Scar classification systems

Recommendations

Identify and Treat the Cause
1 NA Level of Evidence
Not Assessed


Address patient-centered Concerns
2 NA Level of Evidence
Not Assessed


Provide Local Burn Care
3 Select a clinical assessment system and use it consistently with burn patients. Level of Evidence
Not Assessed


Provide Organizational Support
4 Educate all raters on the use of the selected system and review subjective interpretation periodically to maximize rater consistency. Level of Evidence
Not Assessed


Background

Maturation of burn scars may take from 18 months to 2 years. Scar maturation is characterized by redness, pigmentation, pain, itching, hypertrophy, retraction and induration. Interventions during maturation can limit functional and cosmetic consequences of scarring. During this stage, assessment of inflammation and scar evolution is necessary to adapt treatments and evaluate treatment effects. Clinical assessment may use a variety of scar assessment scales, which may evaluate different scar characteristics. Scores become more reliable with rater experience and training. The major clinical assessment tools for burn scars are the following:

• Vancouver Scar Scale (VSS): The VSS is also known as the Burn Scar Index. The VSS evaluates vascularity (redness), height (hypertrophy), pliability (contracture and elastic texture) and pigmentation. The VSS has been validated on defined scar areas of 4 cm2, but application of this subjective scale is difficult on large irregular areas where scarring is not homogeneous. Modifications proposed include separate assessments of colour, correlation between VSS and the patient’s subjective opinion and incorporation of a visual analogue scale.

• Visual analogue scale (VAS): The VAS scale rates global aspects of the scar.

• Modified VSS (MVSS): Modifications include use of two colour scales, for Caucasian and Aboriginal patients, to reduce subjectivity of the vascularity scale, and a Plexiglas tool to evaluate height and pigmentation scales. Inter-rater reliability testing found that only total scores should be used because individual subscale scores had inadequate reliability.

• Patient and Observer Scar Assessment Scale (POSAS): POSAS includes the patient opinion; this scale was tested on linear scars. The observer scale includes vascularity, pigmentation, thickness, relief, pliability and surface area, whereas the patient scale assesses pain, itching, colour, stiffness, thickness and relief. Evaluation of this scale determined that the POSAS is a suitable, reliable, appropriate subjective and complete tool for evaluation of linear scars.

• Manchester Scale: The Manchester Scale assesses colour compared with surrounding skin, matte or shiny appearance, contour (flush with surrounding skin to keloid), texture (normal to hard), margins (distinct or not), size and number (single or multiple). At each evaluation, these data are included with others in the Manchester scar proforma, along with a standardized colour photograph.

Despite subjectivity, clinical assessment scales are all useful in daily practice. The VSS may be more suitable for burn scars. Itching and pain are important to include in assessment of scar evolution.

Various technical tools can also be used to assess individual scar parameters more accurately than subjective assessment. Tristimulus colorimeter, durometer, cutometer and tonometer are reliable and easy-to-use tools to assess colour, height, induration, or pliability. In comparison, ultrasound scanners, laser Doppler and 3D analysis are more complicated, expensive and more used for research.

References

Essential Publications
1 Description of Vancouver Scar Scale Quality Indicator
 Type: Scale Description
Baryza MJ, Baryza GA. The Vancouver Scar Scale: An Administrative Tool and Its Interrater Reliability. J Burn Care Rehabil 1995; 16:535-538.
In this article the Vancouver Scar Scale, its validation, and the use of a 3x5 inch plexiglass tool to aid assessment and documentation, are described. The VSS is used to rate burn scares evaluating such variables as vascularity, redness, height, hypertrophy, pliability, contracture and elastic scar texture and pigmentation.
2 Description of Visual Analogue Scale (VAS) Quality Indicator
 Type: Scale Description
Beausang E, Floyd H, Dunn KW, Orton CI, Ferguson MW. A new quantitative scale for clinical scar assessment. Plast Reconstr Surg, 1998; 102: 1954-61.
The VAS is a modified VSS scale that is used to rate global aspects of the scar. This scale requires 3 observes to be reliable. It is easy to use, does not rely on expensive equipment and is applicable to a wide range of scars from well healed surgical scars to problematic hypertorphic and keloid scars. It is thus a useful clinical tool in the evaluation of scar prevention or treatment regimens.
3 Description of Modified Vancuover Scar Scale (MVSS) Quality Indicator
 Type: Scale Description
Forbes- Duchart L, Marshall S, Strock A, Cooper JE. Determination of inter-rater reliability in pediatric burn scar assessment using a modified version of the Vancouver scar scale. J Burn Care Res, 2007; 28: 460-67
The VSS Plexiglas tool was modified using a pictorial color scale to aid with vascularity rating. This study analyzes the inter-rater reliability of the MVSS. Findings indicate that only total scores of the MVSS should be used when determining burn scar outcomes because individual subset scores have little reliability. Further modification of the MVSS and additional research with larger subject population is warranted to improve its clinical usefulness.
4 Description and Validation of Patient and Observer Scar Assessment Scale (POSAS) Quality Indicator
 Type: Validation study
Draaijers LJ, Tempelman FR, Botman YA, Tuinebreijer WE, Middelkoop E, Kreis RW, Van Zuijlen PP. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg, 2004; 113: 1960-5.
The POSAS consists of the observer scale which assesses vascularity, pigmentation, thickness, relief, pliability and surface area and the patient scale which assesses pain, itching, color, stiffness, thickness and relief. The POSAS is an appropriate objective tool for the evaluation of linear scars using patient opinion
5 Validation of Patient and Observer Scar Assessment Scale (POSAS) Quality Indicator
 Type: Validation study
Van der Kar AL, Corion U, Smeulders MJ, Draaijers LJ, Van der Horst CM, Van Zuijlen PP. Reliable and feasible evaluation of linear scars by patient and observe scar assessment scale. Plast Reconstr Surg, 2005; 116: 514-22.
This study assesses POSAS evaluation of 100 linear scars concerning vascularity, pigmentation, thickness, pliability and surface area as well as using a patient scale which examined pain, itchiness, color, stiffness, relief and thickness. The internal consistency of the observer and patient scales was good (=0.96 for observer and =0.94 for patient, p < 0.001). Good agreement was evident as the coefficient of variation of the total score was 10.4% for the observer scale and 15.8% for the patient scale. Based on internal consistency and agreement POSAS is a good objective tool for the evaluation of linear surgical scars.
6 Description of Manchester Scale Quality Indicator
 Type: Scale Description
Bayat A, McGrouther DA, Ferguson MWJ. Skin scarring. BMJ, 2003; 326:88- 92.
The Manchester Scale assesses 7 parameters associated with scars including scar color, skin appearance, contours from flush with surrounding skin to keloid, texture, margin distinction and size. This scale is a useful assessment for localised burns cars, especially for the development of hypertrophic or keloid scars, but does not include an analysis of vascularity.
7 Summary of VSS, VAS, POSAS and Manchester Scale Quality Indicator
 Type: Narrative Review
Roques C, Teot L. A critical analysis of measurements used to assess and manage scars. Lower Extremity Wounds, 2007; 6(4): 249-53.
This review clinical analyses four scar assessment tools, The Vancouver Scar Scale, Visual Analogue Scale, Patient and Observe Scar Assessment Scale and the Manchester Scale. Each scale is different and provides various methods of assessing different scar characteristics. Each scale is easy to use, but subject to errors. The VSS appears to be more suited to burn scars despite being subjective. Overall clinical assessment scales are subjective and each one rates different items useful for scar assessment, making each tool useful in daily practice.


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