Journal of Cosmetic and Laser Therapy

ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: www.tandfonline.com/journals/ijcl20

Scar characteristics and treatment expectations:

A survey of 589 patients

Sung Bin Cho, Dong Jin Ryu, Sang Ju Lee, Jin Moon Kang, Young Koo Kim,
Won Soon Chung & Sang Ho Oh

To cite this article: Sung Bin Cho, Dong Jin Ryu, Sang Ju Lee, Jin Moon Kang, Young Koo Kim,
Won Soon Chung & Sang Ho Oh (2009) Scar characteristics and treatment expectations:
A survey of 589 patients, Journal of Cosmetic and Laser Therapy, 11:4, 224-228, DOI:
10.3109/14764170903341723

To link to this article: https://doi.org/10.3109/14764170903341723

Published online: 01 Dec 2009.

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Journal of Cosmetic and Laser Therapy, 2009; 11: 224–228

ORIGINAL ARTICLE

Scar characteristics and treatment expectations: A survey

of 589 patients

SUNG BIN CHO1, DONG JIN RYU1, SANG JU LEE2, JIN MOON KANG2,
YOUNG KOO KIM2, WON SOON CHUNG2 & SANG HO OH1
1Department of Dermatology and Cutaneous Biology Research Institute,Yonsei University College of Medicine,

Seoul, Korea and 2Yonsei Star Skin & Laser Clinic, Seoul, Korea

Abstract
Background: Scar tissue formation by skin injury is common and patients need treatments for cosmetic or functional
improvement. Objective: To determine the relationship between various characteristics of scars and patients’ treatment
expectations. Methods: The subjects were patients who had one or more scars regardless of their intention for treatment
between August 2007 and February 2008. The survey was conducted using paper forms on patients’ first visits. Results: A
total of 589 patients (mean age 29 years) with various types of scars participated in this survey. Of the causes described
by the patients, trauma was the most common (681 answers), followed by cutaneous diseases (189), and surgery (133).
The treatment history of scars was recorded in 233 patients (39.6%), namely topical agents in 146 (62.7%), laser therapies
in 79 (33.9%), and skin grafts or surgical scar revisions in eight (3.4%). Patients with a treatment history showed a more
prominent expectation for the next treatment outcome (p ⬍ 0.05) and were willing to spend more time on scar treatment
(p ⬍ 0.05). Conclusion: Although it could not play a major role in choosing treatment modalities, treatment expectations
can be significant as a part of a healthy doctor–patient relationship, of which the ultimate goal is always the best outcome
for the patient.

Key Words: Epidemiology, expectation, scar

Background type of prior treatment, treatment expectations, and

patients’ compliance. Selection of an appropriate
Scar tissue formation by skin injury is relatively com-
laser system and treatment protocol can be made
mon. Patients with scars have various complications
only after the patient and the scar have been fully
and emotional problems and need treatments for
evaluated (1). In this study, we highlight the relation-
cosmetic or functional improvement. A variety of
ship between various characteristics of scars and
treatment modalities have been attempted according
patients’ treatment expectations.
to scar characteristics, such as intralesional steroids,
surgical scar revision, cryosurgery, radiotherapy,
pressure therapy, silicone gel sheeting and topical
Methods
silicone gels, pulsed dye laser, carbon dioxide laser,
intense pulsed light, and erbium:YAG laser, with The subjects in this study were 589 Korean patients
variable patient satisfaction (1). The recently intro- with one or more scars regardless of their intention
duced fractional photothermolysis system is also for scar treatment between August 2007 and Febru-
widely used singly or combined with other methods ary 2008. The survey was conducted as a paper ques-
for scar treatment (2,3). tionnaire at patients’ first visits.
When considering laser scar revision, patients The questionnaire consisted of 20 items concern-
should be evaluated based on several factors as sug- ing sex, age, scar characteristics (including cause and
gested by Alster (4), including skin phototype, con- location), treatment history, desire for treatment,
current infection or inflammation, medication in use, amount of improvement expected if treated, duration

