Wednesday, September 8, 2010

Scar Scales and Measuring Devices

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

In clinical practice, scars are most often evaluated simply by the patient and surgeon’s subjective assessments of color (redness, traumatic tattooing, faded since last assessment, etc) and physical qualities (adherent, depressed, flat, raised, texture, etc).   The patient may comment that the scar is painful or itchy. 
Some objective measurements such as length and width can easily be made and compared over time.  Thickness is a bit trickier to easily measure without specialized tools.
I recently stumbled over a review article of the scales and measuring devices used for scar assessment on Medscape (full reference below).  Most, I admit, I have never seen or used as I am not an academic plastic surgeon.  The article is a nice review.  While it may help me better understand research articles I read, I doubt it will change how I assess scars in my practice.
Scar-measuring devices used for objectively measuring certain scar traits:
  • Pneumatonometer uses pressure to objectively measure skin pliability. It is composed of a sensor, a membrane, and an air-flow system that measures the amount of pressure needed to lock the system.  Most commonly used to measure intra-ocular pressure.
  • Cutometer is a noninvasive suction device that has been applied to the objective and quantitative measurement of skin elasticity.  It measures the viscoelasticity of the skin by analyzing its vertical deformation in response to negative pressure.   (photo credit)
  • Durometer measures tissue firmness by applying a vertically directed indentation load on the scar.   It was originally described for use in scleroderma.
Tools developed to objectively measure scar color use spectrophotometric color analysis to calculate erythema and melanin index.  These devices include:
  • Chromameter (Minolta, Tokyo, Japan)
  • DermaSpectrometer (cyberDERM, Inc, Media, PA, USA)
  • Mexameter (Courage-Khazaka, Cologne, Germany)
  • Tristimulus colorimeter

  • Ultrasound scanners, such as the tissue ultrasound palpation system (TUPS) --   “TUPS was found to demonstrate a moderate correlation in terms of reliability.  TUPS does have drawbacks, however, in that it requires technical training and experience in image interpretation and is relatively expensive compared to other modalities.”

Three-dimensional Topography
Three-dimensional systems may be attractive for their ability to capture scar surface characteristics with high definition and reproducibility, but their expense makes them more applicable to research than in my office.
  • 3-dimensional optical profiling system (Primos imaging) made by GFMesstechnik (Germany)

Scar scales are subjective measurements used to quantify scar appearance.   The article mentions 5 scar scales that are currently used and were originally designed to assess subjective parameters in an objective way.  All of these scar scales are observer-dependent.  Scales are best used to determine change within an individual rather than between individuals.
  • The Vancouver Scar Scale (VSS) --  first described by Sullivan in 1990.  It assesses 4 variables: vascularity, height/thickness, pliability, and pigmentation. Patient perception of his or her respective scars is not factored in to the overall score.
  • Manchester Scar Scale (MSS)  -- proposed in 1998. It assesses and rates 7 scar parameters: scar color (perfect, slight, obvious, or gross mismatch to surrounding skin), skin texture (matte or shiny), relationship to surrounding skin (range from flush to keloid), texture (range normal to hard), margins (distinct or indistinct), size (<1 cm, 1–5 cm, >5 cm), and single or multiple.  
  • Patient and Observer Scar Assessment Scale (POSAS) -- includes subjective symptoms of pain and pruritus and expands on the objective data captured in the VSS.   It consists of 2 numerical numeric scales: The Patient Scar Assessment Scale and the Observer Scar Assessment Scale. It assesses vascularity, pigmentation, thickness, relief, pliability, and surface area, and it incorporates patient assessments of pain, itching, color, stiffness, thickness, and relief. The POSAS is the only scale that considers subjective symptoms of pain and pruritus, but like other scales it also lacks functional measurements as to whether the pain or pruritus interferes with quality of life.
  • Visual Analog Scale (VAS) -- is a photograph-based scale derived from evaluating standardized digital photographs in 4 dimensions (pigmentation, vascularity, acceptability, and observer comfort) plus contour. It sums the individual scores to get a single overall score ranging from "excellent" to "poor." It has demonstrated high observer reliability and internal consistency when compared to expert panel evaluation, but it has shown only moderate reliability when used among lay panels.
  • Stony Brook Scar Evaluation Scale (SBSES)  --  was proposed in 2007.  It is a 6-item ordinal wound evaluation scale developed to measure short-term cosmetic outcome of wounds 5 to 10 days after injury up to the time of suture removal. It incorporates assessments of individual attributes with a binary response (1 or 0) for each, as well as overall appearance, to yield a score ranging from 0 (worst) to 5 (best).  It was designed to measure short-term rather than long-term wound outcomes. 

A Review of Scar Scales and Scar Measuring Devices; Regina Fearmonti, MD; Jennifer Bond, PhD; Detlev Erdmann, MD, PhD; Howard Levinson, MD; Posted: 08/24/2010; ePlasty. 2010;10:e43 © 2010 Open Science Company
The Vancouver Scar Scale: An Administrative Tool and Its Interrater Reliability;  Baryza MJ, Baryza GA.; J Burn Care Rehabil 1995; 16:535-538.
A new quantitative scale for clinical scar assessment;  Beausang E, Floyd H, Dunn KW, Orton CI, Ferguson MW.;  Plast Reconstr Surg, 1998; 102: 1954-61
The Patient and Observer Scar Assessment Scale: a reliable and feasible tool for scar evaluation; Draaijers LJ, Tempelman FR, Botman YA, et al.;  Plast Reconstr Surg. 2004;113:1960–65.
Visual Analogue Scale scoring and ranking: a suitable and sensitive method for assessing scar quality?; Duncan JAL, Bond JS, Mason T, et al.;   PRS. 2006;118(4):909–18.
Development and validation of a novel scar evaluation scale.;  Singer AJ, Arora B, Dagum A, et al.;  Plast Reconstr Surg. 2007;120(7):1892–7

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