension, infection, or prolonged inflammation, can also contribute to their formation. It’s also noteworthy that individuals with a family history of hypertrophic scars are at a higher risk, indicating a potential genetic predisposition.

What are the risk factors for developing hypertrophic scars?

While anyone can develop hypertrophic scars, certain factors can significantly increase the likelihood of their formation.

Genetics: A family history of hypertrophic scars or keloid scars can increase an individual’s predisposition towards developing such scars.
Age and Sex: Young individuals and adolescents are more prone to hypertrophic scarring. There’s also a slightly higher incidence in females than in males.
Ethnicity: People with darker skin tones, such as those of African, Hispanic, or Asian descent, are more likely to develop hypertrophic scars.
Wound Infection: The prolonged inflammatory response can enhance hypertrophic scar formation if a wound becomes infected.
Location of Injury: Wounds on certain body parts, like the chest, shoulders, and upper back, are more likely to result in hypertrophic scars due to the high skin tension in these areas.
Poor Wound Care: Neglecting proper wound care can lead to increased tension on the wound, delayed healing, and, ultimately, a higher risk of hypertrophic scarring.

Signs and Symptoms

Hypertrophic scars are characterised by a distinctive physical appearance that sets them apart from other scars. Firstly, they are elevated with a thickened texture and firm to the touch. This results from the overproduction of collagen, which creates a raised surface over the site of the original wound. Second, these scars usually exhibit a red or pink colouration, which can become more pronounced over time, making them more noticeable.

Itchiness or discomfort is another common symptom associated with hypertrophic scars. Individuals may experience varying degrees of itchiness, ranging from mild irritation to severe, disrupting itchiness. The discomfort can also manifest as pain, particularly when the scar is touched or stretched.

Finally, hypertrophic scars may lead to limited flexibility in the affected area, especially when they occur over a joint or in larger areas of skin. This is due to the tight, hardened nature of the scar tissue, which can restrict movement and cause discomfort during physical activities.

Diagnosis and Evaluation

Diagnosing hypertrophic scars typically involves a comprehensive evaluation by a healthcare professional. The process begins with visually inspecting the scar assessing its appearance, size, shape, colour, and texture. The doctor may also palpate the scar to gauge its firmness and height.

Alongside the physical examination, understanding the patient’s medical history is crucial. Information such as the cause and timing of the scar plays a significant role in the diagnosis. The presence of discomfort, itchiness, or restricted mobility associated with the scar can provide additional insight. Family history and wound care practices are also considered. Sometimes, a skin biopsy may be recommended to rule out other conditions.

Diagnosing hypertrophic scars involves a comprehensive approach combining examination and understanding of the patient’s history.

Hypertrophic Scar Treatment Options

1. Topical Treatments

Topical treatments serve as an initial strategy for managing hypertrophic scars, encompassing medicated creams, gels, and silicone sheets. Creams and gels, often formulated with onion extract or Vitamin E, provide anti-inflammatory benefits, diminishing redness and itching and contributing to the softening and flattening of hypertrophic scars. Their efficacy, however, varies and depends on the scar’s characteristics and maturity.

Silicone sheets or tapes are an alternative, exerting constant pressure on the scar to lessen its prominence and height. By fostering a moist environment, they also help soften the scar and reduce redness. These sheets are usually applied for extended periods, typically during sleep, and may be used for several months. Although silicone sheets can be cumbersome compared to creams or gels, they are frequently favoured for treating larger or more noticeable scars.

2. Corticosteroid Injections

Corticosteroid injections effectively treat hypertrophic scars, especially thicker ones. They reduce inflammation, slow cell proliferation, and flatten scars. Injections of corticosteroids, like triamcinolone, directly into scar tissue suppress the inflammatory response, reducing redness, itchiness, and discomfort. It also inhibits collagen synthesis, preventing further thickening. Treatment involves a series of injections at regular intervals, typically every 6 to 8 weeks, until optimal results.

3. Surgical Interventions

In certain cases of hypertrophic scars that do not respond to non-surgical methods or are particularly large, surgical options may be considered. Scar revision surgery modifies the scar’s size, direction, or placement to make it less visible, employing techniques like W-plasty or Z-plasty that align the scar with natural skin folds. Scar excision, a more invasive option, involves removing the scar tissue completely and closing the wound, sometimes with a skin graft or flap for larger scars, to form a subtler scar.

4. Laser Therapy

Laser therapy is a non-invasive approach increasingly utilised for hypertrophic scar treatment, improving appearance and reducing discomfort. Ablative lasers like the CO2 laser strip away the top scar layers, encouraging new skin growth and reducing scar thickness, but may alter pigmentation and carry infection risks. Non-ablative lasers focus on the deeper scar tissue, promoting collagen production and softening the scar without surface damage, though they may require more sessions. Fractional lasers combine these approaches, causing micro-injuries to trigger healing with fewer side effects.

5. Pressure Garments

Pressure garments are effective, non-invasive methods to manage hypertrophic scars from burns or surgery. They apply continuous pressure to reduce scar thickness and improve appearance over time. By reducing blood flow, they slow down excessive cell proliferation, as seen in hypertrophic scars. These custom-made garments alleviate pain and itching. Worn for 23 hours a day over months to a year, patient compliance may be challenging due to discomfort. Consult a healthcare professional for correct usage and to discuss potential side effects.

