Classification of skin scars

A scar is a connective tissue structure that appears at the site of skin damage caused by various traumatic factors to maintain the body's homeostasis.

Whatever the scar, it causes discomfort to its owner, especially when located on open areas of the body, and an active desire to improve its appearance. However, the lack of a unified approach to the problem of scars, a detailed clinical and morphological classification: confusion of terminology and misunderstanding of the differences between scars led to the fact that doctors tried to help patients on their own, without contact with related specialists and, sometimes, without making a distinction in the tactics of treating scars of different types. As a result, this led, at best, to the absence of an effect from treatment, and at worst - to a deterioration in the appearance of the scar.

In order to decide on the methods of treating scars, their clinical type is of decisive importance, since scars of different sizes, periods of existence and nosological form require different treatment. And what will be good for improving the appearance of one scar is completely unacceptable for treating scars of another type.

Dermatologists and surgeons have attempted to systematize scars and combine them into a classification, but due to the lack of a unified methodological approach to the management of such patients, the relationship between doctors, the stages and continuity in their treatment, none of the numerous classifications satisfied, and could not satisfy, the practicing physician.

Thus, several variants of clinical classification of skin scars were proposed. Attempts were made to classify scars by type (star-shaped, linear, Z-shaped); by duration of existence (old and young); by nature of injury (postoperative, post-burn, post-traumatic, post-eruptive); by aesthetic characteristics (esthetically acceptable and aesthetically unacceptable): by influence on functions (affecting and not affecting). K. F. Sibileva proposed to classify keloid scars by shape (star-shaped, fan-shaped, keloid cicatricial cords) and by reasons for their occurrence (post-burn, at the site of injury, after inflammatory processes, after surgical interventions). A. E. Belousov classified scars by shape (linear, arcuate, figured, planar); by depth (deep and superficial): by localization (open areas of the body and closed areas of the body); according to the pathogenetic principle (pathological and simple), according to the clinical and morphological principle (atrophic, hypertrophic and keloid).

M.L. Biryukov proposed to classify scars according to the histological principle). He divided scars into hyalinized; old scars with sharp hyalinosis; fibrous with non-specialized fibers; hyperplastic with strong proliferation of fibroblasts: fibromatous with focal proliferation of fibroblasts in the upper layers and the formation of growths such as soft fibromas. Despite the great work done by the group of researchers, the analysis of the obtained results led to the creation of a very vague, uninformative and unacceptable for practical work classification.

Thus, it can be said that all the above classifications did not add clarity in defining the types of scars and, as a consequence, could not provide the doctor with a direction for their differential diagnosis and a rational approach to treatment.

From our point of view, the most informative and useful for a practicing physician is the clinical-morphological classification, which is based on: the relief of the scar relative to the level of the surrounding skin and its pathomorphological characteristics. The closest to this idea were: A.I. Kartamyshev and M.M. Zhaltakov, who divided scars into atrophic, hypertrophic and flat: I.M. Serebrennikov - into normotrophic, hypotrophic and hypertrophic: V.V. Yudenich and V.M. Grishkevich - atrophic, hypertrophic and keloid scars. A.E. Reznikova distinguished pathological and simple scars. In turn, pathological scars were divided into hypertrophic and keloid, and simple scars - into flat and retracted. Each of the above classifications only partially reflects the essence of the issue and is not a clear scheme based on which a practicing physician can classify a scar into a particular category, make a correct diagnosis, from which the tactics of managing a particular patient and treating the scar will follow. Analysis of attempts to classify scars revealed the "Achilles heel" of this problem. It turns out that despite the global nature of the issue, there is simply no clear idea of the definition of different types of scars. In this case, how can we systematize nosological forms and create a classification if it is not clear what scars are meant by flat, atrophic and hypotrophic. Are these different scars or the same? In the literature, you can read that some authors interpret acne scars as atrophic. What then - hypotrophic or retracted or deep (according to other authors)? What is the difference between hypertrophic and keloid scars and what is the difference in the treatment of these scars? These are not idle questions, since the correct tactics for treating patients with scars largely depend on the correct diagnosis.

However, there are authors who do not see any difference between "scars" and "keloids" at all, and accordingly, they offer the same treatment for them! Such "professional" literature causes colossal harm to rehabilitation medicine and the specialists who work in it. There is no need to explain that as a result of reading such primary sources, doctors develop a completely false idea about the problem of scars, which, first of all, and sometimes quite dramatically, affects our patients, and secondly, affects the reputation of rehabilitation medicine specialists.

