With Suzanne Rea.

Today I’d like to welcome to the PodMD studio Dr Suzanne Rea

Dr Rea completed her undergraduate medical degree at the Royal College of Surgeons of Ireland and obtained her fellowship in Plastic Surgery from the Royal College of Surgeons.

After relocating to Western Australia, she completed a fellowship in Burns Surgery under the supervision of Professor Fiona Wood. Suzanne was awarded her fellowship of the Royal Australasian College of Surgeons in the specialty of plastic and reconstructive surgery in 2014. She was also awarded a doctorate by research (PhD) for her research on scarring completed at the University of Western Australia.

Today, we’ll be discussing the topic of self harm scars

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We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

The topic of today’s discussion is self harm scars. Suzanne, Can you describe for our listeners what a self harm scar is?

Suzanne: Sure, self-harm scars can sometimes describe the self harm scars or linear scars. These are usually injuries that are intentionally caused to the skin, frequently caused by cutting, but can be from other things like burning or branding or chemical injuries. These usually occur on the limbs. Often the non-dominant limb to start with, and so upper and lower limbs in particular, but they can be in any other part of the body as well.

How would a patient with self harm scars typically present?

Suzanne: So as a plastic surgeon, we see people who’ve had self-harm scars in a number of different ways. Often, we see them acutely in the emergency department if the lacerations or the burn injury is a severe injury and they need primary care when they have initial wound treatment, potentially suturing or grafting as required, dressings and ongoing management. But probably more commonly we see people with established scars as a result of these injuries, so patients who have scars from cutting in particular, often have multiple scars. They usually come to see us at three type of different time points.

Now initially, sometimes after the first or second presentation of an acute injury. There is concern about what can be done about the scar and often these are young people. So the commonest age for self-harm to occur is around the age of 13. So these are often young people who’ve maybe brought it to the attention of their parent, who is very concerned about the potential scarring and will bring them to see us at that stage. The second group that we would see are often patients, young people usually who are under the care of treating psychology and psychiatry team. And when they’re a little bit more stable and the harming behaviour has stopped, usually that’s when they come to see us or anything that can be done about the scarring at that stage.

And then finally we see a group of sort of older sort of young in the early 20s, young adults embarking on careers frequently, these young people embark on healthcare related professions. These professions, then have got this policy of bare above the elbows, and we often see people at this stage who come to us to see is there anything that can be done about their scars then. So they’re kind of different stages and phases in their life usually.

What are the challenges of self-harm scars?

Suzanne: Self-harming is a complex situation. It’s not a simple thing. There’s not just one aspect of it, and I think it’s important to understand that it’s very, very common. Recent literature would suggest that about 25% of adults under the age of 30 have experienced an episode of Self Harm. The challenges relate to the fact that the underlying reasons for this behaviour need to be addressed and I think it’s important to emphasise that that’s really, really the care of the treating psychology and psychiatry team if required, rather than the realms of the plastic surgeon.

From the plastic surgery point of view, from the scar management and scar treatment point of view; patients come to see us because looking at these scars cause memories triggering a bad time in their lives and then people treat people with self-harm scars in different ways. They’re very stigmatising and there’s a lot of research that shows that patients or young people in particular with the stigmata of self harm, don’t do as well in job interviews, don’t do as well in social situations. And so they’re the big challenges. Around actually having this condition and then there’s associated challenges around treating the subsequent scars.

What are the treatment options?

Suzanne: So the treatment options are very individual, really it involves a thorough discussion with the patient. And working out sort of an in-depth assessment around what it is that actually bothers them, which skies bother them the most? Do they have realistic expectations about what can be delivered and what are their desires? You know, if the desire is just, I just want to get rid of them, I just want them all gone, then it’s going to be an uphill battle. Because we are not going to be able to just erase those scars. In terms of the treatment option, it’s really about improving the quality of the scar. We’re looking for something that’s colour matched with the surrounding skin and that is texture matched so that it’s not raised, so there isn’t a raised scar or an indented scar. So really trying to get something that’s flat and confluent with the surrounding skin and colour matched.

The options then around trying to achieve that depends on the type of scar that we’ve got. If it’s a raised scar, we work hard at flattening it. If it’s an indented scar, we work hard to try and work out how we can fill the defect so that it becomes smooth. And if it’s red, we need to address that in turn. Really, the options can be broadly broken down into conservative measures, so pressure, silicon, sun avoidance moisturizer, massage. Then we can move into more invasive treatments like carbon dioxide laser and intra-lesional steroid, both of which can cause raised scars to shrink in on themselves. The redder scars might need to be treated with a vascular laser.

A newer treatment that’s come online now is really looking at cosmetic tattooing. So actually the linear white scars that are quite common, especially if you’ve got darker skin, looking at colour matching those with a medical grade tattoo to actually try and blend that in in a better fashion. And then finally surgery is an option. Surgery I say finally, because really, that’s kind of a last resort. We’re really swapping 1 scar for another. And but some scars are better treated with a surgical intervention initially, especially if someone has multiple self-harm scars and those scars weren’t treated in the initial period of harming because they can be quite wide and quite stretched. So maybe by exercising those and re-suturing them we can come up with a better quality scar.

But again, like I said, there’s no magic wands. There’s no way of sort of reducing these completely. This is the way of improving the scars rather than removing them.

Have there been any developments in treatment in the last years or are there any in trials or development now?

