Now you have a surgical or traumatic skin wound to heal. It may be in a not-so-hidden body location. Maybe on your face? All you hope is that it does not leave a scar. But do you know the exact steps to achieve that? Yes, scarless wound healing. It’s possible! Especially if what you got is an everyday, minor skin wound.

Hi guys, let’s talk scarless wound healing! Even if you don’t have a cutaneous wound or recent scar at the moment. Then, next time, you will know what to do and won’t make the same scar-fostering mistakes all over again – yes, we all have made them sometime –. 

What happens in your skin when a wound occurs?

Skin repair versus skin regeneration

When a skin wound comes up, our body tries to repair the wounded tissue as soon as possible. It’s a survival response that is not perfect and leaves a scar (even if you don’t see much of it externally, with your eyes).

However, we know that scarless healing is possible since that occurs in the fetus at the early stages of pregnancy. In that situation, what happens is not a repair response but a tissue regeneration response instead. The latter is a much less steep reaction that results in a completely new piece of tissue without a trace of a scar.

Skin regeneration versus repair (illustration): regeneration of the tissue results in scarless healing whereas tissue repair  leads to the formation of a scar.

The most simple scar treatment products for at-home use and the most avant-garde biotech strategies try to resemble that regenerative response and scarless healing 1 seen in the fetus. And that’s also what we need to strive for when any skin wound arises in our everyday life.

Wound healing steps for scarless healing

We already know that it is possible to accomplish a seemingly scarless wound site. Let’s get to know then the cascade of molecular events of the healing process and how to favor the scarless look.

There are four stages that we can optimize from the outside:

Stage 1 – Clotting

When we get, for example, a cut, the first thing that happens is that platelets extravasate from the blood to the cut location and aggregate with the protein fibrin to form a clot that clogs up the cut and prevents any further infiltration of debris and bacteria.

Skin wound healing step I: coagulation (illustration).

Stage 2 – Inflammation

Platelets and skin cells at the wound secrete soluble growth factors (such as PDGF, Platelet-Derived Growth Factor) and cytokines that attract inflammatory cells to the wound bed.

Then neutrophils and macrophages pop into the site to kill bacteria, remove debris, and start an inflammatory response that will induce the recovery and remodeling of the injured tissue. 

Thus, pro-inflammatory molecules and cells (such as M1 macrophages) are required at the beginning of this phase. However, to progress optimally to the next stage of wound healing and diminish the chances of scarring, the inflammation has to resume.

With that purpose, late anti-inflammatory cells and molecules replace their early pro-inflammatory counterparts. For instance, M2 macrophages (anti-inflammatory macrophages) secrete the anti-inflammatory cytokine IL-10 (interleukin-10) at the wound site.

Stage 2 of skin wound healing: early and late inflammation (illustration). M1 macrophages and neutrophils get rid of bacteria and debris during the early pro-inflammatory phase. And M2 macrophages secrete anti-inflammatory molecules during the late phase of the inflammation stage.

The hallmark of scarless healing is reduced inflammation. Thus, we should manage to keep the early pro-inflammatory stage at the bare minimum. Then, we will more likely end up with an invisible scar. We will see how to do that later on 🙂

Stage 3 – Proliferation

Now it’s time to fix or, ideally, regenerate the dermis at the injured site. Molecules secreted by macrophages and other cells during the inflammation stage induce, initially, the proliferation of fibroblasts (the cells of the dermis). While fibroblasts multiply, they also synthesize and secrete collagen III to fill in the wound with what is known as granulation tissue.

Stage III of skin wound healing: proliferation (illustration): the formation of granulation tissue takes place. Fibroblasts produce collagen type III at the site.

Fibroblast proliferation is much more likely to run smoothly if pro-inflammatory cells and molecules do not take the reins of the inflammation stage before.

That is of utmost importance since a key to scarless healing is that those fibroblasts do not grow too much nor produce excessive amounts of collagen. Otherwise, we would end up with a not-so-beautiful or even nasty scar (such as a hypertrophic or keloid scar).

Once the dermis fills up with the granulation tissue, the keratinocytes (the cells that comprise the epidermis) proliferate and migrate to close the wound at the surface level, a process known as re-epithelialization.

Stage 4 – Remodeling

At this last stage (which can last months or even a year), the granulation tissue is reshaped to create a more robust tissue that resembles the original skin.

To achieve that, collagen I (the most abundant type of collagen in the skin) will replace collagen III at the wound site.

Collagen I is stiffer than collagen III. Hence, despite being softer, an excess of collagen III during the granulation phase would yield a stiff, excessive scar in the end.

Skin wound healing stage IV: tissue remodeling (illustration). Remodeling enzymes (MMPs) work at the injury site and collagen III is replaced with collagen I. That results in the final scar.

Practical steps towards a scarless look (or how to cure a wound optimally)

Based on all the above, there are four wound healing requirements to achieve a scarless look.

