The role of the epidermis in bad scars and keloids

Epidermis is the top layer of your skin.  Scarring has long thought to be an issue of the dermis, the lower layer of skin, not the epidermis.  Some of the experts on scarring (those plastic surgeons who presented their basic science research at the TIPS meeting in San Francisco on how scars form) think the epidermis is important.  When they spoke, it resonated with me because it gives a reason for things like “Why does the Csection scar only form a bad scar in the center?” and “Why does silicone gel work?”

We know when you are healing your epithelium resurfaces the wound in 24 hours (this is for a surgical scar, not road rash from falling off your bike).  This is why we don’t let you shower for the first 24 hours after surgery.  What they have found in their research is basic and simple, but powerful.

• If you have a delay in epithelialization, you form SCAR.
• In children if a wound took more than 2 weeks to heal, 75% of them were hypertrophic.
• If you restore the epithelium, it causes a decrease in collagen synthesis and inflammatory cells.  (You want enough collagen to heal the wound, but in bad scarring wounds they find you have too much collagen.)

So the goal? The goal is to have your epithelium resurfaced and water tight as quickly as possible.  Clean wounds, covered wounds, bacitracin on open wounds.  Get it to heal fast = better scar.

BUT  BEWARE.  There are nuances to this.  You can’t just cover a wound with really occlusive tape and be done with it.  All wounds can have discharge.  They can have infection.  They can have too much moisture.  If discharge, infection, or too much moisture gets trapped under the bandage it will cause the skin to break down.  A covered infection is like a lid on a pot- it boils and gets worse.  Also taking the tape on and off a lot will cause irritation and inflammation, which would cause bad scar.  My patients know I cover scars and will sometimes uncover part and keep other parts covered.

So what to do?

See your doctor.  I see my patients often after surgery.  Come in.  While you think we are just talking, I am looking at your wounds and treating them.  Follow my directions.  I am trying to help you heal the best you can.  And don’t blow off your appointments, particularly the one at 3 months.  The best way to help with scars is to be proactive.