Toddler Scars: A Parent’s Guide to Childhood Scarring

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Although we try to keep them out of harm’s way, children are active little beings, and it’s likely that most will end up with a scar or two – some being more serious than others. Dr Debbie Norval shares her insights to help parents understand when to intervene with a scar and when to let it naturally fade away. 

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The healing process in children depends on their age and affects childhood scarring. Babies under six months tend to heal rapidly with subtle scars because of their still immature inflammatory response. Between six months and two years, scar healing becomes less predictable: it’s often discreet but can also be highly inflammatory.

After this – from age two into the teenage years – the inflammatory response is strong, so the resulting scar is rich in collagen and very dense. Scars can occur very quickly in this age group and there is a greater risk of abnormal or pathological scarring.

Challenges with paediatric scars

Children grow with their scars, which tend to stretch, thicken, or become more noticeable as the child grows. 

If scars are fibrous and dense, they may develop contractures because the scar doesn’t grow as much as the child. A contracture occurs when the skin and underlying tissues tighten and contract, restricting movement and functionality, as well as potentially causing pain and discomfort. 

Scars over joints or in areas of high movement can limit function and mobility, impacting developmental milestones.

Another challenge for children is that they struggle to stick to strict scar treatment regimes. Wearing pressure garments or special plasters and applying regular topical treatments can be tricky in younger kids. 

On the mental side, pain and fear are often entangled with scars. Fear and anxiety surrounding scars can make treatment very challenging. 

The psychological impact of scars also evolves over time, through childhood and the teenage years. What might be unnoticed as a toddler becomes distressing to a teen. Visible scars have the potential to affect a child’s self-esteem and body image, especially during adolescence. 

Therefore, children with scars should be followed all through their growth period to detect the need for scar revision, whether for functional purposes or aesthetic and psychological reasons. 

What is an acceptable scar?

A scar is the normal result of the healing process. The ideal scar is thin, flat, skin-coloured, supple, elastic, and painless. Scars can never go away completely but can get to a point where they are barely visible. Pathological scars, however, result from dysregulation of the healing process and prolonged inflammation. This results in lumpy hypertrophic or keloid scars.

When to treat a scar

Not all paediatric scars require active management, but many do – especially if there is a risk of hypertrophic or keloid scarring, functional impairment, or potential psychological impact. 

The decision to actively manage a scar hinges on various factors, particularly its size and location. Scars in visible or mobile areas – like the face, neck, elbows, knees, and hands – often require intervention for both cosmetic improvement and functional preservation. This is especially crucial for scars that hinder movement or function around joints, to ensure proper development and prevent contractures.

The type of scar-causing injury is important, as certain types of injuries such as burns or surgical incisions frequently result in more significant scarring. Children with a history of hypertrophic or keloid scars, or those with a family history of abnormal scarring, may need proactive management. 

Lastly, there are potential cosmetic and psychological concerns. Visible scars can affect a child’s self-esteem, with self-conscious behaviour affecting social interactions.

First aid to minimise scarring

Taking a proactive approach to wound care helps to reduce the chance of scarring. Begin by gently cleansing the wound with mild soap and water (or disinfectant), removing any dirt or debris. Do this without scrubbing to avoid further tissue damage. 

Applying antibiotic ointment helps prevent infection and promotes healing. Cover the wound with a sterile bandage or dressing to shield it from additional injury. To avoid scarring, closed, moist healing is preferable to open, dry healing.

Encourage the child to avoid picking, scratching, or rubbing the wound to prevent delays in healing. If necessary, keep the area covered with a bandage to prevent irritation. 

Minimise sun exposure and protect the healing wound by covering it with clothing or applying a broad-spectrum sunscreen with SPF 50 or higher. Sun can cause hyperpigmentation and worsen a scar’s appearance.

Once the wound is healed, maintain moisture by applying a gentle, hypo-allergenic moisturiser to keep the skin hydrated to promote optimal healing.

How to know if your child needs stitches 

Deciding whether a child needs stitches depends on factors like the size, depth, location, and cause of the injury. 

Larger, deeper, or gaping wounds – especially those over 1.3 cm long – often require stitches for proper healing. 

If the wound extends beyond the skin’s superficial layers, and you can see deeper tissues like fat, muscle or bone, stitches are necessary to approximate the layers. 

Areas prone to movement, like joints or those under tension (such as the hands and feet), may need stitches to prevent delayed healing or reopening. 

Persistent bleeding in a wound, despite applying pressure for 10 to 15 minutes, may need stitches to control bleeding. 

Dirty, contaminated wounds or those at risk of infection might need stitches to reduce complications. Dog bites always warrant medical attention, including antibiotics and a tetanus jab, but are regularly left unsutured. 

Jagged or irregular wound edges are more likely to require stitches compared to clean, straight cuts. 

What about steri-strips and tissue glue?

