title: Current tools for noninvasive objective assessment of skin scars.
abstract: BACKGROUND
  Cutaneous scarring is affected by genetic, physiologic, and biochemical factors. These produce a continuum of scar types (i.e., keloid, hypertrophic, atrophic, contracted, and fine line) that can be symptomatic, aesthetically unsatisfactory, psychologically distressing, and functionally restrictive to the affected individual. Accurate scar assessment allows for quantification of scar evolution and management, and is key to evaluating the effectiveness of applied modulating therapies and treatments. Numerous objective instruments exist for the evaluation of different scar characteristics, but no consensus has been reached as to the most appropriate device. This review aims to explore the current range of noninvasive objective assessment tools available for cutaneous skin scarring, with specific emphasis on their application to research trials and clinical practice.
  
  
  METHODS
  An extensive search of the literature was completed to assemble comprehensive data surrounding the objective assessment of skin scars by both validation studies and clinical trials.
  
  
  RESULTS
  A wide range of tools exist to monitor cutaneous scar physical characteristics. Primarily, there are four parameters explored by these instruments: (1) color, including pigmentation and vascularity (e.g., laser Doppler); (2) surface area (e.g., three-dimensional scanning); (3) height/depth (e.g., ultrasonography); and (4) pliability (e.g., tonometry). Many studies appraise single instruments in specific scar patient groups with subjective comparator tools.
  
  
  CONCLUSIONS
  There is no overall valid and reliable noninvasive objective assessment tool for measurement of cutaneous skin scar characteristics. Further studies are warranted that compare multiple, parameter-specific instruments in a single-sample group and across a range of scar types.
authors.affiliation: Manchester, United Kingdom From Plastic and Reconstructive Surgery Research, School of Translational Medicine, Manchester Interdisciplinary Biocenter, University of Manchester, and the Department of Plastic and Reconstructive Surgery, Manchester Academic Health Science Center, University Hospital of South Manchester Foundation Trust, Wythenshawe Hospital.
authors.forename: Donna M
authors.initials: DM
authors.lastname: Perry
authors.forename: Duncan A
authors.initials: DA
authors.lastname: McGrouther
authors.forename: Ardeshir
authors.initials: A
authors.lastname: Bayat
mesh_terms: D002921:Cicatrix / Q000473:pathology*; D003880:Dermatology / Q000379:methods; D006801:Humans; D012867:Skin / Q000473:pathology*
references.citation: Bayat A, McGrouther DA, Ferguson MW. Skin scarring. BMJ. 2003;326:88–92.
references.citation: Sund B, ed. New Developments in Wound Care. London: PJB Publications; 2000.
references.citation: Gangemi EN, Gregori D, Berchialla P, et al. Epidemiology and risk factors for pathologic scarring after burn wounds. Arch Facial Plast Surg. 2008;10:93–102.
references.citation: Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic burn scars: Analysis of variables. J Trauma 1983;23:895–898.
references.citation: Bombaro KM, Engrav LH, Carrougher GJ, et al. What is the prevalence of hypertrophic scarring following burns? Burns 2003;29:299–302.
references.citation: Dedovic Z, Koupilova I, Brychta P. Time trends in incidence of hypertrophic scarring in children treated for burns. Acta Chir Plast. 1999;41:87–90.
references.citation: Spurr ED, Shakespeare PG. Incidence of hypertrophic scarring in burn-injured children. Burns 1990;16:179–181.
references.citation: Kischer CW. The microvessels in hypertrophic scars, keloids and related lesions: A review. J Submicrosc Cytol Pathol. 1992;24:281–296.
references.citation: Idriss N, Maibach HI. Scar assessment scales: A dermatologic overview. Skin Res Technol. 2009;15:1–5.
references.citation: Bayat A, McGrouther DA. Clinical management of skin scarring. Skinmed 2005;4:165–173.
references.citation: Bayat A, McGrouther DA. Spectrum of abnormal skin scars and their clinical management. Br J Hosp Med (Lond.) 2006;67:527–532.
references.citation: Broughton G II, Janis JE, Attinger CE. The basic science of wound healing. Plast Reconstr Surg. 2006;117:12S–34S.
references.citation: Roh TS, Rah DK, Park BY. The fetal wound healing: A review. Yonsei Med J. 2001;42:630–633.
references.citation: McGrouther DA. Hypertrophic or keloid scars? Eye (Lond.) 1994;8:200–203.
references.citation: Ferguson MW, Whitby DJ, Shah M, Armstrong J, Siebert JW, Longaker MT. Scar formation: The spectral nature of fetal and adult wound repair. Plast Reconstr Surg. 1996;97:854–860.
references.citation: Lau JC, Li-Tsang CW, Zheng YP. Application of tissue ultrasound palpation system (TUPS) in objective scar evaluation. Burns 2005;31:445–452.
references.citation: Sullivan T, Smith J, Kermode J, McIver E, Courtemanche DJ. Rating the burn scar. J Burn Care Rehabil. 1990;11:256–260.
