Classification of skin scars

The scar is a connective tissue structure that arose at the site of skin damage by various traumatic factors during the maintenance of the body's homeostasis.

Whatever the scar, it causes discomfort in the wearer, especially when placed on exposed areas of the body, and an active desire to improve its appearance. However, the lack of a unified approach to the problem of scars, detailed clinical and morphological classification: the confusion of terminology and the misunderstanding of differences between scars led to the fact that doctors tried to help patients independently, without contact with related specialists and, at times, making no distinction in the tactics of treating scars of different kinds . As a result, this resulted, at best, in the absence of the effect of treatment, and at worst, on deterioration of the scar.

To solve the problem of how to treat scars, their clinical variety is of decisive importance, since scars of different size, duration and nosological form require different treatments. And what will be good for improving the appearance of one scar is absolutely unacceptable for the treatment of scars of a different kind.

Dermatologists and surgeons attempted to systematize scars and combine them into a classification, but due to the lack of a single methodological approach to managing such patients, the relationship between doctors, the stage and continuity in their treatment, none of the numerous classifications satisfied, and could not satisfy, the practitioner doctor.

Several variants of the clinical classification of skin scars have been proposed. Scars tried to classify by sight (star, linear, Z-shaped); but the terms of existence (old and young); but the nature of the injury (postoperative, post-burn, post-traumatic, post-eruptive) according to aesthetic characteristics (aesthetically acceptable and aesthetically unacceptable): influence on functions (affecting and not affecting). KF Sibileva proposed classifying keloid cicatrices in the form (stellate, fan form, keloid cicatricial cords) and for reasons of their occurrence (post-burn at the site of injuries, after inflammatory processes, after surgical interventions). AE Belousov classified scars according to the form (linear, arc-shaped, figured, planar); depth (deep and superficial): localization (open areas of the body and closed areas of the body); on 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 the scars into hyaline ones; old scars with a sharp hyalinosis; fibrous with non-specialized fibers; hyperplastic with a strong proliferation of fibroblasts: fibromatous with focal proliferation of fibroblasts in the upper layers and the formation of proliferation of the type of soft fibers. Despite the great work done by a group of researchers. The analysis of the obtained results led to the creation of a very vague, little informative and unacceptable classification for practical work.

Thus, it can be said that all of the above classifications did not add clarity to the definition of varieties of scars and as a consequence. Could not give the doctor a direction for their differential diagnosis and rational approach to treatment.

From our point of view, the most informative and useful for a practical physician is the clinico-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 thing to this idea were: A.I. Kartamyshev and MM. Zhltakov, who divided the scars into atrophic, hypertrophic and flat: IM Serebrennikov - on normotrophic, hypotrophic and hypertrophic: V.V. Yudenich and V.M. Grishkevich na - atrophic, hypertrophic and keloid scars. AE Reznikova distinguished pathological and simple scars. In turn, the pathological scars divided into hypertrophic and keloid, and simple - to flat and retracted. Each of the above-mentioned classifications only partially reflects the essence of the issue and is not a clear scheme, on the basis of which the practitioner can assign a scar to one or another category, to make the right diagnosis, from which the tactics of conducting this particular patient and treating the scar will follow. An analysis of attempts to classify scars revealed the "Achilles heel" of this problem. It turns out that for all the globality of the question, there is simply no clear idea of the definition of a different kind of scars. In such a case, how can one organize the nosological forms and create a classification if it is not clear which scars are meant for flat, atrophic and hypotrophic ones. Are these different scars or the same? In the literature it can be read that some authors treat scars after acne as atrophic. What, then, is hypotrophic or entangled or deep (according to the data of other authors)? What is the difference between hypertrophic and keloid scars and what is the difference in the treatment of these scars? All these are not idle questions, since the correct tactics of managing patients with scars largely depends on the correctly diagnosed diagnosis.

