There are different types of scars, including mature and immature normotrophic scars, hypertrophic scars, keloids, contractures, and Marjolin's ulcers. Each type of scar has its own specific characteristics and the best ways to prevent and treat them. For all scars, it is important to start treatment immediately after a burn injury to prevent scar contractures and reduce long-term effects.

Mature and immature normotrophic scars

As soon as the wound has healed, the maturation phase starts. In normal scar formation, an immature scar forms first.

Immature scars:

Are red

May be flat or a little elevated

Can be itchy

After a period of several months to years, the pink color fades to a pale scar; a hypo-pigmented area remains with a slightly altered skin pattern, forming a mature scar. It can take years for the skin to completely recover, sometimes to a (near) normal appearance.

Hypertrophic scar

Scar formation in hypertrophic scars is excessive, but it does not extend beyond the borders of the original wound. A hypertrophic scar starts developing after wound healing, and progression stops at its maximum about six months after injury. 

A hypertrophic scar:

Is heavily swollen and red

May show contraction

Has an irregular surface

Is itchy and can be painful

Regression of this type of scar is slow, and it may take years for the red color and itching to diminish. The scar can remain irregular, widened and elevated.

Keloid

Keloid is excessive scar formation that extends beyond the borders of the original wound. It may start to develop shortly after wound healing, but it can occur up to a year later. The major risk factors for keloid are ethnicity (people with dark skin tones and Asian populations) and age (20-30 years).

Keloids most commonly occur in scars on the ear lobe, shoulders and sternal notch. Simple surgical excision of a keloid is rarely recommended because it has high recurrence rates with new keloids that may become even worse. An optimal treatment has not yet been developed.

Contractures

Scars have the tendency to contract, especially when located around joints or other areas where the mobility of the skin is essential for the function of body parts (e.g. eye, mouth, genitals). The deformity that remains after scar contraction is often accompanied by a limited range of movement (ROM) and is defined as a ‘contracture’.

Scar contractures can cause considerable limitations to daily life. Surgical treatment by ‘contracture release’ is often indicated to improve function and quality of life.

Marjolin’s ulcer

A Marjolin’s ulcer is a cutaneous malignancy that arises from areas of longstanding scars and chronic wounds, for example at the site of an old burn scar. In most instances, biopsied lesions demonstrate well- differentiated squamous cell carcinomas (SCC) but they can also be basal cell tumors or melanomas.

Marjolin’s ulcers:

Are aggressive 

Have a poor prognosis with a high rate of recurrence 

Can be prevented by adequate (burn) wound treatment

Adequate treatment requires a multidisciplinary approach. We strongly advise to check the hospital protocol for the treatment of SCCs (e.g. additional investigations and therapeutic options) or consult a specialist if you suspect a Marjolin’s ulcer.