• TREATMENT

Introduction

It is difficult to pick up a women’s and often a men’s magazine which does not have at least one article on dermatology; scar and stretch mark prevention or treatment and anti-aging skin care regimens are among the most popular. In fact, the major reason skin undergoes what is commonly referred to as "aging" (e.g., appearance of wrinkles and dark spots, changes in texture and elasticity) is not chronological age itself as much as it is exposure to the sun. This is clearly evident if one compares the skin on the underside of her arm to that on the outside.15 Since scar tissue is likely to darken more than surrounding normal tissue when it is exposed to sun, there is also some overlap between products used for the prevention and treatment of scars and for anti-aging effects (sunscreens, etc.)

Some online resources for information on scars and related products are listed in Table 1 (please note similarities of some brand names and Web sites). Suggested questions for patient assessment and counseling tips are outlined in Table 2.9,25

A wide variety of treatments have been proposed over the years for scars and stretch marks. In both cases it is, if possible, preferable to prevent their formation, rather than treat them after the fact. When assessing the efficacy of products, it is also important to consider the possible benefits of regular rubbing of the affected skin, contributions from the base (e.g., petrolatum), and especially of "tincture of time" (passing of time). Massaging and pressure may help scars, possibly by mechanically breaking up scar tissue and promoting better blood supply to the affected area. Too much or too vigorous rubbing, however, can cause irritation. It is thought that products such as cocoa butter, for example, may be useful because they help keep the skin supple and prevent it from being irritated from regular rubbing.12 All products require regular use for prolonged periods of times, ranging from several weeks to several months.

Pharmacists can be an invaluable help to patients or consumers, helping them choose the product most likely to be helpful, explaining how to maximize its efficacy while minimizing costs (e.g., avoid using too much) and recognizing conditions and complications which require consultation with a physician.

Since the degree of occlusiveness is important to successful treatment, common drug delivery systems will be reviewed. Nonprescription products which will be discussed include vitamin A, aloe vera, alpha hydroxy acids (AHAs), avocado, vitamin C, cocoa butter, dimethylsulfoxide (DMSO), vitamin E, emu oil, furfuryladenine, vitamin K, methylsulfonylmethane (MSM), olive oil, onion and silicone, among others.

Drug delivery systems

As a brief review, dermatological delivery systems commonly used when trying to prevent or treat scars include ointments, creams, lotions and gels. The primary function of the delivery system is to act as a vehicle for the medication(s) it "carries."9 Medications usually cross the skin by diffusion; the concentration gradient will, therefore, affect the amount of drug absorbed, as will the pH gradient. Other factors which may result in increased absorption include injured skin and increased temperature, hydration and circulation to the affected area.

Recall that the cardinal findings following inflammation, regardless of its cause, are heat (calor), swelling (tumor, edema,) redness (rubor, erythema) and pain (dolor). Transdermal drug absorption is also increased if the skin is thinned, such as that which may occur with the use of corticosteroids. Many different types of dressings are also available to treat wounds, such as primary, secondary, wet-to-dry, absorbent, nonadherent, transparent, hydrocolloid, foam and alginate dressings.11

Ointments: Ointments are occlusive and usually contain an inert base, commonly petrolatum. Ointments may be water insoluble or soluble and may also be emulsified with water. Because ointments are occlusive, they are commonly used to relieve dryness or brittleness. Ointments should not be applied to areas of the body where their heat and moisture-trapping characteristics may cause problems. Ointments are usually messy, greasy and may be cosmetically unacceptable. Protecting most lesions, except those which are wet, from the air by the use of an ointment, with or without a bandage, usually speeds healing, perhaps by preventing water loss.9

Creams: Creams are usually oil-in-water emulsions. Creams are less occlusive than ointments, and are also usually less messy and greasy, and more cosmetically acceptable. Using too much of a cream and/or not rubbing it into the skin until the cream has vanished are common problems, and result in decreased therapeutic effect and/or waste of money.9

Lotions: Lotions are suspensions or solutions, utilizing a water vehicle and are less occlusive than ointments or creams. Lotions may be useful in cases where creams or ointments might be too painful to apply. They may also be useful in wounds which have some degree of oozing, especially if an astringent, such as aluminum, is included to help dry and seal the wound by precipitating protein9. Lotions should not be used on wounds which have a great deal of oozing or applied to hairy areas of the body. They are also not as useful for treating dry skin as ointments or creams. Lotions which are suspensions should be shaken before use.9

