Aldara is the brand name of 5% imiquimod cream. This prescription cream is mainly used to treat genital warts, basal cell skin cancers and other skin conditions. It has also shown to improve the quality of new hypertrophic scars after surgery in one preliminary clinical trial. Knowledge about this treatment is limited. Some side effects have been reported but you could always ask your doctor or surgeon for more information when undergoing surgery.

Aldara Imiquimod Scar Cream

Aldara cream seems to work by stimulating the body’s natural immune system to oppose scar tissue formation.

I think this can be an option in case nothing else works. The following post on the breasthealthonline.org shows it did improve a very problematic scar:

“I had a horrible keloid scar and the doctor cut it out and then I began treatment with A ldara. The scar did NOT keloid up again. The only thing is that your scar will look a LOT worse before it looks better. The Aldara causes the area to scab up and look really bad, (but that is indication that it is working)”
Source: breasthealthonline.com

There are a few clinical trials showing evidence for the efficacy of this prescription cream.

“In one study, 15 patients with 2 months old hypertrophic breast surgery scars were treated with either petrolatum (e.g. Vaseline) or imiquimod 5% cream. After 24 weeks when the scars were evaluated (by assessment with standardized scales) almost all the scars treated with imiquimod cream scored better . Conclusion of this study was that imiquimod cream improved scar appearance after surgery.” (Topical Treatments for Hypertrophic Scars. Zurada, Kriegel, and Davis)

Other studies have shown imiquimod cream to be effective when applied after a keloid scar had been excised. More than one studies showed that none of the keloids reoccurred after the treatment. Minor side effects reported were a mild irritation during and right after the application of the cream. (some patients a had to temporarily stop using the cream). Also scar redness (hyperpigmentation) occurred on more than half of the patients in this study.

Rosehip seed oil, also referred to as rosa mosqueta, is considered to have many skin care benefits. This oil is a natural source of unsaturated fatty acids. It should have a rejuvenating action and diminish wrinkles, fine lines, age spots and even stretch marks by boosting cell renewal and collagen and elastin production. Moreover, according to research (by Horst Kehl and Bertha Pareja, 1990) rosehip seed oil should improve the appearance of scars. It is supposed to reduce redness and elevation and prevent keloid and hypertrophic scars from developing.

The use of rosehip oil as a skin care product is said to have a vitalizing influence on the innermost skin cell layers. Its beneficial effect on cells that produce collagen, elastin, and other compounds, is said to be responsible for skin firmness and elasticity (Kasayama S et al, 1994) That’s why it is thought to work on stretch marks as well.

The fact that Indians in the Andes in Chile have been using this oil for centuries also seems to be in favor of rosehip seed oils supposed efficacy. But what does science have to say? Let’s have a look at the available clinical studies.

Rosa mosqueta, Rosehip seeds

Aforementioned doctors Pareja and Kehl attributed rosehip seed oil’s replenishing activity mainly to the presence of transretinoic acid (retinol, retin-A). However the presence of this vitamin is disputed. A study conducted in Chile states that “the analysis of a batch of rosehip seed oil contained 0.83 mg of trans-retinoic acid / 100 g of oil.” Another study carried out by King’s College London failed to find any trace of this vitamin in the soil samples they examined.



Rosehip seed oil is rich in unsaturated fatty acids, linoleic and linolenic acids, known to be involved in cell regeneration related processes. Therefore this oil is of great use to promote wound healing. (Moreno Jiménez JC et al., 1990). But what about scar treatment?

Photo by Naturaleza | Creative Commons

A study was carried out with women between 45 and 68 years, who had undergone mastectomy (breast removal surgery). These women applied rosehip seed oil after suture removal, twice a day (morning and evening) for a three months period. After three month, less apparent scars, no skin thickening and improved skin elasticity and color were observed (Pareja B & Kehl H, 1990).

In another study, 10 patients suffering from varicose ulcers and post-surgery wounds were applied a 26% rosehip seed oily solution. Enhanced epithelization (wound closure) was observed in these patients as compared with a control group. No side effects were observed. These results lead the researchers to the conclusion that this preparation is helpful to treat this kind of processes (Moreno Jiménez JC et al., 1990). Source: Centerchem.com (pdf file)

Camacho F et al (1994) also evaluated the effects of pure rosehip seed oil on post-surgery scars and defects. Unfortunately I could not find any results of this particular study.

