by Professor Kayvan Shokrollahi, BSc MB ChB MSc MRCS(Eng) FRCS(Plast) LLM - firstname.lastname@example.org
What is a scar?
Believe it or not, this most fundamental question is not that easy to answer. A variety of dictionaries define scars variably:
- Websters Dictionary: Middle English escare, scar, from Middle French escare scab, from Late Latin eschara, from Greek, hearth, brazier, scab. First Known Use: 14th century, A mark left (as in the skin) by the healing of injured tissue
1. A mark left on the skin after a surface injury or wound has healed
2. A lingering sign of damage or injury, either mental or physical
- Collins Dictionary: Any mark left on the skin or other tissue following the healing of a wound
- dictionary.cambridge.org: A mark left on part of the body after an injury, such as a cut, has healed
- dictionary.reference.com: Any blemish remaining as a trace of or resulting from injury or use
- A lasting effect of grief, fear, or other emotion left on a person’s character by an unpleasant experience (www.oxforddictionaries.com)
Whilst some may understand the word to mean a permanent mark, others may feel permanency is not prerequisite to the definition and differentiate scars by resence or absence of the descriptor ‘permanent’. Some would argue that a clinical or scientific definition of a scar would usually allude to a permanent mark, but this probably is not the case from a practical or legal point of view, necessitating the expert assessor to comment specifically on permanency or otherwise.
How is a scar formed?
A scar is formed as part of the normal process of repair after injury to the skin, and is characterised by the deposition of Collagen which contracts and strengthens the wound replacing the normal cellular anatomy of the tissues permanently. The initial healing phase then becomes a period of maturation over approximately 18 months whereby a scar usually improves in colour, texture and vascularity. Very superficial injuries to the skin which affect the superficial
part of the skin only (epidermis) can heal by regeneration (rather than repair) without permanent scarring, usually accompanied by temporary redness.
Nevertheless, superficial injuries can still result in scarring either due to pigmentation or another pathological process including keloid scars. The only other type of scar-less healing occurs in the foetus, and which is an active area of research.
The deeper an injury encroaches into the dermis of the skin, the more likely scars will form. This is relevant in terms of depth of burns and resultant risk of scarring. Similarly, scars can be avoided or minimised in the treatment of some skin lesions by use of precision lasers which limit dermal injury compared with surgery.
In the absence of specific complications such as an infection, the time to healing of a wound and the initial acute management are the most important factors to minimise scarring and maximise the outcome. Hence, meticulous direct closure of traumatic or surgical wounds will allow rapid healing with reduced scarring ompared with a dressing with delayed wound healing (so called secondary intention healing). Wounds should be cleansed and debrided, with good approximation of the wound edges using an appropriate surgical technique and avoiding tension – the debridement and cleansing being more important than closure initially.
As previously mentioned, whilst scars are generally thought of as permanent, some skin changes such as redness or pigmentation may resolve with time or treatment. The history, anatomy and examination will be important at determining the potential either for permanent scarring or for improvement or resolution. For practical and legal purposes, any mark that was previously not present and occurred as a result of some trauma or intervention can reasonably be referred to as a scar on the basis that it will score positively and differently to unscathed skin when measured using an objective or clinical scar assessment scale or tool.
Common causes of scarring
Traumatic injuries and burns (e.g. laceration or scald, bites)
Surgery and medical interventions (e.g. elective or emergency surgery)
Medical conditions and skin disorders (e.g. skin infections and acne scars)
Tissue distortion (e.g. 'stretch marks')
Normal versus Problematic Scars
Features of a good quality, albeit permanent 'normal'
- Narrow in width
- Good colour match with surrounding skin
- Asymptomatic (lack of itching, pain, sensitivity)
- Absence of contraction
- Matured and optimum by about 18 months to 2 years
Common Types of problematic scars
Hypertrophic scars - thickened, itchy, raised but within the boundaries of the original injury
Keloids - severely thickened, itchy, and raised but growing in a tumour-like fashion beyond the boundaries of the original injury
Stretched and atrophic scars - thin and fragile skin with widening. Often pale and depressed or pitted.
Pigmented scars - these can be hypopigmented (lighter) or hyperpigmented (darker) than surrounding skin or have a mixed pattern
Mixed scars – these show a combination of a number of different morphologies
Scar contractures - where scars limit movement or distort anatomy due to shortening of the scar leading to deformity, reduced range of motion and reduced function
Stitch marks (cross-hatching) – the marks left behind from stitches used for surgical wound closure
Special and specific types of scars: e.g. burns scars, acne scarring, donor sites from skin graft harvest, scar alopecia (hair loss from burns)
Assessment of Scars
When taking a history, it is important to ask the patient about the following 3 S’s:
On clinical examination of the scar, another 7 S’s are important:
A basic assessment and description of a scar will first entail a full and detailed history with reference to the medical records and any available photographs, followed by a medical examination. Specialists may use more objective methods of description and assessment. Key features to note include the location (or percentage surface area) and orientation of the scars, the degree of redness and pigmentation, and how raised or lumpy the scars are. Objective scar assessment tools do exist and range from spectrometry and ultrasound, to profilometry and cutometry but are not in widespread use and I would question their clinical utility or validity at this time outside a research setting. A photographic record is important with a good quality camera and consistent lighting.