Correspondence: Sang Ho Oh, Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, 134
Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea. Fax: 82 2 393 9157. E-mail: [email protected]

(Received 17 March 2009; accepted 13 August 2009)

ISSN 1476-4172 print/ISSN 1476-4180 online © 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/14764170903341723
 Survey on scars 225

of treatment willing to tolerate, and quality of life characteristics and treatment expectations. Duncan’s
influenced by the scar. Concerning the validity of the multiple range tests were used to analyze the relation
study, this survey was conducted without the consul- between questions reflecting quality of life influ-
tation of dermatologists. Also, by this reason, the enced by scars and their causes. Differences were
types of scarring, such as hypertrophic or atrophic considered statistically significant when the p-value
scarring, hypo- or hyperpigmented scarring, and was less than 0.05. Statistical analyses were per-
keloid, were not requested from the participants. For formed with the Statistical Package for the Social
statistical analysis of correlation with other factors, Sciences, version 11.0 (SPSS Inc., Chicago, IL,
patients were additionally categorized by age group- USA).
ings (in years): 0–9, 10–19, 20–29, 30–39, 40–49,
and over 50. Age groups of scar formation were cat-
egorized (in years) as 0–5, 6–15, 16–25, 26–35, and Results
over 36.
Scar characteristics, past treatment, and desire for
Patients were asked to check the most appropri-
treatment
ate cause of the scars (multiple if applicable), of
which the main groups were classified into trauma, Origin of the scar
surgery, and cutaneous diseases. The trauma group A total of 589 Korean patients (Fitzpatrick skin types
was further subcategorized into knife, nail scratch, IV–V) with various scars participated in this survey;
burn, traffic accident, and unspecified causes; sur- 277 (47.0%) were male and 312 (53.0%) were female
gery into cesarean section and others; cutaneous dis- (mean age 29 years; range 5–58 years). Among 589
eases into acne and others such as chickenpox, atopic patients, 289 (49.1%) had solitary causes of scars
dermatitis, and psoriasis. and 300 (50.9%) complex. Of the causes described
Questions about the location of the scar involved by all patients, trauma was the most common (681
the face, scalp, neck, upper extremities, lower extrem- answers: knife 118, 11.8%; nail scratch 118, 11.8%;
ities, anterior trunk, back, and buttocks (multiple burn 111, 11.0%; traffic accident 47, 4.7%; unspec-
locations were all recorded). Responders were asked ified 287, 28.6%), followed by cutaneous diseases
to write the exact location of the scar. The locations (189 answers: acne 178, 17.7%; other cutaneous dis-
of the facial scars were further subcategorized in eases 11 (seven chickenpox, three atopic dermatitis,
order to provide a more detailed profile (again, mul- one psoriasis), 1.1%), and surgery (133 answers:
tiple scars were all checked). For statistical analysis Cesarean section 18, 1.8%; others 115, 11.5%). The
of correlation with other factors, scar location was relationship between the age of onset and origin of
additionally categorized as exposed areas without the scar as well as the origin of the scar according to
seasonal variation (including the face, neck, and sex is summarized in Tables I and II.
scalp), exposed areas to some extent with seasonal
variation (upper and lower extremities), and rela-
tively little exposed areas (anterior trunk, back, and Location of the scar
buttocks). The question of whether the patient had
The frequency of the site of the scar in 589 patients
a strong desire for scar treatment (e.g. a strong desire,
was as follows in decreasing order: lower extremities
moderate desire, little desire, or no desire for treat-
(31.5%), face (30.0%), upper extremities (27.2%),
ment) was also included.
anterior trunk (7.5%), back (2.1%), neck (1.3%),
As a preliminary inquiry for future studies aimed
buttocks (0.2%), and scalp (0.1%). Among 281
at the effect of scarring on quality of life, a few
patients with facial scars, 139 (39.3%) had scars on
selected questions were briefly included in the ques-
the cheeks, 98 (27.7%) on the forehead, 71 (20.1%)
tionnaire: whether patients had experienced fear dur-
on the chin and perioral area, and 46 (13.0%) on the
ing scar exposure or while going outdoors (reflecting
periorbital area.
psychological shrinking); whether the scar influenced
work or school activities; or if scarring influenced
daily activities such as choosing attire (e.g. wearing
Treatment history by sex and scar location
a hat or dark glasses).
Treatment expectation was based on five grading Treatment history of scars including topical agents,
scales: less than 20%, 21–40%, 41–60%, 61–80%, laser therapies, scar revisions, and skin grafts was
and 81–100% (near total improvement). The dura- recorded in 233 patients (39.6%), namely topical
tion that patients were willing to spend on scar ther- agents in 146 (62.7%), laser therapies in 79 (33.9%),
apy was classified into five categories: 1–3 months, and skin grafts or surgical scar revisions in eight
4–6 months, 7 months – 1 year, over 1 year, and over (3.4%). Among 233 patients, the number of females
2 years. with treatment history (47.4%) was significantly
The t-test, Pearson’s correlation analysis, and higher than that of males (30.7%) with statistical sig-
analysis of variance were used to determine the sta- nificance (p ⬍ 0.001).Treatment history was observed
tistical significance of the differences between scar in 52.3% of patients with scars on exposed areas
226 S. B. Cho et al.