1· Stay away from infection

In other words, keep your wound clean. Once the injury happens, clean it well with plenty of water and apply pressure if necessary until any bleeding stops. Then remove the remaining debris (if any) with, for example, sterilized tweezers. 

Only if needed, use a gentle soap to clean the wound. And clean it every day, at least until the wound surface closes. An eventual infection would lead to inflammation. And you know that inflammation won’t help with scar minimization!

You can also use a hypochlorous acid solution or spray to minimize any chance of infection without irritating the wound or enhancing future scarring. Hypochlorous acid is non-toxic. Some of our cutaneous immune cells, such as neutrophils, produce this acid to kill pathogens swiftly. There are hypochlorous acid sprays or solutions that you can buy at the pharmacy.

I realized that hypochlorous acid was suitable to treat skin wounds when I had blepharitis (an inflammation of the eyelids). Back then I used to spray hypochlorous acid on the eye surface to avoid undesired microorganisms (see the product I used below; you can purchase it without a medical prescription). 

Ocudox Electrolysed Solution (Brill Pharma)

2· Make sure that the wound remains hydrated

In the early fetus – that undergoes true scarless skin healing after injury – there are higher levels of High Molecular Weight Hyaluronic Acid at the wound site. Apart from being anti-inflammatory, those large hyaluronic acid molecules bind and retain elevated amounts of water within the wound.

That hydration at the wound site fosters better cell proliferation and migration. And, hence, a more seamless formation of granulation tissue and epidermal wound closure. 

On the contrary, Low Molecular Weight Hyaluronic Acid, which occurs in wounds after birth, is pro-inflammatory. So it is paramount to counteract its effect as much as possible by maintaining optimal wound hydration.

To keep the skin hydrated after we clean the injury and on the days after, the best is to seal the wound, for example, with a silicone gel or silicone sheet. Silicone sheets might be irritating (especially at this very early stage); if that happens, stick to the silicone gel (or apply pure Vaseline).

My silicone patches.
Silicone patches.

At this stage, you can also use healing ointments made with skin humectants such as hyaluronic acid, glycerin, or sorbitol (you can find them at any pharmacy). Nonetheless, they will not seal the wound as much as a silicone gel will do.

My healing ointment with high concentrations of skin humectants (you can find similar products in any pharmacy).
Healing ointment, rich in skin humectants (sold at any pharmacy).

A common mistake is to clean the wound with alcohol. Alcohol dehydrates the skin. Therefore, wound treatment with alcohol will likely leave a non-pleasant scar.

Hydrogen peroxide might not be the best either. It is better to adhere to water (or water and mild soap) for the daily cleaning of the wound.

3· Avoid increasing inflammation

That means that you should strive to keep the wound undisturbed so that those fibroblasts and keratinocytes can do their best to heal your skin beautifully. I would evade any potentially irritating substance. Also, better to avoid touching the wound or any physical effort that could hurt its integrity.

The new keratinocytes will migrate on the wound surface during the proliferation stage and close the wound before the remodeling phase. Until that happens, you don’t need to cover the wound (with a band-aid, for example), but you can do it if it is in a place where it would otherwise get easily disturbed. 

After the scab (if any) falls, you can use scar reduction patches. I got a small traumatic scar on my forehead last April, and right after the scab fell, I started using polyurethane patches (from Trofolastin, see below). They work in different ways to diminish scarring.

I will go through that in more detail below. For example, they have an Ultraviolet Protection Factor of 50+ and protect the scar from UV radiation, which is critical to keep inflammation low.

My polyurethane scar reduction patches.
My polyurethane scar reduction patches.

Additionally, when the wound has fully closed, you can apply lighter or thicker creams of your choice to the wound site to help the skin stay hydrated and recover.

You don’t need to develop a headache researching skincare ingredients. The most beneficial active ingredients at this stage are simple, effective, and clinically proven:

– skin humectants: probably the best one is glycerin;

– and botanical ingredients with scientifically-proven skin regenerative properties. I would highlight the following:

Centella asiatica (also known as Gotu kola) is a top-tier anti-scarring ingredient.

You might come across some of the isolated beneficial components of Centella asiatica in skincare products (such as Asiaticoside, Madecasosside, Asiatic acid, or Madecassic acid). A good product with Centella asiatica that you can use is La Roche Posay Cicaplast Baume B5.

Green tea (Camelia sinensis) is another pro-healing ingredient that helps minimize scarring.

You may encounter Epigallocatechin gallate (EGCG, a key active molecule from green tea) on its own in skincare products. Solution for Scars by Science of Skin (a British brand) has green tea. I have not tried that product. However, it seems a good choice. A surgeon looking for a topical solution to minimize surgical scars developed it. You can find other products with reasonable amounts of green tea (or its components) on the market anyway.