How to prevent hypertrophic scars?

Preventing hypertrophic scars can be achieved through a few preventive measures:

Effective Wound Care: Minimising the scar starts with proper wound management. To promote optimal healing, keep the wound clean, moist, and protected from infection. Avoid picking or scratching the wound, as it can disrupt healing and increase the risk of a hypertrophic scar from developing.
Early Intervention: Starting treatment promptly can help prevent this scarring. If you’re prone to this type of scarring, consult a healthcare professional as soon as a wound occurs. Options may include silicone sheets or gels, pressure garments, or other treatments.
Sun Protection: Protect wounds from sun exposure to prevent darkening and more noticeable scars. Use a strong sunscreen (SPF 30 or higher), wear protective clothing, or stay in the shade.
Scar Massage: Massaging a healing wound can prevent a hypertrophic scar from developing. It breaks down collagen build-up, improves circulation, and aligns collagen fibres. Before starting scar massage, wait until the wound has fully closed, and follow your healthcare professional’s advice on technique and duration.

Living with Hypertrophic Scars

Living with hypertrophic scars can be challenging, impacting physical appearance and emotional well-being. To manage the psychological effects, consider these strategies:

Seek professional counselling: Mental health professionals can help process emotions and develop coping mechanisms.
Join support groups: Connect with others who share similar experiences and gain advice and support.
Practice self-care: Engage in activities like mindfulness, meditation, or yoga to manage stress and promote well-being.
Use positive affirmations: Boost self-esteem and acceptance by repeating empowering phrases.
Consult dermatologists or plastic surgeons: Discuss concerns and explore options for scar improvement.

Complications and Follow-Up

A hypertrophic scar can lead to complications if not managed correctly. Infections are possible, indicated by pain, redness, swelling, and pus, necessitating prompt medical care. There’s also a risk of recurrence, particularly in genetically susceptible individuals, which can be both emotionally distressing and a cosmetic concern, highlighting the need for ongoing care. Scars near joints may restrict movement due to tissue rigidity, and pain or itching can cause significant discomfort. Beyond the physical, the psychological impact of these scars, such as reduced self-esteem and social anxiety, can be substantial, warranting a comprehensive treatment approach that includes psychological support.

Regular Follow-ups: A Must

Regular follow-ups with your healthcare provider are essential when managing a hypertrophic scar. These visits allow for ongoing assessment of the scar’s progress, potential treatment adjustments, and early detection of complications. The healthcare provider can track the effectiveness of the treatment plan and make necessary modifications. Regular follow-ups allow patients to voice their concerns, discuss discomfort, and receive emotional support if needed.

Are hypertrophic scars permanent?

Hypertrophic scars aren’t always permanent. They may fade over time, typically within one to two years. However, the duration can vary based on scar size, location, individual healing, and treatment effectiveness. Consult a healthcare professional or dermatologist for the best treatment options for your case.

How do hypertrophic scars affect skin texture and colour?

Hypertrophic scars can greatly affect the skin’s appearance. The raised, thick scar tissue creates an uneven surface, making it feel rough. These scars may also cause changes in skin pigmentation, especially in darker skin tones. These texture and colour changes can cause emotional distress and impact self-esteem. Fortunately, treatments like laser therapy or dermabrasion can improve texture and colour.

Do hypertrophic scars continue to grow?

No, hypertrophic scars don’t continue growing indefinitely. Unlike keloid scars, another type of raised scar, they don’t extend beyond the original wound. a hypertrophic scar usually stops enlarging within a year after the injury. The scar may initially appear red and raised, but it flattens and fades over time.

What happens if you cut off a hypertrophic scar?

It is not recommended to remove a hypertrophic scar surgically unless done by a trained medical professional. Attempting to remove it at home can lead to serious complications like infection or worsened scarring and may even trigger the formation of a more extensive scar, such as a keloid scar. Surgical removal is usually considered a last resort after non-invasive treatments have failed due to the risk of recurrence or worsening of the scar.

Are hypertrophic scars hard or soft?

Hypertrophic scars are firmer and harder than the surrounding skin due to excess collagen during healing. The thickness and raised appearance can make them feel rigid compared to unaffected skin. However, the hardness varies between individuals and may change as the scar matures and responds to treatment. Note that a sudden change in scar hardness, especially with other symptoms like pain, redness, or heat, may indicate a potential complication.

Conclusion

Hypertrophic scars, although not always permanent, can greatly affect a person’s physical and psychological life. They have raised scars that can itch, be painful, limit movement, change skin texture and colour, and cause emotional distress. Regular follow-ups with healthcare providers are essential for managing these scars, allowing for treatment adjustments, early complication detection, and emotional support.

Treatments such as silicone sheets, pressure garments, scar massage, corticosteroid injections, cryotherapy, and laser therapy may help reduce these scars over time. Avoid attempting self-removal of these scars, as it can lead to serious complications. Always consult a healthcare professional for advice and treatment options.