“Scars Reveal the Strength of the Human Soul” (1), however, the potential subsequent psychosocial dysfunction often renders such phrases less meaningful for those suffering from the consequences of scars. There are many factors that influence how we perceive scars, these include the reason behind the scar, the location, severity, our sex and age. Whilst some scars are a source of pride, others may be psychosocially debilitating. Emerging studies have shown that patients express high levels of concern regarding scarring following skin injury and routine surgery. Disparities also exist in patient-clinician communication regarding what level of recovery to expect with scar management (2).
Before divulging into the politics, ethics and economics of scar treatment on the NHS, it is worth understanding what is involved in the formation of a scar. Following damage to the skin, the regeneration follows different phases of repair and resolution. This involves an intricate interplay of carefully orchestrated communication between a variety of cell types, ranging from immune to inflammatory and resident to circulating cells; all serving under the commanding trio of molecular, genetic and environmental factors (3).
Successful repair of the damage depends on the activation of specific genes by stimulated cells that result in production of proteins and activation of pathways that aim to heal the damage. However, the complexity of these pathways leaves room for irregularities, that can lead to impaired damage response, chronic inflammation and aberrant scarring. In addition, this complexity is furthered by genetic heterogeneity in patient cohorts which results in variable levels and various states of response to treatments and therapies.
Where are we now?
The NHS is currently facing the biggest challenge in its existence; rising costs, change in public expectations and an ageing population are a substantial part of the problem. However, the humanistic spirit within the NHS strives to help all individuals in need of medical attention, no matter how big or small in clinical objectivity but also the patient’s perception of their own problem (4). As such, funding treatments have been subject to clinical efficiency and patient centeredness. The decision as to who merits access to scar management on the NHS is a complex and time worthy issue, requiring careful analysis of current practices and future directions (5). Intrinsic to all decision making are the four principles of clinical effectiveness, cost effectiveness, service availability and patient acceptability.
As a general NHS policy for scar revision, funding approvals will be given when there is clear evidence of potential for the patient to benefit from a specific treatment, which has proven effective for the intended outcome. On the occasion that the requested treatment has been shown to be of limited or diminishing benefit to previous patients with the same abnormality, funding is likely to be denied.
Current NHS guidance for the public on whether a scar would be likely to be treated using public funding is based on the following criteria:
• Scars resulting in impaired movement or those which are inherently painful
• Unsightly scars on the face that are longer than 2cm
• Self-harming scars that are older than 3 years will be assessed individually
Purely cosmetic issues are very unlikely to be treated, however in extreme cases, each patient will be assessed and a panel will give their decision as to whether the patient’s scar warrants surgery.
Types of scar
There are several reasons as to why a scar looks different to the tissue it replaces, amongst these, reduced elasticity and different structural composition in terms of the lay of the collagen fibres are key. Each scar is unique in terms of collagen overexpression; the two most common types are hypertrophic and keloid scarring; these types of scar are associated with excessive collagen growth that often overextends the tissue and hinders its normal regeneration. Another form of scarring also known as sunken scarring or atrophic, which follows a similar pattern of collagen over expression but with the difference of not overextending the tissue, thus giving the scar a sunken look.
Table 1 (below) outlines different treatments available for scar management with their associated benefits and limitations.
Type of treatment
Mechanism of action
|Chemical peels||Chemical removal of the epidermal layer with various chemicals depending on the depth of peel required||Superficial acne scars||Not suitable for dark skinned individuals and those susceptible to keloid scar formation or with active infections|
|Filler injections||Injection of collagen to raise atrophic scars to match the surrounding skin||Improving the image of atrophic, sunken scars.||Allergic reaction|
|Non-ablative Laser treatment||Smoothening of the epidermis via contact cooling||Hypertrophic and keloid scars.||Multiple sessions required before noticeable result|
|Ablative laser treatment||Works by destroying the epidermis to a certain depth||Atrophic and acne scars.||Slower healing with higher risk profile|
|Radiotherapy||Reduce recurrence of severe scarring by slowing down cell division.||Severe keloid and hypertrophic scarring||Long-term side effects from radiation|
|Silicone dressing||Wound hydration||Burns and hypertrophic scars||Weak evidence of effectiveness|
|Steroids||Breakage of bonds between collagen fibres, reducing scar tissue beneath the skin
|Keloid and hypertrophic scars||Requires a long-term course|
|Surgery||Cutting the scar out and allowing skin to heal by primary intention rather than secondary intention.||Keloid and hypertrophic scars||High recurrence rate with keloid scars. Deep scars require multi-layered closure|
|Vitamin E||Decreasing fibroblast and keratocyte activity||Non-specific scar improvement||Causes contact dermatitis in up to 33% of patients and weak evidence of improving cosmetic appearance of scars|
|Vitamin C||Neutralisation of reactive oxygen species destructive to the skin and promotion of skin healing
|Pigment lightening||Nothing of note|
|Cosmetics||Use of professional makeup to cover scars||Facial scars||Temporary measure|
|Dermabrasion||Mechanical surgical skin planing
|Acne scarring, traumatic scars, rhinophyma, wrinkles, tattoo removal, and actinic keratoses||Invasive procedures that typically require a local anaesthetic and specialised centres/ surgical suits.
