Scars
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A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an
injury An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, o ...
. Scars result from the biological process of wound repair in the skin, as well as in other
organ Organ may refer to: Biology * Organ (biology), a part of an organism Musical instruments * Organ (music), a family of keyboard musical instruments characterized by sustained tone ** Electronic organ, an electronic keyboard instrument ** Hammond ...
s, and tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound (e.g., after accident, disease, or
surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
) results in some degree of scarring. An exception to this are animals with complete
regeneration Regeneration may refer to: Science and technology * Regeneration (biology), the ability to recreate lost or damaged cells, tissues, organs and limbs * Regeneration (ecology), the ability of ecosystems to regenerate biomass, using photosynthesis ...
, which regrow tissue without scar formation. Scar tissue is composed of the same protein (
collagen Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
) as the tissue that it replaces, but the fiber composition of the protein is different; instead of a random basketweave formation of the collagen fibers found in normal tissue, in fibrosis the collagen cross-links and forms a pronounced alignment in a single direction. This collagen scar tissue alignment is usually of inferior functional quality to the normal collagen randomised alignment. For example, scars in the skin are less resistant to ultraviolet radiation, and
sweat gland Sweat glands, also known as sudoriferous or sudoriparous glands, , are small tubular structures of the skin that produce sweat. Sweat glands are a type of exocrine gland, which are glands that produce and secrete substances onto an epithelial sur ...
s and
hair follicle The hair follicle is an organ found in mammalian skin. It resides in the dermal layer of the skin and is made up of 20 different cell types, each with distinct functions. The hair follicle regulates hair growth via a complex interaction between h ...
s do not grow back within scar tissues. A myocardial infarction, commonly known as a heart attack, causes scar formation in the heart muscle, which leads to loss of muscular power and possibly
heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...
. However, there are some tissues (e.g. bone) that can heal without any structural or functional deterioration.


Types

All scarring is composed of the same collagen as the tissue it has replaced, but the composition of the scar tissue, compared to the normal tissue, is different. Scar tissue also lacks elasticity unlike normal tissue which distributes fiber elasticity. Scars differ in the amounts of collagen overexpressed. Labels have been applied to the differences in overexpression. Two of the most common types are hypertrophic and
keloid Keloid, also known as keloid disorder and keloidal scar, is the formation of a type of scar which, depending on its maturity, is composed mainly of either type III (early) or type I (late) collagen. It is a result of an overgrowth of granulation t ...
scarring, both of which experience excessive stiff collagen bundled growth overextending the tissue, blocking off regeneration of tissues. Another form is atrophic scarring (sunken scarring), which also has an overexpression of collagen blocking regeneration. This scar type is sunken, because the collagen bundles do not overextend the tissue. Stretch marks (striae) are regarded as scars by some. High melanin levels and either African or Asian ancestry may make adverse scarring more noticeable.


Hypertrophic

Hypertrophic scars occur when the body overproduces
collagen Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
, which causes the scar to be raised above the surrounding skin. Hypertrophic scars take the form of a red raised lump on the skin for lighter pigmented skin and the form of dark brown for darker pigmented skin. They usually occur within 4 to 8 weeks following wound infection or wound closure with excess tension and/or other traumatic skin injuries.


Keloid

Keloid scars are a more serious form of excessive scarring, because they can grow indefinitely into large, tumorous (although benign) neoplasms. Hypertrophic scars are often distinguished from keloid scars by their lack of growth outside the original wound area, but this commonly taught distinction can lead to confusion. Keloid scars can occur on anyone, but they are most common in dark-skinned people. They can be caused by surgery, accident, acne or, sometimes, body piercings. In some people, keloid scars form spontaneously. Although they can be a cosmetic problem, keloid scars are only inert masses of collagen and therefore completely harmless and not cancerous. However, they can be itchy or painful in some individuals. They tend to be most common on the shoulders and chest. Hypertrophic scars and keloids tend to be more common in wounds closed by secondary intention. Surgical removal of keloid is risky and may exacerbate the condition and worsening of the keloid.


