Scars Formation & Skin Lesions
The human body can sustain a variety of injuries, including penetrating trauma, burn trauma and blunt trauma. All of these insults set into motion an orderly sequence of events that are involved in the healing response, in which the normal functional tissue (skin) is replaced by connective tissue (scar) and the healing response is characterized by the movement of specialized cells into the wound site.
Healing is the complex and dynamic process that results in the restoration of anatomical continuity and function. There are four basic responses that can occur following an injury:
Regeneration (exact replacement) is the elegant process that occurs when there is loss of structure and function but the organism has the sophisticated capacity to replace that structure by replacing exactly what was there before the injury. Lower forms of life, such as the salamander and crab, can regenerate tissues in this manner. As man has evolved, we have lost this capacity and can only replace a limited amount of damaged tissues by the process of regeneration.
Normal repair (reestablished equilibrium), is the response where there is a re-established equilibrium between scar formation and scar remodeling.
Excessive healing (fibrosis and contractures), there is too much deposition of connective tissue that results in altered structure and, thus, loss of function.
Deficient healing (chronic ulcers) is the opposite of fibrosis; it exists when there is insufficient deposition of connective tissue matrix and the tissue is weakened to the point where it can fall apart.
Wounds and Scars
We classify two groups of scars: Mayor and Minor scars.
Among Mayor Scars we include Burn Scars, Keloids and Hipertrophic Scars. As minor scars we include atrophic scars, sun related scars and general scars.
Sun related Scars are Actinic Keratosis, Age spots, and wrinkles.
Finally general scars are razor bumps, razor burns, ingrown hairs and others such conditions.
A burn is always an injury that damages and destroys skin layers on different deep levels, and are caused by exposure to excessive heat (from the sun, hot liquids, flames, hot objects touching the skin), electricity or certain chemicals. Extreme cold can also cause burning.
When tissue is burned, fluid leaks into them from the blood vessels, causing swelling and pain. In addition, damaged skin and other body surfaces are easily infected because they can no longer act as a barrier against invading organisms.
Severity of burns is related with its deepness. A first degree burn is limited to the epidermis. Sometimes referred to as partial thickness burns, second degree burns are characterized as either “superficial” or “deep.” Both types penetrate deeper than a first degree burn and destroy the epidermal layers, extending into the dermis layer. A third degree burn-also known as a full thickness burn destroys all the epidermal and dermal skin layers. All burns leave behind burn scars.
Skin tissue repair results in a broad spectrum of scar types, ranging from a “normal” fine line to a variety of abnormal scars, including widespread scars, atrophic scars, scar contractures, hypertrophic scars, and keloid scars.
Widespread (stretched) scars appear when the fine lines of surgical scars gradually become stretched and widened, which usually happens in the three weeks after surgery. They are typically flat, pale, soft scars often seen after knee or shoulder surgery. Stretch marks (abdominal striae) after pregnancy are variants of widespread scars in which there has been injury to the dermis and subcutaneous tissues but the epidermis is unbreached. There is no elevation, thickening, or nodularity in mature wide-spread scars, which distinguishes them from hypertrophic scars.
Atrophic scars are flat and depressed below the surrounding skin. They are generally small and often round with an indented or inverted centre, and commonly arise after acne or chickenpox.
Scar contractures -scars that cross joints or skin creases at right angles are prone to develop shortening or contracture. Scar contractures occur when the scar is not fully matured, often tend to be hypertrophic, and are typically disabling and dysfunctional (fig 4). They are common after burn injury across joints or skin concavities.
Raised skin scars
Raised skin scars are described as hypertrophic or keloid scars.
Hypertrophic scars are raised scars that remain within the boundaries of the original lesion, generally regressing spontaneously after the initial injury. Hypertrophic scars are often red, inflamed, itchy, and even painful. They typically occur after burn injury on the trunk and extremities.
