The following is an excerpt from the Glow Journal podcast. To listen to the full interview, subscribe now on iTunes or Spotify
In this instalment of our Ask An Expert series with our friends at Candela Medical, we’re taking YOUR questions to Dr Liz Dawes-Higgs. A recipient of the Schering-Plough Award for her laboratory-based research, Dr Dawes-Higgs is the New South Wales State Examiner on the National Examiners Committee for the Australasian College of Dermatologists and has a particular interest in women’s skin health and ageing. This in mind, I felt that Dr Dawes-Higgs was the ideal doctor to answer your questions on this episode’s rather specific topic- scarring, from C section and endometriosis scars to those from surgery, injury and even piercings.
Away from our regular brand founder conversations, I am frequently asked so many highly specific questions about the skin. Given that I am an educated consumer and by no means an expert, it would be extremely unethical for me to even attempt to address your skin concerns- which is why I have long insisted on taking those questions to a medical doctor. That’s why I truly love producing this Ask An Expert series with Candela. Although the series itself is sponsored, doctors legally and ethically have to remain completely objective in interviews like this. For this reason, this series is the single most authentic way for me to integrate branded content into the podcast because it’s giving you, the listeners, completely unbiased expert answers to your most specific skin questions.
GLOW JOURNAL: I was sent so many, really specific, questions about different forms of scars, so I thought we might start quite broad then hone right in. So firstly, what actually is a scar? Why do we see scars, and what is happening to (or within) our skin when it produces a scar?
DR LIZ DAWES-HIGGS: A scar is this amazing, evolutionary defence mechanism that we have developed to protect internal organs if we injure ourself. You can imagine, if you’re running around and you’ve traumatised yourself, if you have an open wound for a long time, you run the risk of infection and the external environment coming internal- and that’s not what we want. So [a scar] is this stop gap measure that humans have come up with to protect our internal organs. And some of it is good and some of it is not so good, but it’s what we have.
Is it ever too late to reduce the appearance of a scar?
It’s never too late, but the earlier you get a scar the better. If you know that you’re going to get a scar, say if you’ve got a planned procedure, if you can try and prevent and look after that wound and really get your skin in good condition before you go into surgery, that’s the best thing. But you can still treat scars later on, but you won’t be doing as good a job as if you were really [taking care of it] early on.
Well, I think based on that, I know the answer to this next one- do fresh scars need to be treated differently to scars that are, say, several years old?
Absolutely. When you look at treatments for scars, there are so many, and some are great at the beginning, some are great at the end of wound healing, and it really depends on what sort of scar, where it is, how old it is and what caused it. You can really tailor your approach to scar treatment based on how old it is.
I would love to start the audience questions with surgical scarring. One listener has asked “To tape or not to tape?” Before we answer that, what does taping a scar do?
Taping a scar involves literally getting a bit of preferably a nice clean wound dressing that you buy from a chemist (not just your average, every day sticking tape), and you literally pull the wound edges together. And that’s what sutures do- they’re bringing the edges closer together so that you get a thinner scar. You get a scar that heals up quicker, and it takes the tension off. Once you get tension in a scar, it tends to heap up a little bit and it goes red, it goes thicker and it raises up off the skin and you can feel it. So that’s what taping does.
If you have the right tape, can also add a little bit of moisture into the wound as well. You want to keep your wound nice and moist. You don’t want to let it dry out. The main thing is it’s taking tension off the wound.
Okay great, so that’s a yes to tape. How long do we need to tape for?
It depends on what your scar is, because if it’s an incision, so just a straight line scar, a surgical scar or even a traumatic knife wound, you’re taping it to bring those edges together but even when those edges are together, a week down the track you’ve only got about 3% of your skin strength back. Two weeks down the track, say if you get stitches put in and you get your stitches out two weeks later, you’ve got something like 20% of your wound strength back. So you think when you get your sutures out, everything’s fine. I’m good to go. And in fact, you’ve only got 20% of your strength back. So you’ve got to tape the scar for a good three months. And at three months, you’ve only got 80% of your wound strength back.
The scar is what it is, but it’s how you look after it in those first three months. And if you strap it and you take the tension off and you’re not going to do silly things like start doing an exercise that pulls that skin apart, you know, you go and do your tummy crunches and you’re pulling that apart, then it doesn’t matter how much strapping you do- you’re going to pull it apart. And that stretch does not look so good. The scar, when it’s stretched, it’s stretched. It’s really hard to undo that.
