Xaida

Best creams for scars after surgery

I've recently had a surgery on my lower back due to slipped disk (laparoscopic) and left a scar on my back. After a couple of months, it's now causing irritation and has been really itchy. What the best cream to help ease the irritation?

18 January 2017

Thank you for contacting Health at Hand.

To have an itchy scar on your back must be very awkward. Often scars like this can cause anxiety and disrupt sleep, so we can understand it must be causing you considerable discomfort.

The best treatment is to wash the skin with a moisturising shower gel or a bath additive. This will prevent the skin becoming dry. Then apply and massage a fragrance free moisturiser cream or ointment into clean dry skin. You will need to do this on a daily basis for several months and maybe even longer. Silicone based gels and sheets can be particularly effective for stubborn deep scars.

As the scar is healing it is important to protect it from sunlight to prevent it becoming dark and prominent. It is a good idea to keep it covered for a year or more. Alternatively use a suntan lotion or cream or sun block of SPF 35 or greater if your back is going to be exposed to the sun.

An itchy, hot painful scar can be a sign of infection which will need medical attention, from a doctor or a prescribing nurse. If the scar is just itchy, taking antihistamine tablets can help to stop the itching. This in turn stops the itch scratch cycle, so helping to prevent infection.

We have included the information below because we thought it may help you to understand the nature of scars and how best to care for them.

What happens when you have a cut or wound, for example after surgery?

When you have a cut in the skin the body repairs itself. Immediately after a break in the skin a scab forms, closing the gap and preventing infection. This layer is not very strong.

Once the scab is formed, the healing process starts from the inner layers of the skin and progresses to the upper layers. A cut or a wound heals in 3 phases.

  1. Initial inflammatory phase. This is a natural response and the first phase where the blood vessels contract to form a clot. Once the bleeding has stopped the blood vessels dilate to allow white blood cells, antibodies and other essential nutrients into the area.

  2. The proliferation phase. During this phase the granular tissue, which contains collagen builds up to form new skin. Healthy granulation tissue is dependent on a number of factors, including a good source of oxygen and nutrients. It often looks uneven and is pink in colour and less likely to bleed. The appearance of the wound at this stage gives an idea of whether the wound is healing well or if it’s infected.

  3. The maturation or remodelling phase is the final stage of repair. During this stage the scar flattens and becomes softer as some of the collagen disappears. This process can last anywhere between 12-18 months, or even longer in some cases.

It’s important to remember that the healing process of a wound or cut is not a linear one. It can go back and forth through the second and the third phase. Ideally the wound should heal from the deeper layers to the upper layers and this can take time. If the wound heals from the top layer the deeper layers can still be raw and the wound will then break open again. This is why care, time and ideal conditions are needed to allow the wound to heal.

What is a scar?

A scar is a raised area of thickened skin that leaves a permanent mark after a wound is healed. Scarring is a natural part of tissue repair where the wound appears red at first, then as time progresses regains the appearance of normal skin. This process can take up to two years providing the scar is regularly massaged and moisturised.

However, some scars don’t heal well and can grow over normal skin, causing problems. There are two main types of scars that are difficult to heal:

  • Hypertrophic scar, and
  • Keloid scar

Hypertrophic scar

A hypertrophic scar generally forms when the deeper layer of the skin - called the dermis - is damaged. They occur when the body makes an excess amount of collagen during the repair process. Key characteristics of hypertrophic scars:

  • They tend to be red, raised and thick in appearance, and can be itchy
  • They appear around three weeks after an injury or surgery and settle naturally after 1 – 2 years
  • This type of scar usually doesn’t spread outside the original injured area.

Keloid scar

A keloid scar on the other hand tends to spread outside the original injured or wound boundary. Other ways to identify keloid scars:

  • They develop 3 – 12 months after the original injury or excision from surgery, again because of an (even greater) excess of collagen produced at the site of a wound
  • They can stay elevated and are unlikely to disappear completely, though most will improve in appearance over time. A keloid scar is usually shiny, hairless, elevated above the skin, hard and rubbery and red or purple at first, before becoming pale or dark.
  • They’re usually painless but can become tender, itchy and painful.

You mention that you had the surgery a couple of months ago. This means that the scar is still fresh so it’s difficult to determine at this stage what type yours is.

Medications to help to reduce scars

Keeping the skin moisturised once the initial wound has healed, after approximately 3 weeks, is the best method of preventing or reducing scars. Bath emollients and moisturisers can also help to restore the skin’s smoothness and elasticity.

Emollients

Emollients are preparations that soften the skin. Sometimes the skin can become too dry whilst it’s healing, causing it to become puckered. Using soap and water to cleanse the skin can cause it to become dry and irritated.

Emollients can help to prevent this effect and may help to calm the scar. Adding bath oil or additive or using an emollient shower gel can help to soothe, hydrate and smooth the skin. However, the effects are short lived so a moisturising cream or ointment needs to be applied to the area as well, to provide longer term benefit. Examples of suitable emollients include:

  • Aveeno bath oil
  • Balneum bath oil
  • Cetraben emollient bath additive
  • Doublebase emollient bath additive or shower gel
  • E45 bath oil or E45 wash cream
  • Oilatum emollient bath additive or shower gel
  • QV bath oil and QV gentle wash, and
  • Zeroneum.

