Almost all people will have a scar somewhere on their body. But because most scars are not disturbing, they tend not to draw any attention. For larger scars that are obvious, problems may arise. Large, but also sometimes small scars can have traumatising effects on the patient. It is astonishing how many misinterpretations can be observed from both patients as well as from doctors. In the Western culture we tend to see scars as ugly. But in other cultures people like intentionally elicited scars (cicatrix). In many rural tribes scars are marks of honour or decoration. It is an honour to be marked for life. For German naval cadets this is still in use (Mensur).

Keloid tattoos (cicatrix) applied as decoration in many African tribes


If only the upper layer of the skin is damaged, e.g. in case of surface grazes, there may be no scar at all after the healing process has finished. In the coloured skin we often see that the skin shows a darker or lighter colour. This is mostly genetically determined. More about this you can read in the chapter Skin Discolourations.

Scars and collagen

Scars are made of scarring tissue that exists for the greater part of connective tissue (collagen). Following accidental laceration wounds and surgical scars it can be often observed that after 10 to 30 days the wounds starts to show signs of hypertrophy or keloid formation. The pathological examination of these wounds using a microscope shows that fibroblasts in the scar have an unstructured non-organized growth pattern.

Electron-microscopy carried out by M. van der Bergh-Weerman and K. Dingemans, Academic Medical Centre, Amsterdam.
Histopathology by: R.J. van Suylen, Academic Hospital Maastricht.

Types of scars

Disfiguring scars can develop as a consequence of wounds and surgical procedures. There are different types of scars:

Hypertrophic scars - hard and thick, sometimes painful, raised above its border, often coloured, white or reddish.

Very painful hypertrophic-keloidal scar after 7 surgical procedures and several steroid injections (skin type A I – after Fitzpatrick skin typing)

Very painful hypertrophic-keloidal scar after laceration of the epidermis (coloured skin type) – patient tends easily to keloid formation

Red hypertrophic-keloidal scar after an accident and surgical treatment

Hypertrophic scars and discolourations after removal of tattoos by plastic surgery. It’s almost impossible to obtain good results in these cases due to large tension in the skin.

Hypertrophic scars, discolourations and hyperpigmentations after tattoo removal by plastic surgeons.

Atrophic scars - these types of scars are generally the least disfiguring. They can mostly be observed between the hairs e.g. on the scalp of people with a negroid or asiatic origin. The scar tissue is soft, supple, flexible and shiny. If the scars are large, they can be reduced by plastic surgery to a small line; other treatments are not recommended.

Automutilation by the patient using glass

Atrophic scar after thorax surgery 1 week after removal of the stitches: Edula® Ointment once daily under occlusion (Tegaderm® or clingfilm / Fixomull®) for 6 months; the picture was taken after 1 year follow-up.

Atrophic scar after surgery of the forearm: 1 week after removal of the stitches: Edula® Ointment once daily under occlusion (Tegaderm® or clingfilm / Fixomull®) for 6 months; the picture was taken after 1 year follow-up

Keloid - this is a special type of hypertrophic scar, it consists of very hard and thick tissue, often very painful and red coloured. Keloids grow over the margins of the wounds and can involve very large areas of the skin. The skin of the chest, shoulders, upperarms and ears are the most common places where keloids can develop. This happens often spontaneously after an accident or surgery. In about 70% of the people with a dark skin keloids develop spontaneously after damaging the skin. In fair skinned people this is only about 4%. This tendency to spontaneous keloid formation is often genetically determined and sometimes hereditary.

Keloid developed after removal of warts with liquified nitrogen applications

Keloid spontaneously developed after thorax surgery; there was no follow-up treatment

Keloid spontaneously developed after damaging the skin (scratching of a little itching wound)