references.citation: Nedelec B, Correa JA, Rachelska G, Armour A, LaSalle L. Quantitative measurement of hypertrophic scar: Interrater reliability and concurrent validity. J Burn Care Res. 2008;29:501–511.
references.citation: McOwan CG, MacDermid JC, Wilton J. Outcome measures for evaluation of scar: A literature review. J Hand Ther. 2001;14:77–85.
references.citation: Oliveira GV, Chinkes D, Mitchell C, Oliveras G, Hawkins HK, Herndon DN. Objective assessment of burn scar vascularity, erythema, pliability, thickness, and planimetry. Dermatol Surg. 2005;31:48–58.
references.citation: Li-Tsang CW, Lau JC, Liu SK. Validation of an objective scar pigmentation measurement by using a spectrocolorimeter. Burns 2003;29:779–784.
references.citation: Murison M, James W. Preliminary evaluation of the efficacy of dermatix silicone gel in the reduction of scar elevation and pigmentation. J Plast Reconstr Aesthet Surg. 2006;59:437–439.
references.citation: Serup J, Agner T. Colorimetric quantification of erythema: A comparison of two colorimeters (Lange Micro Color and Minolta Chroma Meter CR-200) with a clinical scoring scheme and laser-Doppler flowmetry. Clin Exp Dermatol. 1990;15:267–272.
references.citation: Taylor S, Westerhof W, Im S, Lim J. Noninvasive techniques for the evaluation of skin color. J Am Acad Dermatol. 2006;54:S282–S290.
references.citation: Cotton S. A Non-invasive Imaging System for Assisting in the Diagnosis of Malignant Melanoma. Birmingham, Ala: University of Birmingham; 1998.
references.citation: Westerhof W. CIE colorimetry. In: Serup J, Jemec GBE, eds. Handbook of Non-Invasive Methods and the Skin. Boca Raton: CRC Press; 1995:385–397.
references.citation: Andreassi L, Flori L. Practical applications of cutaneous colorimetry. Clin Dermatol. 1995;13:369–373.
references.citation: Draaijers LJ, Tempelman FR, Botman YA, Kreis RW, Middelkoop E, van Zuijlen PP. Colour evaluation in scars: Tristimulus colorimeter, narrow-band simple reflectance meter or subjective evaluation? Burns 2004;30:103–107.
references.citation: Takiwaki H, Serup J. Measurement of color parameters of psoriatic plaques by narrow-band reflectance spectrophotometry and tristimulus colorimetry. Skin Pharmacol. 1994;7:145–150.
references.citation: van Zuijlen PP, Angeles AP, Kreis RW, Bos KE, Middelkoop E. Scar assessment tools: Implications for current research. Plast Reconstr Surg. 2002;109:1108–1122.
references.citation: Van den Kerckhove E, Stappaerts K, Fieuws S, et al. The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring. Burns 2005;31:696–702.
references.citation: Takiwaki H, Overgaard L, Serup J. Comparison of narrow-band reflectance spectrophotometric and tristimulus colorimetric measurements of skin color: Twenty-three anatomical sites evaluated by the Dermaspectrometer and the Chroma Meter CR-200. Skin Pharmacol. 1994;7:217–225.
references.citation: Brandt MG, Moore CC, Conlin AE, Stein JD, Doyle PC. A pilot randomized control trial of scar repigmentation with UV light and dry tattooing. Otolaryngol Head Neck Surg. 2008;139:769–774.
references.citation: Kono T, Ercocen AR, Nakazawa H, Nozaki M. Treatment of hypertrophic scars using a long-pulsed dye laser with cryogen-spray cooling. Ann Plast Surg. 2005;54:487–493.
references.citation: Nedelec B, Correa JA, Rachelska G, Armour A, LaSalle L. Quantitative measurement of hypertrophic scar: Intrarater reliability, sensitivity, and specificity. J Burn Care Res. 2008;29:489–500.
references.citation: Dusch M, Schley M, Rukwied R, Schmelz M. Rapid flare development evoked by current frequency-dependent stimulation analyzed by full-field laser perfusion imaging. Neuroreport 2007;18:1101–1105.
references.citation: Leung KS, Sher A, Clark JA, Cheng JC, Leung PC. Microcirculation in hypertrophic scars after burn injury. J Burn Care Rehabil. 1989;10:436–444.
references.citation: Davey RB, Sprod RT, Neild TO. Computerised colour: A technique for the assessment of burn scar hypertrophy. A preliminary report. Burns 1999;25:207–213.
references.citation: Roques C, Teot L. A critical analysis of measurements used to assess and manage scars. Int J Low Extrem Wounds 2007;6:249–253.
references.citation: van Zuijlen PP, Angeles AP, Suijker MH, Kreis RW, Middelkoop E. Reliability and accuracy of techniques for surface area measurements of wounds and scars. Int J Low Extrem Wounds 2004;3:7–11.