Conclusion
The limited reports show rosehip seed oil has an anti-inflammatory action. Whether this is due to the possible presence of retinol or solely because of gamma-linolenic acid (GLA) is not clear. (according to Wikipedia also the effect of GLA on inflammation is disputed.) The large deal of the studies are concentrated on wound care and not specifically on scar treatment. So I can only conclude that rosehip seed oil will probably have some beneficial effects on wound healing but whether or not it works as an effective scar treatment product remains to be seen. It might be worth a try but there are better alternatives which do have evidence behind them.

Silicone scar sheeting is used by hospitals, cosmetic surgeons, burn centers, and dermatologists to treat especially surgical and burn scars and prevent the formation of new scars. The sheets are thought to provide a protective barrier which mimics the natural barrier function of normal, healthy skin.

Neosporin scar solution is a silicone scar treatment brand for the consumer market that does not exist anymore. The Pfizer company held the license to manufacture Neosporin Scar Solution using patented Silon® technology since 2002. In 2006 Johnson & Johnson purchased Pfizer Inc. and took it out of production. Because the demand kept growing the product was continued under the new brand name ScarAway in 2008.  These ScarAway silicone sheets, produced by Mitchell-Vance Laboratories, are largely the same as the Neosporin sheets. They are improved by making them bigger, thinner, and more adhesive.

A common heard complaint is the (lack of) adhesion. I have used them myself and I know from experience the sheets can be, especially on difficult parts of the body such as the face, hard to keep attached. Especially when the sheets have been worn for a few days and are cleaned and dried (which is recommended after a while) they get less sticky. I solved this by using silk tape to keep them attached. For my face I used a silicone gel (liquid version) during daytime. Although less effective than sheets according to studies the gel was a welcome addition.

So if you are searching for Neosporin scar solution, keep in mind they are called ScarAway nowadays. And keep in mind that it will take some dedication to keep them attached but it’s worth the effort because there is no better over the counter scar treatment available. The sheets are available online at Drugstore.com and Amazon

The c section scar is the result of the vertical incision made during the surgical procedure and is approximately 4-6 inches long. How wide it is depends on how well it is treated, how healthy someone lives, genetics, and how well the wound heals. The scar is located on the lowest part of the tummy, just above the pubic bone. Because of its location it is mostly covered by underwear or clothes. Here are some c-section scar photos.



I stumbled upon this question on Yahoo Answers about c-section scar treatment and the answers given point out how many misconceptions about scar healing (in general) exist.

The question:

“I had a C-section 6 weeks ago and the scar is red and puffed up. Does anyone recommend a scar treatment for it? and when should I start applying the scar treatment?”

In the answers many of the common, so called effective, scar treatments are mentioned but a really truthful and helpful answer isn’t there. Yes, of course scar tissue improves over time as mentioned by one of the answerers. But no, Mederma is not a proven effective remedy actually. Studies show it works just as good, or even slightly less effective, as Vaseline.

Why so many people swear such products work for them possibly has to do with the massaging of the scar, improved blood circulation, and hydration. Regarding vitamin E capsules, better leave those where they are, or use them where they are intended for but do not use them topically. Studies have shown rubbing vitamin e into scars can make their appearance worse and cause skin reactions.



Wound Care vs Scar Treatment
Also the remark that the wound shouldn’t be treated until it’s fully healed should be clarified. In fact, optimal scar healing actually starts with proper wound treatment and if done well this can really make a difference. When speeded healing occurs and problematic aspects such as inflammation and infections are avoided the chances on developing more prominent scar tissue are decreased. The other way round; wounds that are not kept clean and looked after are prone to poor scar healing. Always consult your surgeon about the fastest way to heal open wounds. Tip: ask your medic about Medihoney wound dressings.

But the person giving this advice has a point. A clear distinction should be made between wound care and scar treatment. Scar healing remedies of a c-section scar should never be started before the incision wound has healed and closed.

The Best C-Section Scar Treatment
In this particular case, where this woman’s c-section scar is red and puffed up silicone strips can be a practical solution. It it is true that many scars, especially those resulting from surgery, can be red, bumpy, and look awful but eventually will improve. But silicone strips, which are in many cases FDA Class 1 Medical Devices, do not only improve the scar appearance, they also reduce or take away itchiness and pain. On top of that they reduce the chance on developing hypertrophic (red and raised) and keloid c-section scars. (keloids are scars that grow beyond the normal wound boundaries.)

