We read with great interest the review article titled “Management of keloid scars:
noninvasive and invasive treatments.”[1] The author presents a comprehensive review of the available literature on the current
management options of keloid scars and the potential therapies that hold promise for
the future. The proposed treatment algorithm of the practical guidelines for scar
management is especially clinically useful and can hopefully encourage the adoption
of a standardized management strategy for keloids around the world.
We would, however, like to expand on the point touched upon by the author regarding
the psychological burden caused by keloids and other forms of abnormal scarring, and
highlight the need for a greater incorporation of psychosocial therapy into the management
of keloids. As the author points out, keloid scars are not only a type of physical
and aesthetic impairment but also have psychological and social sequelae, which can
further impair patients' quality of life.[2] No further mention is given in the review to the management of these psychological
factors however. Scarring has been shown to be associated with the development of
depression and anxiety; feelings of shame and worthlessness. This creates strain in
social interactions, resulting in stunted communication, reduced intimacy, and avoidant
behaviors.[2] Despite the clear associations demonstrated between scarring and its impact on mental
health, there is currently comparatively little emphasis placed on the management
of the psychological aspects of scars versus the physical aspects. This deficiency
is likely multifactorial and may be attributed to the lack of awareness and training
of plastic surgeons and the wider multidisciplinary team in the recognition and management
of psychosocial issues associated with scarring.[2] The positive effects of psychological therapy in helping patients overcome the negative
psychological effects of visible scarring are well documented. Cognitive behavior
therapy (CBT) is effective in supporting patients to come to terms with the visible
difference, aids in decision making, and shows to be effective in overcoming social
anxiety.[3] Additionally, the administration of structured programs incorporating CBT, social
interaction training, and anxiety management for patients suffering from visible scars
have demonstrated significant improvements in multiple domains of mental health, including
general anxiety, depression, satisfaction with life, social anxiety, and appearance-related
anxiety.[4] Specifically designed questionnaires assessing the quality of life of patients with
keloid scarring can help in the early identification of patients who are more at risk
of negative psychological impact; therefore, they aid in the subsequent triage and
management of these patients.[5] As a result, the future holistic management of scarring must encompass a multidisciplinary
approach that considers both its physical and psychological effects.
