October 2019

Scar massage is one of the most commonly recommended treatments in scar management. However, advice and evidence on when, why and how to massage a scar is lacking.  This article provides some guidance on the topic based on currently available evidence and expert clinical opinion.

What scar features indicate that massage may be beneficial?

1. Tethering – scar mobilisation may loosen scars, which are firmly attached to underlying or surrounding tissues
2. Pain, hypersensitivity and itch– scar massage may improve such troublesome symptoms
3. Tightness – soft tissue manipulation may soften scars and increase pliability
4. Bulk– scar massage may help flatten certain bulky scars; nevertheless, keloid scars are unlikely to benefit.

What is the rationale for massaging scars?

By applying mechanical forces to the skin, a number of biological events are triggered including:

• increased blood flow
• hormonal release e.g. oxytocin
• induction of mechanotransduction (i.e. activation of molecular signalling within the scar) aiding remodelling of the scar structure

What is the evidence behind massaging scars?

Surprisingly, there are very few high quality studies supporting massage techniques in scar management.

• There is good evidence that massage can help reduce symptoms of pain, itch as well as anxiety and depression in burns victims (Field, 2000, Roh YS, 2007)
• One study has indicated that massage may improve colour as well as elasticity in burn scars (Cho YS, 2014)
• Other studies have failed to unequivocally support the efficacy of scar massage to increase joint range of movement (Silverberg, 1996 and Morien, 2008).

Is massage good practice for all types of scars?

Although massage has traditionally been considered a universally beneficial component of scar management, recent ideas support the use of vigorous techniques for mature scars only. An immature scar is one that has been created recently from trauma or surgery and appears to be red/inflamed with a quick refill time (i.e. if pressed with the tip of the finger, a rapid return of colour is seen). Scars, generally speaking, tend to be red and inflamed for the first 3-9 months. On the contrary, a mature scar has colour similar to neighbouring skin, shows no signs of inflammatory activity (i.e. the refill time is slow) and represents an older injury to the skin. 

What is the best way to massage my scar?

There are a variety of methods proposed in the literature; in clinical practice, these vary extensively depending on the exact type and maturity of the scar they are applied to. 

• For younger immature scars, movements of low intensity and frequency are recommended, whereas older mature scars can be treated with more aggressive soft tissue mobilisation techniques.
• It is important to avoid friction on the skin; circular movements with local pressure appear to be safer and are generally preferred. Other useful techniques involve creating a skin fold (i.e. lifting the scar) gently and carefully mobilising it.
• Traditionally, scar massage is done with a cream medium, but this makes some techniques (e.g. skin fold) difficult because the skin cannot be easily grasped; cream can increase the tendency to move over the skin and create friction rather than mobilise the scar.
• There is no evidence to support the best frequency or duration of scar massage. Common advice is to massage a scar of 10cm² for 5 minutes 3-4 times a day.
• Moisturisation / hydration is very important for every scar irrespective of whether massage is indicated and should be encouraged four times a day a day or as needed to prevent any dryness.
• A scar specialist could help guide on the type of massage although often the massage once demonstrated can be done independently by patients/carers.

Key messages for scar massage

• Moisturisation is universally recommended for all scars as opposed to massage, which needs to be tailored to the type of scar and degree of scar maturity/age.
• Scar massage can ameliorate a number of scar characteristics including tethering, tightness, pain itch and hypersensitivity.
• Special attention needs to be given to fresh, inflammatory scars, since aggressive soft tissue techniques may worsen inflammation and associated scar characteristics.
• Certain scar types should only be massaged under the supervision of a qualified scar management professional.
• It is important to take expert advice to ascertain if your scar is suitable for scar massage, and what the most appropriate techniques are.

Ioannis Goutos, Consultant Plastic Surgeon
Specialist Interest in Scar Management

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References

Cho YS, Jeon JH, Hong A, Yang HT, Yim H, Cho YS, Kim DH, Hur J, Kim JH, Chun W, Lee BC, Seo CH.  The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: a randomized controlled trial. Burns. 2014 Dec;40(8):1513-20

Roh YS, Cho H, Oh JO, Yoon CJ.  Effects of skin rehabilitation massage therapy on pruritus, skin status, and depression in burn survivors.  Taehan Kanho Hakhoe Chi. 2007 Mar;37(2):221-6.

Field T, Peck M, Scd, Hernandez-Reif M, Krugman S, Burman I, Ozment-Schenck L. Postburn itching, pain, and psychological symptoms are reduced with massage therapy.  J Burn Care Rehabil. 2000 May-Jun;21(3):189-93.

Silverberg R, Johnson J, Moffat M.  The effects of soft tissue mobilization on the immature burn scar: results of a pilot study.  J Burn Care Rehabil. 1996 May-Jun;17(3):252-9.