So you want to strap it. You want to keep it free of an infection. You want to keep it nice and moist. All of those things really help to get the best possible scar.
A large number of readers and listeners have submitted questions regarding C section scars. What is the best way to go about treating those?
Here goes those crunches! Those tummy crunches!
Caesar scars are really common. They’re really, really common. And the thing with that is you’ve got to take the tension off. The scar has to be aligned in a certain way, and we leave it up to the obstetricians to do that. They generally heal up reasonably well. Some of them become a little bit heaped up- they get red and they get heaped up, which is what we call a “hypertrophic scar.” If you have a tendency to a keloid scar, you could develop a keloid scar in that area, but generally they heal up really well and they do flatten out- but it does take years. It takes a year or two years to heal and to really repair itself. But they’re very common.
So would we be looking at trying to heal that topically or is laser the best option? Where do we start?
I think you just throw everything at it, to be honest. You do everything that we’ve already spoken about. You use moisturisers, you can use a topical retinoid. There are other topical things. And then you get in there really quickly with a laser. So the quicker you can get a laser in there, the better.
Caesar scars are usually quite red, so they respond really well to a red laser- what we call a vascular or pulsed dye laser. They are really the gold standard to get the redness out of it. They’re not difficult to have [treated], it’s a quick and easy procedure for you to have done. It makes it a little bit redder in the beginning, and then that calms down and it’s really trying to stop those blood vessels that have come in there, just to try and dampen that redness down. And then, pretty soon after that, you can start with an ablative laser as well to try and calm that scar down and stop it from heaping up.
I also received many, many questions regarding scars from endometriosis surgery. How are those scars best treated?
They are slightly different. A caesar scar tends to be really long and takes quite a long time to settle down, but really because of the length of it and it’s really obvious. A scar from an endometriosis procedure, we call that a laparoscopic procedure, that’s a key hole surgery, they tend to be really small because they just allowing a very small instrument to go into the abdomen and blow up the abdomen with a bit of gas so you can see where that endometriosis is. They [the scars] tend to be small and they do, in general, heal up pretty well if you can keep them infection free and you can strap them.
The other thing we haven’t spoken about is a silicon sheeting, which is great for these sorts of scars. Because these scars are small it’s much easier, and they’re on your tummy so you can hide these silicon gel sheets quite easily. You put those over the scars, and the silicon works in a few ways. One of them is to keep that area nice and moist and allow the skin to breathe and get a little bit more oxygen to the scar to heal it up a little better. That’s another thing that you can use for these sorts of scars
One listener has asked about reducing recurring scars, specifically her endometriosis incisions. Firstly, why are some scars recurring? And secondly, you should those be treated?
A scar is a scar, and if it “recurs” or it’s getting worse, then really it’s a keloid scar.
A keloid scar is something that tends to occur in darker skinned individuals, and also in teens and those in their twenties. People in their twenties tend to develop these sorts of scars, and it’s not that they recur, it’s that they keep getting worse.
If it’s been treated and it’s looking worse, it’s had some extra damage to it. Whether that’s another procedure has gone into the same hole (because often a surgeon will use the same hole to try and minimise the number of scars), or if you’ve damaged it in some way, you’ve opened it up or you’ve pulled it apart early on. I presume she’s talking about a keloid, which means that rather than a keloid, it’s getting worse.
It’s a good time to distinguish between what is a hypertrophic scar and what’s a keloid scar. A keloid scar, like I’ve said, is one that just keeps going. It goes beyond where that original wound was and tends not to get better- it’s really hard to treat. You often have a family member who’s developed a keloid scar, or you personally have a keloid scar, usually around the shoulder or chest area, the neck, or you might have seen someone in the street with a big keloid scar on their ear because they occur where you get your ear piercing.
A hypertrophic scar stays in the area of the wound and it doesn’t get any bigger. It doesn’t expand beyond that original injury. That means you’re doing a great job of healing up and producing the scar, but you’re just doing too good a job and your body doesn’t know how to turn itself off. Eventually, it sort of does and it can get a bit better, but with a keloid scar you can’t turn that process off.