Table I. Relationship between age of onset and origin of scar. Table II. Origin of scar according to sex.

Age of onset Male Female

(year) Number (%) Origin of scar Number (%) Origin of scar Number (%) Origin of scar
0–5 17 (30.4) Burn 143 (29.7) Trauma of 144 (27.3) Trauma of
13 (23.2) Trauma of unspecified causes unspecified unspecified
10 (17.9) Nail scratch causes causes
8 (14.3) Surgery (except c/s) 79 (16.4) Knife 110 (21.1) Acne
4 (7.1) Cutaneous disease 68 (14.1) Acne 79 (15.1) Nail scratch
3 (5.4) Knife 63 (13.1) Surgery 55 (10.6) Burn
1 (1.8) Traffic accident 56 (11.6) Burn 52 (10.0) Surgery
(except c/s)
6–15 112 (37.7) Trauma of unspecified causes
39 (8.1) Nail scratch 39 (7.5) Knife
42 (14.1) Knife
31 (6.4) Traffic accident 18 (3.5) Cesarean
36 (12.1) Acne
section
33 (11.1) Nail scratch
3 (0.6) Other 16 (3.1) Traffic
33 (11.1) Burn
cutaneous accident
23 (7.7) Surgery (except c/s)
disease
16 (5.4) Traffic accident
8 (1.5) Other
2 (0.7) Cutaneous disease
cutaneous
16–25 119 (27.9) Acne disease
110 (25.8) Trauma of unspecified causes c/s, Cesarean section.
57 (13.3) Nail scratch
51 (11.9) Knife
39 (9.1) Burn
30 (7.0) Surgery (except c/s)
16 (3.7) Traffic accident 0.001). There were also statistically significant differ-
5 (1.2) Cutaneous disease
ences among age groups; in particular, patients
26–35 44 (25.1) Trauma of unspecified causes between 0 and 19 years old showed more desire to
38 (21.7) Surgery (except c/s) be treated than those between 30 and 39 years.
23 (13.1) Acne Patients with treatment history showed signifi-
19 (10.9) Knife
cantly more desire for treatment compared to those
16 (9.1) Burn
15 (8.6) Nail scratch without treatment history (p ⬍ 0.001). Patients with
12 (6.9) Traffic accident scars on exposed areas without seasonal variation
8 (4.6) Cesarean section (including the face, neck, and scalp) expressed the
strongest desire to be treated, followed by those with
36+ 16 (33.3) Surgery (except c/s)
10 (20.8) Cesarean section scars on exposed areas with seasonal variation (upper
8 (16.7) Trauma of unspecified causes and lower extremities) and non-exposed areas (ante-
6 (12.5) Burn rior trunk, back, and buttocks). The desire for scar
3 (6.3) Nail scratch treatment was significantly correlated with the degree
3 (6.3) Knife
of exposure of the scar (p ⬍ 0.001).
2 (4.2) Traffic accident

c/s, Cesarean section.