Atrophic

An atrophic scar takes the form of a sunken recess in the skin, which has a pitted appearance. These are caused when underlying structures supporting the skin, such as fat or
muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...
, are lost. This type of scarring is often associated with acne,
chickenpox Chickenpox, also known as varicella, is a highly contagious disease caused by the initial infection with varicella zoster virus (VZV). The disease results in a characteristic skin rash that forms small, itchy blisters, which eventually scab ...
, other diseases (especially ''
Staphylococcus ''Staphylococcus'' is a genus of Gram-positive bacteria in the family Staphylococcaceae from the order Bacillales. Under the microscope, they appear spherical (cocci), and form in grape-like clusters. ''Staphylococcus'' species are facultative ...
'' infection), surgery, certain insect and spider bites, or accidents. It can also be caused by a genetic
connective tissue Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tiss ...
disorder, such as Ehlers–Danlos syndrome.


Stretch marks

Stretch marks (technically called ''striae'') are also a form of scarring. These are caused when the skin is stretched rapidly (for instance during pregnancy, significant weight gain, or adolescent growth spurts), or when skin is put under tension during the healing process (usually near joints). This type of scar usually improves in appearance after a few years. Elevated
corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
levels are implicated in striae development.


Umbilical

Humans and other placental mammals have an umbilical scar (commonly referred to as a navel) which starts to heal when the umbilical cord is cut after birth. Egg-laying animals have an umbilical scar which, depending on the species, may remain visible for life or disappear within a few days after birth.


Pathophysiology

A scar is the product of the body's repair mechanism after tissue injury. If a wound heals quickly within two weeks with new formation of skin, minimal collagen will be deposited and no scar will form. When the extracellular matrix senses elevated mechanical stress loading, tissue will scar, and scars can be limited by stress shielding wounds. Small full thickness wounds under 2mm reepithelize fast and heal scar free. Deep second-degree burns heal with scarring and hair loss. Sweat glands do not form in scar tissue, which impairs the regulation of body temperature. Elastic fibers are generally not detected in scar tissue younger than 3 months old. In scars, rete pegs are lost; through a lack of rete pegs, scars tend to shear easier than normal tissue. The
endometrium The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional laye ...
, the inner lining of the uterus, is the only adult tissue to undergo rapid cyclic shedding and regeneration without scarring, shedding and restoring roughly inside a 7-day window on a monthly basis. All other adult tissues, upon rapid shedding or injury, can scar. Prolonged inflammation, as well as the
fibroblast A fibroblast is a type of cell (biology), biological cell that synthesizes the extracellular matrix and collagen, produces the structural framework (Stroma (tissue), stroma) for animal Tissue (biology), tissues, and plays a critical role in wound ...
proliferation, can occur. Redness that often follows an injury to the skin is not a scar and is generally not permanent (see wound healing). The time it takes for this redness to dissipate may, however, range from a few days to, in some serious and rare cases, a few years. Scars form differently based on the location of the injury on the body and the age of the person who was injured. The worse the initial damage is, the worse the scar will generally be. Skin scars occur when the
dermis The dermis or corium is a layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided i ...
(the deep, thick layer of skin) is damaged. Most skin scars are flat and leave a trace of the original
injury An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, o ...
that caused them. Wounds allowed to heal secondarily tend to scar worse than wounds from primary closure.


Collagen synthesis

An injury does not become a scar until the wound has completely healed; this can take many months, or years in the worst pathological cases, such as keloids. To begin to patch the damage, a clot is created; this clot is the beginning process that results in a provisional matrix. In the process, the first layer is a provisional matrix and is not a scar. Over time, the wounded body tissue overexpresses
collagen Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
inside the provisional matrix to create a collagen matrix. This collagen overexpression continues and crosslinks the fiber arrangement inside the collagen matrix, making the collagen dense. This densely packed collagen, morphing into an inelastic whitish collagen scar wall, blocks off cell communication and regeneration; as a result, the new tissue generated will have a different texture and quality than the surrounding unwounded tissue. This prolonged collagen-producing process results in a fortuna scar.


Fibroblasts

The scarring is created by
fibroblast A fibroblast is a type of cell (biology), biological cell that synthesizes the extracellular matrix and collagen, produces the structural framework (Stroma (tissue), stroma) for animal Tissue (biology), tissues, and plays a critical role in wound ...
proliferation, a process that begins with a reaction to the clot. To mend the damage, fibroblasts slowly form the
collagen Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
scar. The fibroblast proliferation is circular and cyclically, the fibroblast proliferation lays down thick, whitish collagen inside the provisional and collagen matrix, resulting in the abundant production of packed collagen on the fibers giving scars their uneven texture. Over time, the fibroblasts continue to crawl around the matrix, adjusting more fibers and, in the process, the scarring settles and becomes stiff. This fibroblast proliferation also contracts the tissue. In unwounded tissue, these fibers are not overexpressed with thick collagen and do not contract. EPF and ENF fibroblasts have been genetically traced with the Engrailed-1 genetic marker. EPFs are the primary contributors to all fibrotic outcomes after wounding. ENFs do not contribute to fibrotic outcomes.


