Scar formation is the final part of our body's healing process, but not all scars follow the typical trajectory of fading over time. Some scars remain unstable and frequently break down leading to loss of skin covering over the scar. This in turn may cause pain, functional limitation, and the risk of Marjolin's ulcer, a rare but severe form of skin cancer. In this article, we will explore what unstable scars are, their causes, the impact they have on individuals, the risk of Marjolin's ulcer, and the treatment options available.
I. WHAT IS AN UNSTABLE SCAR?
An unstable scar is a scar that fails to mature and stabilize during the natural healing process. These scars often present ongoing issues, such as frequent breakdown, pain, discomfort, and an unsightly appearance. Unlike stable scars, which gradually fade and become less noticeable, unstable scars remain problematic and can even worsen over time.
The open wounds will cause pain, bleeding, and irritation. Patients will be in long-term need for wound care and be at risk of infection. If left unresolved for a long time, there may be an increased risk of skin cancer developing from the unstable scar (Marjolin's ulcer).
Several factors may contribute to the formation of unstable scars:
1. Poor Wound Care
Neglecting proper wound care, including cleanliness and dressing changes, increases the likelihood of an unstable scar.
2. Deep wounds left to heal by secondary intention
Healing by secondary intention means a wound will be left open (rather than being sutured) and left to heal by itself, filling in and closing up naturally. While this approach is suitable for more superficial wounds (e.g. minor abrasion, minor burn), deep wounds may fail to heal in a stable manner and can result in unstable scars.
3. Poor healing power
Underlying diseases and conditions, e.g. diabetes, venous insufficiency, previous irradiation, may limit the healing power of a patient. Wounds that may heal uneventfully in other patients may result in unstables scars in patients with poor healing power
Unstable scars have a significant impact on individuals, affecting both their physical and emotional well-being:
1. Pain and Discomfort
Unstable scars are often painful, itchy, or sensitive to touch, leading to discomfort that can reduce the quality of life.
2. Functional Impairment
The persistent pain and need for wound care can cause significantly hinder daily activities, work, exercise, and affect one's overall function. Scars near joints are particularly problematic.
3. Psychological Consequences
Living with unstable scars can lead to emotional distress, including anxiety, depression, and diminished self-esteem, especially when these scars significantly alter appearance or daily life.
IV. RISK OF MARJOLIN'S ULCER
Marjolin's ulcer is a rare but aggressive form of skin cancer that can develop within unstable scars or chronic non-healing wounds. It is characterized by the following features:
Marjolin's ulcer accounts for less than 2% of skin cancers and typically arises several years to decades after the initial trauma or scar formation. The recognition of Marjolin's ulcer is essential as early diagnosis and intervention can significantly impact the prognosis. The occurence of a wound on an old scar should always be biopsied.
In the management of unstable scars, surgical treatment options often take center stage, as medical treatments often exhausted already and are generally less effective.
In most circumstances, the surgery involves removing the unstable scar, either partially (only the most problematic parts, especially in large scars) or completely (especially in smaller scars). The procedure has the advantage of providing a histological diagnosis to rule out malignancy, minimizing future scar instability, improve functionality, and overall aesthetics improvement.
The resultant defect may be closed directly or reconstructed with skin grafts or skin flaps. More advanced techniques, e.g. sequential excision or tissue expansion may also be used, but may involve extra procedures and time.
Unstable scars can have a profound impact on individuals, affecting their physical and emotional well-being. The risk of Marjolin's ulcer adds a layer of concern to these unstable scars. Surgical treatments, customized to each patient's specific needs, offer the best chance for improving scar stability, reducing discomfort, and restoring confidence and quality of life. If you are dealing with an unstable scar, consult with a plastic surgeon to explore the most suitable treatment options for your unique situation. With the right care and support, unstable scars need not dictate your overall well-being.