Now that we’re on keloid scars, you’ve mentioned ear piercings. I actually had a listener ask how to treat keloid scars from piercings- so is it possible to treat these?
Yes, it is possible to treat them. You can make a difference. It’s worth doing. It’s certainly worth it’s doing. So this is where you have your ears pierced, and usually you get your ears pierced when you’re younger which is that prime time to develop keloid scars. It’s your biggest risk. And it’s in an area where you tend to keloid scar. So it’s this collision of all these really terrible things all coming together, and suddenly you’ve got a keloid scar on your ear. Often you think “Oh, you could just cut it out,” but you cut it out and it just grows back- so you can’t really cut it out.
It’s very hard to treat, but you can. You can actually start again by cutting it out, but then suddenly putting some pressure on, so you’re trying to stop it from growing back. You’re injecting it with anti-inflammatories and trying to stop it from forming in the beginning. They can be a bit difficult to treat, but essentially you’re putting pressure on them. That’s your main thing. There’s lots of little devices, like little earring that puts pressure on that ear and tries to stop the keloid from starting up.
I had another listener ask about treating keloid scarring, post colposcopy. Would that be treated differently to what we’ve just discussed?
No, it’s very similar. It’s very, very similar. These scars, they’re painful, tender and itchy. You want to get them treated, even if you like the look of them. You’re still seeking treatment because they can be quite uncomfortable. Essentially it’s pressure again. It’s trying to sort it out before it develops [a keloid scar].
A listener has asked about reducing scarring on the face from a diathermy skin lesion removal. What would be the best way to remove a scar of that nature?
The scar from a diathermy, I presume they’ve developed a flat sort of scar. Scars come in three types- they’re either flat, they’re indented or they’re raised above the skin. Often with these sorts of procedures, you get a flat, white scar. If it’s dented in, you’re going to need to fill it up. If it’s flat, you just to try and get the look of it better.
Lasers, the CO2 laser, is a great laser because you’re basically causing another injury to it, which sounds really brave, doesn’t it?! They’re injuring an injury to try and get it better. What the ablative lasers do is they are literally putting a column of heat down into the skin and injuring that skin, creating another wound to heal up, but heal up in a more controlled manner. They can work very well in those sorts of scars because the face, coming back to silicone sheeting, it’s very hard to put a piece of silicone sheeting on your face and walk around. That’s why we’ve got lots of options for scarring, because certain places it’s easy, other places it’s not so easy. It’s difficult, on your face, to put something on 24 hours a day.
While we are talking about facial scarring, I had a reader ask about topical treatments to reduce surgical scarring on her face and on her neck, as she doesn’t love the idea of laser treatment on the face. What would you recommend? Are there any particular topical ingredients that she should be looking out for?
There are. There’s quite a few topical ingredients, and these are best applied at the beginning. Right at the beginning, a moisturiser to keep that skin moist and not letting it dry out can be a real benefit. There are some topicals that you can use a little bit later on. So after you’ve got a nice covering over the wound, you can use creams that are based on Vitamin A and things like retinoids, retinol, they tend to have anti-inflammatory and skin controlling mechanisms where they allow the scar to heal up in a more organised way. They’re quite useful as well. There’s some newer things that are coming out in some other components- like onion extract and those sorts of things. And then there’s the old fashioned Vitamin E. As long as you’re basically keeping it moist and keeping it hydrated, those are the main things.
While we’re still on the face, I’ve had one listener tell me that she has a scar on her lip following having stitches removed about a year ago. She says that the scar isn’t “visible,” but it has formed a lump. Is there anything that she can do to minimise the size and the appearance of that lump?
Massage! That’s what we haven’t spoken about!
She can’t see it, and the other treatment options that we have spoken about are really addressing the aesthetic side of it. Massage helps with the thickness of it, so as soon as you get your sutures out, you can start to massage. Massaging breaks down that scar. If it’s a really deep wound, it can also stop your skin from tethering deeper down and sort of anchoring it down. So massage is a really, really good option here. The way she would do that is to literally, three times a day for 10 minutes, firm pressure, grab the lump, and between her thumb and her forefinger, sort of rotate and just give it a good massage. Using a bit of moisturiser as well at the time helps.
I would love to discuss scars from injury, because I feel like this is something a lot of people can relate to- one listener tells me that she has a very dark scar on her shin from tripping up a flight of stairs, which I think everyone has done at some point or another. How should she look to treat this?