Hypertrophic scars sometimes are difficult to distinguish from keloid scars histologically and biochemically, but unlike keloids, hypertropic scars remain confined to the injury site and often mature and flatten out over time. Both types secrete larger amounts of collagen than normal scars, but typically the hypertrophic type exhibits declining collagen synthesis after about six months.
Keloid scars are raised scars that spread beyond the margins of the original wound
Keloids scars are thick, puckered, itchy clusters of scars that spread beyond the edges of the wound or incision and invade the surrounding normal skin in a way that is site specific . They are often red or darker than the surrounding skin. Keloids appear when the body continues to produce collagen long after the initial wound healing has taken place.
Ear lobe keloids often grow as large lobules, central sternal keloids commonly develop a butterfly shape, and deltoid keloids tend to extend vertically. A keloid continues to grow over time, does not regress spontaneously, and almost invariably recurs after simple excision. It is difficult to apply the term keloid until a scar has been present for at least a year, although there is no precise time interval. Histologically, keloids have a swirling nodular pattern of collagen fibres.
Scars that are difficult to categorize have been termed intermediate scars. However, if a raised scar is still emerging after a year, a true keloid is a potential diagnosis, whereas hypertrophic scars should show some evidence of regression within this time.
Keloids may be inflamed, itchy, and painful, especially during their growth phase. Common presentations are in the ear lobe after ear piercing, the deltoid after vaccination, and the sternum after acne, chickenpox, trauma, or surgery. Keloids are unique to humans, and there seems to be some genetic predisposition, with dark skinned races being more prone to them, though there are few large epidemiological studies. They develop predominantly in people aged 10 – 30 years, with an apparent predilection for emergence and deterioration during puberty and pregnancy.
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Atrophic scars are characterized by a thinning and diminished elasticity of the skin due to a loss of normal skin architecture. An example of an atrophic scar is striae distensae, also known as stretch marks. Striae commonly occur in postpartum women after childbirth and also during times of larger-than-average weight gain and also in association with steroids. Atrophic scars are sometimes also observed after trauma, infection (acne scars) and disease, and may show loss of surface markings and smoothness or dry, fine wrinkles over time.
Sun Related Scars
Here we can include Actinic Keratosis, Age spots, and wrinkles as a response of excessive sun exposure conditions or damaged.
Actinic keratosis is one of the most common sun-induced pre-cancerous skin lesions and precursor of squamous cell carcinoma as well as basal cell carcinoma.
Individuals with light skin are most likely to develop actinic keratosis. The condition is directly associated to sun exposure, and therefore is sometimes called “solar keratosis”. In fact, fair- skin ned individuals living in sunny climates have over 50 percent chance of developing actinic keratosis. Furthermore, regardless of age, all individuals with blue eyes and or childhood freckling are at a higher risk to develop actinic keratosis.
You shave to make your skin look better -smooth, hair-free, sleek. So the last thing that you want is to whisk the razor over your legs and rise up an ugly red rash. Unfortunately, a lot of women do just that when they shave incorrectly. They slap on soap and quickly shave over it, and end up with chafed, red skin -also known as razor burn.
Razor burn is actually a skin irritation. When you shave, you’re basically peeling off part of your epidermis -the top layer of skin. The redness is a normal response to tissue injury. Blood flow increases to the area to heal the wound, and blood vessels dilate and become red. Razor burn is hard to get rid of. Every time you shave again, you re-irritate your skin.
An Ingrown Hair appears when the end of the hair shaft is cut resulting in a sharpened edge that as it grows, curls back into the same hair follicle and results in an inflammatory response (redness, itchiness, and/or raised infected area).
The hair curls over inside the follicle under the skin (just like the “razor bump” hair curls above the skin). By curling and being trapped, the hair creates a foreign body reaction in the hair follicle, causes inflammation in the follicle and results in a bump.
The most common symptom of an ingrown hair is an inflammation of the skin, followed by pus formation. Each ingrown hair results in a tiny, mildly painful pimple with a barely visible hair curling into the center. It is generally itching, tingling, more or less painful, hard, prominent, and often generates scars in chronic cases.
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