Emulsions: Emulsions can be divided into two categories, oil-in-water or water-in-oil and may be either solid or liquid. Most ointments are water-in-oil emulsions, while many creams are oil-in-water emulsions. Liquid oil-in-water emulsions are more occlusive than lotions and are better for hydrating dry areas. Liquid water-in-oil emulsions are less occlusive than ointments, but are easier to apply and may be more cosmetically acceptable. Liquid emulsions need to be shaken prior to use.9

Gels: Gels are a type of ointment (semisolid emulsion) which contain propylene glycol and carboxypolymethylene.9 Gels are clear, non-greasy, non-staining, non-occlusive and quick drying.9 Gels may sting upon application and some are thixotropic, becoming fluid when shaken or stirred and then becoming semisolid again.

Vehicle selection: When choosing a product, there is an old generalization in dermatology that if a wound or lesion is wet, then dry it; if it is dry, then wet it.9 Patients may prefer to use more than one drug delivery system or vehicle, especially with chronic conditions. An example of this would be the use of a cream during the day and an ointment at night, since creams are generally more cosmetically acceptable, while an ointment is more occlusive and usually more effective in hydrating an area.9

OTC agents

Aloe vera: Aloe vera, which is also known as aloe, aloe gel, aloe leaf gel, aloe capensis and salvia, is used topically to promote wound and burn healing, reduce pain and inflammation, and for its "tonic effects." Aloe vera (gel) is not the same as aloe juice, which is also known as aloe latex, burn plant and aloe dried juice from leaf and latex, among others. Aloe juice contains anthraquinones, which are cathartic laxatives. Aloe vera gel products which are sold for internal use may be contaminated with aloe juice or latex and, therefore, anthraquinone laxatives.

Aloe vera gel contains salicylate and carboxypeptidases, which can decrease pain by inhibiting bradykinin. The magnesium lactate constituent in aloe vera (gel) may reduce itching by inhibiting histamine. Other components may speed the healing of burns by slowing the formation of thromboxane. Aloe vera (gel) may also have antibacterial and antifungal activity. Stabilized aloe gel may not be effective topically.29

Products with aloe vera as an ingredient include Kinerase cream, MSM Rejuvenator, Perma burn and scar cream, Perma stretch mark cream, Rejuvana acne scar therapy and Rejuvana stretch mark therapy.

Alpha hydroxy acids (AHAs)30: Alpha hydroxy acids (AHAs) are a group of natural fruit acids and include glycolic acid, which is also known as hydroxyacetic acid, citric acid, lactic acid, malic acid, tartaric acid, mixed fruit acid and gluconolactone. AHAs are used topically to remove the top layers of dead skin cells (exfoliate), improve the appearance of aging (photo-damaged) skin, treat stretch marks and acne. They may also be used to moisturize and treat dry skin. Hyperkeratinization is thought to contribute to many of the indications for which AHAs are used and exfoliation is likely to improve these. AHAs generally improve the appearance of aging skin, for example, by making the skin smoother and reducing hyperpigmentation (dark spots).

The degree of exfoliation which occurs is determined by the AHAs chosen, as well as its concentration, pH and other constituents in the product. AHAs may cause a range of adverse reactions, ranging from mild irritation and stinging to severe irritation, burning and sloughing of the skin. Severe erythema or redness, rash, burns, blistering, swelling, itching and bleeding may also occur, with the risks being greater when higher concentrations of AHA are used.

Individuals with sensitive skin may find that products containing AHA increase skin irritation and sloughing, making their skin look worse. Patients, especially those with sensitive skin, should test AHA products on a small area of skin prior to trying it on larger areas. AHAs may also increase photosensitivity, so regular use of sunscreen which protects against both ultraviolet A (UVA) and ultraviolet B (UVB) (including that used in tanning booths) and has a sun protection factor (SPF) of at least 15 is recommended.

Products with alpha-hydroxy acids as an ingredient include Epilyt lotion, LactiCare lotion, M.D. Forte hand and body cream, Perma stretch mark cream, Rejuvana acne scar therapy, and sCarRinG lighten and brighten cream.