Myofibroblast

Mammalian wounds that involve the dermis of the skin heal by repair, not regeneration (except in 1st trimester inter-uterine wounds and in the regeneration of deer antlers). Full-thickness wounds heal by a combination of wound contracture and edge re-epitheliasation. Partial thickness wounds heal by edge re-epithelialisation and epidermal migration from adnexal structures (hair follicles, sweat glands and sebaceous glands). The site of keratinocyte stem cells remains unknown but stem cells are likely to reside in the
basal layer The ''stratum basale'' (basal layer, sometimes referred to as ''stratum germinativum'') is the deepest layer of the five layers of the epidermis, the external covering of skin in mammals. The ''stratum basale'' is a single layer of columnar or ...
of the
epidermis The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and hypodermis. The epidermis layer provides a barrier to infection from environmental pathogens and regulates the amount of water rele ...
and below the bulge area of hair follicles. The fibroblast involved in scarring and contraction is the myofibroblast, which is a specialized contractile fibroblast. These cells express α-smooth muscle actin (α-SMA). The myofibroblasts are absent in the first trimester in the embryonic stage where damage heals scar-free; in small incisional or excision wounds less than 2 mm that also heal without scarring; and in adult unwounded tissues where the fibroblast in itself is arrested; however, the myofibroblast is found in massive numbers in adult wound healing which heals with a scar. The myofibroblasts make up a high proportion of the fibroblasts proliferating in the postembryonic wound at the onset of healing. In the rat model, for instance, myofibroblasts can constitute up to 70% of the fibroblasts, and is responsible for fibrosis on tissue. Generally, the myofibroblasts disappear from the wound within 30 days, but can remain in pathological cases in hypertrophy, such as keloids. Myofibroblasts have plasticity and in mice can be transformed into fat cells, instead of scar tissue, via the regeneration of hair follicles.


Mechanical stress

Wounds under 2mm generally do not scar but larger wounds generally do scar. In 2011 it was found that mechanical stress can stimulate scarring and that stress shielding can reduce scarring in wounds. In 2021 it was found that using chemicals to manipulate fibroblasts to not sense mechanical stress brought scar-free healing. The scar-free healing also occurred when mechanical stress was placed onto a wound.


Treatment

Early and effective treatment of acne scarring can prevent severe acne and the scarring that often follows. In 2004, no prescription drugs for the treatment or prevention of scars were available.


Chemical peels

Chemical peels are chemicals which destroy the epidermis in a controlled manner, leading to exfoliation and the alleviation of certain skin conditions, including superficial acne scars. Various chemicals can be used depending upon the depth of the peel, and caution should be used, particularly for dark-skinned individuals and those individuals susceptible to
keloid Keloid, also known as keloid disorder and keloidal scar, is the formation of a type of scar which, depending on its maturity, is composed mainly of either type III (early) or type I (late) collagen. It is a result of an overgrowth of granulation t ...
formation or with active infections.


Filler injections

Filler injections of
collagen Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whole ...
can be used to raise atrophic scars to the level of surrounding skin. Risks vary based upon the filler used, and can include further disfigurement and allergic reaction.


Laser treatment

Nonablative lasers, such as the 585 nm
pulsed dye laser A dye laser is a laser that uses an organic dye as the lasing medium, usually as a liquid solution. Compared to gases and most solid state lasing media, a dye can usually be used for a much wider range of wavelengths, often spanning 50 to 100 ...
, 1064 nm and 1320 nm Nd:YAG, or the 1540 nm Er:Glass are used as laser therapy for hypertrophic scars and keloids. There is tentative evidence for burn scars that they improve the appearance. Ablative lasers such as the carbon dioxide laser (CO) or Er:YAG offer the best results for atrophic and acne scars. Like
dermabrasion Dermabrasion is a type of surgical skin planing, generally with the goal of removing acne, scarring and other skin or tissue irregularities, typically performed in a professional medical setting by a dermatologist or plastic surgeon trained speci ...
, ablative lasers work by removing the epidermis. Healing times for ablative therapy are much longer and the risk profile is greater compared to nonablative therapy; however, nonablative therapy offers only minor improvements in cosmetic appearance of atrophic and acne scars. Combination laser therapy and
microneedling Collagen induction therapy (CIT), also known as microneedling, dermarolling, or skin needling, is a Medical aesthetics, cosmetic procedure that involves repeatedly puncturing the Human skin, skin with tiny, sterile needles (microneedling the skin) ...
may offer superior results to single modality treatment. The biggest recent advance in scar management is the use of fractionated CO laser and immediate application of topical steroid Triamcinolone.