However, there are authors who do not see the difference between "scars" and "keloids", respectively, and they offer the same treatment for them! Such "professional" literature inflicts enormous harm to rehabilitation medicine and the specialists who work in it. It is not necessary to explain that as a result of reading such primary sources, doctors have a completely wrong idea about the problem of scarring, which is primarily and dramatically burdensome, affects our patients, and the second - on the reputation of specialists in rehabilitation medicine.

Summarizing the above, it becomes obvious that the form, localization and origin of the scar does not solve anything in the tactics of its treatment, but the relief of the scar relative to the surrounding skin can fundamentally change the approach to its treatment. So. For example, the therapeutic measures necessary and possible to improve the type of hypotrophic rumen are completely unacceptable for the treatment of atrophic scars. Hypertrophic scar can be almost fearlessly excised or polished, at that time. As a keloid after excision can be 1.5-2 times greater than the previous. It is also impossible to polish a keloid scar. Thus, there is an urgent need to create a classification of skin scars, giving an idea of the pathogenetic foundations of the corresponding cicatricial pathology, its clinic, with the resulting trends for prevention and treatment, helping doctors dermatologists, cosmetologists and surgeons.

In 1996 an international conference on skin scars was held in Vienna. On which it was decided to divide all skin scars into physiological and non-physiological (pathological), pathological in turn - to hypertrophic and keloid. However, in our opinion, this classification does not give a complete idea of the subject of research and does not allow us to systematize the entire huge variety of scars. From the point of view of dermatologists, the scar is always a pathology, and scarring is a pathophysiological process. However, there are scars that are formed due to adequate pathophysiological reactions (hypotrophic, normogrophic, atrophic) - group number 1. And there are scars, in the emergence of which involves additional pathophysiological factors of general and local significance (group number 2)

In connection with the foregoing, and also on the basis of the literature data and the clinical and morphological results of our own studies, we proposed an extensive clinical and morphological classification of skin scars.

The presented classification considers scarring of a limited area. Extensive scars, scar deformities, contractures are the prerogative of surgeons. Dermotocosmetological correction of such a pathology can not be corrected, therefore, these variants of scars are not represented in this classification. Extensive scars as well as scars of a small area can be referred to both group No. 1 and group 2.

Group 1 includes the prevailing majority of scars, which are formed as a result of an adequate pathophysiological response of the organism in response to skin damage. They all have a similar pathomorphological structure. Depending on the location and depth of skin destruction, such scars can have different clinical manifestations.

So the scar, located flush with the skin, not causing deformation of the skin and underlying tissues is called normotrophic.

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

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

As for group 2. Most researchers include keloid and hypertrophic scars. Absolutely to agree with this position it is not possible, as at hypertrophic scars in pathogenesis, clinical and morphological picture of cicatrical process there are the features characteristic both for one, and for other group of cicatrixes. The main feature that unites hypertrophic and keloid scars is the relief that protrudes above the surface of a healthy rut, that is (+) tissue. The generality of pathogenesis and external characteristics, and also that. That they are included in one group, often leads to incorrect diagnosis and treatment tactics, while there should be caution to keloid scars. It is important, for example, not to miss a keloid scar and not to incarcerate it or to subject it to rapid grinding. While with hypertrophic scars, these treatments have a right to exist. Therefore, hypertrophic scars should be allocated to a separate group, and occupy an intermediate position between the conditionally 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 because of that. That these specialists are indirectly guilty of the appearance of such scars in patients. True pathological scars (keloid) are a scourge of modern medicine. Especially difficult is the occurrence of keloid scars in patients in open areas of the body (face, neck, hands). In addition to the ugly and coarse "scar", the keloid has a cyanotic red color and worries the patient with a sensation of pain and itching. Independently, keloids do not disappear, excising them should be followed by special tactics, since instead of the excised it can grow a keloid of a larger size.

