Q&A: Treating pediatric scars a team effort

Scars — whether from burns, injuries or other causes — can impact an individual’s life in many ways, and oftentimes these physical marks first appear in childhood.

Recent technologies, however, have made scar treatments better and more accessible. Healio spoke with Andrew C. Krakowski, MD, the network chair of dermatology for St. Luke’s University Health Network, in Bethlehem, Pennsylvania, and a pediatric dermatologist who founded the St. Luke’s Scar Treatment and Rehabilitation (S.T.A.R.) program, about how scars affect their patients — especially children — and how the program goes about treating scars.

Healio: What types of scars do dermatologists deal with?

Andrew C. Krakowski

Krakowski: The types of scars we treat, in both children and adults, range from keloids and hypertrophic scars to atrophic scars and even well-healed surgical scars.

Infants and younger children tend to seek treatment for traumatic scars, such as those caused by burn injuries, motor vehicle collisions or dog bites — scars that may be affecting normal physical growth and function and psychosocial development. Adolescents are most interested in treatment for atrophic scars that come directly from inflammatory skin conditions such as acne vulgaris. Adults tend to seek assistance with scars that are the consequence of larger surgeries, such as skin cancer surgeries or larger corrective procedures that were necessary to treat an underlying condition.

No matter the age or specific mechanism of injury, the common thread between all of our patients is that they want to be made as close to whole as possible. This goes well beyond “for cosmetic’s sake.” We try to give them some of their life back by helping to improve range of motion, restore lost function and rehabilitate a scar with the specific goal of minimizing scar-related complications such as erythema, pain, pruritus and dysesthesias.

Healio: Who is most likely to be affected by burns and scars?

Krakowski: Kids are particularly prone to trauma, so it is not surprising that burn scars and scars from trauma, especially from mechanical injury, make up the majority of scars for which we provide care. Referrals from orthopedic surgery and cardiothoracic surgery are probably a close second right now. Scars from inflammatory skin conditions such as acne vulgaris and hidradenitis suppurativa also account for a large subset of patients. In the pre-adolescent and adolescent populations, we are now getting better at recognizing self-cutting behaviors and diagnosing the unique scars that may be associated with underlying emotional pain, intense anxiety and frustration.

We also help treat the consequences of child abuse and other “reminders” of difficult past traumatic events — physical or otherwise. One such example is how we work with oncology patients who have beaten their cancers and are doing great save for the scars from their port-a-caths. It is rare, but I have worked with some of these patients who look in the mirror, see their scar, and get immediately transported back to the time of their chemotherapy — with genuine feelings of discomfort and nausea — even though it may have been years since their last treatment. If minimizing a scar helps those patients to feel better, then we are compelled to try.

Healio: What kind of special considerations do children need for treatment?

Krakowski: Children are, by definition, a vulnerable population, and I have evolved my style for treating pediatric scars over the last 10 years to address this fact. I would say the most valuable lessons I have learned are the argument for appropriate, early intervention and the importance of a multi-disciplinary approach.

In pediatrics, there is this phenomenon of “use it or lose it” in which a child’s developmental pathways eventually get re-routed or even shut down if the necessary stimuli are lacking. Any time a scar impacts function or limits range of motion, there is concern of this happening, and interventions need to be made quickly and effectively.

This is the exact reason why a pediatric scar team is a model whose time has come. The idea is that the subjective and objective comorbidities of a scar should drive specific management efforts, with the child’s own pediatrician serving as the all-star quarterback for the team of scar specialists. The scar team tries to capture every aspect of the scar that could impact the individual’s treatment course and ultimate long-term outcomes.

The scar team starts by performing an intake around the experience that led to the scar, as well as documenting complaints of prolonged pruritus, or pain within the child’s scar, and incidents of “dysesthesia,” such as when a scar feels “weird” or “tingly.” Anxiety, depression, anger, social isolation, etc. are also scar-related comorbidities.

Occupational therapy should be consulted in order to record at baseline the extent of any functional deficit (ie, range of motion, decreased strength, etc.). This is especially critical when the hands are involved, and I recommend involving a certified hand therapist as early as possible whenever the scar affects “from the elbow down.”

Another objective finding that needs to be considered is the visceral reaction elicited by a scar when observed by a stranger, as it may affect everyday considerations such as social relationships, employment opportunities and, ultimately, how patients are able to reintegrate into their own lives. Consequently, the scar team should consult with a mental health expert, especially if a patient is displaying any signs of PTSD or unhealthy coping mechanisms.

