September 2023

Topical gels/ creams for scar management 

This article aims to outline the evidence behind some commonly used non-invasive scar management options, which are available in gel/cream/ointment form.

Silicone Gels

Silicone has been used in scar management since the 1980’s and is known to interfere with the growth of blood vessels as well as collagen production.  Its beneficial effect is thought to relate to a number of the following actions (Tollefson, 2012)

• Scar compression
• Maintenance of hydration
• Regulating of oxygen tension/temperature
• Creation of a static electric field and
• Direct silicone absorption by the scar 

A meta-analysis (high quality summary) of studies looking at the value of silicone gel failed to demonstrate a statistically significant difference for the prevention of unfavourable scarring; most interestingly, the findings were more positive with regards to the use of silicone sheets; nevertheless, the quality of the studies included was found to be poor (Hsu KC et al, 2017).

Another meta-analysis investigated the value of both silicone gel and sheets in the prevention and treatment of scars.  The authors identified that both silicone gel and sheets are equally effective in reducing pigmentation (i.e shade of colour), height/bulk and pliability (i.e softness) of scars at 6-8 months follow up. Most interestingly, according to this study, silicone was not superior to other non-silicone topical therapies including steroid cream preparations (Wang F et al, 2019). 

Treatment of burn scars

There is some evidence that silicone gel can improve features of bulky burn scars (Momeni M et al, 2009 and van der Wal 2010) as well as decrease the height, redness and symptoms of pain and itch in hypertrophic and keloid patients (Chernoff G 2007).

A common limitation of most studies is that scars were not followed up for sufficient period of time to assess long term results upon discontinuation of silicone treatment.  In conclusion, the use of silicone for the prevention and treatment of scars has limited evidence behind it, hence its use should be tailored by a qualified professional to ensure maximum benefit. 

Onion extract products 

Onion extracts have been investigated in the medical literature given the fact that they can have beneficial effects through reducing inflammation, interfering with the growth of scar forming cells and hence decreasing overall collagen production. 

Most studies have focused on prevention of bulky scarring; four comparative studies failed to show an advantage compared to petrolatum or silicone-based products (Owji N, 2018, Song T, 2018, Chung VQ, 2006, Jackson BA, 1999).

An even smaller number of studies have investigated 10% onion extract products for hypertrophic and keloid scar treatment with two out of four studies showing that silicone based products are superior to onion extract (Karagoz H, 2009, Perez et al, 2010). One study supported the combination of silicone gel sheeting and onion extract for superior therapeutic results (Hosnuter M, 2007) and the fourth showed a superior effect on reducing redness, itch and consistency compared to steroid treatment (Beuth, 2006). 

A recent literature review concluded that the level of evidence to support onion extract products for scar management is low (inconsistent or inconclusive studies) (Grigoryan KV et al, 2020). 

Vitamin E

Vitamin E is a group of lipid-soluble micronutrients, which act as anti-oxidants and thought to inhibit collagen synthesis and reduce scar cell (fibroblast) proliferation.  A small number of studies have been conducted with two randomized double blinded trials showing that vitamin E provided no benefit for the prevention/early treatment of scars (Baumann LS et al, 1999, Khoo TL et al.  2011).  On the basis of existing studies, there is little evidence to support the use of vitamin E for scar prevention or treatment.

Steroid creams

There are only two small studies examining the standalone treatment of scars with steroid (one using 0.1% triamcinolone acetonide combined with a hydrating agent lotion and the other using 0.2 % fluocinolone acetonide cream) with some encouraging results (Yii NW, 1996, Marsden CW, 1968). 

Two others used steroid ointment in combination with injections (Hayashi T, 2012) or in combination with a silicone occlusive dressing gel product (Nor NM, 2017) and yielded positive outcomes.  One comparative study showed that application of methylprednisolone cream every 48hrs had similar efficacy compared to silicone gel applied twice a day on linear scars from gynecological surgery (Meseci E, 2017).

Given the small number of studies available, the value of steroid cream/ointments for scar management is limited; steroid plasters appear to be more popular with patients , hence are increasingly more popular in clinical practice (Goutos, 2017). 

Ioannis Goutos, Consultant Plastic Surgeon
Specialist Interest in Scar Management

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References

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Hsu K-C, Luan C-W, Tsai Y-W.  Review of silicone gel sheeting and silicone gel for the prevention of hypertrophic scars and keloids.  Wounds 2017;29(5):154-158.

Wang F, Li X, W X, Jiang X.  Efficacy of topical silicone gel in scar management; a systematic review and meta-analysis of randomised controlled trials.  Int Wound J.  2020;17:765-73.

Momeni M, Hafezi F, Rahbar H, Karimi H.  Effects of silicone gel on burn scars.  Burns 2009 35:70-74.

Van der Wal MBA, Van Zuijlen PP, Van de Ven P, Middelkoop E.  Topical silicone gel versus placebo in promoting the maturation of burn scars: a randomized controlled trial.  PRS 2010 Aug; 126(2):524-31.

Chernoff WG, Cramer H, Su-Huang S.  The efficacy of topical silicone gel elastomers in the treatment of hypertrophic scars, keloid scars and post-laser exfoliation erythema.  Aesth Plast Surg 2007 31:495-500.

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