June 2020

Management of self-harm scarring presents unique challenges in the reconstructive field.  A variety of different treatments have been described to improve the strongly stigmatising pattern of scars and lessen the significant psychological burden for affected individuals.  The aim of this article is to provide insights into the importance of taking a holistic approach to managing this condition.

The background of self-harm injuries

Self-harm injury has been traditionally associated with a wide range of mental health conditions including psychosis, depression and personality disorders (1).  Alarmingly, self injury is increasingly being observed as a coping strategy for emotional distress amongst teenagers and young adults; this has been attributed to a number of ‘contagion factors’ including peer pressure, and risk taking behaviour promoted by popular media (2). 

Clinical presentation of self-harm scars

There are a number of common features seen when patients present with self harm scars relating to (3):

• Bodily site, with the non-dominant arm most frequently affected followed by the lower limb and trunk
• Scar pattern, which tends to demonstrate multiple scars found in close proximity to each other
• Scar quality; most scars are ‘atrophic’ (i.e. contain decreased amounts of collagen) and have a depressed appearance
• Psychological manifestations; most individuals adopt a number of behavioural patterns in order to hide their scars and avoid being challenged in social encounters.

Management principles of self-harm scars

Team approach.  Patients need to be managed within a multidisciplinary setting comprising plastic surgery, psychology/psychodynamic therapy and other allied health care professionals able to address the complex needs of each individual.  Close liaison with mental health services is important in order to help support patients with the internal conflicts that appear central to their self-harming behavior as well as addressing difficult emotions, which may arise during scar management (4,5).

Camouflage approaches.  The option of makeup products and medical tattooing is valid for patients wishing to reach a better colour match between the scars and surrounding skin (6).  One of the main drawbacks with the camouflage approach is the temporary nature of results and need for repeat application of skin products and pigments to maintain the desired effect.

Needling.  These techniques rely on creating small perforations in the skin using a device in order to remodel collagen and ‘blend in’ scars with the surrounding tissues (7).  Appropriately chosen needling devices (i.e. long enough to reach the deep layer of the skin) need to be used for a satisfactory regenerative effect to occur.

Laser resurfacing.  A number of different technologies can be used as standalone treatments including erbium fibre/carbon dioxide lasers and encouraging results have been reported in the literature (8,9).  Over the last number of years, lasers are increasingly used in combination with surgery to maximise final scar outcomes.

Surgery.  A number of different surgical techniques have been evaluated including:

a) Removal of selected wide scars and closure. This approach aims to decrease the number of scars present and hence improve the associated stigmatising pattern.

b) ‘Artificial skin’. This technique involves extensive removal of the scarred area and application of a skin graft on top of the ‘artificial skin’ product. The resulting scar tends to have a more cosmetically acceptable texture and overall appearance (10).

c) Tissue expansion (stretching). This refers to the insertion of an inflatable balloon (under anaesthesia) close to the involved area of skin, which is gradually inflated as an outpatient procedure. Once enough skin has been generated from the expansion, the scarred area is removed and the ‘extra skin’ is draped over the resulting defect to allow wound closure into a single scar. This option represents a long surgical journey and the associated risks need to be carefully considered.

d) Skin graft techniques. A number of traditional techniques involve removal of the scarred area and the use of skin from a distant site (e.g. thigh) for resurfacing. More modern approaches, such as the isotopic split skin graft are increasing in popularity, since they avoid additional scarring in a distant bodily site (11).

Conclusion - self-harm scarring is complex and sensitive

Self-harm scarring is a complex and sensitive condition frequently associated with feelings of guilt and regret as well as body image disturbance.  Individuals are best managed within an experienced multidisciplinary team, who can offer their combined expertise to address the unique physical and psychological needs of each individual.

If you are struggling with self-harm issues or self-harm scarring, please get in touch with your GP who will be able to advise the appropriate steps and health care professionals for your situation.

Ioannis Goutos, Consultant Plastic Surgeon
Specialist Interest in Scar Management

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References

 1) Acikel C, Ergun O, Ulkur E, Servet E, Celikoz B.  Camouflage of self-inflicted razor blade incision scars with carbon dioxide laser resurfacing and thin skin grafting. PRS 2005 116: 798-804.

2) Derouin A, Bravender T. Living on the edge: the current phenomenon of self-mutilation in adolescents. MCN Am J Matern Child Nurs. 2004 Jan-Feb;29(1):12-8; quiz 19-20.

3) Agris J, Simmons CW. Factitious (self-inflicted) skin wounds. PRS 1978 62(5): 686-92.

4) Briere J, Gil E.  Self-mutilation in clinical and general population samples: prevalence, correlates and functions. American Journal of Orthopsychiatry 1998 68(4):609-20.

5) Welch JD, Meriwether KRC, Trautman R. Stigmata: part I. Shame, Guilt and Anger. PRS 1999 104(1): 65-71

6) Guyuron B, Vaughan C.  Medical-grade tattooing to camouflage depigmented scars. PRP, 1995; 95(3).

7) Aust M, Bahte S, Fernandes D. ‘Applications Scars from cut injuries’ in Illustrated guide to percutaneous collagen induction by Quintessence Publishing UK, 2013.

8) Guertler A, Reinholz M, Poetschke, Steckmeier, Schwaiger H, Gauglitz GG. Objective evaluation of a non-ablative fractional 1565nm laser for the treatment of deliberate self-harm scars. Lasers Med Sci 2018 33:241-50.

9) Lee SJ, No YA, Kang JM, Chung WS, Kim YK, Seo SJ, Park KY. Treatment of hesitation marks by the pinhole method.  Lasers Med Sci 2016 31: 1339-42.

10) Ismail A, Jarvi K, Canal ACE.  Successful resurfacing of scars from previous deliberate self-harm using Integra dermal matrix substitute. JPRAS 2008 61, 839-41.

11) Goutos I, Ogawa R.  Isotopic split skin graft for resurfacing of deliberate self harm scars.  Plast Reconstr Surg Glob Open 2018;6:e1801; doi: 10.1097/GOX.0000000000001801.