Summarizing the above, it becomes obvious that the shape, localization and origin of the scar do not decide anything in the tactics of its treatment, but the relief of the scar relative to the surrounding skin can radically change the approach to its treatment. For example, therapeutic measures necessary and possible to improve the appearance of a hypotrophic scar are completely unacceptable for the treatment of atrophic scars. A hypertrophic scar can be excised or ground almost without fear, while a keloid scar after excision can become 1.5-2 times larger than the previous one. It is also impossible to grind a keloid scar. Thus, there is an urgent need to create a classification of skin scars that gives an idea of the pathogenetic basis of the corresponding cicatricial pathology, its clinical picture, with the resulting trends for prevention and treatment, helping dermatologists, cosmetologists and surgeons in their work.

In 1996, an international conference on skin scars was held in Vienna. At the conference, it was decided to divide all skin scars into physiological and non-physiological (pathological), pathological in turn - into hypertrophic and keloid. However, in our opinion, this classification does not give a complete picture of the subject of research and does not allow us to systematize the huge variety of scars. From the point of view of dermatologists, a scar is always a pathology, and scarring is a pathophysiological process. However, there are scars that are formed as a result of adequate pathophysiological reactions (hypotrophic, normotrophic, atrophic) - group No. 1. And there are scars in the occurrence of which additional pathophysiological factors of general and local significance take part (group No. 2)

In connection with the above, as well as on the basis of literary data and clinical and morphological results of our own research, we proposed a detailed clinical and morphological classification of skin scars.

The presented classification considers scars of limited area. Extensive scars, cicatricial deformations, contractures are the prerogative of surgeons. It is impossible to correct such pathology with dermocosmetological correction, therefore these types of scars are not presented in this classification. Extensive scars, as well as scars of small area, can belong to both group No. 1 and group No. 2.

Group No. 1 includes the overwhelming majority of scars that form as a result of an adequate pathophysiological response of the body to skin damage. They all have a similar pathomorphological structure. Depending on the localization and depth of skin destruction, such scars may have different clinical manifestations.

Thus, a scar that is located flush with the skin and does not cause deformation of the skin and underlying tissues is called normotrophic.

When the injury is located on the surface of the body where the hypodermis is practically absent (knees, back of the feet, hands, frontotemporal region, etc.), the scar looks thin, flat, with translucent vessels - atrophic (similar to atrophic skin). These scars are located flush with the surrounding skin, so they can be considered a variant of normotrophic scars.

If the injury (burn, inflammation, wound) was located on the surface of the body with a sufficiently developed layer of subcutaneous fat and was deeply destructive, the scar may take the form of a retracted, hypotrophic, or a scar with (-) tissue due to the destruction of the hypodermis. Since such scars are clinically the opposite of hypertrophic, that is, scars that form on the skin (+ tissue), the name hypotrophic absolutely corresponds to its morphological essence and clinical picture and contributes to the unification of terminology.

As for group No. 2, most researchers include keloid and hypertrophic scars in it. It is impossible to agree with this position completely, since hypertrophic scars in the pathogenesis, clinical and morphological picture of the cicatricial process have features characteristic of both groups of scars. The main feature uniting hypertrophic and keloid scars is a relief protruding above the surface of a healthy scar, that is, (+) tissue. The common pathogenesis and external characteristics, as well as the fact that they are classified in one group, often leads to an incorrect diagnosis and treatment tactics, while there should be caution with keloid scars. It is important, for example, not to miss a keloid scar and not to excise it or subject it to surgical polishing. While with hypertrophic scars, these treatment methods have a right to exist. Therefore, hypertrophic scars should be classified as a separate group and occupy an intermediate position between the conventionally named groups No. 1 and No. 2.

The problem of keloid scars is extremely complex and borderline for dermatology, surgery and cosmetology, and not only because patients seek help from these specialists, but also because these specialists are indirectly guilty of the appearance of such scars in patients. True pathological scars (keloid) are the scourge of modern medicine. The appearance of keloid scars in patients on open areas of the body (face, neck, hands) is especially difficult to experience. In addition to the ugly and rough-looking "scar", the keloid has a bluish-red color and bothers the patient with a feeling of pain and itching. Keloids do not disappear on their own, they should be excised using a special tactic, since a larger keloid may grow in place of the excised one.

