It’s a myth that children don’t scar like adults, according to Dr. Jon A. Dyer.
In fact, children often scar worse than adults, he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Children have more aggressive healing and inflammatory responses, a highly elastic dermis and connective tissues, and a high activity level that increases the risk of stressing the wound, and they may pay less attention to it, he explained.
Additionally, children can be more difficult to treat for scars because they are often more fearful and anxious, they have a short attention span, and they move around – a lot, he said. This leads to greater anxiety on the part of both the dermatologist and the family, which can lead to rapidly completing a procedure, said Dr. Dyer of the University of Missouri, Columbia.
Successful treatment of a wound or lesion – that is, getting the best initial scar possible – requires good planning, proactive application of surgical principles, and careful patient and family counseling and follow-up, he said.
Among Dr. Dyer’s tips for minimizing scarring when treating lesions in children:
• Do the simplest possible procedure.
• Make the scar as small as possible, keeping in mind that pediatric skin is more elastic.
• Remember that fusiform closures in children do not always require a 3:1 ratio. Tips settle, and divots fill in in young children, he said.
• Operate before puberty when the lesion is located in a cosmetically important area.
Also, consider performing a staged excision if possible; this allows a reduction in final scar length, provides tissue expansion, and allows assessment of individual wound healing. Take as much of the lesion as possible the first time, and remember that central excision is preferable to lateral excision, Dr. Dyer said.
The ideal time to wait between stage 1 and 2 is 4-6 weeks. Longer intervals will lead to more spread and more hypertrophy, and will negate the benefits of staging, he said.
Keep in mind that purse-string sutures can be particularly effective for suturing small spaces and for closing dead spaces, he said, adding that use of a purse-string closure for a round defect can reduce the final scar length by at least 50%.
Scar prevention or minimization requires strict adherence to good surgical principles, Dr. Dyer said, explaining that attention must be paid to perfecting the excision through proper use of skin tension lines, clean wound edges, sharp corners with no or minimal boating, undermining, and removing bulk if necessary.
Track marks are more likely on nonfacial skin and can be avoided by using running subcuticular sutures; in some cases of excellent approximation with no tension, the wound surface can be secured with Dermabond, he said.
Dr. Dyer also outlined the best closure choices for specific areas. For the scalp, use running cuticular sutures; for the extremities, trunk, axilla, or groin, use running subcuticular sutures; for the face, feet, or hands, use interrupted sutures; and for a punch biopsy, consider not using any closure, he advised.
If cuticular stitches are used, minimize scarring by pulling them within 5 days on the face, and within 7-10 days on the body. If dehiscence is a concern, pull the cuticulars and follow with either Dermabond or SteriStrips, he said, but strongly consider using running subcuticular sutures.
Once a wound is closed, secure it with Dermabond or with Steri-Strips and Mastisol and provide protective dressing.
“The bulkier and more colorful the dressing, the happier and more compliant the child,” he said.
Minimize postoperative wound tension in high-risk scars or sites and restrict movement and trauma for as long as possible; 6 weeks is ideal, he added, noting that movement restriction is critical for ensuring a good outcome.
To reduce the trauma of suture removal, “cut ’em long and leave ’em long,” and be sure to use proper scissors, he said.
Running subcuticular suture removal doesn’t hurt; enlist parents’ help in convincing the child of this, he suggested.
Finally, be specific when counseling patients about restrictions, discuss possible complications, provide a written summary including contact numbers, address the scar, and give the follow-up appointment time in writing, he said.
If dehiscence occurs – and it’s not uncommon in children – let it heal and restart the process, he said, noting that prevention is best and can be achieved in many cases with aggressive pre- and postop education, restriction of movement, and proper dressing.
Dr. Dyer stressed that good surgical principles for use in children can also be utilized to improve results in adult patients.