How does a scar mature and how long does it take?
A scar forms in three phases. In the first days the wound is inflamed, then the body fills the gap with new tissue, and from about the third week the remodelling begins. This last phase takes around a year, often longer. The scar keeps changing all that time.
Wound closure and finished scar are two different moments, and months lie between them. The skin is shut after two weeks; the tissue underneath goes on sorting its fibres for the whole following year.
- Inflammatory phase, the first days: the wound is red, warm and swollen. That is not an infection as long as it is settling.
- Building phase, up to about the third week: the body fills the gap with new, well supplied tissue. The scar is red and soft.
- Remodelling phase, from around three weeks: the fibres realign, the tissue becomes firmer and paler. That takes about a year.
Between the sixth week and the third month a scar is often at its hardest and reddest. Anyone looking closely for the first time then takes it for a worsening. Usually it is the normal course, and the scar becomes flatter and paler over the following months. It compares to the healing of a graze: the wound edges are pale pink and therefore very well supplied, and that young tissue needs time to settle.
Why does a scar on the hand get in the way more than elsewhere?
Because tendons, nerves and joints lie immediately under the thin skin of the hand. A scar that sticks to the tendon sheath slows the gliding of the tendon, and the finger no longer straightens or bends fully. On top of that, the hand is densely supplied with touch nerves.
How mobile a scar stays also depends on how much tissue lies beneath it. On the thigh there is enough fat under the skin to keep a scar flexible. On the palm side of the fingers there are millimetres, and a scar there has almost no room to move.
- Sticking to tendons: the tendon has to glide several centimetres when you bend. If the scar holds it, the finger loses that travel.
- Pull across a joint: a scar running across a flexion crease tightens as it matures and can draw the joint into a bent position.
- Sensitivity to pressure: the palm and fingertips carry a great many touch receptors. A scar there reports in with every grip.
- Constant use: a hand cannot be rested like a back. Every task loads the scar and moves it at the same time.
So in hand therapy a scar is rarely about appearance. What we measure is how far the fingers move, whether the scar can be shifted, and what hurts when you grip. The appearance usually improves on its own; the movement does not.
How scar treatment fits into the course after an operation is set out in hand therapy after surgery. After a repaired tendon additional rules apply; those are in the article on a tendon injury in the hand.
When may I start treating the scar?
As soon as the wound is fully closed and the stitches are out. Before that only the surroundings are moved, not the scar itself. Crusts, weeping areas and increasing redness are a reason to wait. When you are ready is decided by the doctor who operated or stitched.
Stitches on the hand usually come out after ten to fourteen days, in occupational therapy or at the surgery. After that the skin often needs a few more days until the last crusts are gone. Rubbing earlier tears the young join open again.
- Wound fully closed, stitches out, no crust left: only now may the scar itself be touched.
- Start with a greasy, unperfumed cream and at first only cream the scar, without pressure.
- After a few days shift instead of rubbing: move the skin over the scar in small circles against the layer beneath.
- Only then add the directions in which the scar feels tight, and move the fingers along with it.
You may usually move the hand long before that, as far as the aftercare protocol allows. Movement keeps the tendon going and the scar mobile without anyone pulling on the fresh wound. It is therefore the first scar treatment, and it often starts in the first week.
What does scar massage do and how well is it supported?
Scar massage is meant to keep the scar mobile so it does not stick to the layer beneath, and it makes touch easier to bear. The evidence is thinner than the popularity of this treatment suggests: a review found a set of studies with very different approaches, only a few of them on the hand and wrist.
The idea behind it is simple: a scar moved daily in every direction sticks less to what lies under it. A second benefit comes with it. Anyone who touches their own scar regularly gets used to being touched and trusts the hand with more.
- Short and often rather than long and seldom: a few minutes, several times a day.
- Work with a greasy, unperfumed cream so the skin does not chafe.
- Shift rather than rub: move the scar against the layer beneath, do not rub it raw.
- The pressure stays bearable. Pain is no measure of effect.
- Move the fingers afterwards, so the mobility you have gained is put to use.
The basis for this is thin. A review in a hand therapy journal collected the available studies. All of them reported favourable results, but they used a great many different outcome measures, and the approaches ranged from a single session to three times a day over half a year.
It does not follow that scar massage is useless. It follows that nobody knows the right dose, and that promises about millimetres and weeks are not covered. It stays sensible because it carries little risk and brings the hand back into use.
What do silicone and compression achieve?