Influence of scars on quality of life (preliminary
survey)
Psychological shrinking
without seasonal variation (including the face, neck, Among 589 patients, 217 (36.8%) had some fear
and scalp), 38.2% with scars on exposed areas with about scar exposure to others and 93 (15.8%) were
seasonal variation (upper and lower extremities), and exceedingly afraid of scar exposure. The rest (279
13.2% with scars on non-exposed areas (anterior patients; 47.4%) did not show concern about scar
trunk, back, and buttocks). Patients with exposed exposure. Sex, age, and location of the scar were not
scars had more frequent history of past treatment correlated with the degree of fear of scar exposure to
(p ⬍ 0.001). others.
Most patients (479; 81.3%) did not think that
their scars had an influence on going outside. A total
Desire for scar treatment according to treatment history
of 94 patients (16.0%) answered that they avoided
and scar location
going outside to some degree due to their scars and
Among 589 patients, 205 (34.8%) showed no desire 16 (2.7%) especially avoided going outdoors. This
for treatment, 132 (22.4%) had a strong desire, 131 result was proven to be influenced by sex, age, and
(22.2%) had a moderate desire, and 121 (20.5%) location of the scar (p ⬍ 0.001). Patients with acne
had little desire. Female patients had significantly scars were more affected when it came to going out-
more desire to be treated compared to males (p ⬍ doors than those with other scars.
 Survey on scars 227

Limitations on working activities Female patients showed significantly higher expecta-

tions than males (p ⫽ 0.004). However, treatment
Most patients (479; 81.3%) did not think that their
expectations were not influenced by age or cause of
scars influenced their work or school. Ninety-four
the scar.
patients (16.0%) had trouble with employment or
Patients with scars on exposed areas including
school activities to some extent because of the influ-
the face, neck, and scalp had higher expectations
ence of their scars and 16 (2.7%) had great trouble.
compared to those with scars on other locations
This result was proven to be influenced by sex and
(p ⫽ 0.01). Those with treatment history showed
location of the scar (p ⬍ 0.001), but not age. Patients
higher expectation rates for new treatments com-
with acne scars were more limited in getting a job or
pared to those without treatment history (p ⫽ 0.02).
school activities compared to those with other
The treatment expectations were mutually correlated
scars.
with desire for treatment (p ⫽ 0.01). The effects of
various factors on treatment expectations were
Discomfort on lifestyle summarized in Figure 1.

Scarring influencing daily activity such as choosing

attire (including wearing a hat or dark glasses) was Time investment
reported by 160 patients (27.2%), and 39 (6.6%)
The number of patients willing to spend 1–3 months
stated that they had great limitations in choosing
on scar therapy was 338 (57.4%), 4–6 months was
clothes. Scars did not influence dress in the rest (390
157 (26.7%), 7–12 months was 65 (11.0%), over 1
patients; 66.2%). This result was proven to be influ-
year was 18 (3.0%), and over 2 years was 11 (1.87%).
enced by sex (female participants were proven to be
Patients with experience with non-surgical scar man-
more influenced, p ⬍ 0.001) but not age or location
agement at dermatology clinics were more willing to
of the scar. The origin of the scar, particularly with
undergo long-term management compared to other
Cesarean section scars, influenced patients – espe-
patients (p ⬍ 0.001). This result was proven to be
cially when choosing clothes.
influenced not by sex, age, and location of the scar
but by the origin of the scar, especially scars from
Treatment expectations and time investment traffic accidents and burns.
Those with treatment history were willing to
Treatment expectations spend more time on scar treatment compared to
Among 589 patients, 337 (57.2%) expected 81–100% those without treatment history (p ⬍ 0.001). Patients’
improvement, 211 (35.8%) 61–80%, 29 (4.9%) desire for treatment was mutually correlated with
41–60%, eight (1.4%) less than 20%, and four time willing to spend on treatment (p ⬍ 0.001).
(0.7%) 21–40%. These findings were more remark- However, there was no relation between treatment
able in patients having experience with non-surgical expectations and duration of treatment patients were
management at dermatology clinics (p ⬍ 0.001). willing to undergo.