Here’s a short review:

“The patches are called scaraway and are silicone sheets. I used them for my c-section scar and am VERY pleased. (My friends scar got red and bumpy..mine healed flat and pretty thin and is regular skin color now).. They adherer to your skin without tape (but they are not sticky like bandaids)..hard to explain..I hardly noticed they were on me…hope that helps”

Scar Pain and Massage
Some women experience pain in their c-section scar. This can vary from tingling to real pain as well as a numb feeling. Where some women loose sensitivity on the skin located around the scar tissue others experience extra sensitivity. Sometimes scar contractions can cause pain and discomfort. This can be solved by massaging the scar tissue because massage loosens the tissue, boosts circulation and thus makes the tissue softer.



C-Section Scars and Compression
Next to silicone strips compression is another scar healing therapy for which clinical evidence exists it actually works (although in lesser amount). Some women use compression belts also called C-Section compression bindersfor extra comfort, pain reduction and faster wound and scar healing. (Also scars seem to benefit from compression.)

Always avoid exposing your c-section scar to direct sunlight or use a high SPF sunscreen. Also when wearing thin clothes because many fabrics do not prevent the sun radiation from coming through.

It will soon be possible to get a medicine injected just before surgery in order to prevent scars (or at least to reduce scarring considerably). Three clinical trials have shown this medicine promotes the regeneration of healthy skin thus resulting in less prominent scarring.

The medicine administered in these studies was Avotermin which is marketed by the biopharmaceutical company Renovo under the brand name Juvista. The studies examining both short-term and longer-term effects showed improved scar appearance compared with standard wound care and placebo.

“With low doses injected locally around the time of surgery, Avotermin is a well tolerated and convenient treatment. These studies suggest that avotermin has potential to provide an accelerated and permanent improvement in scarring.” says Mark Ferguson, of the University of Manchester, United Kingdom.

The active constituents of this scar reducing medicine work according the same principle as that in scarless healing embryo´s. The technical name for this ingredient is Transforming Growth Factor Beta 3 (TGFβ3). This is a protein present in high levels in embryonic skin and wounds. This substance is also present in adult wounds but only in very low levels. Source: Renovo

Juvista can also be injected near the wound location when no surgery is performed. For example when an open wound as a result of an accident needs to be stitched. When this scar preventing medicine will be injected at the time of wound closure it will probably help prevent scar development.

At the moment Renovo is still conducting clinical trials. When these are finished, approximately 2011, the product will be available around the world.

Popular beliefs on over the counter scar treatment products differ considerably. Frequently used products are scar creams based on vitamin E, topical vitamin E, ointments based on onion extract such as Mederma, Aloe Vera, Bio Oil, cocoa butter, cucumber butter, lime juice, skin remodeling copper peptides and so on. Abundant positive reviews on these remedies seem to support these beliefs. Less commonly accepted is the fact that there is no scientific evidence these products work. In some cases clinical trials showed these products in fact do not work.

Mederma for example, a currently popular scar treatment cream containing onion extract, does not seem to improve scar appearance and has not shown any benefit over petroleum lubricants (Vaseline). Several studies show the onion extract gel did not benefit scar treatment when results were compared with a petrolatum-based ointment. A leading dermatology website advices medical personnel to tell their patients that using products based on onion extract will likely not cause any harm but will not lead to an improvement either.

This applies to the other aforementioned products as well. For example the topical application of vitamin E on scars. Clinical trials illustrate that vitamin E provides no more effect than other moisturizing ointments, and hydration appears to be its only beneficial effect. Furthermore, topical vitamin E may actually cause more harm than good, possibly worsening a scar’s appearance and causing contact dermatitis (red rash), and other skin irritations in a large percentage of patients.