So trauma medic scars are quite different to surgical scars. I actually treat quite a lot of traumatic scars, and there’s the old saying- “Every scar tells a story.” And with traumatic scars, you don’t necessarily want that story retold, which is quite different to surgical scars. So when we are talking about improving a scar, it’s not just the aesthetics, it’s about the story behind it. I think that’s very important with a traumatic scar, of any activity. You’re treating two things now, with those sorts of scars.
In this case, when the scar is brown, you can try to de-colour the scar. When you de-colour the scar, you try to just bring it back to the colour of that person’s normal skin. I’m presuming that the scar is darker than their normal skin colour. So you’re just trying to lighten it down to the level of their skin. And then you can camouflage it, you can use tanning products, all those sorts of things to just go over the top of it and just smooth it out a little but more. There are some creams, the Vitamin A based creams can help with pigmentation, hydroquinone preparations, you often need to get those compounded together. Using those both at the same time, that involves seeing a doctor because you do need a script for those two products. Tranexamic acid helps, as well, in combination with the retinoids and hydroquinone to try and de-colour. But if the colour is due to gravel or a foreign body, then there’s not much that’s going to take that out, unfortunately. Some people opt to get that cut out, if it’s a problem. That’s where looking after the scar in the very beginning [is important]. When that trauma occurs, those first few days are so important- keeping that wound clean, getting rid of any foreign material, going on antibiotics if it’s appropriate and if it’s a dirty wound, all of those sorts of things can really, really help.
So go to the doctor!
That’s very true! Sometimes when I see a scar, it’s because that wound had been left for too long before they sought medical help. It could have been sutured up earlier. It could have been realigned in a better way, and part of it removed and pushed into another direction.
There’s this lovely analogy, actually. You’ve got a house, and you’ve got roof tiles on your house. A stone comes along and your tiles… a section of your roof sort of blows off. And that’s what’s happened. There’s some sort of injury, and part of these tiles have blown off, and suddenly there’s rain pouring through your house until you put this tarp over, and that’s your cloth. That’s your immediate go to. Not picking at it, not removing it- that’s the scab you get. So you get your tarp over it, but you know that’s just your immediate stop gap. And then you’ve got to try and get the best looking tile to fit the other tiles that are on that roof. And they’re never going to look the same, but you can try and get the closest match you possibly can. It’s all in that initial period.
Very different type of scar, and I’m not even sure that it is deemed a scar, but I received so many questions about stretch marks. I think it’s super important to note that I don’t think anyone should feel pressured to remove or to treat stretch marks, because they’re so normal and they’re just a fact of life, abut I do know that a lot of people want to get rid of them, just for themselves and just to make them feel that bit more confident. So, that in mind, what is the best way to treat and reduce the appearance of stretch marks?
I would agree with everything that you’ve said- stretch marks are very, very common and you could call them normal. But, having said that, some people still do seek treatment for the stretch marks because they’re a little self conscious of them, and that’s okay! If somebody is seeking treatment, they would like to be helped.
Some of the help that you can get with the stretch marks depends on what they look like. Some of those stretch marks are quite red. If they’re red, you can have a vascular laser. Again, that pulsed dye laser is great for taking out those broken capillaries. If they’re white, that usually means they’ve been there for a little bit longer. What you can look to do there is again, laser, but a combination of two lasers is quite good. It’s like one plus one equals three!
Then you try to improve not just the colour, but the texture of them. That’s the main thing. Again, you’re trying to prevent. “Is there anything I need to address? Do I have any other medical condition that I need to see an endocrinologist for?” There are some conditions that lead to more of these [stretch marks] than others. “Have I been changing my weight too drastically?” Of course we know pregnancy can do it. Bodybuilders tend to get them a lot. I don’t know if anybody’s got kids in the audience, but they might see, particularly in boys when they go through a really quick growth spurt, but they get what looks like a strap mark or like they’ve been beaten on their back. There’s these lines, and they are stretch marks. The kid has literally grown so quickly that the skin can’t keep up, and it looks like somebody’s beaten them. The skin has stretched. They’re often quite red. They can be treated with a red laser. They’re very common, and it really depends on how much they bother you as to what you want to undertake to improve them.
So would stretch marks on different areas of the body need to be treated differently? Say, stretch marks on the stomach compared to say stretch marks on the breasts?