Avocado31: Avocado oil is used topically to soothe and heal skin; the fruit pulp is used topically to speed wound healing. These actions may be due to the constituents found in avocado, including high concentrations of unsaturated fatty acids and other components (e.g., oleic acid, tocopherols, vitamin E, sterols and volatile oils). Cross sensitivity to avocado may occur in individuals who are allergic to latex.

A product with avocado as an ingredient includes Jimi-Gel.

Cocoa butter: Cocoa is also known as cacao and theobroma cacao, but is not synonymous with coca, which is the source of cocaine.34 Cocoa butter is also known as "theobroma oil." Cocoa butter is the fatty portion obtained when cocoa seeds are roasted. It contains oleic acid 37 percent, stearic acid 34 percent, palmitic acid 26 percent and linoleic acid 2 percent.34 Topical cocoa butter has long been used to prevent or treat stretch marks during pregnancy. Cocoa butter is also a popular base for ointments and suppositories and is generally considered safe, though rashes have occasionally been reported. Cocoa butter is popular, but its efficacy with respect to stretch marks and scars has not been documented by scientific study.34

Massaging and pressure may, themselves, help scars, possibly by mechanically breaking up scar tissue and promoting better blood supply to the affected area. Too much or too vigorous rubbing, however, can cause irritation. Cocoa butter may be useful because it keeps the skin supple and prevents it from being irritated by regular rubbing.14 Cocoa butter may also have a beneficial effect on the growth of collagen in skin.35

Products with cocoa butter as an ingredient include Barmon stretch mark cream and Jimi-Gel.

Dimethylsulfoxide (DMSO): The only indication for dimethylsulfoxide (DMSO) currently approved by the Food and Drug Administration (FDA) is that for intravesical instillation for treatment of interstitial cystitis.36 However, one of its "off-label" uses for topical administration is that of flattening raised keloid scars.36 DMSO has been reported to decrease skin adhesions, possibly by selectively dissolving collagen, but not elastic fibers36. DMSO is also a solvent which readily penetrates the skin and is widely distributed in tissues and body fluids after administration by any route.9,36 DMSO can enhance dermal absorption of some other drugs and it is used off-label as a vehicle in combination with idoxuridine to treat herpes zoster infections.36 Several products commercially available to treat hypertrophic and keloid scars state that DMSO is included, at least partially, to facilitate absorption of other components.

There is concern that industrial or veterinary grade DMSO is being used topically for self-treatment of several diseases. These grades may not be as pure as DMSO used in human research and the solvent properties of DMSO may facilitate absorption of these impurities through the skin.36 Use of DMSO by any route may result in a distinctive body odor, which has been described as garlic-onion-oyster-like; garlic-like taste and breath may also occur.36

DMSO may worsen the symptoms of asthma and possibly cardiac disease and neurological disorders.36 DMSO may potentiate the effects of medications which are administered concomitantly; this may even occur with topical administration of DMSO and oral administration of other medications.36 DMSO, including topical administration, may potentiate the effects of insulin and should be used with caution in patients who have diabetes. More frequent monitoring of blood glucose may be warranted.36 It is also recommended that patients using DMSO have complete blood counts, liver function tests and renal function tests monitored every six months.36 Full eye examinations are recommended before initiating DMSO and during treatment.36

Emu oil: The emu is a bird which has been sacred to Australian Aborigines for thousands of years, in part due to its purported healing properties.42 Emu oil appears to be safe, and the Australian government classifies emu meat as "fit for human consumption."42 Emu oil is not standardized, but usually contains myristic, palmitic, palmitoleic, stearic, oleic (omega-3), linoleic and linolenic (omega-6) fatty acids.38,42 Oleic acid is believed to have a local antiinflammatory effect and linoleic acid appears to aid muscle and joint pain.42 Emu oil is also reported to be a rich source of vitamin E.38

Emu oil is reported to be "penetrating, emulsifying, non-comedogenic, non-irritating and highly moisturizing."38 Emu oil penetrates the skin, possibly due, in part, to its lack of phospholipids.42 Some product literature states that emu oil, similar to the properties of DMSO, facilitates absorption of other components of the product.43 Emu oil, again like DMSO, is also used in veterinary practices, so concern may be present that veterinary grade products are not suitable for human consumption.

