Atrophic scar is a connective tissue defect located below the level of a healthy skin. Such a scar has the appearance of an altered depigmented area of the dermis, often with transverse striation, which sinks in comparison with neighboring tissues. The skin above it is thinned. Stretch marks serve as a kind of atrophic scars. Diagnosis is carried out during dermoscopy, if necessary – biopsy. Methods of physiotherapy (ultrasound therapy, phonophoresis), hardware cosmetology (laser, microdermabrasion, needle RF-lifting), injection cosmetology (dermal fillers, lipofilling), chemical peels, etc. are used to correct scars.
ICD 10
L90.5 L90.6
General information
A scar is a section of newly formed connective tissue that occurs on the site of a damaged skin. Skin scars can have different localization, configuration, sizes. Depending on the amount of connective tissue forming them, scar defects are divided into normotrophic, hypertrophic, keloid and atrophic. All skin scars, except normotrophic, are pathological. The latter often have an unaesthetic appearance, cause cosmetic changes in appearance, and therefore the search for methods of correcting scar changes does not stop.
Causes
Atrophic scars occur at the site of deep skin lesions that heal with collagen deficiency. Considering the etiology, the following groups of factors of pathological scarring can be distinguished:
- Acne. Chronic inflammatory process in the dermis, as well as various manipulations (squeezing out pimples, opening comedones with a needle, rough mechanical cleaning, etc.) lead to disruption of reparative processes, pathological scarring. The result of such traumatization of the skin are post-acne scars.
- Infectious diseases. Atrophic scars may remain after the resolution of elements of chickenpox rash, infectious granulomas in syphilis, tuberculosis of the skin, leprosy. Also, “minus-tissue” defects are formed at the site of ulcers, deep pyoderma.
- Burns. Post-burn scars are formed due to chemical, thermal, radiation skin lesions. In addition to a cosmetic defect, they often lead to functional disorders – contractures of the joints.
- A sharp increase in weight. A significant weight gain is accompanied by micro-tears of collagen fibers, as a result of which stretch marks form on the body. Atrophic stripes occur when the skin overgrows during pregnancy, obesity, and Itsenko-Cushing’s disease.
- Other reasons. Atrophic scars may appear at the injection sites of corticosteroids, animal bites, surgical interventions.
Risk factors
Most scarring defects are localized on the face, in the sternum, upper back, shoulders, abdomen, thighs, shins, hands. There are conditions under which atrophic scars are formed many times more often. The formation of pathological elements contributes to:
- long-term (more than 1 year) chronic inflammation;
- additional injury or secondary infection of the wound;
- metabolic disorders: metabolic syndrome, diabetes mellitus, hypoproteinemia, hypovitaminosis;
- individual characteristics (childhood and adolescence, IV-VI phototype of the skin).
Pathogenesis
When the integrity of the skin is violated, a cascade of reparative processes develops aimed at replacing the resulting defect with connective tissue. There are 3 stages in the course of the wound process: inflammation, proliferation, scar formation and organization. Immediately after damage, the destroyed cells secrete active substances that cause vasoconstriction and activation of clotting factors. The formation of a blood clot creates the necessary conditions for subsequent epithelialization of the wound.
In the phase of the inflammatory reaction, cytokines are released, which attract neutrophils, macrophages, phagocytic microorganisms to the wound. Fibroblasts also migrate to the site of injury, which play an important role in the construction of granulation tissue. In the proliferation phase, there is an active synthesis of intercellular substance consisting of glycosoaminoglycans and collagen. New capillaries grow in the wound. The granulation lining is covered with epithelial cells on top. By the end of this stage, a young immature scar is formed. In the future, the number of vessels and cellular elements in the scar tissue is reduced, the connective tissue is compacted, the scar pales.
It is assumed that in the pathogenesis of atrophic scars, the most significant factor is a decrease in the ability of fibroblasts to synthesize collagen and elastin with the preserved synthesis of metalloproteinases (collagenases, elastases) with high collagenolytic and elastinolytic activity. As a result, the processes of collagen degradation prevail over its formation. The wound is not filled with extracellular matrix proteins to the level of surrounding tissues, the scar is tightened in all directions, which leads to the formation of a sinking defect of the dermis.
Classification
In modern dermatology, the classification of atrophic scars based on their depth, width and spatial location, proposed by S. Jacob, has been adopted. According to the listed parameters, there are 3 types of scar defects:
- M-shaped (Rolling). It has the shape of a navicular recess with a width of 5 mm. The skin relief in the scar area is wavy.
- V-shaped (Ice pick). It has the appearance of a narrow (D)
- U-shaped (Boxcar). It has the shape of a rectangular recess that does not taper to the base. Such atrophic scars can be both superficial and deep.
According to the shape, there are point, circular, angular, Z-shaped, mixed atrophic scars. According to the time of occurrence, scarring defects are divided into fresh (up to 1 year) and old (more than a year).