Recently, cases of formation of keloid scars after trauma, surgical interventions, cosmetic manipulations against the background of secondary infection, decreased immunological status, endocrinopathy and other factors have become more frequent. Chronicization of the inflammation process contributes to an unbalanced accumulation of macromolecular components of the connective tissue of the dermis, its deregulation. Free radicals, destructive proteins ,. NO stimulate the proliferative and synthetic activity of fibroblasts, as a result of which, after epithelization of the wound defect, fibroblasts continue to actively synthesize connective tissue components of scar tissue, which leads to the appearance of tumoral formations on the site of the former trauma. Thus, only all variants of keloid scars (keloids of earlobes, keloid limited in area, acne-keloid, extensive keloids, and also keloid disease) should be attributed to the true scars of group 2. The division of keloid scars into clinical forms is justified by the different tactics of conducting 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 arises and develops according to their own laws, has a specific pathomorphological and clinical picture, so that these scars were even attempted to classify as tumors. Keloid scars most often occur some time after the epithelization of the wound defect, go beyond the former trauma in all directions, have a crimson color and disturb the patient with itching. The occurrence of keloid scars on intact skin without previous injuries and even bruises is also treated as a "keloid disease" and in this case the etiopathogenesis of the keloids formed differs from the etiopathogenesis of the true keloid scars.

So, depending on the localization, the nature of the trauma, the depth of destruction, the state of health of the macroorganism, different kinds of scars can arise on the skin, which most often disturb patients because of their non-esthetic appearance. In order to choose the right methodology for the treatment of scars, it is very important for the doctor to be able to classify scars, since the tactics of reference, the tools, methods and technologies that depend on the determination of their type depend on them. Researchers have made many attempts to find the best methods for diagnosing scars to facilitate medical work. So the following methods were used: X-ray structural, radioisotope, radioautographic, immunological, determining the structure of amino acids, histoenzymatic. All of them have not found their practical application because of technical difficulties. However, the histological and ultrastructural methods of investigation are used and are completely demonstrable. 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 scarring belongs to the clinical picture, which is closely related to the etiopathogenesis of the trauma and the ways of its repair.

To help the practicing dermatologist, dermatocosmetologist and surgeon, a clinico-morphological classification of scars was proposed, based on the principle of correlation of the level of the surrounding skin with the surface of the rumen. So all the scars were divided into 5 groups - normotrophic, atrophic, hypotrophic, hypertrophic and keloid. Normotrophic, atrophic, hypotrophic scars are grouped in group 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, as in their pathogenesis and clinical picture there is a resemblance to keloid scars, but according to the histological structure and dynamics of the scar process they do not differ from scars No. 1. In turn, keloid scars refer to group 2 and are divided into: keloid scars of earlobes, acne-keloid, extensive keloids, area-limited keloids and keloid disease (spontaneous keloids). We consider the listed variants of keloid scars to be isolated by separate nosological units, since they have peculiarities not only in the clinical picture, but also in the treatment. It should be noted that back in 1869 Kaposi described acne-keloid as an independent disease.

This classification is applicable both to scars of a small area, and to scars of a large area, which can be improved by the first stage with the help of surgical methods.

Scars of a large area, cicatricial contractures. Cicatricial deformations are objects for surgeons. Conditionally, such a pathology can be called "surgical scars". Without the scalpel and the hands of the surgeon, it is impossible to improve the appearance of these scars. But, unfortunately, after the surgical correction there are scars that disturb the patient and which can be improved only with dermatocosmetological means and methods.

Scars that remain after the work of surgeons or for some reason can not be operated by surgeons can be conditionally attributed to the group. So-called, "cosmetic scars" with which dermatologists, dermatologists and cosmetologists should and can work. Most often these are scars, a limited area. Some patients are satisfied with the results of plastic surgery, but most patients would like to further improve the appearance of scars. Such patients turn to dermatocosmetologists, who work with scars further. Figure 1 shows the percentage of patients with different scars that we identified. Of the total number of patients seeking treatment, about 18% is in the proportion of patients with keloid scars, although the percentage of such patients is increasing every year. About 8% for patients with hypertrophic scars, approximately 14% for patients with hypotrophic scars. The majority of patients with normotrophic scars (about 60%) and least of all patients with atrophic scars (about 4%).

[1], [2], [3], [4], [5], [6], [7]