A comparison of available studies on popular over the counter scar treatment products leads to the conclusion that, either there is clinical proof or there has not been done any research on the effects of the product. (On cucumber, lime,  lemon juice and cocoa butter are no studies done)

A remarkable exception are silicone gel scar treatment products. Although it remains uncertain how these silicone scar patches actually work, various studies demonstrate their efficacy. Silicones are known to be the most effective over the counter scar treatment for burn, surgical, and other deep wound scars. They also prevent the development of hypertrophic and keloid scars. Used and recommended by burn centers, cosmetic surgeons and dermatologists they are considered ‘the golden standard in scar treatment’. Although starting treatment in an early stadium is recommended silicone patches also benefit treatment of older scars. Additional advantages are they are relatively easy to use, relief itch and pain and their use has no side effects.

Furthermore there are clinical trials showing hydration is a crucial scar treatment factor. Silicone gel sheets are thought to aid hydration but there’s no consensus among experts. Others say it’s the occlusion of the scar tissue. It is clear that hydration of the scar tissue and the surrounding skin benefits scar treatment. None of the examined products have shown to perform better than the commonly used petroleum ointment called Vaseline. In fact, in some cases Vaseline showed to have better hydrating properties than the scar creams it was compared with.

Another, potential, effective scar treatment product is honey. It is clear that the use of honey in wound care speeds wound healing and thus, indirectly, results in less scarring.  A recent review (evaluated the results of 22 clinical trials involving more than 2,000 patients) concluded that honey also minimizes scarring, removes infected and dead tissue and speeds healing by stimulating new tissue growth.

A 1996 study from India showed that burns treated with honey healed sooner than those treated with conventional methods (petrolatum and gauze) and that scarring was reduced. (6.2% of the 450 patients treated ended up with scars compared to 19.7% of the same number of patients who received conventional treatment) So these preliminary studies are promising regarding honey and its scar fading properties. More dermatologists say applying honey to a healing wound or existing scar has not shown to be harmful and may improve scar appearance. Whether or not the topical application of honey on scar tissue works has to be seen. There has not been done  any research on this particular subject but a certain type of honey, Manuka honey, is renowned for its many healing properties of which one is its excellent moisturizing action.

Recent trials show an increased temperature will significantly increase the process that decreases scar tissue (collagenolysis). So heat application products such as paraffin wax and heat packs could be useful too.

Summarizing, the best scar treatment products are silicone gel sheets, moisturizing agents such as Vaseline (and maybe Manuka honey) and paraffin wax or heat packs. More information consumer experiences with brands .

polyurethane scar dressings

Polyurethane dressings are used in scar treatment. Brands available on the consumer market are Curad Scar Therapy and Cutinova Thin Dressings. Both brands offer self-adhesive, breathable, flexible products in either semi-transparent, skin tone or clear formulations. But do polyurethane dressings really work on scars?

Studies on polyurethane dressings show a positive effect on scar appearance. The dressings are hydroactive which means they maintain a moist environment and prevent bacterial contamination which is useful when the dressings are used as a wound occlusive. (they are used both in wound care as well as scar treatment) There is also some evidence for the prevention of hypertrophic scar formation. Some studies show a slight advantage when these dressings are combined with pressure therapy.

One study of 60 patients noted significant improvements in blood supply (microcirculation) and surface qualities in patients who were treated with polyurethane dressings for 6 weeks after surgical incisions.

A report called ‘Topical Treatments for Hypertrophic Scars‘ by Zurada, Kriegel, and Davis notes that the use of polyurethane dressing in scar therapy has: “unclear effects on the development of new hypertrophic scars but has been shown to improve the prominence and appearance of mature scars in a small randomized trial. Further studies are necessary to elucidate its role in hypertrophic scar treatment.”
Conclusion of this report: There is questionable evidence for the effectiveness of polyurethane scar dressings in preventing hypertrophic scars and some evidence for effective treatment of mature scars.

The same report mentions silicone scar sheets as a more effective product; “the most accepted treatment for old and new hypertrophic scars is silicone gel sheeting”. A score rating the overall efficacy of the two products is given.
Polyurethane dressings: +/-
Silicone sheets: ++

The dressings should be applied daily (most convenient will probably be overnight) for approximately 12 hours. This should be maintained for at least a month or two. One study compared the use of the dressings for 12 hours with 24 hours per day. No relevant differences between the scars appearance (color, softness and elevation) was noted.

Which are better for mature scars, polyurethane dressings or silicone dressings?

In another study four treatments on mature scars (2.5 to 4-year old) were compared. The four therapies were;  polyurethane dressings; polyurethane with compression; silicone sheeting with compression; and compression alone.

