Scarring

Normal Wound Healing

Hypertrophic scar: Raised, red, and thickened scars that remain within the boundaries of the original wound.
Atrophic scar: Depressed or sunken scars often seen after acne or chickenpox.
Contracture scar: Tightening of the skin that can affect underlying muscles and tendons, often seen after burns.

Pathological Scarring

Keloid scar: Excessive scar tissue that extends beyond the boundaries of the original wound, often with a genetic predisposition.
Hypertrophic scar: Similar to keloid but remains within the wound boundaries, tends to regress over time.
Acne scars: Can be atrophic (e.g., ice-pick scars) or hypertrophic, depending on the nature of acne and treatment.
Surgical scars: Vary depending on the surgical technique, wound care, and patient factors.
Traumatic scars: Result from injury, may be irregular in shape, and prone to hypertrophic or keloid formation.
Burn scars: Can lead to contractures, hypertrophic, or keloid scarring depending on the depth and care.
Scarring alopecia: Hair loss accompanied by scarring, as seen in conditions like lichen planopilaris or discoid lupus erythematosus.
Post-inflammatory hyperpigmentation: Not a scar per se, but a common sequelae after inflammatory conditions like acne or eczema.
Radiation-induced scars: Often thickened, fibrotic scars seen after radiotherapy, may progress to radiation-induced fibrosis.
Scars in connective tissue diseases: Such as scleroderma, where skin thickening and fibrosis can occur.

History of Presenting Complaint

Onset: Determine when the scar first appeared and whether it has changed over time.
Precipitating factors: Ask about the event leading to scarring, such as surgery, trauma, or burns.
Evolution: Whether the scar has become more prominent, regressed, or altered in appearance.
Symptoms: Explore associated symptoms such as pain, itching, or restricted movement.
Previous treatments: Inquire about any treatments or interventions attempted, such as silicone sheets, corticosteroid injections, or surgery.
Impact on function: Assess if the scar affects daily activities, especially in cases of contractures or scars over joints.
Cosmetic concerns: Discuss the patient’s concerns regarding the appearance of the scar and any psychosocial impact.
Previous scarring history: Any history of abnormal scarring, keloid, or hypertrophic scars in the past.
Associated conditions: History of acne, surgery, burns, or inflammatory skin conditions that might contribute to scarring.
Family history: Ask about a family history of keloids or other abnormal scarring tendencies.

Background

Medical history: Chronic diseases such as diabetes or connective tissue disorders may affect healing and scarring.
Medication history: Review medications that can affect healing, such as corticosteroids or immunosuppressants.
Previous surgical history: Inquire about past surgeries and their outcomes, particularly regarding scar formation.
Occupational history: Consider jobs or activities that might contribute to trauma or repetitive stress on scars.
Social history: Assess lifestyle factors such as smoking, alcohol consumption, and nutrition, all of which can impact healing.
Allergies: Inquire about any allergies, particularly to materials used in wound dressings or medications applied to scars.
Family history: Consider genetic predispositions to conditions like keloids or hypertrophic scars.
Exposure history: Include any history of radiation exposure, especially if there are signs of radiation-induced scarring.
Psychosocial factors: Explore the impact of scarring on the patient’s mental health, self-esteem, and social interactions.
Previous treatments: Document any prior interventions for scarring, including their effectiveness and side effects.
Nutritional status: Poor nutrition, particularly protein or vitamin deficiencies, can impair healing and worsen scarring.

Clinical Examination

Visual inspection: Assess the appearance of the scar, including size, shape, color, and any evidence of hypertrophy or keloid formation.
Palpation: Determine the texture, firmness, and any underlying tethering or contracture.
Range of motion: Assess if the scar restricts movement, particularly in areas over joints or tendons.
Functional assessment: Evaluate the impact of scarring on function, such as gripping, walking, or other activities.
Sensory testing: Assess for any changes in sensation over or around the scar, which could indicate nerve involvement.
Photographic documentation: Consider taking photographs for baseline comparison and monitoring progression over time.
Dermatological consultation: Referral to a dermatologist may be necessary for specialized assessment or treatment.
Psychological evaluation: Consider if scarring has a significant impact on mental health or quality of life.
Biopsy: In rare cases, a biopsy may be indicated to rule out other pathologies if the scar appearance is atypical.

Additional Investigations

Ultrasound: To assess the depth of scar tissue and any involvement of underlying structures.
MRI: May be indicated in complex cases to evaluate deeper tissues or when planning surgical intervention.
Patch testing: If there is suspicion of contact dermatitis contributing to or exacerbating scarring.
Histopathology: If biopsy is performed, histological examination can confirm the diagnosis and rule out malignancy.
Blood tests: Assess for underlying systemic conditions that may affect healing, such as diabetes or autoimmune disorders.
Genetic testing: In cases of suspected hereditary conditions predisposing to keloid formation or other abnormal scarring.
Tissue culture: If there is an associated infection within the scar tissue, a culture may guide antimicrobial therapy.
Intradermal skin test: To evaluate for hypersensitivity reactions contributing to scar formation.
Nerve conduction studies: If there is suspicion of nerve involvement, such as in cases of painful or tethered scars.

Dermatology