Symptoms
An atrophic scar is a skin defect that falls in relation to the surrounding tissues. The skin covering the scar is thinned, flabby, sometimes with transverse stripes. When squeezed with fingers, it gathers into thin folds resembling tissue paper. Often atrophic scars do not contain pigment, therefore they have a white color. They are formed mainly in places where there is practically no hypoderma (on the face – in the area of the temples, cheekbones, on the legs – on the front surface of the lower leg and the back of the feet, on the hands – in the area of the hands).
Striae are usually localized on the skin of the anterior abdominal wall, mammary glands, and thighs. They are longitudinal strips of thinned skin, slightly retracted into the depths. Fresh stretch marks have a pinkish-bluish color, old ones are pearl-white.
Post-acne scars look like crater-shaped depressions on the skin, giving it an uneven, “pitted” relief. Usually they are multiple, have different sizes and shapes. Favorite localizations are cheeks, forehead, chin. They are often combined with hyperpigmentation, stagnant spots, milium, cysts of the sebaceous glands.
Complications
Scars, especially located on the face and exposed areas of the body, in 10-40% of their owners cause a decrease in self-esteem and psychological adaptation in society, the development of anxiety-depressive symptoms. Changes in the mental sphere in people with post-acne scars are expressed by increased anxiety (85%), self-doubt (78%), isolation (42%), irritability (33%), sleep disorders (5%).
Fixation on a defect often leads to attempts to get rid of it yourself or with the help of unprofessional actions. At the same time, allergic dermatitis, skin infection, the formation of post-traumatic hyperpigmentation, an increase in the depth and area of scarring may be noted.
Diagnostics
As a rule, the diagnosis is made on the basis of clinical data obtained during a consultation with a dermatocosmetologist. When examined under a magnifying glass (dermoscopy), areas of uneven thinned white skin (“minus-tissue”) are found. Histological examination of the biopsy reveals loose fibrous tissue with areas of atrophy and fibrosis, devoid of blood vessels, stretched / torn collagen fibers.
Additional diagnostic methods are not used. Atrophic scars differentiate with other skin defects:
- expanded pores;
- wrinkles;
- hypopigmentation, vitiligo;
- normotrophic scars.
Treatment of atrophic scars
The purpose of treatment is to raise the bottom of the sinking defect and smooth it with the surrounding skin. Physiotherapy, cosmetology, and surgical techniques are used to correct atrophic scars:
- Physical therapy. Methods of physical influence are most effective at the stage of a young scar. Electrophoresis with vitamin and trace element complexes, phonophoresis, laserophoresis with reparants are used to improve trophic processes in the scar tissue area, stimulate collagen formation. Cryomassage and vacuum massage are also performed in the early stages.
- Injection techniques. Mesotherapeutic cocktails with extracts of aloe, placenta, ascorbic acid, nicotinic acid, and homeopathic preparations are injected into the defect area. It is also possible to fill the skin defect with hyaluronic fillers, collagen preparations, autologous fat (lipofilling).
- Laser therapy. It is considered the gold standard for the correction of atrophic scars. Laser beams stimulate collagenogenesis and trigger skin restructuring, allowing you to achieve aesthetically significant results. The most popular procedures are laser resurfacing, fractional photothermolysis.
- Fractional radiolifting. It is a combination of RF therapy and microneedling. It affects the deep dermal layers, contributing to the remodeling of the dermis without significant damage to the epidermis. A good effect on the alignment of atrophic scars was noted in 91% of patients after a single procedure.
- Mechanical and chemical grinding. Mechanical grinding is carried out using dermabrasion, diamond microdermabrasion, microneedling (mesoroller). Of chemical peels, 30% and 70% glycolic, 40-70% pyruvic, 20-35% TCA, 30% salicylic acid are used to correct scar defects.
- Skinbiogeting. Intradermal stimulation consists in separating the scar from the underlying tissues using an injection needle. As a result of the injury, aseptic inflammation develops, as a result of which fibroblasts are activated, additional connective tissue is formed, the bottom of the atrophic scar is leveled.
- Excision of the scar. After excision, a normotrophic scar is formed on the site of an atrophic scar, which is then subjected to mechanical or chemical grinding.
Prognosis and prevention
Small, shallow single atrophic scars are well amenable to correction with the help of modern cosmetic methods. On the contrary, deep extensive defects cannot always be completely eliminated. However, in almost all cases it is possible to achieve an improvement in the condition of the skin and an aesthetically acceptable result.
Prevention of pathological of atrophic scar scarring requires prevention of traumatization of the skin, development of secondary infection, self-treatment. It is necessary to control your weight, eliminate hormonal disorders in a timely manner. It is better to start treatment of atrophic scars in the first 6-12 months after their formation.