“All treatment modalities were found to have significant effects both on tissue function and scar tissue surface structure. The most pronounced effects were achieved with the combination of polyurethane dressing plus compression or silicone sheeting plus compression. The positive effect of the polyurethane dressing alone on scar tissue was even slightly superior to that of compression therapy alone.” Source: Effect of four treatment variants on the functional and cosmetic state of mature scars.

Another report by Dr. Thomas Mustoe states:

We have investigated the effects of silicone gel sheeting (Cica-Care: Smith & Nephew, Largo, FL) in a rabbit model of hypertrophic scarring . As expected, silicone gel sheeting effectively reduced scar hypertrophy in this model system. A polyurethane dressing (Op Site: Smith & Nephew, Largo, FL) [..] did not have similar beneficial effects on scarring.

Since advantages over silicone sheeting in immature scars are unclear or not present and this type of therapy is equally effective on mature scars I would tend to conclude silicone sheets have more evidence behind their overall efficacy.

centella asiatica

Centella Asiatica is a mildly antibacterial, anti-viral, anti-inflammatory herb indigenous to south and south east Asia. The plant grows in swampy areas in India, Sri Lanka, Indonesia, Malaysia, Iran, northern Australia,  Melanesia, and New Guinea.

The herb has been used for ages for its medicinal qualities in both traditional Chinese medicine and traditional Indian (Ayurvedic) medicine as well. It is also known as Gotu Kola, Asiatic or Indian Pennywort, Rau má in Vietnam and Saraswathi Plant” in India.

(photo by suatu ketika | Creative Commons)

Ascribed benefits of its culinary and medicinal use are stimulation of overall health, rejuvenation, boosting the nervous system and increasing concentration. Some extracts have been used traditionally to treat leprosy. In Thailand it is used as a detoxifying agent to aid treatment of opium addicts.

A popular folklore tale from Sri Lanka speaks of a prominent king from the 10th century AD named Aruna Withane who claimed that Gotu Kola provided him with energy and stamina to satisfy his 50-woman harem.  Source: Wikipedia

Centella Asiatica Scar Creams
Several studies show Centella asiatica’s ability to improve wound healing. Some aspects of the chemical compounds in this herb seem to aid scar treatment as well. More specific; the main substances; asiatic acid, asiaticoside and brahminoside seem to stimulate type 1 collagen production which leads to less prominent scars.

Also inflammation, which is a major factor in (abnormal) scar creation, is reduced. Apart from this, the process of myofibroblast production, which boosts wound healing by contracting the edges of the wound, is decreased. It is theorized that residue myofibroblasts are the reason for hypertrophic and keloid scar development.

Madecassol
A segment of the chemicals in the Asiatic acid are also described as madecassol. This madecassol has shown to be an effective treatment of keloid scars. (E1-Hefnawi H: Treatment of keloids with asiaticoside. Dermatologica 125:387, 1962)

Another scientist found that when taken orally madecassol turned out to be “an active scar improver with few side effects”.  His conclusion was that although more extensive study on its true mechanism of action and long-term safety needs to be done, it is promising regarding effective treatment of keloids. (Bosse JP: Clinical study of a new anti-keloid agent. Ann Plast Surg 3:13, 1979)

Landes reported about his 20 years of experience with madecassol ointment. He reported to use madecassol as additional treatment after cosmetic surgery. (Landes E: Konservative Therapie yon Narben und Falten. Z Hautkr 62:805, 1987)

No Side Effects
Studies as well as anecdotal reports have not shown any side effects of the topical application of Centella asiatica extract.  Because the plant and its three main chemical substances (terpenoids) are weak sensitizers skin irritations are considered unlikely, and have not been reported.


Centella Asiatica based Scar Creams
A well known scar cream is Alpha Centella cream. This product is used by some physicians, especially in Asia, to prevent and treat scars. The cream has two main ingredients.  Apart from the aforementioned three extracts of C. asiatica it also has extracts of the Bulbine frutescens plant in it. This herb possesses moisturizing and antibacterial properties and its action is sometimes compared with Aloe Vera (as is C. asiatica).

A newcomer on the market is Scartini serum with main ingredients Centella asiatica and lychee extract. As far as I know, this is the first cream with this centella asiatica (Gotu Kola) ingredient on the American consumer market, which could be promising. How much of the Centella asiatica ingredient is present in the product is unclear. Also the dermal benefits of lychee extract are not convincing when examining available research.