Emu oil is used topically and orally for a wide variety of indications, including improving healing of wounds and incisions and preventing or treating scarring, keloid and stretch marks.42 Emu oil is also purported, among many other indications, to promote skin rejuvenation, decrease inflammation from acne, protect skin from sun damage, reduce bruising, help sore muscles and joints and decrease many other forms of pain and inflammation.42

Combination products containing emu oil and glycolic acid, an exfolliant, are available and used to help prevent scarring, among other indications.42 Crushed emu shell, taken orally, is purported to be an aphrodisiac. There is insufficient reliable information to assess emu oil’s (or shell’s) efficacy for any of its indications.42

Products with emu oil as an ingredient include Perma burn and scar cream, Perma stretch mark cream, Rejuvana acne scar therapy and Rejuvana stretch mark therapy.

Furfuryladenine: Furfuryladenine, which is also known as N(6)-furfuryladenine or kinetin, is a plant growth hormone which is used topically to treat "aging skin" (e.g., wrinkles, brown spots, blotchiness, roughness) and increase the skin’s moisture. Unlike topical tretinoin products (e.g., adapalene-Differin; tretinoin-Avita, Retin-A; tretinoin-Renova; alitretinoin-Panretin; tazarotene-Tazorac28.) furfuryladenine does not require a prescription; it may also be less irritating that alpha hydroxy acid (AHA) products. Furfuryladenine does not appear to increase photosensitivity, but regular use of sunscreen which protects against both ultraviolet A (UVA) and UVB (including that used in tanning booths) and has an sun protection factor (SPF) of at least 15 is recommended.

Products with furfuryladenine as an ingredient include Kinerase cream.

Methylsulfonylmethane (MSM): Methylsulfonylmethane (MSM), also known as crystalline DMSO, DMSO2 and dimethyl sulfone, is an odorless breakdown product of dimethyl sulfoxide (DMSO47,48). MSM may act as a source of sulfur, which is required for the formation of keratin and collagen.48 MSM is used topically and orally to treat burns, scars and stretch marks, as well as chronic pain, arthritis, bursitis, tendinitis and a wide range of other problems. There appear to be no documented interactions between MSM and other drugs or diseases. Its efficacy, however, has also not been clearly documented.47,48

Products with MSM as an ingredient include MSM Rejuvenator.

Olive oil: Olive oil is also known as sweet oil, salad oil and olive oleum.49 Olive oil is the fatty oil pressed from the fruit of olive trees. Free oleic acid content is used, in part, to classify olive oils: extra virgin has a maximum of 1 percent, virgin 2 percent, ordinary olive oil 3.3 percent and unrefined olive oil with greater than 3.3 percent free oleic acid is considered unfit for human consumption.49 Oleic acid is believed to have a local anti-inflammatory effect.49 Olive oil has been used topically to prevent and treat stretch marks during pregnancy. Its efficacy has not been proven, but it appears to be safe, though delayed hypersensitivity and contact dermatitis have been reported, as well as rare instances of allergic reactions.49

Onion extract: Onion, which is also known as allii cepae or allium cepa, offers many health-related benefits.50,51 With respect to scars, onion appears to inhibit the function of fibroblasts, and the production of a ground substance which contributes to the scar matrix. It may also decrease prostaglandins a nd leukotrienes, and inhibit inflammation and histamine release.1 Onion is a rich source of quercetin, an antiinflammatory.14

Onion is available as a proprietary botanical extract (cepalin) in the United States in a greaseless gel, which also contains allantoin. The product does not smell like onion, but instead has an aroma reminiscent of rose water.14 This product is regulated as a cosmetic rather than a drug, although it may be found in skin care section of a pharmacy.3,14,53

As with other products, wounds need to be healed to the point of no raw, open areas before using onion extract. Onion extract is generally considered safe to use during pregnancy and breastfeeding, as well as in young children and has even been used on infants in neonatal intensive care unit.17 Onion extract gel is massaged into the skin three to four times a day.1,14 Once the gel has dried, cosmetics may be applied, if desired.14 Onion extract may also help resolve post inflammatory hyperpigmentation (PIH), which may occur following acne or skin trauma (e.g., surgery, accident17).