With accurate and precise subjective and objective findings documented, the scar team can start to address the specific issues affecting the child. Often, involvement from the surgical specialties is necessary for complex scar revisions that utilize Z-plasty, for example. This technique has proven invaluable for rehabilitating scars by counterintuitively lengthening scars in order to decrease the mechanical tension running through them. If larger procedures such as these are planned, the scar team may opt to obtain a nutrition consult in order to tweak the patient’s dietary status with optimal wound healing in mind.

Once most of the “heavy-lifting” is complete, dermatology should be available to offer the bevy of services that we employ to improve a scar.

A key aspect of the scar team is simply the way its members approach the individual procedures in the first place. Kids respond to the emotions and body language of the people around them. Our team members have become skilled at calming themselves which, in turn, calms our young patients. The goal is to relax the patients to the point that they actually want to willingly have the procedure done and buy fully into the process. Once you have the kids on your side, you will be amazed at what they will allow you to do without much coaxing at all.

Healio: Which lasers in particular are you using?

Krakowski: St. Luke’s University Health Network has been wonderful in supporting and developing both our new dermatology clinic and our fledgling residency in dermatology. As a faculty, we decided that we would purchase hardware that could serve multiple purposes and that would be the same tools that our graduates would see “out in the real world.” For the treatment of scars, it was an easy decision to purchase the Lumenis UltraPulse, with its DeepFx and SCAAR FX software. From an academic perspective, a large portion of the articles that mention fractional carbon dioxide laser for the treatment of scars reference this specific device, so we wanted to ensure that our residents could directly apply other scar experts’ experiences to their own scar patients. From a practical perspective, the UltraPulse leads the field in terms of the power and depth of penetration that it provides. With it, we can get up to 4 mm of penetration, including the zone of cauterization, into skin. It is fast, too, which is important when you are lasing large burn scars.

Healio: What does a typical treatment session look like?

Krakowski: Our protocols vary greatly. Generally, we start with a pre-operative visit in which I have the chance to meet the patients and their families. It never ceases to amaze me how well some children do with just some straight talk and a simple demonstration of what to expect on the day of surgery.

We talk a little about what bothers them about their scars, what they hope to gain from any treatment and realistic expectations. We can almost always improve a scar, but we cannot erase it — not yet at least!

We also spend time discussing risks, benefits and potential side effects of treatment options. Families have to understand that, when used incorrectly or inappropriately, some of our scar revision techniques could actually worsen a scar or cause skin color changes in the form of post-inflammatory hypo- or hyperpigmentation. Postoperative infection is something we take very seriously, so proper wound care is discussed.

Finally, we address pain issues. While some patients certainly require general anesthesia — usually because of the size or anatomic location of their scars — most kids do very nicely with topical anesthesia combined with a generous amount of patience and understanding.

In terms of the procedure itself, we may start by utilizing the pulsed dye laser to help decrease the redness of a scar, or we may use our hair removal lasers to help reduce unwanted hair growth from within a graft or flap that was taken from a hair-bearing area in order to better repair a large defect. Next comes the fractional carbon dioxide laser. Treatment sessions are usually 4 to 6 weeks apart for at least four to six sessions.

One of the most important aspects of treatment is the postoperative care. Typically, we apply petrolatum ointment directly to the wound and cover it with Telfa and Hypafix. That bandage stays on for 24 hours. After that, the bandage can come off and normal showering or bathing is allowed, but the petrolatum ointment continues to be applied for the next week or so, until full reepithelization has occurred. Sun avoidance and sun protection are crucial to preventing post-inflammatory skin color changes; I recommend using a physical sunscreen with at least SPF 50 that will not clog pores.

Above all else, we counsel families about what to look for in regard to infection. We want to know about a potential issue before it becomes an actual problem.

Healio: What sort of results are you seeing?

Krakowski: The results continue to impress me. Subjectively, we see softer, lighter-colored scars that are less painful and less itchy. The best is when the patients tell you there is improvement. For me, however, the real home run is the scar we treat where function was originally compromised but is now showing objective improvement. Our physical therapy/occupational therapy team does a wonderful job evaluating range of motion, functional deficit and scar pliability. Seeing that a teenager can now open his hand the entire way or that a young girl is able to smile more evenly is what impacts me the most.

Healio: What's next for the St. Luke’s Scar Treatment and Rehabilitation Program?

Krakowski: With more and more people seeking scar therapy, we are going to see an influx of new modalities that will become the next “game changers.” I think all of us look forward to the day when we as humans do not have to heal with a conventional scar. Right now, a major focus of the St. Luke’s Scar Treatment and Rehabilitation Program is to make sure that all children – regardless of their ability to pay – get the treatment they need in order to enjoy life to its fullest. That is what keeps us motivated and living our mission!