Not necessarily. With a stretch mark, literally, the skin has torn. It’s like getting a piece of paper, you’ve ripped it apart and you’re trying to get that sticky tape and stick it all back together again.
If there’s weight, so say with the breasts there’s the soft tissue of the breast there’s weight, and that can stretch the skin a little bit more and make it more difficult to treat. So a good fitting bra can actually stop that skin from stretching. That would be the only thing- otherwise, a stretch mark is a stretch mark. It doesn’t matter where it is on the body.
While we are on different parts of the body, I’ve had a listener ask about a raised scar on the palm of her hand. Do different areas of the body, something like the hand that we’re obviously using all the time, would that need to be treated differently to a raised scar elsewhere or is the treatment pretty uniform?
It would be very case specific and site-specific because, like you’re saying, if it’s on the hand and you’re using using the hand, it can be very difficult to undergo the normal activities of daily living where you can’t hold a pen because that scar is tight. That’s what comes down to sometimes burns scars on the hands, because the burn contract and it pulls your hand, and you can’t actually stretch out your fingers anymore. The treatment in that case is for functional improvement. You’re trying to stretch that skin out a little bit more so you can open and close your hand. So there is a difference in the treatment, and depending on the site it comes down to function- what function have you lost to scarring?
Again, if you know that you’re going to get a scar, a good plastic surgeon is going to orientate that scar in a way that is not going to be a functional problem. So they’ll try and avoid putting a scar over a joint that has to move all the time.
You mentioned having a white scar earlier, and this was a question that I found particularly interesting. A reader tells me that she has a white scar on her skin following the removal of seborrheic keratosis via laser. Why do we sometimes see that white scarring? And can this be treated?
A scar, as it gets older, goes white. It just doesn’t have the colour cells. And it depends on what your normal background skin colour is, depending on how much that will bother you. If you have a lighter skin tone and you have a white scar, you may not be able to see it so much. If you have a darker skin type and you get a whiter scar, then that will look more obvious.
The colour disparity, again, can be improved with lasers, and sometimes you do just have to physically cover them up. You might use a special grade makeup or fake tan.
Is there anything that can be done to reduce chickenpox scarring?
The trouble with chicken pox scars are that they tend to be the ones that dent in. So what you do with those, and this is something we haven’t spoken about, is where you have those scars that dent in you really have got to fill them up. You can use fillers to literally try and bring that scar up. There is another procedure where you actually put acid- another one where you’re scarring a scar. You’re putting a really strong acid at the base of the scar to try and contract it up and pull it up.
I received a few questions about scarring and the health of the skin, which I think is a really nice way to wrap up because you have brought it back several times to the health of the skin and why it’s so important that we are treating the skin, ideally, before we have a scar. One listener has asked “Is there any correlation between scarring and dry skin? I had an operation in April and was left with a scar and I have experienced dryness in the skin ever since.”
So when you have a scar, it disrupts all of the glands. It disrupts the little tiny nerves, the little tiny blood vessels that are coming into the skin there. And they’ve all been repaired, but they don’t go back to normal. So I presume what’s happened here is, somewhere along the lines, the oil glands have been damaged as well just, in that area. That’s the problem.
So moisturiser will help. And just going back to the health of the skin- if you know you’re going to have a procedure that’s gonna leave a scar you need to go in with the healthiest skin you possibly can. That’s external and internal- a good diet, a diet with lots of fruit and vegetables, really looking after yourself, using lots of moisturiser, using a sunscreen beforehand, all of those things.
Finally, and actually on that note, a reader asks “Are you more likely to develop skin cancers in scars than in healthy skin?”
That’s such a great question, because you can get skin cancers in areas where the cells are rapidly turning over because they lose their way. They stop communicating to each other correctly. Then it’s just another step to then go off track and become a skin cancer.
But you can also get skin cancers that look like scars. There’s a type of a basal cell carcinoma that we call sclerosing basal cell carcinoma, because it looks just like a scar. You could, say, have had a skin cancer in the past and maybe it wasn’t treated correctly, or there’s another one that has come up just on the side. It grows into a scar and it looks like there’s a skin cancer in the scar, and the whole thing has to be cut out. So yes, you can. It’s probably not very common. But it can occur the other way. You can get skin cancers that look like scars.