A study carried out in Germany assessed scar development in 45 young patients who underwent thoracic surgery.54 The control group received no treatment. The study was carried out for a year and patients were assessed every month. The appearance of the scar (type, size, color) was assessed by a physician. Scar width was less in treated patients; no differences in scar length and height were seen.

Treated scars were superior with respect to color and type, and hypertrophic and keloid scars developed less often in treated patients. The clinical course of scar development was rated "very good" or "good" in greater than 90 percent of treated patients. In untreated patients, fewer than 40 percent of patients reported a "good" clinical course, with greater than 60 percent evaluating their courses as "moderate" or "bad." The tolerability of the drug was "good" or "very good" in all patients.54

Another study published by some of the same authors as the previous study, was conducted at the same site in Germany.55 Scar development in 65 children who underwent thoracic surgery was assessed; 38 received treatment and 27 did not. The treatment period was six months, and before and during this time, scar macromorphology and color were evaluated; a global evaluation of the therapeutic result was also made.

Scars were also assessed after a six-month treatment-free follow-up period. The global evaluation of the therapeutic result was superior in treated patients, with the rating being "very good" or "good" in 84 percent of treated cases and 59 percent in the untreated patients. The treated scars also showed a tendency toward faster paling and fewer hypertrophic or keloid scars developed in the treated group. The tolerability of the drug was "very good" in 37 and "good" in one of the 38 patients treated. Scar results continued after the end of treatment.55

In considering the German studies, it is important to note that, in addition to this onion extract and allantoin, the product available in Europe (Germany-Contractubex) also contains heparin. Heparin is believed to act solely by decreasing the proliferation of fibroblasts, and doing so to a lesser extent than onion extract.1

In a small study carried out in the United States, the scars of 17 post-surgical patients were monitored. The control group was treated with an emollient ointment, while the active group was provided with onion extract in a gel. The results of the study indicated that petrolatum-based ointments may provide improved hydration when compared to a gel.56

Another study was carried out in which 99 adults, whose scars ranged in age from three weeks to eight years, received either the onion extract gel or a placebo gel57. Assessments were made at one week, one month and two months of treatment, by board-certified plastic surgeons, as well as continuous monitoring carried out by subjects. Two patients dropped out of the study prior to the one-week follow-up, and 73 patients kept all three follow-up appointments.

At one week, more placebo patients than treated patients reported improvement, with a less noticeable scar (p<0.05) and a less red scar after one month (p<0.001). More treated patients reported improvement with a softer scar after two months (p<0.001). No differences in improvement were noted for physician-related measures between the two groups.

The data from the 73 patients who kept all three follow-up appointments revealed a significant difference between the two groups with respect to patient-reported improvement in the scar being less noticeable (75.6 percent of treated vs. 53.1 percent of placebo, p<0.05). Other analysis showed that the placebo group was more likely to report less redness (p<0.01) and more treated patients to report a softer scar (p<0.05).

Complaints of adverse effects were similar between the two groups and included mild itching, erythema and/or rash. One patient complained of mild hypopigmentation of the skin surrounding the scar; it was not clear whether this person received active treatment or placebo. No data were presented from beyond two months of study.57

One product with onion extract as an ingredient is Mederma skin care for scars gel.

Silicone: Silicone is available as a gel and sheeting, which is a rubbery-like material that is applied to the skin.16,25,58 Silicone gel is primarily intended for use on the face and skin folds, where it would be difficult to use sheeting. The mechanism(s) by which silicone sheets help scars is not really known. Silicone may work by forming a static-electric field between the silicone and the skin.16 It is thought that this helps the irregular, disorganized collagen fibrils align themselves more closely to the organized pattern found in normal skin. The scar tends to flatten out and lighten in color, to become more like that found in surrounding normal skin. The sheets may also trap moisture, which is believed to help fade scars, though some of this data is from in vitro studies.16,59 Silicone may also change the water balance (hydration barrier) in the collagen, reducing the blood flow to the scar, thereby shrinking its size. Gentle pressure supplied by the sheet may also be beneficial.16 Ease of use of silicone sheeting may be related to the size and location of scars.