Conclusion
The positive effects of C. asiatica in wound healing are convincing (documented to aid wound healing in a large number of scientific reports) Also evidence for the improvement of, especially, keloid scar appearance is available but more research has to be done. Key effects appear to be speeding scar maturity, anti-inflammatory action and the decrease of excessive scar tissue (myofibroblast production). 

Or as this study abstract on New Innovations in Scar Management puts it:

“Centella asiatica has been documented to aid wound healing in a large number of scientific reports. The most beneficial effect appears to be the stimulation of maturation of the scar by the production of type I collagen and the resulting decrease in the inflammatory reaction and myofibroblast production.”
That’s why this report mentions Centella asiatica together with effective measures such as; pressure therapy, hydration, and silicone sheeting.

Since there do not seem to be any really effective scar ointments (except for the prescription cream Imiquimod (brand name Aldara) and silicone gel creams) Gotu Kolu based scar creams might be a worthy contribution to the effective scar products pool.

The anchor pattern surgery is the most invasive breast reduction procedure. This variant is also called; T-incision, inverted T pattern, or Weiss Method. This 30 sec. YouTube video shows clearly how this procedure is performed and the scar it will leave: Anchor Breast Reduction Procedure.

Because this is the most radical procedure it results in the most scarring. In order to avoid ugly scars it is recommended to treat them right away. This means as soon as the wound has closed and certainly not before.

Anchor shaped, self-adhesive silicone gel pads are the most efficient way of preventing hypertrophic and keloid scarring. Silicones have shown to make surgical scars less red, flatter and softer. These dedicated products also come in an aureola circle shape. This way maximum convenience is provided and cutting large sheets into customized shapes is not necessary.

Dedication and determination are required because the pads should be worn on the breast reduction anchor scar for at least 12 hours every day for a period of at least two months.  But the efforts are worth it because it is clinically proven that the results are far better then those gained when using creams or lotions. More information here.

Silicone scar sheeting is used by hospitals, burn centers,  cosmetic surgeons, and dermatologists to treat and prevent scarring. Having used many products myself I have come to the conclusion that not only are silicone sheets the best solution for (surgical) wound scars but also that it matters which brand you choose. The best option is to use medical grade, or the so called doctor approved brands. ScarAway is such a brand.

ScarAway (formerly known as Neosporin Scar Solution) is released on the consumer market by Bio-Med Sciences. These sheets ( or patches, strips) are manufactured with the proven Silon technology. The last years ScarAway silicone scar sheets were improved with a slightly larger size and significantly better adhesion.

Supporting my own findings here are two comments/ reviews posted on my web page about my experiences with scar treatment:

Lori D says:

The only silicone sheet available that is professional grade and also thin (more comfortable) is Scar Away. I tried a few without success and then finally found scaraway sheets. Here is my experience. I tried rejuvaness, but it is just piece of rubber…it does not have any stickiness to help it stay on so even when i taped it on, it would slide and fall off. No effect whatsoever on my scar. I tried another sheet (blaines scarcare?) it was so thick and lumpy that it was really uncomfortable and felt itchy. No way I could wear that 12 hours a day!. I was very discouraged. When I went to my doctor for help with my scar, she recommended ScarAway. I used the 7″ x 1.5″ strips for my C-section scar. The strip was VERY thin and has a nice soft fabric on the outside . I left mine on almost all of the time and each strip lasted longer than the week suggested. The package came with enough for the whole treatment (my doctor recommended 12 weeks). My scar is barely even visible now

steve p says:

I just went to drugstore.com to order ScarAway silicone scar sheets and found out they have a new 100% silicone gel that does not have any “useless” ingredients like vitamin e. cortizone. etc. So if you are looking for the scienticfically proven silicone only, I am going to use the scaraway sheets in combination with the silicone serum when i am not wearing he sheet. I know I have to wear the sheet 12 or more hours, and will wear the gel the other hours. I read that the longer silicone is in contact with your skin, the better. I also found the scaraway on drugstore.com and amazon.com comes with a free case to keep it in.

Why you should avoid silicone strips that are too sticky and too thick, and more advice on silicone scar products in this ScarAway review.