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What is a Scar?
Body's natural way of repairing skin and other tissues after an injury (such as from a cut, burn or, surgery)
Is primarily made up of collagen
Collagen is fiber-like structure that rebuilds the damaged area by holding connective tissue together
Collagen is functional, but not identical to the original skin or tissue it replaces
The collagen fibers change overtime, in a process called remodeling/scar remodeling
What is Scar Remodeling?
Is the last stage of wound healing
Initial scar tissue transforms into a more organized and stronger scar
What happens:
There is an increase in the crosslinks between collagen fibers
These crosslinks are what make the collagen fibers more organized and dense
The early stage collagen (type III) gets replaced by stronger, more mature collagen (type I)
The type I collagen forms densely packed, parallel fibers that make up the final scar tissue
The collagen fibers align along tension lines
Arrange in the same direction as the natural pull or stretch in the skin
Scar tissue becomes less flexible (Stretches about 15% of its original length, compared to normal skin which stretches up to 50% of its original length)
Scar tissue becomes more strong (80% stronger than normal skin)
However, if this process goes wrong, it can lead to abnormal scarring that is in further sections below
Scars tissue cannot be "destroyed", but scar tissue can change shape over time, allowing for greater range of motion and function if a scar is affecting a joint
In summary, scar remodeling is the final stage of healing where collagen fibers are reorganized and strengthened, improvising the tissue's strength and function
How Scars Tie Into Hand Therapy
Scars can lead to joint stiffness
The buildup of collagen can create tightness, limiting range of motion in affected joints
Scars can impact sensory function
Scars can affect sensation, especially if they are near nerve endings
Can cause numbness, tingling, or hypersensitivity
After surgery or an injury, it is important for scars to be monitored and treated
Through scar mobilization, stretching, and silicone gel sheets
Orthoses may be fabricated in some cases to protect the scar tissue as it heals and improve joint mobility
Types of Scars
Scars can be classified as either "mature" or "immature"
Mature scars can then be further classified as either:
Normal
Atrophic
Hypertrophic
There can also be a presence of keloid scars in a mature or immature scar
Immature scars:
Scar that is still in the early stages of healing and remodeling
Appearance: Typically pink, raised, and exhibit erythema (redness) due to increased blood flow and collagen formation
Ridge present (from edema and collagen forming)
May be itchy or painful
Collagen accumulation peaks around 3 weeks after injury
Collagen fibers in immature scars are loosely organized and oriented randomly
Scar is not as strong as mature scar
Immature scar phase typically lasts a few months after an injury or surgery
Cicalderm. Different Types of Scars. https://cicalderm.com/en/different-types-of-scars/.
Mature scars:
Final stage in the healing process after an injury or surgery
The scar undergoes changes from when it is an immature scar to being a mature scar
Appearance:
White or hyperpigmented
Flat
Due to edema resolving
No erythema (redness) present
Due to inflammatory processes subsiding over time
Collagen fibers are more organized compared to immature scar
Collagen fibers are more densely packed, more cross-linked, and align along lines of tension (increases the scar's tensile strength and reduces its thickness)
Can take several months to a year or longer for an immature scar to become a mature scar
Scar reaches maximum strength in around 6 months, but remodeling continues for years so elasticity of the scar can improve even after significant time since the initial injury
Reminder that mature scars can be further classified as either normal, atrophic, or hypertrophic (discussed below)
Cicalderm. Different Types of Scars. https://cicalderm.com/en/different-types-of-scars/.
Normal scars:
Flat
White or hyperpigmentated (darker than surrounding skin)
No itching present
Collagen fibers are arranged in multiple directions, making the scar more stiff
Cicalderm: Different Types of Scars. https://cicalderm.com/en/different-types-of-scars/.
Atrophic scars:
Is sunken or depressed below the surface of the surrounding skin
Occur from a reduction in collagen formation or a decrease in inflammation during healing
Causes the scar to become thinned or sunken
There is a chance for an atrophic scar to form when a scar is transitioning from an immature to mature scar
Are permanent but appearance can potentially be improved
Wikipedia. Atrophic scar of Ehlers-Danlos syndrome. https://en.wikipedia.org/wiki/Scar#/media/File:Atrophic_scar_of_Ehlers_Danlos_syndrome.jpg.