Figure 1. Flowchart summarizing the effects of various factors on treatment expectations.

228 S. B. Cho et al.

Discussion that all patients with any scarring were allowed to

participate in our survey, not just patients with plans
For decades, patients had been informed that little
to have scar treatment. This was done to eliminate as
could be done about their scars and that they had to
much patient bias as possible. Also, a large number
accept their appearance (5). Today, patients are get-
of attendances had replied that the scars did not have
ting up-to-date information about the available
an influence on choosing their attire. This could have
modalities for scar treatment through various media,
been influenced by the fact that many patients had
such as advertisements, television, the Internet, mag-
acne scars, located on the face, which were not influ-
azines, and newspapers, but many think that nothing
enced by dress attire.
can be done and will accept even a slight improvement
The results of our study are preliminary because
of their scars (5). However, exaggerative advertise-
it was only designed to evaluate the general charac-
ments and information from non-professional sources
teristics of the scars and patients’ treatment expecta-
can influence patients’ treatment expectations and
tions regardless of their purposes for visiting our
may even result in impractical expectations. Treat-
clinic. However, our results showed that patients with
ment expectations are usually based on patients’ hope,
treatment history were willing to invest more time on
which usually becomes more realistic or lowered after
scar treatment and had higher expectation rates for
explaining all the treatment modalities and possible
the next treatment outcome compared to those with-
outcomes. In this study, the survey was conducted
out treatment history. These results could have been
during patients’ first visit, and before consulting the
influenced by the patients’ practical understanding
dermatologists in our clinic, in order to raise the valid-
of the course of the treatment and active attitude
ity of the report. Because it seems that laser therapy is
during treatments.
not capable of achieving complete scar removal, rather
Although it could not play a major role in choos-
it can improve scar quality, Alster and Zaulyanov (1)
ing treatment modalities, treatment expectations can
emphasized that patients should have practical expec-
be significant as a part of a healthy doctor–patient
tations when undergoing laser scar revision.
relationship, of which the ultimate goal is always the
In this study, female patients presented the char-
best outcome for the patient.
acteristics of (i) a relatively higher proportion of acne
and nail scratch scars, (ii) having previous treatment
history, (iii) having a strong desire to receive therapy, Declaration of interest: The authors report no
(iv) being more influenced by scars when going out- conflicts of interest. The authors alone are respon-
doors, getting a job, or choosing attire, and (v) higher sible for the content and writing of the paper.
treatment expectations compared with male patients.
However, there was no statistically significant differ-
ence in avoiding exposure of scars and their willing- References
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to male patients. Although there were statistically Surg. 2007;33:131–40.
significant relations between age groups and their 2. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser
desire for treatment, we could not give much value photothermolysis for the treatment of atrophic scars. Dermatol
Surg. 2007;33:295–9.
to this result due to the differences between the num-
3. Glaich AS, Rahman Z, Goldberg LH, Friedman PM. Frac-
bers of attendances according to each age group. tional resurfacing for the treatment of hypopigmented scars:
Moreover, the replies of patients in the 0–9-year-old A pilot study. Dermatol Surg. 2007;33:289–94.
group might reflect the opinions of their parents. 4. Alster TS. Laser treatment of scars and striae. In: Alster TS,
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PA: Lippincott-Raven; 2000. p. 89–107.
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intended for future studies, they revealed that a rela- silicone gel elastomers in the treatment of hypertrophic scars,
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influence their daily lives. This results from the fact Plast Surg. 2007;31:495–500.