Solution for Scars from Science of Skin is clinically proven to improve the appearance of scars. It contains green tea extract.
Solution for Scars from Science of Skin contains green tea extract.

4· Optimize scaffolding at the wound site

You may be thinking: what the hell does that mean? I got you 😉 It means it’s best to diminish the mechanical load at the injury site. Why and how?

The Extra-Cellular Matrix (ECM) properties at the wound site directly impact the healing outcome. The proteins (like elastin), glycosaminoglycans (like hyaluronic acid), and other components of the ECM act not only as a scaffold for the healing process. They also sense physical forces (like pressure) at the injury site and transmit those signals to the cells that repair the cutaneous tissue. 

If components of the ECM at the wound site detect too much pressure, they activate receptors on cells (such as integrins). And, in turn, those induce unwanted cell responses to that excessive mechanical load. Like enhanced inflammation, overproduction of collagen, or inappropriate tissue reshaping during the remodeling phase. And we know those reactions may result in a nastier scar!

The most critical job of the scar reduction patches (such as those polyurethane sheets that I mentioned before) is to alleviate excessive pressure at the wound and thus allow better ECM-cellular interactions and optimal ECM reshaping. That yields less visible scarring

I think those patches make a difference. You should definitely apply them if you start seeing an abnormal wound shape or appearance after re-epithelialization (that might hint at a potential keloid or hypertrophic scar). 

The reduction of mechanical forces at the wound site with scar reduction patches results in diminished scarring (illustration).

I still use those scar reduction patches over the small scar on my forehead while at home (right after the scab fell, I wore a patch most of the time for at least three months) and will continue to use them until next April, when the scar will be one year-old (call me crazy!).

Additional yet highly effective approaches to erasing a scar

It’s possible to improve the appearance of a scar, whether it is a recent (less than a year) or an older mark. The scar reduction patches might help with older scars but won’t be as effective – you could try them and see what happens.

Along with the scar reduction patches, I would consistently apply a dual treatment with two types of active ingredients: retinoids and chemical exfoliants (alpha- and beta-hydroxy acids).

Remember, the more recent the mark, the better and faster the results. But older scars will also benefit from the dual treatment.

Retinoids (such as retinol, retinal, or retinoic acid) will trigger a quicker and more organized epidermal renewal. That’s why, after a while, you will see a more polished and brighter, less pigmented skin surface. They will also foster desirable remodeling of the dermis with optimal collagen production that will aid in diminishing the mark. So, if your skin handles them well, they are a must.

I would suggest these retinal products (retinal is more potent than retinol) from Geek & Gorgeous that are available in two different strengths, especially if you are an experienced retinol user:

Geek & Gorgeous A-Game 5

Geek & Gorgeous A-Game 10

They work well and have a non-greasy texture.

My retinal products from Geek & Gorgeous. They come in a convenient opaque and airless pump.
Retinal products from Geek & Gorgeous. They come in a convenient opaque and airless pump.

If you are not so used to retinoids, you can have a look at my post Smoothly Kickstart Retinoids if you wish to initiate yourself into the retinoid world.

Alpha- and beta-hydroxy acids are chemical exfoliants that will help you smooth the skin surface and keep it hydrated. They can fade any line or mark and even out post-inflammatory hyperpigmentation (if you have any). Also, they enhance the effects of your moisturizer and any additional ingredient that you may be applying to your scar (such as Centella asiatica).

If your skin can deal with glycolic acid, I highly recommend this alpha-hydroxy acid for scar treatment. It is smaller than other exfoliating acids and more effective. For example, you can use this solution from Neostrata: it is an alcoholic yet not drying solution that works well (I have used it for years).

My Neostrata solution with 15% glycolic acid.
My Neostrata solution with 15% glycolic acid.

If you have prominent post-inflammatory hyperpigmentation, retinoids and chemical exfoliants might not be enough to fade it completely. That happens very often in darker skin tones. In that case, you may want to try active ingredients like hydroquinonetranexamic acid, or azelaic acid. They reduce excessive melanin production in the skin. Hydroquinone usually requires a medical prescription. To know more about azelaic acid, you can take a look at my recent blog post about it.

I would start with hydroxy acids and retinoids (you can use them on alternate nights, for example). And introduce any depigmenting ingredient afterwards (for instance, after one or a few weeks). If any skincare ingredient (the aforementioned or others) makes your skin too irritated, definitely stop using it.

If, after all, you are not happy with the appearance of your mark, you might want to try laser skin resurfacing. That will be more costly but worth the money if any scar bothers you.

I hope you liked this post.

Do you have any scars? Were your attempts to fade them effective? And what did you use? Leave your thoughts in the comments section below!

You can also ask me anything on Instagram (@drmariamonterrubio).



For your reference:

1 Regenerative scar-free skin wound healing. Monavarian M et al., Tissue Eng Part B Rev, 2019; 25 (4): 294-311.


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