Why do we Scar?

Summary: Scars can appear after almost every dermal injury. While for some people they are something unimportant, some others can end with severe scarring, deformations and even functional alterations.

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Scars are the end point of the normal process of mammalian tissue repair. The ideal resolution would be total healing, with the new tissues 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 smaller vertebrates, such as salamanders, and some invertebrates (spineless creatures).

What, if any, are the benefits of scarring, and why do we scar?

A plausible hypothesis is that wound healing is evolutionarily optimized for speed of healing under septic conditions, where a multiple and redundant, compensating and rapid inflammatory response with overlapping cytokine and inflammatory cascades allows the skin to heal quickly to prevent infection and future wound complications. A scar may therefore be the price we pay for evolutionary survival after wounding.

Skin scarring: the clinical problem

Scars can be seen after almost every dermal damage-rare exceptions include tattoos, superficial scratches, and punctures of veins to take blood samples. Scars are often considered unimportant, but they can be disfiguring and aesthetically unpleasant and cause severe itching, tenderness, pain, sleep disturbance, anxiety, depression, and disruption of daily tasks. Other psychosocial sequelae include development of posttraumatic stress reactions, loss of self esteem, and stigmatization, resulting in diminished quality of life. Physical deformity as a result of scar contractures can be invalidating. Many scars take several years to pale and mature.

In spite of media suggestions to the contrary, scars cannot yet be made to vanish. Many people arrive at plastic surgery clinics with unrealistic expectations. Medical judgment is required when considering the right treatment, balancing the potential benefits of the various treatments available against the likelihood of a poor improvement and possible infectious complications.

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 are similar to those of the early embryo. People with pigmented skin are more prone to greater skin scarring than white people.

Scarring can bring several physical and psychological problems. To know the different types of scars is important to find an effective treatment.

Recent Research about Scarring Causes

Inflamatory response and scar formation

Stramer BM, Mori R, Martin P.
Department of Physiology, School of Medical Sciences, University of Bristol, Bristol, UK.

Skin wounds healing is a complex process involving many cell lineages. In adult tissues, repair is always accompanied by a robust inflammatory response, which is necessary to counter the potential for infection at any site where the skin barrier is breached. Unlike embryonic tissues that can repair perfectly without a remnant scar at the wound site, adult tissue repair always leads to formation of a fibrotic scar where the wound has healed. In recent years, it has become clear that the wound inflammatory response may be, at least in part, responsible for fibrosis at sites of tissue repair. In this review, we consider the beneficial vs the detrimental functions of inflammatory cells during the repair response and compare data from other tissues, the lung, and liver, where fibrosis and its resolution may be related to a damage-triggered inflammatory response.

We also consider how it may be possible to molecularly disentangle the potentially good from the bad influences of inflammatory cells during tissue repair and how fundamental studies in inflammatory cell biology may prove the way forward for development of drug targets in this respect.