Each year in the developed world 100 million patients acquire scars, some of which cause considerable problems, as a result of 55 million elective operations and 25 million operations after trauma. There are an estimated 11 million keloid scars and four million burn scars, 70% of which occur in children. Global figures are unknown but doubtless much higher. People with abnormal skin scarring may face physical, aesthetic, psychological, and social consequences that may be associated with substantial emotional and financial costs. This article reviews the spectrum of abnormal scar types, a range of problems associated with scarring, and provides advice on assessment, treatment, and new therapeutic developments.
Method
This article is based on our scientific and clinical experiences in dermal scarring and on selected articles in recent issues of journals on plastic and reconstructive surgery, dermatology, and wound healing. Key terms included keloid disease, hypertrophic scars, and contractures, plus diagnosis, prevention, and treatment.
Why do we scar?
Scars are the end point of the normal continuum of mammalian tissue repair. The ideal end point would be total regeneration, with the new tissue having the same structural, aesthetic, and functional attributes as the original uninjured skin. Scarless skin healing occurs in early mammalian embryos, and complete regeneration occurs in lower vertebrates, such as salamanders, and invertebrates.
What, if any, are the advantages of scarring, and why do we scar? We hypothesise that wound healing is evolutionarily optimised for speed of healing under dirty conditions, where a multiply redundant, compensating, rapid inflammatory response with overlapping cytokine and inflammatory cascades allows the wound to heal quickly to prevent infection and future wound breakdown. A scar may therefore be the price we pay for evolutionary survival after wounding.
Skin scarring: the clinical problem
Scars arise after almost every dermal injury— rare exceptions include tattoos, superficial scratches, and hopefully venepunctures. Scars are often considered trivial, but they can be disfiguring and aesthetically unpleasant and cause severe itching, tenderness, pain, sleep disturbance, anxiety, depression, and disruption of daily activities. Other psychosocial sequelae include development of post-traumatic stress reactions, loss of self esteem, and stigmatisation, leading to diminished quality of life. Physical deformity as a result of skin scar contractures can be disabling. Many scars take two to three years to pale and mature.
In spite of media suggestions to the contrary, scars cannot yet be made to disappear. Many patients arrive at plastic surgery clinics with unrealistic expectations. Clinical judgment is required when considering treatment, balancing the potential benefits of the various treatments available against the likelihood of a poor response and possible iatrogenic complications. The evidence base for the use of many current treatments is poor, and some may have only placebo benefit.
There is considerable quantitative and qualitative variation in scarring potential between individuals and even within the same individual: scars are normally worst in the deltoid and sternal regions and best in intraoral tissues, reflecting biological and mechanical differences between such sites. Injury in adolescents and young adults normally results in worse scarring than does similar injury in elderly people, reflecting the altered inflammatory and cytokine profile of old wounds, which in many respects resemble those of the early embryo. Individuals with pigmented skin are more prone to severe skin scarring than white people.
Responses
5 June 2003: Preventation of scarring
Retired Registered Nurse
The following method reduces the incidence of unsightly scarring, especially on the face.
I have had numerous skin cancers removed from my face by curretting, liquid nitrogen and plastic surgery. My skin is prone to scarring even from mosquito bites or minor abrasions. This method has left me with little or no scarring on my face.
1. Clean the wound gently with witch hazel; never use soap or alcohol. Soap is alkaline and destroys the natural acid mantle of the skin. Alcohol toughens the skin. Use a facial tissue, clean cotton cloth or gauze; avoid anything with the potential to leave lint in the wound. Blot, don't wipe.
2. Apply Polysporin or Bacitracin ointment to the pad of a bandaid before applying to affected area. Once daily treatment is sufficient as long as there is no sign of infection.
3. As soon as the raw wound has filled in with normal skin tissue, apply Vitamin E 400 IU to the area once or twice a day and cover with a bandaid to avoid accidental scratching. Use a sterilized, glass-headed pin to poke a hole in the Vitamin E capsule, squeeze a little Vitamin E on the wound and replace the pin in the hole in the capsule.