Moisturisers

Moisturisers allow the skin to retain moisture for a longer time than the bath additives and shower gel and should be used after the skin is washed and dried thoroughly. Sun block cream with SPF 35 or greater may be suitable for skin that is exposed to sunlight. The following examples are suitable to use for small scars:

  • Aveeno cream
  • Cetraben cream, lotion or ointment
  • Diprobase cream or ointment
  • Doublebase cream or ointment
  • Epaderm ointment
  • E45 cream
  • Hydromol ointment
  • Oilatum cream.

The difference between creams and ointments is that ointments tend to be oil based and stay on the skin longer but can have an oily feel. Creams on the other hand are water based and tend to rub well into the skin, so are easier to apply but need to be reapplied more frequently.

Silicone gel products

For deeper scars, such as the hypertrophic and keloid scars described above, silicone based products have proved to be more effective. They help to reduce scar elevation and pigmentation so prevent the scar becoming darker.

Silicone gel
You would need to apply a small amount of the silicone based gel and massage it into the scar with your fingers in a circular motion. Massaging the wound for about 10 minutes two or three times a day, every day, for several months after surgery will help to clear the scar tissue.

Silicone gels approved by for use in the UK include:

  • Bapscarcare
  • Ciltech
  • Dermatix
  • Kelo-Cote UV
  • Kelo-Cote gel
  • Kelo-cote spray
  • NewGel+E
  • ScarSil
  • Silgel STC-SE.

Source: National Institute for Health and Care Excellence (NICE).

Why massage the scar? Is it really necessary?
As mentioned above, the wound healing process is changing all the time. About three weeks after surgery the wound can tolerate pressure. Massaging the scar using gentle pressure allows the wound to heal in such a way that the restored skin is soft and supple and has the normal range of movement and elasticity.

Silicone based sheets
Using silicone sheets may be another option. These sheets can be applied to the scar once a day for 12-23 hours. They are very easy and convenient to apply.

Silicone sheets approved by for use in the UK include:

  • Advasil Conform
  • Bapscarcare T
  • Cica-Care
  • Ciltech
  • Dermatix
  • Mepiform
  • Scar FX, and
  • Silgel.

Source: National Institute for Health and Care Excellence (NICE) .

Antihistamines

It isn’t uncommon for scars to feel itchy following the healing process, this itchiness can last several months but can be managed with antihistamine treatment. We suggest that you can take an antihistamine tablet or capsule if you do not have any accompanying pain and the wound is not hot or throbbing. As we mentioned earlier taking antihistamine tablets can help to stop the itching. This will in turn stop the itch scratch cycle and so help prevent infection.

Types of antihistamine
Antihistamines can be classified into two different groups:

  • 1st generation antihistamines (drowsy) - alimemazine, chlorphenamine, clemastine, cyproheptadine, hydroxyzine, ketotifen and promethazine. These are known to be useful if the itchiness is causing sleep disturbances

  • 2nd generation antihistamines (non-drowsy) - acrivastine, cetirizine, desloratadine, fexofenadine, levocetirizine and loratadine- These are newer antihistamines that are associated with less drowsiness, however care should still be taken as a degree of sedation is still possible when taking these, for example, when taken with alcohol.

Although this may vary depending on the formulation, antihistamines typically take approximately 30 minutes to act with its effectiveness peaking around one to two hours after administering.

Side effects of antihistamines
Most people respond well to antihistamines, and side effects are usually known to be minor. However the most commonly reported side effects include:

  • Drowsiness
  • Headache
  • Dizziness
  • Dry mouth
  • Agitation
  • Blurred vision
  • Difficulty passing urine
  • Stomach discomfort.

Which antihistamine to choose?
There are various antihistamine tablets on the market that you can buy from the pharmacy or even from a supermarket or drug store. Here we compare the pros and cons of some of the most popular over-the counter remedies to help you make your choice. If you’d like more information on all the options available, your local pharmacy will be happy to help.

Chlorphenamine 2mg tablets, more commonly known by the brand Piriton.

Advantage:
• You can take up to three tablets in a 24hour day.

Disadvantage:
• It can make you drowsy so you cannot drive or operate machinery all the time you are taking this tablet.

Cetirizine, Loratadine and Acrivastine are all non-drowsy antihistamine tablets

Cetirizine and Loratadine

Advantage:
• The dose of Cetirizine and Loratadine are one tablet once a day.

Disadvantage:
• If the symptoms return you cannot take another tablet until 24hours after the previous dose.

Acrivastine

Advantage:
• It can be taken up to three times a day so if symptoms return another tablet can be taken 8 hours after the first tablet.
• It works in 15 minutes.

Disadvantage:
• It is more expensive than the other antihistamines available over the counter
• It cannot be sold to anyone of 65years old because of lack of evidence based data.

Other treatments

You asked about creams to help calm the irritation caused by your scar, so that’s what we’ve focused on here. However, there are a range of other treatments to help soothe or improve the appearance of scars, some available on the NHS and others privately, that you can read about in more detail via the link (or see further reading suggestions below).

Next steps

We suggest that if your GP hasn’t examined the scar recently, it would be good idea to see him/her before using any of the products listed above, so that you can rule out any accompanying infection or eczema.

Your GP may prescribe a steroid cream if he/she thinks it is necessary.

Please do not hesitate to contact Health at Hand if you need further information.

Answered by the Health at Hand nurses 

Sources and further reading

Scars – NHS factsheet

Skin conditions hub - AXA PPP healthcare

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