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A multidisciplinary approach to scars: a narrative

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Journal of Multidisciplinary Healthcare
12 August 2015
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Emiliano Zanier 1,2 Abstract: The purpose of this article is to carry out a narrative review regarding the approach
Bruno Bordoni 1,3 to scars through complementary and alternative medicine focusing on osteopathy, naturopathy,
and other minor methods and traditional rehabilitative medicines, such as physiotherapy and
1
AITOP (Accademia Italiana Terapia
Osteopatica Posturale), Castelvetro manual therapies. We analyzed the existing literature regarding the possible influences of tech-
(MO), Italy; 2EdiAcademy, Milan, Italy; niques relaxing the diaphragm – both manual and psychophysical relaxing techniques – and the
3
Department of Cardiology, Santa
Maria Nascente Institute IRCCS, Don consequent local response to events leading to scar tissue healing. The objective of the study
Carlo Gnocchi Foundation, Milan, Italy is to become a useful instrument of knowledge for those manual therapists and professionals
who deal with patients affected by discontinuity of the skin surface due to trauma or surgery.
This article also intends to stimulate research in order to find and propose new methods of scar
treatment, taking into consideration the information gained so far from other complementary
and alternative disciplines.
Keywords: scar, wound, complementary and alternative medicine, osteopathy, naturopathy

Psyche and its influence on scar tissue healing:

relaxation techniques, expressive writing,
and hypnosis
There are several hypotheses regarding the alteration of the scar tissue healing
processes.1 The main types of scars related to nonphysiological healing processes are
keloids (K), hypertrophic scars (HSs), and atrophic scars.1 Currently, there are many
hypotheses, including the theory of neurogenic inflammation, explaining the altered
biochemical events that produce scars, which are considered treatable.2 According to
some authors, these assumptions could confirm the importance of the psychological
effect on scar tissue healing.3 The effects of stress on the alteration of inflammatory
parameters, through the mediation of the hypothalamic–pituitary–adrenal (HPA) axis,
are well known.2 It has already been demonstrated how restraint and social disruption
can activate the HPA system in a different manner, resulting in the increase of corti-
costerone in the plasma as a response to the proinflammatory cytokines, a phenomenon
observed in wound healing process.3 Recently, Pyter et al4 have shown how different
mechanisms related to stress (ie, physical restraint and social isolation) can equally
affect wound healing, although with different methods and timing. In an animal model,
Correspondence: Bruno Bordoni
Department of Cardiology, Santa the administration of oxytocin, a hormone linked to social contact, could positively
Maria Nascente Institute IRCCS, or negatively affect wound healing depending on the stimulus given.5 According to
Don Carlo Gnocchi Foundation,
Via Capecelatro 66, Milan, Italy
Furtado et al,6 psychological stress should be recognized as a risk factor for K recur-
Email [email protected] rence in patients who have undergone surgery in order to hinder the formation of K.

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These mechanisms of action related to oxidation are still not burns, whether it be an adult or a child.17 Motion techniques
fully explained by the existing literature. are used to reeducate patients and bring them back to self-
According to some authors, skin symptoms, such as itch- sufficiency, because very often, skin injuries result in the
ing and pain associated with scars, are associated with the loss of motor patterns acquired previously, thus preventing
presence and synthesis of neuropeptides govern the ­patterns an individual from being autonomous.17
of cutaneous reinnervation, inflammation, and wound heal- Literature is divided in the evidence that supports mas-
ing.7 This phenomenon is further corroborated by the fact sage therapy in the treatment of scars. Some studies have
that the use of the hyperbaric chamber can improve wound reported good results, such as less pain and itching, and
healing in stressed animals by increasing the level of oxygen massage therapy was found to be effective in the presence
in the wounds.8,9 Moreover, the mechanism by which the of scars and burns.18 However, some studies concerning the
relaxation strategies, which involve diaphragmatic breathing use of massage in analogous pathological circumstances have
or meditation, directly influence the oxidation mechanisms reported inconsistency in achieving effective results.19 Thus,
should be emphasized.10,11 With reference to the oxidative there are dissenting views in literature with regard to the use
stress, which is the result of tissue oxygenation, the effect of of massage and further studies are needed.
diaphragmatic activity should be analyzed from a vascular The cupping therapy, which has its origin in Chinese medi-
and lymphatic perspective as well (as described in our previ- cine, consists in creating a vacuum inside a small cup – which
ous work). This could lead to multidisciplinary integration can be made of bamboo, glass, bakelite, or plastic (always
between psychological therapy, relaxation techniques, and through suitable equipment) – lying on the skin surface of the
osteopathic therapy.12,13 scar or next to it. According to the professionals who apply
With reference to the neurocognitive approach, Koschwanez this technique, it enables the disposal of toxins and of any
et al14 have emphasized the role of expressive writing (a form potential edema and restores the lymphatic circulation, with
of therapy that uses writing to facilitate the communication consequent effects even in areas that are far from the zone of
of the posttraumatic emotional state) in increasing the rapid- application. Although there are several studies regarding the
ity of reepithelization, without any changes to perceived application of this technique, further studies are needed in
stress, depressive symptoms, health-­related behaviors, order to undoubtedly affirm its effectiveness.20 However, it is
­lipopolysaccharide-induced proinflammatory cytokine produc- important that this technique is used by experienced profes-
tion, or the number of medical visits over the study period.14 sionals, because such practices could impede the improvement
In this study, the authors have assumed that psyche may be of the scar itself.21 Among its many applications, acupuncture
involved in the wound healing process in a way that has not is also used in the treatment of scars and plays an important
been fully explained from a psychological and biological role in the correct healing process.22 The needles may be con-
point of view.14 nected to low-level voltage or various mixtures of seasonings
Hypnosis has been proven to accelerate the process of and spices can be applied to the needles.22
wound healing after surgery.15 Hypnosis has also been shown A similar therapy is dry needling or dry-needle tech-
to be useful in the management of wounds originating from nique, which uses very thin needles on an area considered
burns, as well as for painful symptoms.16 A study by Berger painful or fibrotic, without medication; the objective of the
et al showed that a protocol in pain management including technique is to loosen tissues, enabling the various layers to
hypnosis reduced patient anxiety and exposure to pain; slide over each other.23 Currently, there is very little literature
increased early opioid delivery; and decreased general anes- regarding symptomatic treatment of scars, but the results
thesia requirements, length of hospital stay, and costs.16 look promising.24
Connective tissue massage; deep transverse friction
Mechanical and manual massage, also known as Cyriax deep transverse massage
rehabilitative approaches to scars (Figure 1); shiatsu; crochetage; and diacutaneous fibrolysis
Manual medicine, physiotherapy, and osteopathy are some of are used by many professionals in the treatment of the scar
the manual rehabilitative approaches to treat scars. Although tissues. However, currently, there is no peer-reviewed litera-
most professionals commonly use these techniques, there is ture concerning the application of these techniques to skin
little peer-reviewed literature on these techniques. areas that are not intact.
Occupational therapy mainly consists in reeducating the Literature does not report the use of indirect osteopathic
patient who had suffered from skin damage due to surgery or techniques for the treatment of scars (Figure 2), although