I have had numerous skin cancers removed from my face by curretting, liquid nitrogen and plastic surgery. My skin is prone to scarring even from mosquito bites or minor abrasions. This method has left me with little or no scarring on my face.
1. Clean the wound gently with witch hazel; never use soap or alcohol. Soap is alkaline and destroys the natural acid mantle of the skin. Alcohol toughens the skin. Use a facial tissue, clean cotton cloth or gauze; avoid anything with the potential to leave lint in the wound. Blot, don't wipe.
2. Apply Polysporin or Bacitracin ointment to the pad of a bandaid before applying to affected area. Once daily treatment is sufficient as long as there is no sign of infection.
3. As soon as the raw wound has filled in with normal skin tissue, apply Vitamin E 400 IU to the area once or twice a day and cover with a bandaid to avoid accidental scratching. Use a sterilized, glass-headed pin to poke a hole in the Vitamin E capsule, squeeze a little Vitamin E on the wound and replace the pin in the hole in the capsule.
Surgeon
The excellent review by Bayat et al has once again highlighted the many variables which can affect the severity of scarring, including the size, depth, and location of the wound, the blood supply to the area, the thickness and colour of the skin, and the direction of the scar.
Recently, there are several reports in the literature to suggest that immediate injection of botulinum toxin into the muscles underlying a wound can improve the cosmetic outcome of cutaneous scar. This is because one of the major factors in determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. By injecting through the skin into the underlying muscle, botulinum toxin paralyzes the muscles and relieves the tension. As a result of the chemo-denervation, more aesthetic scar can thus be achieved. Using primate models, Gassner et al. at the Mayo Clinic has shown that surgical wounds that had been immobilized with botulinum toxin were rated as significantly better in appearance than the control wounds.
This adds to the list of wide variety of clinical applications of botulinum toxin, and may be our next weapon in combating facial scarring.
References
1. Bayat A, McGrouther DA, Ferguson MWJ. Skin scarring. BMJ 2003; 326: 88-92 ( 11 January ).
2. Sherris DA, Gassner HG. Botulinum toxin to minimize facial scarring. Facial Plast Surg 2002; 18: 35-39.
3. Wieder JM, Moy RL. Understanding botulinum toxin. Surgical anatomy of the frown, forehead, and periocular region. Dermatol Surg 1998; 24: 1172-1174.
4. Gassner HG, Sherris DA, Otley CC. Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates. Plast Reconstr Surg 2000; 105: 1948-1953; discussion 1954-1955.
Recently, there are several reports in the literature to suggest that immediate injection of botulinum toxin into the muscles underlying a wound can improve the cosmetic outcome of cutaneous scar. This is because one of the major factors in determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. By injecting through the skin into the underlying muscle, botulinum toxin paralyzes the muscles and relieves the tension. As a result of the chemo-denervation, more aesthetic scar can thus be achieved. Using primate models, Gassner et al. at the Mayo Clinic has shown that surgical wounds that had been immobilized with botulinum toxin were rated as significantly better in appearance than the control wounds.
This adds to the list of wide variety of clinical applications of botulinum toxin, and may be our next weapon in combating facial scarring.
References
1. Bayat A, McGrouther DA, Ferguson MWJ. Skin scarring. BMJ 2003; 326: 88-92 ( 11 January ).
2. Sherris DA, Gassner HG. Botulinum toxin to minimize facial scarring. Facial Plast Surg 2002; 18: 35-39.
3. Wieder JM, Moy RL. Understanding botulinum toxin. Surgical anatomy of the frown, forehead, and periocular region. Dermatol Surg 1998; 24: 1172-1174.
4. Gassner HG, Sherris DA, Otley CC. Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates. Plast Reconstr Surg 2000; 105: 1948-1953; discussion 1954-1955.
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