Recently, there have been more frequent cases of keloid scar formation after injuries, surgeries, cosmetic procedures against the background of secondary infection, decreased immunological status, endocrinopathies and other factors. Chronic inflammation contributes to unbalanced accumulation of macromolecular components of the connective tissue of the dermis, its dysregeneration. Free radicals, destructive proteins, NO, stimulate proliferative and synthetic activity of fibroblasts, as a result of which, even after epithelialization of the wound defect, fibroblasts continue to actively synthesize connective tissue components of scar tissue, which leads to the occurrence of tumor-like formations at the site of the former injury. Thus, only all variants of keloid scars (keloids of the auricles, keloids limited in area, acne keloid, extensive keloids, as well as keloid disease) should be classified as true scars of group No. 2. The division of keloid scars into clinical forms is justified by the different tactics of managing such patients despite the common pathogenetic and pathomorphological factors. The pathological nature of keloid scars is also illustrated by the fact that this special form of scars appears and develops according to its own laws, has a specific pathomorphological and clinical picture, due to which these scars were even tried to be classified as tumors. Keloid scars most often appear some time after the epithelialization of the wound defect, go beyond the former injury in all directions, have a purple color and bother the patient with itching. Cases of keloid scars on intact skin without previous injuries and even bruises are also interpreted as "keloid disease" and in this case the etiopathogenesis of the resulting keloids differs from the etiopathogenesis of true keloid scars.

Thus, depending on the localization, nature of the injury, depth of destruction, health condition of the macroorganism, various types of scars may appear on the skin, which most often bother patients because of their unaesthetic appearance. To choose the right methodology for treating scars, it is very important for a doctor to be able to classify scars, since the tactics of management, the means, methods and technologies used depend on determining their type. Researchers have made many attempts to find optimal methods for diagnosing scars to facilitate treatment. Thus, the following methods were used: X-ray structural, radioisotope, radioautographic, immunological, determining the structure of amino acids, histoenzyme. All of them have not found their practical application due to technical difficulties. However, histological and ultrastructural research methods are used and are quite conclusive. They are especially relevant for differential diagnostics between hypertrophic and keloid scars. Nevertheless, it can be said that the main role in the diagnosis of scars belongs to the clinical picture, which is most closely related to the etiopathogenesis of the injury and the ways of its reparation.

To help the practicing dermatologist, dermatocosmetologist and surgeon, a clinical and morphological classification of scars was proposed, based on the principle of the relationship between the level of the surrounding skin and the surface of the scar. Thus, all scars were divided into 5 groups - normotrophic, atrophic, hypotrophic, hypertrophic and keloid. Normotrophic, atrophic, hypotrophic scars are combined into group No. 1. These are scars formed as a result of an adequate pathophysiological reaction of the skin in response to trauma or destructive inflammation. They have a similar histological structure. Hypertrophic scars should be placed on the border between this group and keloid scars, since their pathogenesis and clinical picture are similar to keloid scars, but in terms of histological structure and the dynamics of the cicatricial process, they do not differ from scars No. 1. In turn, keloid scars belong to group No. 2 and are divided into: keloid scars of the earlobes, acne keloid, extensive keloids, keloids limited in area and keloid disease (spontaneous keloids). We believe it is appropriate to distinguish the listed variants of keloid scars as separate nosological units, since they have features not only in the clinical picture, but also in treatment. It should be noted that back in 1869, Kaposi described acne keloid as an independent disease.

This classification applies to both small-area scars and large-area scars, which can be improved by surgical methods as a first step.

Large-area scars, cicatricial contractures, cicatricial deformations are objects for surgeons. Conventionally, such pathology can be called "surgical scars". Without a scalpel and the hands of a surgeon, it is impossible to improve the appearance of these scars. But, unfortunately, even after surgical correction, scars remain that bother the patient and can only be improved by dermatocosmetological means and methods.

Scars that remain after the work of surgeons or for some reason cannot be operated by surgeons can be conditionally attributed to the group of so-called "cosmetological scars" with which dermatologists, dermatosurgeons and cosmetologists should and can work. Most often, these are scars of a limited area. Some patients are satisfied with the results of plastic surgery, but most patients would like to further improve the appearance of the scars. Such patients turn to dermatocosmetologists, who then work with the scars. Diagram No. 1 shows the percentage of patients with various scars that we have identified. Of the total number of patients seeking medical care, about 18% are patients with keloid scars, although the percentage of such patients increases every year. About 8% are patients with hypertrophic scars, approximately 14% are patients with hypotrophic scars. The largest number of patients have normotrophic scars (about 60%) and the smallest number have atrophic scars (about 4%).

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