Silicone products soften, smooth and flatten scars and restore skin to a more normal texture. It appears that silicone products are more likely to help hyperpigmentation than hypopigmentation.25 Silicone products may also relieve the burning and itching which can accompany scars, and relief may occur almost instantaneously.16,25

Silicone does not appear to be absorbed systemically from sheets or topical products, but some patients or consumers may be concerned over silicone’s association with breast implant problems.16,17,58 The Food and Drug Administration (FDA) has suggested patient appropriate information dissemination among women seeking silicone breast prostheses.60 When sheeting or gel is used, studies have shown no silicone in treated tissues.61,62

As with other products, wounds need to be healed to the point of no raw, open areas before using silicone gel or sheets. Silicone sheets are reusable, washable with ordinary soap and water, can be cut with ordinary scissors and are applied to the skin with high-quality hypoallergenic tape (e.g., that are available from the manufacturer, 3M or Johnson & Johnson16,25,58.) One sheet can usually be used for the entire duration of treatment.

Every day before use, the silicone sheet should be washed with mild soap and water, rinsed and dried thoroughly. The scarred area should also be washed and dried. The silicone sheet should be placed, either side up, directly on the scar. The sheet should overlap the scar by at least 1cm (1⁄4 inch). The sheet should be secured in place with high quality, hypoallergenic tape (e.g., from the manufacturer, 3M or Johnson & Johnson).16, 25, 58

Reactions are uncommon and are usually from the tape being used to hold the sheet in place. It is, therefore, important that only high-quality, hypoallergenic tape be used; however some people react to even the hypoallergenic tape.

Reactions due to the sheet are usually "sweat rashes." If a sweat rash develops, the sheet should be removed and not used for 24 hours. After 24 hours without the sheet (possibly two to three days 25), the scarred area should be washed with mild soap and water and dried thoroughly. The sheet should then be applied for one hour and wearing time should be increased by one hour each day. If the problem continues, the sheet should be removed and a physician or pharmacist consulted.16,25

A prospective, controlled clinical trial was carried out to assess the efficacy of silicone sheets in treating scars.61 The sheeting was applied to 10 adults with 14 hypertrophic scars for eight weeks. Untreated, mirror-image or adjacent scars on these same patients served as controls. Scars were photographed, biopsied and measured elastometrically before and after treatment. Photography and elastometry were repeated four weeks after treatment was discontinued. All scars which had been treated for at least 12 hours a day with silicone sheeting improved clinically after four weeks. There was further improvement during the second four weeks of treatment.

Elastometrically, the treated scars, but not the controls, improved significantly at four, eight and 12 weeks (p<0.05).

Control scars were elastometrically unchanged. Clinical improvement of treated scars was still present at the time they were checked, four weeks after treatment was discontinued. The sheets were well tolerated, with only occasional rashes and superficial maceration, both of which resolved when the sheet was removed. The silicone did not appear to enter the treated tissues, since there was no histologic evidence of inflammation or foreign body reaction.61 Others have also reported no silicone in treated tissues.62

The same investigators studied the usefulness of silicone sheeting in 19 patients with hypertrophic burn scars.63 Mirror image or adjacent hypertrophic scars served as the controls. Quantitative serial measurements of the scars’ elasticity were made using an elastometer. Scar elasticity in the treated group improved after both one and two months; improvement was not seen in the controls. Treated scars also showed clinical improvement, which lasted for at least six months.

In another cohort, 21 surgical incisions were measured for scar volume changes before and after one and two months of treatment with silicone sheeting. Treated incisions gained less volume than controls after both intervals. Clinical assessment agreed with these findings. The authors concluded that silicone sheeting is efficacious, both in the prevention and treatment of hypertrophic scars.63

The usefulness of silicone sheets in the treatment of both new and long-standing hypertrophic and keloid scars on the lower extremities of 94 patients was investigated.64 In this group, there were 80 patients who had true hypertrophic scars; 74 (92.5 percent) of these patients were greatly improved with treatment and five (6.25 percent) were somewhat improved. One patient (1.25 percent) showed no improvement. Results were poorer in the remaining 14 patients having keloid scars, with five (35.7 percent) greatly improved, five (35.7 percent) somewhat improved and four (28.6 percent) showing no improvement.64

Others have also found silicone sheeting to be at least moderately successful in preventing or treating hypertrophic and keloid scars62,65, and in the management of scars secondary to burns.66 One study of five pediatric outpatients found improvement in scar size, thickness, texture (softening), vascularity (decreased) and pigmentation (more uniform) following the use of silicone sheeting, but also noted problems with silicone sheet application and durability, as well as adverse effects (e.g., rash, skin breakdown, no further improvement in scars67). Another study of 129 female patients who had undergone breast surgery found that silicone sheets or gel did not help prevent the formation of hypertrophic scars; the scars treated with silicone may have even developed more hypertrophy than controls, which used Micropore (3M, The Netherlands68).