Radiotherapy

Low-dose, superficial
radiotherapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...
is sometimes used to prevent recurrence of severe keloid and hypertrophic scarring. It is thought to be effective despite a lack of clinical trials, but only used in extreme cases due to the perceived risk of long-term side effects.


Dressings and topical silicone

Silicone scar treatments are commonly used in preventing scar formation and improving existing scar appearance. A
meta-study A meta-analysis is a statistical analysis that combines the results of multiple scientific studies. Meta-analyses can be performed when there are multiple scientific studies addressing the same question, with each individual study reporting me ...
by the Cochrane collaboration found weak evidence that silicone gel sheeting helps prevent scarring. However, the studies examining it were of poor quality and susceptible to bias.
Pressure dressing A dressing is a sterile pad or compress applied to a wound to promote healing and protect the wound from further harm. A dressing is designed to be in direct contact with the wound, as distinguished from a bandage, which is most often used to hol ...
s are commonly used in managing burn and hypertrophic scars, although supporting evidence is lacking. Care providers commonly report improvements, however, and pressure therapy has been effective in treating ear keloids. The general acceptance of the treatment as effective may prevent it from being further studied in clinical trials.


Verapamil-containing silicone gel

Verapamil, a type of calcium channel blocker, is considered a candidate drug for the treatment of hypertrophic scars. A study conducted by the catholic university of Korea concluded that verapamil‐releasing silicone gel is effective and is a superior alternative to the conventional silicone gel where decreased median SEI, fibroblast count, and collagen density in all verapamil‐added treatment groups were observed Gross morphologic features suggested that the combination of verapamil and silicone improves the overall quality of hypertrophic scars by reducing scar height and redness. This was verified with quantifiable histomorphometric parameters. but Oral verapamil is not a good choice because of its effect of lowering blood pressure. Intralesional injection of verapamil is also suboptimal because of the required frequency for injections. Topical silicone gel combined with verapamil does not lead to systemic hypotension, is convenient to apply, and shows enhanced results.


Steroids

A long-term course of
corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
injections into the scar may help flatten and soften the appearance of keloid or hypertrophic scars. Topical steroids are ineffective.Jenkins M, Alexander JW, MacMillan BG, Waymack JP, Kopcha R. Failure of topical steroids and vitamin E to reduce postoperative scar formation following reconstructive surgery. J Burn Care Rehabil. 1986 Jul–Aug;7(4):309–312. However, clobetasol propionate can be used as an alternative treatment for keloid scars. Topical steroid applied immediately after fractionated CO2 laser treatment is however very effective (and more efficacious than laser treatment alone) and has shown benefit in numerous clinical studies.


Surgery

Scar revision is a process of cutting the scar tissue out. After the excision, the new wound is usually closed up to heal by
primary intention Wound healing refers to a living organism's replacement of destroyed or damaged tissue by newly produced tissue. In undamaged skin, the epidermis (surface, epithelial layer) and dermis (deeper, connective layer) form a protective barrier agains ...
, instead of
secondary intention Wound healing refers to a living organism's replacement of destroyed or damaged tissue by newly produced tissue. In undamaged skin, the epidermis (surface, epithelial layer) and dermis (deeper, connective layer) form a protective barrier agains ...
. Deeper cuts need a multilayered closure to heal optimally, otherwise depressed or dented scars can result. Surgical excision of hypertrophic or keloid scars is often associated to other methods, such as pressotherapy or silicone gel sheeting. Lone excision of keloid scars, however, shows a recurrence rate close to 45%. A clinical study is currently ongoing to assess the benefits of a treatment combining surgery and laser-assisted healing in hypertrophic or keloid scars. ''Subcision'' is a process used to treat deep rolling scars left behind by acne or other skin diseases. It is also used to lessen the appearance of severe glabella lines, though its effectiveness in this application is debatable. Essentially the process involves separating the skin tissue in the affected area from the deeper scar tissue. This allows the blood to pool under the affected area, eventually causing the deep rolling scar to level off with the rest of the skin area. Once the skin has leveled, treatments such as
laser resurfacing Photorejuvenation is a skin treatment that uses lasers, intense pulsed light, or photodynamic therapy to treat skin conditions and remove effects of photoaging such as wrinkles, spots, and textures. The process induces controlled wounds to the sk ...
, microdermabrasion or chemical peels can be used to smooth out the scarred tissue.