Hypertrophic scars:
Grow within the borders of the wound
Are usually thick and raised
Are often red compared to the surrounding normal skin
Generally permanent, but tend to improve more naturally over time compared to keloid scars
Verywell Health. Hypertrophic Scar. https://www.verywellhealth.com/hypertrophic-scar-7104196.
Keloid scars:
Grow at the ends of a wound but extend beyond the actual borders of the wound
Are thick, rounded, and irregular clusters of scar tissue
Often red or darker compared to the surrounding normal skin
May form months to years after the injury/surgery
Is formed from excessive collagen production during the healing process
Generally permanent, but their appearance can potentially be improved
Jobskin. Understanding Keloid Scars. https://www.jobskin.co.uk/understanding-keloid-scars.
Scar Adherence
Scar adherence is the way the scar tissue adheres/binds/sticks to surrounding structures, such as muscles, tendons, or bones
The less scar adherence, the better as it will allow greater mobility and function in the area affected by the scar
Mild adherence:
Scar tissue is slightly attached to the underlying tissues
Allows for some movement and gliding over the underlying structures
Minimal restriction in movement, less likely to cause significant functional issues
Moderate adherence:
Scar is more firmly attached to the underlying tissues
Leads to noticeable restriction in movement
Greater loss of mobility, especially in joints or tissues near the scar
Scar mobilization is important to change the shape of the adhesions
Severe adherence:
Scar tissue is firmly bound to the underlying tissues
Causes severe loss of movement in the area
Can result in functional impairment
Great importance of scar mobilization to change the shape of the adhesions
Quiz Questions
1. What is the primary structural component of scar tissue?
A. Elastin
B. Collagen
C. Keratin
D. Fibronectin
2. What is a key feature of mature scars compared to immature scars?
A. Elevated temperature and redness
B. Ridge formation due to edema
C. Loose collagen arranged randomly
D. Densely packed collagen aligned along tension lines
3. Why can scar tissue near joints restrict range of motion?
A. It pulls on surrounding ligaments
B. It increases joint fluid pressure
C. It is less flexible and stretches only ~15% of its original length
D. It weakens muscle contraction strength
4. Which of the following describes a hypertrophic scar?
A. Sunken below the surrounding skin
B. Raised and confined within the original wound borders
C. Flat and blends with surrounding skin
D. Thick scar that spreads far beyond the injury site
5. What is a key difference between hypertrophic and keloid scars?
A. Hypertrophic scars are darker in color than keloids
B. Keloid scars extend beyond the original wound borders
C. Keloid scars form sooner than hypertrophic scars
D. Hypertrophic scars cannot improve over time
6. Which type of scar adherence is most likely to cause functional impairment?
A. Mild adherence
B. Moderate adherence
C. Severe adherence
D. Elastic adherence
7. When does collagen accumulation peak after an injury?
A. 1 week post-injury
B. Around 3 weeks post-injury
C. 2 months post-injury
D. During the remodeling stage
8. Which description best fits an immature scar?
A. Pink, raised, with erythema and a ridge
B. Flat, white, and well-aligned fibers
C. Sunken with loss of tissue
D. Thick and extends beyond wound border
Quiz Answers
B
D
C
B
B
C
B
A
References
Jeschke, M. G., Wood, F. M., Middelkoop, E., Bayat, A., Teot, L., Ogawa, R., & Gauglitz, G. G. (2023). Scars. Nature Reviews Disease Primers, 9(1), 1–16. https://doi.org/10.1038/s41572-023-00474-x
Mustoe, T. A. (2020). International scar classification in 2019. In L. Téot, T. A. Mustoe, E. Middelkoop, & G. G. Gauglitz (Eds.), Textbook on Scar Management: State of the Art Management and Emerging Technologies. Springer. http://www.ncbi.nlm.nih.gov/books/NBK586057/
Scars. (n.d.). https://www.hopkinsmedicine.org/health/conditions-and-diseases/scars
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