Certain wounds are better managed with adhesive steri-strips or tissue glue, also known as surgical glue. This is especially useful in children, as sutures involve a painful local anaesthetic injection. These alternatives are far less traumatic, with easier application and removal. 

Steri-strips and tissue glue are ideal for small, shallow lacerations with clean straight edges, where the edges of the wound can easily be approximated. They work well in areas where there is minimal tension, movement, or stress on the wound. Sutures can contribute to scar formation; in areas of cosmetic importance – like the face – steri-strips often give a better result. Steri-strips are ideal for finger lacerations. 

Tissue glue, particularly medical-grade cyanoacrylate adhesives, can sometimes cause a mild stinging sensation when applied. This stinging is usually brief and not severe.

Tissue glue is designed to naturally slough off as the wound heals. Typically, it will peel away on its own within 5 to 10 days after application. The adhesive typically falls off as the underlying skin heals and regenerates.

At-home simple scar management

Scar management in children should ideally start a few weeks after the injury or surgery – but only once the wound has fully closed to avoid infection. 

Massage therapy:

Begin by gently massaging the scar tissue daily with any massage cream or oil. Regular massaging of scar tissue improves blood circulation, helping to remove waste and supply nutrients for healing. Massage breaks down scar tissue, increases the softness and pliability of the scar, releases tension, and improves mobility. A physiotherapist will be able to assist with massage and teach parents what to do at home. 

Silicone:

Consider using silicone plasters, sheets, sprays, or gel to minimise scar formation. Silicone restores the water barrier function and hydrates the scar, helping to modulate collagen production, reducing scar thickness and redness. 

ScarScience® is a silicone-based scar gel developed by renowned South Africa-born plastic surgeon Professor Alan Widgerow. Applied to flesh-coloured micropore tape, ScarScience is soft and nearly invisible, which is useful for kids. It doesn’t have to be changed daily, but only when it gets a bit tatty. The tape not only acts as a carrier medium for the slow release of the ScarScience, but it also assists in flattening the scar and approximating the edges. 

Interestingly, the gut microbiome influences the skin microbiome, which impacts healing. Fungi, demodex, viruses, and bacteria all affect scarring. Newer topical treatments for scars such as Biomerenew® Postbiotic Scar Treatment work on the microbiome of the scar. 

Deciding on active scar management in a child

Before initiating more active scar management, it is advisable to have your child evaluated by a professional such as a paediatrician, dermatologist, aesthetic doctor, or plastic surgeon.

The doctor will assess the scar, determine its characteristics, and recommend appropriate scar management strategies based on the child’s age, skin type, and the type of injury. In cases where the child is at high risk of abnormal scarring, such as hypertrophic or keloid scars, consider starting scar management even earlier. 

Active medical management of paediatric scars

If a scar requires more active management, the following options are available:

Pressure therapy:

Pressure garments or dressings are applied over the scar to exert continuous pressure, which helps flatten and soften the scar tissue. These are particularly useful for hypertrophic scars and burns. Occupational therapists and physiotherapists with experience in scar management will recommend and oversee pressure therapy, providing tailored advice and support based on the specific needs of the child.

Kinesio-taping:

Reducing tension on a scar is critical. The tape helps lift and support the skin surrounding the wound, reducing skin tension directly over it. By lifting the skin, the tape helps improve blood and lymph circulation to the wound area, promoting healing. 

Injections:

In cases of hypertrophic or keloid scarring, corticosteroid or other therapeutic injections may be administered directly into the scar tissue to reduce inflammation, itching, and scar size. Multiple injections may be required over time. This can be traumatic in children, and the use of a mesogun is a gentler option. 

Laser treatments:

Among others, pulsed dye laser or fractional laser targets blood vessels, pigment, and scar tissue to improve the appearance and texture of scars. Laser therapy is particularly effective for red or raised scars. However, lasers can be painful and traumatic for young children and several sessions are required. 

Tixel® with transdermal drug delivery:

Tixel® uses thermal energy to facilitate transdermal drug delivery into a scar without the need for needles or lasers. The thermal energy delivered by Tixel® helps remodel scar tissue, improve scar texture and appearance, and promote collagen synthesis, leading to smoother, more even skin. Tixel® treatments are generally well tolerated after the application of local anaesthetic cream, with minimal downtime and discomfort, meaning they are better suited for children. 

Microneedling with DermaPen®:

DermaPen® has a dedicated scar setting that is excellent for the management of scars. The application of numbing cream before needling makes it a tolerable experience, even in children. 

Regenerative therapies:

Exosomes and human growth factors derived from stem cells are exciting new treatments for scars. They don’t have to be injected, but are applied topically to infuse into the scar after microneedling or fractional ablative therapy such as Tixel®. 