Silicone and pressure are the two measures recommended in the German-language guideline on problem scars. Silicone is worn 12 to 24 hours a day for 12 to 24 weeks, compression at 20 to 30 mmHg all day for 6 to 24 months. Both start once the wound has closed.
Silicone comes as a soft sheet and as a gel. It probably works by covering the scar and slowing the water loss from the skin. It is applied only after the wound has closed, and then daily over weeks; using it on the odd day is not enough.
The recommendation is stronger than the data. A Cochrane review assessed 13 studies with 468 participants and rates all results as of low to very low certainty: small numbers, incomplete reporting. Silicone is well tolerated and widely recommended, but on the current state of research a reliable benefit is hard to prove.
Compression works with sustained pressure, on the hand usually through a made-to-measure glove, often with a silicone insert over the scar. Pressure works only if it is applied almost around the clock, and it is correspondingly demanding. It is used above all for overgrown scars and after burns.
Why does the sun harm a fresh scar?
Fresh scar tissue has almost no pigment cells. It burns faster than the skin beside it, and UV light can make the scar permanently darker and more noticeable. International recommendations on scar management therefore advise high sun protection until the scar has matured. On the hand that means almost every day outdoors.
Together with the face, the hand is the part of the body that is least covered. Over a year it takes more UV light than almost any other, including while driving and on snow in winter. A scar on the back of the hand is therefore more at risk than one under a shirt.
- In the first year after the injury, put high sun protection on the scar whenever you go outside.
- Reapply several times: on the hands, sun cream is gone after washing.
- Cover it where you can. A light glove or a plaster works more reliably than any cream.
- A change in pigment, once it has happened, often never fully disappears.
What are hypertrophic scars and keloids?
Both are raised, overgrown scars. A hypertrophic scar stays within the borders of the original wound, usually shows itself within six months and often settles by itself. A keloid grows beyond the wound, often appears later, and does not go away on its own.
The difference decides the treatment. A hypertrophic scar may be watched: it is thickest between week six and month three and often flattens by itself afterwards. A keloid tends to grow without treatment and frequently returns after a plain excision.
- Hypertrophic scar: raised, red, itchy, but within the old wound borders. Usually starts before the sixth month, often settles.
- Keloid: grows sideways into healthy skin, often lumpy and firm. Frequently starts later, does not settle on its own.
- Disposition: keloids run in families, particularly with more strongly pigmented skin. Common sites are the earlobe, the breastbone and the neck.
- Scar contracture: a scar that pulls a joint into a fixed position. On the hand this is the form with the greatest consequences.
For overgrown scars there are medical procedures beyond occupational therapy: injections, cold treatment, laser, and in certain cases surgery. What comes into question is decided by your doctor. The guideline advises having scar contractures over joints assessed surgically without delay.
Have a scar assessed if it grows thicker rather than flatter over months, if it grows sideways into healthy skin, if it itches or hurts permanently, or if a finger straightens progressively less well. The earlier a contracture is noticed, the more likely therapy and a splint will be enough.
What helps when the scar feels every touch?
Desensitisation is a graded programme for oversensitive skin. The scar is touched briefly several times a day with a material that is just about comfortable, then with a rougher one. The aim is that a shirt and a handshake become bearable again and the hand is used in everyday life.
An oversensitive scar arises when fine skin nerves grow into the scar tissue or were caught in the injury. The brain then reads harmless touch as threatening. Sparing the hand because of it can make the problem worse.
- Sort materials from soft to rough: cotton wool, cotton, towelling, wool, hook-and-loop tape, rice, lentils.
- Start with the material that is just about bearable and touch the scar with it for two to three minutes.
- Repeat briefly several times a day rather than once at length.
- Move to the next rougher material only when the current one no longer triggers a flinch.
- The same approach also serves as general sensory training, for instance after a nerve injury or when feeling in the fingertips stays imprecise after an operation.
- Use what you can in daily life, for example when drying off or doing up buttons.
This takes weeks, not days, and it comes in waves. After a demanding day the scar is more sensitive again without anything having gone wrong. If the oversensitivity stays unchanged after months, it belongs in a medical assessment: a nerve knot can lie behind it.
If numbness across the area of a whole nerve comes with it, the scar may not be the whole explanation; the article on carpal tunnel syndrome describes the difference. If you have a prescription, ask through the booking page. In Thalwil and the neighbouring communes treatment at home is possible as well, if the prescription provides for it.