Functional problems should be noted, including contractures, range of movement and symptoms such as pain, itching or hypersensitivity. The examination should also have in mind implications for prognosis and treatments, ranging from topical treatments and massage, sunscreen, and cosmetic camouflage to very specialist areas such as reconstructive surgery or lasers. Anyone making treatment recommendations in this complex area should have sufficient working knowledge of alternative treatments prior to any recommendation.
Objective clinical scar assessment measures such as the Vancouver Scar Scale (VSS) which is a clinicianonly score, and others which can be clinician-andpatient
scores, can be helpful to bring as much objectivity as possible. Similarly, visual or numeric scales of pain or itch (e.g. 0-10), especially when assessing progress over time and response after intervention, can be valuable.
Subjective measures and quality of life indicators can also ber very important and bring added context.
Psychological aspects of scarring should not be underestimated, even for minor scars. There is evidence that the psychological impact of scarring is not directly proportional to the size or severity of the scarring. Small scars, even hidden ones, can have a big impact on patients, and this along with functional limitations can be captured by using quality of life measures. Loss of self-confidence can have a major impact on work, relationships and social interaction as well as overall well-being. Occasionally scars are a stimulus for psychological or psychiatric illness.
Common Treatment options
- Sun avoidance and sunscreen with SPF factor 30+
- Moisturisation with ideally non-perfumed creams
- Specialised scar-specific
- Topical Silicone (sheets, sprays)
- Pressure therapy (e.g. pressure garments, pressure clips)
- Splinting and exercise to stretch scars and restore movement
- Corticosteroid injections (hypertrophic/keloid scars)
- Alternative injectables (5-Fluorouracil, 5-FU) for resistant keloid scars
- Topical treatments and camouflage for pigmentation
- Plastic surgery: scar revision, reconstruction, Z-plasty and flaps, scar release, skin grafts and skin substitutes
- Laser treatments for pigmentation, redness, and hypertrophy
- Topical and medical treatments for itch and pain
- Camouflage and medical tattooing
- Fat transfer: there is some evidence that this improves overlying scars
- Hair restoration for hair-bearing areas with scar alopecia (destroyed hair follicles from burns) – eyebrows, beard and scalp in particular
Complex or burns scars are best assessed and treated with input from a plastic surgeon on the specialist register of the General Medical Council, and the latter from a burns specialist. Burns treatment in the UK is currently provided through specialist burns centres, burns units and burns facilities with major burns treated at the former two. Specialist assessment and treatment allows all treatment options to be explored in an appropriate and holistic context with surgical, non urgical and other specialist options all being discussed and offered, as well as input from a psychologist when required. Newer technologies and techniques such as laser treatment of scars can have dramatic results, but is highly specialised and with a definite risk profile, and can be expensive. Unfortunately, laser and some other treatments for scars are often advertised on the high street with variable results in a currently under-regulated and generally cosmetic sector, and to vulnerable patients whose expectations can be artificially elevated. The recent Montgomery Supreme Court ruling has highlighted the importance of ensuring the consent process provides adequate information regarding all treatment options with patients.
Follow-up may be needed for years, especially for injuries in children. Scars over larger body surface areas require frequent ongoing intensive rehabilitation for months and sometimes years after injury for optimum outcomes and to reduce the need for further intervention such as surgical scar release. In some countries such as France, intensive rehabilitation is routinely available on a residential basis. The Katie Piper Foundation is currently fundraising for a similar intensive residential burns and scar rehabilitation facility in the UK.
For major injuries, peer support, social integration, and help back to work are especially important.
Help and support with scars: The Katie Piper Foundation
The Katie Piper Foundation is a charity that provides a range of services to help patients with scars with a vision of: 'A world where scars do not limit a person’s
function, social inclusion or sense of wellbeing'. They provide national education to healthcare professionals in scar management, and facilitate access for patients to the latest treatments and rehabilitation as well as additional help ranging from peer support to medical tattooing, specialist cosmetic camouflage, hair replacement and transplantation, and access to laser treatments. A key part of their role is signposting patients to those who have the expertise and good utcomes in a variable and often unregulated and bewildering environment, and hence a trusted source to help patients navigate the system. This is especially important to ensure help comes from suitably experienced and qualified practitioners in an area where the complexities of medical scar management can overlap with the beauty and cosmetic industry. The Katie Piper Foundation is looking to imminently launch a residential rehabilitation centre for scars and burns.
Prof. Shokrollahi is a Consultant Burns, Plastic & Laser Surgeon, Chairman of The Katie Piper Foundation, Editor-in-Chief of the Journal Scars, Burns & Healing, and Associate Editor of Annals of Plastic Surgery. He was awarded the Hunterian Professorship of the Royal College of Surgeons in 2007 and graduated with a Master of Law degree in 2005.
He has written a number of textbooks, including the imminent publication of both the Oxford Specialist Handbook: Burns, the International Flap Manual: A Practical Guide to Reconstructive Surgery, and is currently writing the textbook Laser Management of Scars.