Botulinum toxin:

Botulinum toxin is not just for wrinkles. It has several medical uses and can be injected directly into the surrounding muscles or skin near the scar to reduce tension and minimise the pulling forces on the scar. This versatile neurotoxin also helps alleviate pain and itching associated with hypertrophic scars and keloids by blocking the release of neurotransmitters involved in pain transmission and sensory perception. It can be injected or infused after DermaPen® microneedling, Tixel®, or fractional ablative lasers. 

Surgical revision:

In cases of unacceptably severe scarring that affects function or aesthetics, surgical revision may be the best option. A plastic and reconstructive surgeon will cut out the original scar tissue and reconstruct the area to achieve a better outcome. It’s important to know that the revision scar will always be larger than the original scar but will be much neater. 

The emotional effects of scars 

Scarring in children can profoundly impact their emotional well-being and social interactions. Visible scars may trigger feelings of self-consciousness and lead to decreased self-esteem and social withdrawal. 

Children may fear judgement or teasing from peers, potentially resulting in social anxiety and isolation. Bullying or teasing due to scars can cause lasting emotional distress, contributing to depression and anxiety. 

Emotional distress related to scarring can manifest in various behavioural changes, such as aggression, withdrawal, or difficulty concentrating in school. 

Scars may become a focal point in a child’s self-concept, influencing their overall sense of identity and self-worth. Traumatic experiences that caused the scars can further exacerbate emotional challenges, leading to lingering fears and anxieties.

To support children coping with the emotional effects of scarring, professional counselling or therapy offers coping strategies and emotional support, fostering a positive self-image. 

Joining support groups with similar experiences reduces feelings of isolation, while focusing on strengths and achievements rather than appearance builds self-esteem and confidence. By addressing both the physical and emotional aspects of scarring, caregivers and healthcare professionals can help children develop a healthy, positive outlook despite their scars.

What NOT to do when your child is emotionally distressed by a scar 

Parents always have the best intentions for their kids, but sometimes, we get things wrong! None of us is perfect, and it’s important to avoid these pitfalls:

• Never downplay or dismiss your child’s feelings. Comments like, “It’s not a big deal,” or, “You’ll get over it,” or, “Don’t worry, it’ll heal,” can make your child feel unheard.
• But don’t over-emphasise the scar, either. Avoid placing too much focus on the scar’s appearance. Instead, highlight your child’s strengths and other aspects of their identity.
• Consider your words carefully. Don’t use negative or derogatory language about the scar or your child’s appearance, as this can harm their self-esteem. Don’t compare your child’s scar/s to others’ scars or their appearance before the injury. Each child’s experience is unique.
• Never pressure the child to explain or justify their scar. Allow them to share their story at their own pace. Respect boundaries and don’t pressure your child to expose their scar if they are uncomfortable. Support them without pressure.
• People, especially children, are curious and bound to ask about the scar. Help your child memorise a simple, short answer to questions such as these. 
• Be aware of your own feelings and don’t project your anxiety onto your child. Children tend to internalise their parents’ fears about many things, which may include their scars.

A story of courage 

A scar can also positively impact a child, serving as a “badge of honour”, symbolising bravery and resilience. It represents a challenging experience they have overcome – like surgery, an accident, or a medical treatment – showcasing their courage and strength. 

When children feel empowered to share their scar story, it can boost their confidence and self-esteem, turning a potential insecurity into a source of pride.

Embracing a scar helps develop resilience, teaching children to cope with difficult situations and build emotional strength. Overcoming the physical and emotional challenges of a scar fosters personal growth and a sense of pride in handling adversity.

Parents, caregivers, and teachers can help reframe the scar positively, emphasising it as a symbol of bravery and a unique part of their life story. This positive reinforcement shapes a child’s self-perception. A scar contributes to a child’s unique identity, and they can be encouraged to see it as a distinctive feature that sets them apart positively.

Having a scar can also increase a child’s empathy and understanding toward others with visible differences, fostering kindness and inclusivity.

Conclusion

Not all paediatric scars require intervention, but each scar warrants a careful, individualised assessment. Key considerations include the scar’s location, severity, and risk of abnormal healing, as well as its potential impact on function and appearance. Fortunately, there is much that parents can do to minimise the risk of scarring.

That said, if your child is badly scarred, it’s important to consult a healthcare professional to ensure that they receive the most appropriate and effective treatment tailored to their unique needs.

An important message about acne scars in older children

Many incorrectly assume that only severe acne results in scarring; however, recent research indicates that the worst scarring from acne occurs from erythematous macules, which commonly occur after acne lesions. These are the flat red marks left on the skin after a breakout. The redness indicates inflammation, and it is this inflammation that results in scarring. So, even though your teenage daughter might be excellent at using make-up to cover up these flat red marks, they are a warning sign.

Treatments such as DermaPen® microneedling are exceptional therapies, treating both active lesions and scarring. The use of topical 0.3% adaptalene, a new-generation retinol, has also been shown to reduce acne scarring effectively.