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Assessment and Treatment of Scars

Special Reports

by Kayvan Shokrollahi BSc MB ChB MSc MRCS(Eng) FRCS(Plast) LLM Kayvan is a Consultant Burns and Plastic Surgeon, Chairman of the Katie Piper Foundation, and Associate Editor of the international medical journal Annals of Plastic Surgery.

He was awarded the Hunterian Professorship of the Royal College of Surgeons in 2007 and wrote his Master of Law thesis on the subject of consent. He has written a number of textbooks, most recently the Oxford Specialist Handbook of Burns due for publication in 2015, and wrote the medico-legal chapter in the Oxford Handbook of Postoperative Complications.

What is a scar?
Believe it or not, the simplest of questions on this subject, namely 'what is a scar?', is not as easy as one might imagine to answer. It is as important to be
cognisant of any lay definitions as well as any nuances of medical terminology. A variety of dictionaries define scarring variably as:

- 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 (Websters dictionary)

- 1. A mark left on the skin after a surface injury or wound has healed (www.thefreedictionary.com)
  2. A lingering sign of damage or injury, either mental or physical. (www.thefreedictionary.com)

- Any mark left on the skin or other tissue following the healing of a wound (www.collinsdictionary.com)

- A mark left on part of the body after an injury, such as a cut, has healed. (dictionary.cambridge.org)

- Any blemish remaining as a trace of or resulting from injury or use (dictionary.reference.com)

- A lasting effect of grief, fear, or other emotion left on a person’s character by an unpleasant experience. (www.oxforddictionaries.com)

Whilst scars are generally thought of as permanent, if we look at both these definitions above as well as objective measurements and scores of scarring, these can attribute the term 'scar' to skin changes such as redness or pigmentation that may resolve (for example if there is a score greater than zero in an objective scar assessment scale). There are numerous such scar assessment tools, but the most common ones include the Vancouver Scar Scale and POSAS: Patient and Observer Scar Scale.

Assessment of Scars
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 range from spectrometry and ultrasound, to profilometry and cutometry.

Functional problems should be noted, including contractures, range of movement and symptoms such as pain or itching. The examination should also have in mind implications for prognosis and for treatments, ranging from topical treatments and massage, sunscreen, and cosmetic camouflage to very specialist areas such as lasers or reconstructive surgery.

Common Types of scars
Mature scars - generally pale, flat, narrow

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.

Pigmented scars - these can be hypopigmented (lighter) or hyperpigmented (darker)than surrounding skin.

Special and specific types of scars: e.g. acne scarring

Common Treatment options
- Sun avoidance and sunscreen with SPF factor 30+

- Massage

- Corticosteroid injections (hypertrophic/keloid
scars)

- Topical treatments 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 (lumpiness)

- Topical and medical treatments for itch

- Pressure garments and topical silicone for hypertrophic or keloid scars

- Prosthetics - for camouflage or to treat keloid and
hypertrophic scars

- Fat transfer

Complex or burns scars are best assessed and treated with input from a plastic surgeon on the specialist register of the GMC.

Psychology of scarring
Psychological aspects of scarring should not be underestimated, even for minor scars. There is a firm body of opinion that the psychological impact of scarring is not directly proportional to the size or severity of the scarring.

Help and support with scars
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 well being'. They provide national education to healthcare professionals in scar management, and access for patients to the latest treatments and rehabilitation as well as additional support ranging from specialist cosmetic camouflage, psychology, peer support to hair transplantation. Most importantly they can be a trusted source to help patients navigate the system 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.

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