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Dovepress A multidisciplinary approach to scars

Figure 1 Cyriax deep transverse massage. Figure 2 Indirect osteopathic techniques.

Note: DTFM, also known as Cyriax deep transverse massage, helps to limit the Notes: These techniques allow a therapist to follow a tissue in its preferential
nonphysiological evolution of scars. direction, far from the restrictive barrier of inherent motion. The therapist puts the
Abbreviation: DTFM, deep transverse friction massage. hand on the skin allowing it and the subcutaneous layers to guide the palpation.

these techniques are intended to loosen tissues, ie, to release mosqueta (R. aff. rubiginosa) would be particularly helpful in
the skin and the underlying layers. As already reported in reducing inflammation and therefore the altered cell prolifera-
various scientific studies, this results in the resetting of the tion observed in K and HS.29 On the other hand, R. mosqueta
peripheral neurological information (afferents).25 (R. aff. rubiginosa) seemed to be helpful in encouraging the
proliferation phase and the cell regeneration phase during
Naturopathic and herbal approach wound healing.29 With regard to medicinal plants used in case
to scars of burns, Bahramsoltani et al highlighted how garlic (Allium
Some plants are indicated as particularly interesting in the sativum), Aloe vera, Centella asiatica, and Hippophae rham-
herbal and naturopathic tradition. Recently, Läuchli et al have noides can improve the healing of burns.30
proposed the treatment of scars on the head with exposed Some Ayurvedic treatments are noteworthy, which are
skull bone, with a mixture of hypericum oil (Hypericum reported in various articles. The application of Madhu (honey)
perforatum L.) and neem oil (Azadirachta indica), reporting is very effective for the management of Vrana (wounds),
a reduction in the time of healing and consequently a reduc- which is considered as a potent antibacterial, anti-inflamma-
tion of medical costs.26 It must be emphasized that the authors tory, antiviral, and antioxidant element.31–33 Site of the wound,
do not compare the use of honey with a surgical procedure, shape, size, floor, and margin were recorded in the healing
which could considerably reduce the treatment times.26 This process and till the end of the healing for the progression of
mixture of hypericum oil (H. perforatum L.) and neem oil granulation, scar type, shape, size, and clinical symptoms.
(A. indica) was applied to major lesions on the diabetic foot There was significant improvement in the healing process as
as well as in the treatment of burns in children.27,28 Other honey possesses antibacterial, wound cleansing, and wound
plants such as Rosa mosqueta (Rosa aff. rubiginosa) are healing properties, and it showed beneficiary effects. 31
recommended for topical use in the treatment of scars.29 R. According to Al-Waili et  al, wound healing properties

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Zanier and Bordoni Dovepress

of honey include stimulation of tissue growth, enhanced 2. Akaishi S, Ogawa R, Hyakusoku H. Keloid and hypertrophic
scar: neurogenic inflammation hypotheses. Med Hypotheses.
epithelialization, and minimized scar formation. 32 These 2007;1(1):32–38.
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content, osmotic effect, nutritional and antioxidant contents, of stress and wound healing. Wound J Surg. 2004;28(3):327–330.
4. Pyter LM, Yang L, McKenzie C, et  al. Contrasting mechanism by
stimulation of immunity, and unidentified compounds.32 which social isolation and restraint impair healing in male mice. Stress.
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5. Detillion CE, Craft TK, Glasper ER, Prendergast BJ, DeVries AC.
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­Ferreira LM. Psychological stress as a risk factor for postoperative keloid
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The authors would like to thank Philippe Caiazzo, the founder 21. Birol A, Erkek E, Kurtipek GS, Kocak M. Keloid secondary to therapeu-
tic cupping: an unusual complication. J Eur Acad Dermatol Venereol.
of AITOP (Accademia Italiana Terapia Osteopatica Posturale) 2005;19(4):507.
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The authors report no other conflicts of interest in this work. 25. Valouchová P, Lewit K. Surface electromyography of abdominal and
back muscles in patients with active scars. J Bodyw Mov Ther. 2009;
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