Vitamins

Research shows the use of vitamin E and onion extract (sold as
Mederma Mederma is a topical product used to improve scar appearance. It is a gel based on an onion extract and produced by Merz Pharmaceuticals of Frankfurt, Germany, although it is not sold in Germany. Mederma's marketing claims it can make scars "softer, ...
) as treatments for scars is ineffective. Vitamin E causes contact dermatitis in up to 33% of users and in some cases it may worsen scar appearance and could cause minor skin irritations, but Vitamin C and some of its esters fade the dark pigment associated with some scars.Farris PK. Topical vitamin C: a useful agent for treating photoaging and other dermatologic conditions. Although many people claim that vitamin therapy does in fact help. Dermatol Surg 2005;31:814-818.


Other

* Cosmetics; Medical makeup can temporarily conceal scars. This is most commonly used for facial scars. * Dermabrasion involves the removal of the surface of the skin with special equipment, and usually involves a
local anaesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...
. * Massage has weak evidence of efficacy in scar management. Any beneficial effect appears to be greater in wounds created by
surgical incision In surgery, a surgical incision is a cut made through the skin and soft tissue to facilitate an Surgery, operation or medical procedure, procedure. Often, multiple incisions are possible for an operation. In general, a surgical incision is made as ...
than traumatic wounds or burn wounds. *
Microneedling Collagen induction therapy (CIT), also known as microneedling, dermarolling, or skin needling, is a Medical aesthetics, cosmetic procedure that involves repeatedly puncturing the Human skin, skin with tiny, sterile needles (microneedling the skin) ...


Society and culture


Intentional scarring

The permanence of scarring has led to its intentional use as a form of body art within some cultures and subcultures. These forms of ritual and non-ritual scarring practices can be found in many groups and cultures around the world.


Etymology

First attested in English in the late 14th century, the word ''scar'' derives from a conflation of Old French ''escharre'', from Late Latin ''eschara'', which is the latinisation of the Greek ἐσχάρα (''eskhara''), meaning "hearth, fireplace", but in medicine "scab, eschar on a wound caused by burning or otherwise",Online Etymology Dictionary
/ref> and Middle English ''skar'' ("cut, crack, incision"), which is from Old Norse ''skarð'' ("notch, gap"). The conflation helped to form the English meaning. Compare Scarborough for evolution of ''skarð'' to ''scar''.


Research


Treatment

Research, before 2009, focused on scar improvements with research in to molecular mechanisms. Molecular mechanisms such as: juvista,
ribosomal s6 kinase In molecular biology, ribosomal s6 kinase (rsk) is a family of protein kinases involved in signal transduction. There are two subfamilies of rsk, p90rsk, also known as MAPK-activated protein kinase-1 (MAPKAP-K1), and p70rsk, also known as S6-H1 ...
(RSK), and osteopontin were investigated. In 2011, the scientific literature highlighted stress shielding a fresh wound through the wound healing process, brings significant scar improvement and smaller scars.


Prevention

By 2016, skin had been regenerated '' in vivo'', and '' in vitro'' and scar free healing had been operationalized and induced by four main techniques: regeneration by instrument; regeneration by materials; regeneration by drugs; and regeneration by ''in vitro'' 3-D printing. In 2018, a silk-derived
sericin Sericin is a protein created by ''Bombyx mori'' (silkworms) in the production of silk. Silk is a fibre produced by the silkworm in production of its Pupa#Cocoon, cocoon. It consists mainly of two proteins, fibroin and sericin. Silk consists of ...
hydrogel A hydrogel is a crosslinked hydrophilic polymer that does not dissolve in water. They are highly absorbent yet maintain well defined structures. These properties underpin several applications, especially in the biomedical area. Many hydrogels ar ...
dressing was undergoing research, the material was shown to prevent scar formation.


References


External links


WebMd.com: Skin Scars Directory

American Academy of Dermatology: What is a scar?
{{Authority control Healing Skin conditions resulting from physical factors