|Microdermabrasion||Mechanical medium for epidermal exfoliation||For milder forms of scars, such as mild acne scarring.||Mild dryness and sun sensitivity|
|Massage||Thought to break down scar tissue, making the injured tissue more flexible||Surgical incisions such as caesarean scars||Weak scientific correlation|
(Collagen induction therapy)
|Dermis stimulation to produce collagen and elastin||General scar resurfacing and remodelling. Advantageous safety profile, particularly in the skin-of-colour population, compared with more conventional resurfacing modalities
|New technique that needs objective evaluation by a systematic research.|
Table 1 | Current treatments available for management of scars with their respective mechanism of action and limitations (5-14).
Who has priority?
As with all publicly funded services, the notion of prioritising and directing resources towards areas most needed is of high importance, therefore, scar management on the NHS also needs to fit within such a paradigm to be viable.
When considering access priority, we must also factor in statistics and social norms. For example, caesarean scars are very common and increasing in numbers as more patients opt for delivering their babies via this route (15). On the other hand, scars from burns, acid attacks, assault and other forms of extreme and often life altering events are less normative, and more prone to physical and mental repercussions. As such, access to scar management needs to be prioritised for patients of the latter group. However, each case, where possible needs to be individually assessed with respect to criteria outlined earlier. With regards to a multidisciplinary approach to scar management, questions arise include which specialties should be involved in such gatherings, and how efficient would such approaches be in terms of time and cost.
Is surgery the answer?
A study looking at the levels of psychosocial dysfunction and distress at the point of referral in patients seeking publicly funded elective cosmetic surgery in the UK has shown that in general the levels of dysfunction or distress was not clinically significant (16). Patients seeking surgery for physical reasons showed no actual physical dysfunction, and those seeking surgery for aesthetic reasons, although having minimal levels of social and psychosocial impairment, were much less debilitated than that of clinical groups that warrant treatment for psychiatric and psychological problems (17,18).
Previous studies have shown that distress related to physical appearance does not correlate with the degree of abnormality, yet a distinct relation exists between impairment and preoccupation with the perceived abnormality, that is to say, preoccupation causing psychosocial dysfunction and vice versa (19,20).
The consensus amongst similar research is that the presence of psychosocial dysfunction in patients seeking elective cosmetic surgery, appears to be more psychological rather than purely physical. In a sense, it can be argued that conservative approaches towards lessening preoccupation in absence of objective abnormality may serve more useful for such patients as opposed to surgical methods (21).
What non-medical options are available?
In addition to medical management for scars, patients can also benefit from NHS funded para medical services such as counselling and symptomatic relief of scar disfigurements. Such efforts have been successful with the likes of skin camouflage techniques, pioneered by the British Association of Skin Camouflage providing para-medical skin camouflage, in cases where medical treatment is not effective or not sought after by the patient. This is also very effective where there is no change in the structure of the skin (13,22).
In addition, psychological aid, such as cognitive behavioural therapy could be an important adjunct or part of scar management, whereby rebuilding self-esteem, confidence and expectations after a disfiguring injury can have remarkable results on patients’ preoccupation with their scar (24,25).
Each scar is different, and so is each person with the same scar. We must remember that as the public attitudes towards cosmetic surgery becomes more permissive, the population seeking it will become more normative, (21) and as such health care professionals will play a crucial role in prioritising and managing such requests, requests that can often prove difficult in term of weighting the cosmetic and psychological balance of each case. Furthermore, multidisciplinary evaluation of each patient appears to be the most patient centred route for those seeking scar treatment on the NHS. However, this may not be possible, therefore a unified criteria approval checklist can be developed in aid of such decisions where a multidisciplinary approach is not possible.
There are many guidelines devised as to how to make guidelines, however they routinely lack analysis of clinical decision making. To have a reliable and viable guideline for approval of scar treatment on the NHS, it needs to be evidence based and poised for mass adoption by trusts, surgeons, general practitioners and the wider audience dealing with such cases. To achieve this, the guideline needs to incorporate a realistic judgment and clinical assessment from the viewpoint of surgeons and clinicians as well as patient’s expectations, which would be of most help where there is difficulty in decision making and where evidence alone is not sufficient (26). Advances in medicine and surgery as well as technological innovations in health infrastructure pave the way for introducing efficiencies and ideas that can be implemented in the NHS to allow wider access to resources. Future guidelines need to match the complexity of clinical decision making and build on current norms, statistics and practices to include factors such as cost of procedure, degree of abnormality, psychosocial state, and the reasons behind seeking treatment to ensure fair access to limited resources.
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- Khunger. Standard guidelines of care for chemical peels. Indian Journal of Dermatology, Venereology, and Leprology. Medknow Publications; 2008 Jan 1;74(7):5–24
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- Shin TM, Bordeaux JS. The Role of Massage in Scar Management: A Literature Review. Dermatol Surg. 2012 Mar 1;38(3):414–23.
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