Suzanne: So the key factors that affect or influence the success of scary vision really go back to patient selection and ensuring that you’re doing the right procedure for the right patient at the right time. So, for example, you know, doing a scar revision on a 12-year-old boy who is incredibly keen on foot. And choosing to do that just at the start of the footy season, which then means that he’s not going to comply with his period of rest he’s not going to wear his pressure garment and he’s not going to want to sit on the sideline. That’s a guaranteed way for that procedure to fail. So ensuring that you pick the right patient at the right time and then that you build confidence and rapport with the patient and family so that they understand the need for adherence to those protocols is very, very important.

Have there been any developments in scar revision in the last few years or are there any in trials or development now?

Suzanne: This is not an area that’s been trialled, really in isolation and there’s lots of trials around scarring and scar management. But this particular group of scarring conditions are not the focus of any one particular big clinical trial really, just an amalgamation of various bits of clinical information and other parts of trials to use them. I think the big changes afoot at the moment are really looking at more conservative ways. In the past, a lot of people would have used a more artistic tattoo and actually used very strong dark colours to cover these to cover these areas particularly on the forearm now people are looking at a more subtle way of actually colouring in the scar with a with a colour matched pigment rather than actually tattooing over it, so improving the quality that way.

The carbon dioxide laser has also been used with great effect to try and reduce down the swelling and the raised and hypertrophic scarring, and that’s actually quite useful. Skin replacement, so patients often come looking to see if they can have the whole area excised. Can you not just put a skin graft on it and make it just look like I’ve had a burn? That’s a very common request by patients. So skin replacements, there’s a biodegradable temporizing matrix, BTM is what it’s called, which has been developed as an Australian product. And we do use that a lot in burns patients for complex defects.

There may be a role for this in very significant self-harm scars. So the ones that really affect the entire surface of a limb, but that really does involve removing an entire piece of tissue, replacing it with a temporary matrix and then skin grafting over the top, that’s a very significant undertaking and it’s something that would only be done after significant discussion and proper understanding and consent process etc. But that’s probably the biggest developments at the moment.

Are there any warning signs a GP or their patient can look out for?

Suzanne: So I suppose it’s important, again, I keep emphasising this, but it is a complex psychosocial problem. So, you know, the patient’s mental health is obviously paramount and is more important than any scarring process. However, in my experience, the scars themselves can add to that stress and anxiety, and we often find that if a patient sort of in the early stages of self-harming comes with a parent or a support person to come and see us and we can outline a plan for the future and explain that there are options and there’s things that can be done about it and to give some insight into what’s available, that’s one of the things that we can help alleviate some of the anxiety around the scarring itself, and certainly I have lots of patients who come to me whose healthcare professionals have told them there was nothing that can be done for it, and that in itself causes a lot of stress.

So I suppose that’s a myth. We can improve these scars, and that’s some of the anxiety around the scarring. Please you know, let them come and have a chat. We probably won’t intervene at that stage. It’s super important that the patients are stable, that they’re able to embark upon a treatment regime which can be demanding in terms of the requirement of self-care that we need for the post-op treatment or the post-interventional treatments. So really we would generally say that patients who’ve been self-harming in the last six months or even a year depending on the recency of the or the severity of the harm. That they’re probably not suitable so, but I think you know in terms of warning signs, if the anxiety is heightened around the actual scar itself and early referral is useful.

How successful is treatment?

Suzanne: So the treatment is successful if you pick the correct treatment for the correct patient at the correct time. That sounds a bit simplistic, but you know a properly consented, well-informed patient who understands what we can offer and what we can deliver and who undergoes treatment at the time when they’re mentally strong, physically able to commit to the treatment requirements and committed to the process in terms of aftercare, then we have significant success in improving the scars and helping people feel more comfortable with the subsequent scarring.

So I suppose the success is in the patients selection is the most important thing to say, rather than it’s not something we’ll just offer the same one size doesn’t fit all. It’s around picking the correct treatment for the correct patient.

When should a GP refer?

Suzanne: So we’re happy really to see patients at any stage when they want to be seen I think. So often we get mums in particular, occasionally dads, but a lot of mums ringing up and they want to bring their child in and they want to get it fixed. But really, you know, that’s probably not the best thing, it has to be driven by the patient, Like I said, once the scar is causing anxiety, we’re very happy to see patients at that stage, it’s a good time to refer them to discuss the options.

Alternatively, when a patient requires or requests an opportunity to come and discuss the options so it can be at any stage. And I think there’s a little bit of a thought that oh, if it’s too late and nothing can be done at this stage, that’s really not true anymore. Even long term scars that are 15 or 20 years old can actually be improved. Might take a little bit longer and maybe a little bit harder. But so I suppose the big thing is patients could be should be referred whenever they are concerned and want to have come and have a discussion about what the options are.

What role does the GP play in the treatment of the condition?

Look, I think the GP is pivotal in the treatment of self-harms scars. It’s that holistic management. It’s looking after the complex psychosocial needs of the patient and or at the family at that point in time, there can be lots of things going on. This is rarely just self harming in isolation. So the GP is the absolute linchpin of this treatment.

In terms of scar management, simple things that the patient can be offered at the time, you know, things like silicone treatment, which is the topical scar gels or scar treatment that can be used obviously advising patients that moisturizer and massage keeping out of the sun and protecting the wounds from infection are very important. And you know, it goes without saying that all of the GP’s would strongly advise other coping mechanism rather than the permanency of harming. But that’s a bit simplistic. So the GP is really the crucial part of the team at this stage.

Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on self-harm scars.

Suzanne: I suppose the key thing is that, you know, the thought that something can be done about this, these scars can be improved, they can be improved at even a long time out from the time of the injury, and that it’s certainly very worthwhile to seek an opinion and to actually refer patients. Because techniques have changed and the opportunities for treatment have changed. So a referral is always worthwhile.

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