The use of silicone sheeting may also provide earlier symptomatic relief and a more aesthetic scar than injections of triamcinolone into symptomatic hypertrophic scars.69 One study found that the addition of topical vitamin E to the use of silicone sheets resulted in more improvement than the sheets alone and concluded that, in addition to their beneficial effects on fibroblasts and hyperhydration, the silicone sheets may aid in the penetration of vitamin E.41

Products with silicone as an ingredient include ReJuveness sheeting and ScarEase sheeting and gel.

Vitamin A: Topical vitamin A has been tried to improve wound healing, reduce wrinkles and protect the skin against ultraviolet (UV)-induced photo damage. Vitamin A is required to maintain the integrity of epithelial and mucosal surfaces. Although there is insufficient data to assess the effectiveness of topical vitamin A, preliminary studies suggest that it may (as the all-trans-retinoic acid) help protect the skin against UV-induced damage.26,27

Very high doses of vitamin A have been linked to the development of birth defects, as has the use of oral retinoids; this should be kept in mind when counseling women of child-bearing potential. Oral retinoids include isotretinoin- Accutane; acitretin-Soriatane; etretinate-Tegison. Topical retinoids include adapalene-Differin; tretinoin-Avita, Retin-A; tretinoin- Renova; alitretinoin-Panretin; tazarotene-Tazorac.28

Products with vitamin A as an ingredient include Perma burn and scar cream, Perma stretch mark cream, Rejuvana acne scar therapy and Rejuvana stretch mark therapy.

Vitamin C: Vitamin C (ascorbic acid), like vitamin E, is an antioxidant; it has been tried topically to help protect skin from free radicals and pollutants. Although not synonymous with scars, topical vitamin C may be useful in aiding photo-damaged or wrinkled skin. Exposure to ultraviolet light causes free radical formation in the skin; cumulative exposure appears to lead to photo-aging.

When vitamin C is applied topically prior to exposure to ultraviolet light, it may help prevent this skin damage. It is not, however, an effective sunscreen. In addition, vitamin C’s antioxidant properties may help minimize wrinkles. Also, vitamin C is necessary for collagen formation, improving collagen organization and tissue repair.17,19,32 Since vitamin C is water-soluble, it may not be possible to achieve adequate topical concentrations from oral dosing.32

One randomized, double-blind, vehicle-controlled study of three months’ duration investigated the use of topical vitamin C (10 percent vitamin C as L-ascorbic acid, acetyl tyrosine, zinc sulfate, sodium hyaluronate and bioflavonoids) in 19 patients with mild-to-moderate photo-aged facial skin. Coded, unmarked products were randomly assigned to the left and right sides of each patient’s face. An equal amount, three drops, of each product was applied daily, vitamin C product to one side of each patient’s face and vehicle control to the other side. Objective computer-assisted image analysis of skin surface topography and subjective clinical, photographic and patient self-evaluation questionnaires were utilized. At three months, the vitamin C product produced superior results, both objectively and subjectively, in fine and coarse wrinkling, roughness, sallowness and skin tone.32,33

Topical vitamin C has also been used in combination with topical vitamin E and melatonin to try to prevent sunburn; modest protective effects were seen when these were used prior to exposure to ultraviolet (UV) light, but no protective effect was noted if they were used during or after UV exposure.32

Most topical vitamin C creams used to aid aged or wrinkled skin use a concentration of 5 to10 percent vitamin C. Topical vitamin C products should not be applied near the eyes; contact with hair or clothes should also be avoided, since discoloration is possible. Topical vitamin C may cause irritation or tingling at the site of application.32

Products with vitamin C as an ingredient include Cellex-C High potency serum.

