Scar Classification

Summary: There are several causes for scarring, and specific complications will determine the outcome of the scarring process.

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The spectrum of skin scar types

Skin tissue repair processcan result in a wide spectrum of scars, ranging from a "normal" fine line to a variety of abnormal scars, including widespread scars, atrophic scars, scar contractures, hypertrophic scars, and keloid scars.

Widespread (stretched) scars appear when the fine lines of surgical scars slowly become stretched and widened, which usually happens in the 3 weeks after surgery. They are usually flat, pale, soft scarring marks often seen after knee or shoulder surgery. Stretch marks (abdominal striae) after pregnancy are another type of widespread scars in which there has been injury to the dermis and subyacent tissues but the epidermis is unbreached. There is no elevation, thickening, or nodularity in mature wide-spread scars, which makes them different from hypertrophic scars.

Atrophic scars are flat and depressed below the surrounding skin. They use to be small and often round with an indented or inverted centre, and often appearing after acne breakoutsor chickenpox.

Scar contractures -scars across joints or skin creases at right angles have a tendency to develop shortening or contracture. Scar contractures appear when the scar is not completely matured, often tend to be hypertrophic, and are typically disabling and dysfunctional (fig 4). They appear after burn injury across joints or skin concavities.

Raised skin scars

Raised skin scars are also known as hypertrophic or keloid scars.

Hypertrophic scars are raised scars that remain within the boundaries of the original wound, generally regressing by itself after the initial wound. Hypertrophic scars are often red, inflamed, itchy, and even painful. They use to appear after burn injury on the trunk and extremities.

Keloid scars are raised scars that spread beyond the margins of the original injury

Keloids scars are thick, puckered, itchy clusters of scars spreading beyond the edges of the wound or surgicalincision and invade the surrounding healthy skin in a site-specific way. They use to be red or darker than the surrounding skin. Keloids appear when the body continues to produce collagen long after the original lesion healing has been completed.

Ear lobe keloids often grow as large lobules, central sternal keloids commonly develop a butterfly shape, and deltoid keloids tend to grow vertically. A keloid keeps growing over time, does not disappear by itself, and almost invariably reappears after simple excision. It's hard to use the term keloid until a scar has been present for at least a year, although there is no precise time interval. Histologically, keloids have a swirling nodular pattern of collagen fibres.

Scars specially difficult to categorise have been named intermediate scars. However, if a raised scar is still there after a year, a true keloid is a potential diagnosis, whereas hypertrophic scars should show some signs of regression within this time. Keloids can be inflamed, itchy, and painful, especially during their growth phase. Common locations are in the ear lobe after ear piercing, the deltoid after vaccination, and the sternum after acne, chickenpox, trauma, or surgery. Keloids are unique to humans, and there may be some genetic predisposition, with dark skinned races being more vulnerable to them, though there are few large epidemiological studies. They appear predominantly in people aged 10 - 30 years, with an apparent predilection for emergence and deterioration during puberty and pregnancy.

There's not a single, predictable process of scarring. Next, learn about what treatment is the best option for each case.

Recent Research about Wounds Classification

Scarring grading system for acne lesions

Goodman GJ, Baron JA.
Skin and Cancer Foundation of Victoria, Victoria, Australia.

BACKGROUND: There is no global quantitative grading system for assessing the disease load and global severity of disease in a patient with postacne scarring.

AIMS: We intend to provide a quantitative grading system that would allow more objective communication between practitioners of a patient's global disease severity and between investigators, educators, and proceduralists of the efficacy of grade-specific operative interventions or therapies.

PATIENTS/METHODS: We describe a global scoring system that we have found clinically useful to assess disease load and severity of acne scarring and illustrate the reproducibility of this system in a small prospective study. Photographs of 21 patients were assessed independently by four observers, two of whom were physicians and the other two nurses.

RESULTS: A quantitative global acne scarring grading system is presented. No substantial difference among acne scarring scores was seen between observers, with inter-rater agreement within four score points in 19 of the 21 patient-photos assessed.

CONCLUSIONS: A global acne scarring grading system is presented that would allow investigators, educators, and proceduralists to compare their cases more accurately and to have a more objective discussion of the efficacy of operative interventions or therapies. This scoring system is shown to be reproducible among observers independent of medical background, suggesting that patients can be assigned scores equally by physicians and nurses.