Vitamin E: Vitamin E generally contains several forms of tocopherol; wheat germ oil is a rich source of vitamin E, and is used in some topical products (e.g., cold-pressed wheat germ oil37). Emu oil is also reported to be a rich source of vitamin E.38 Vitamin E has been tried, with varying degrees of success, for many indications. It has been found to be the major lipid soluble antioxidant in the skin.39 Antioxidants help prevent the formation of free radicals (reactive oxygen species), and scavenge those which are present.37 Free radicals have been associated with oxidative damage both inside the body and on the skin. Vitamin E may also help stabilize lysosomal membranes.40

Topical vitamin E has, therefore, been tried for a wide variety of dermatological lesions.39 Vitamin E, at least taken orally, appears to have an inhibitory effect on the inflammation process.37 Somewhat paradoxically, topical application of vitamin E has at times been associated with inflammatory reactions, contact dermatitis and eczematous lesions.37

Topical vitamin E has been tried to minimize scars, speed the healing of wounds and burns, and to treat aging skin and dermatitis, among others.37,39 Its usefulness, however, is not clear.

One study looked at the efficacy of topical vitamin E in improving scars in 15 patients who had had surgery to remove skin cancers. All wounds were primarily closed in two layers. Patients then received two ointments, A and B. Ointment A was Aquaphor, an emollient, and ointment B was Aquaphor with vitamin E. Each patient’s wound area was randomly divided into parts A and B, and patients were asked to put ointment A on area A and ointment B on area B, twice a day for four weeks.

The study was double-blinded, and patients and physicians independently assessed the cosmetic appearance of the scars on weeks one, four and 12. The criteria were to determine which side of the scar looked better, if there was a difference. A third blinded investigator was asked to make the same determinations from photographs.

Vitamin E was not found to improve the appearance of scars in this trial and it also led to a high incidence (33 percent of patients studied) of contact dermatitis. It was reported that in 90 percent of the patients in this study, vitamin E either had no effect on or worsened the cosmetic appearance of the scars.39

Another double-blinded study compared vitamin E cream, a topical steroid cream (triamcinolone) and just the cream base in 159 operative procedures for post-burn contractures of interdigital webs (96), the axilla (46), or the neck (17). Range of motion, scar thickness, change in graft size and cosmetic appearance were monitored for a year. Neither vitamin E nor the topical steroid showed a beneficial effect compared to placebo (cream base). Adverse reactions were more common in patients receiving active drug (16.4 percent) than in those receiving the placebo base (5.9 percent.) The authors concluded that neither vitamin E nor the topical steroid effectively decreased scar formation after grafting procedures for reconstruction for post-burn contractures.40

One study found that the addition of topical vitamin E to the use of silicone sheets resulted in more improvement than the sheets alone and concluded that, in addition to their beneficial effects on fibroblasts and hyperhydration, the silicone sheets may aid in the penetration of vitamin E.41

Topical vitamin E has also been used in combination with topical vitamin C and melatonin to try to prevent sunburn. Modest protective effects were seen when these were used prior to exposure to ultraviolet (UV) light, but no protective effect was noted if they were used during or after UV exposure.37 Topical vitamin E has also been used with DMSO to treat chemotherapy extravasation.37

Topical vitamin E has also been used to treat granuloma annulare.37 A granuloma is a mass of granulation tissue with actively growing fibroblasts and capillary buds, among other components, and is associated with a chronic inflammatory process secondary to an infectious disease, such as tuberculosis, or foreign body invasion. Annulare implies being in a circle or ring-shape.7

Products with vitamin E as an ingredient include Barmon skin care stretch mark cream and MSM Rejuvenator.

Others: Hydroquinone, a topical bleaching agent, may also be present in products to treat hyperpigmentation. L-lysine is used, primarily orally, to treat recurrences of herpes simplex labialis infections; lysine has also been investigated for its effects on collagen metabolism and inflammation.70,71 Hamposyl-M is an emollient.35 Products may also contain glycerol (glycerin72), allantoin, hemp seed oil, mineral oil, squalane oil, bee’s wax, Shea butter, tangerine oil and orange oil, among others.

Some products should be totally avoided, or at least used with care. Henbane has been reported to be used topically to treat scars, but there is no standard dose and henbane can cause death by asphyxiation.73,74 The inclusion of lanolin is frequently used as an advertising point in many hand and body creams, but if skin irritation or rash occurs, lanolin should be suspected as its cause, particularly in people who cannot tolerate wool.