references.citation: Young SR, Ballard K. Wound assessment: Diagnostic and assessment applications. Part 2. In: Kitchen S, ed. Electrotherapy: Evidence Based Practice. London: Churchill Livingstone; 2001:308–312.
references.citation: Mahajan AL, Tenorio X, Pepper MS, et al. Progressive tissue injury in burns is reduced by rNAPc2. Burns 2006;32:957–963.
references.citation: de Oliveira GV, Sanford AP, Murphy KD, et al. Growth hormone effects on hypertrophic scar formation: A randomized controlled trial of 62 burned children. Wound Repair Regen. 2004;12:404–411.
references.citation: van Zuijlen PP, Vloemans JF, van Trier AJ, et al. Dermal substitution in acute burns and reconstructive surgery: A subjective and objective long-term follow-up. Plast Reconstr Surg. 2001;108:1938–1946.
references.citation: Taylor B, McGrouther DA, Bayat A. Use of a non-contact 3D digitiser to measure the volume of keloid scars: A useful tool for scar assessment. J Plast Reconstr Aesthet Surg. 2007;60:87–94.
references.citation: Ardehali B, Nouraei SA, Van Dam H, Dex E, Wood S, Nduka C. Objective assessment of keloid scars with three-dimensional imaging: Quantifying response to intralesional steroid therapy. Plast Reconstr Surg. 2007;119:556–561.
references.citation: Teot L. Clinical evaluation of scars. Wound Repair Regen. 2002;10:93–97.
references.citation: Fong SS, Hung LK, Cheng JC. The cutometer and ultrasonography in the assessment of postburn hypertrophic scar: A preliminary study. Burns 1997;23(Suppl 1):S12–S18.
references.citation: Van den Kerckhove E, Staes F, Flour M, Stappaerts K, Boeckx W. Reproducibility of repeated measurements on post-burn scars with Dermascan C. Skin Res Technol. 2003;9:81–84.
references.citation: Timar-Banu O, Beauregard H, Tousignant J, et al. Development of noninvasive and quantitative methodologies for the assessment of chronic ulcers and scars in humans. Wound Repair Regen. 2001;9:123–132.
references.citation: Hambleton J, Shakespeare PG, Pratt BJ. The progress of hypertrophic scars monitored by ultrasound measurements of thickness. Burns 1992;18:301–307.
references.citation: Covington JS, Griffin JW, Mendius RK, Tooms RE, Clifft JK. Measurement of pressure ulcer volume using dental impression materials: Suggestion from the field. Phys Ther. 1989;69:690–694.
references.citation: Nedelec B, Shankowsky HA, Tredget EE. Rating the resolving hypertrophic scar: Comparison of the Vancouver Scar Scale and scar volume. J Burn Care Rehabil. 2000;21:205–212.
references.citation: Sawada Y. A method of recording and objective assessment of hypertrophic burn scars. Burns 1994;20:76–78.
references.citation: Cleary C, Sanders AK, Nick TG. Reliability of the skin compliance device in the assessment of scar pliability. J Hand Ther. 2007;20:232–237.
references.citation: Truong PT, Abnousi F, Yong CM, et al. Standardized assessment of breast cancer surgical scars integrating the Vancouver Scar Scale, Short-Form McGill Pain Questionnaire, and patients' perspectives. Plast Reconstr Surg. 2005;116:1291–1299.
references.citation: Nguyen DQ, Potokar T, Price P. A review of current objective and subjective scar assessment tools. J Wound Care 2008;17:101–102, 104–106.
references.citation: Rodrigues L. EEMCO guidance to the in vivo assessment of tensile functional properties of the skin: Part 2. Instrumentation and test modes. Skin Pharmacol Appl Skin Physiol. 2001;14:52–67.
references.citation: Spann K, Mileski WJ, Atiles L, Purdue G, Hunt J. The 1996 Clinical Research award: Use of a pneumatonometer in burn scar assessment. J Burn Care Rehabil. 1996;17:515–517.
references.citation: Corica GF, Wigger NC, Edgar DW, Wood FM, Carroll S. Objective measurement of scarring by multiple assessors: Is the tissue tonometer a reliable option? J Burn Care Res. 2006;27:520–523.
references.citation: Lye I, Edgar DW, Wood FM, Carroll S. Tissue tonometry is a simple, objective measure for pliability of burn scar: Is it reliable? J Burn Care Res. 2006;27:82–85.
references.citation: Rennekampff HO, Rabbels J, Reinhard V, Becker ST, Schaller HE. Comparing the Vancouver Scar Scale with the cutometer in the assessment of donor site wounds treated with various dressings in a randomized trial. J Burn Care Res. 2006;27:345–351.
references.citation: Draaijers LJ, Botman YA, Tempelman FR, Kreis RW, Middelkoop E, van Zuijlen PP. Skin elasticity meter or subjective evaluation in scars: A reliability assessment. Burns 2004;30:109–114.
references.citation: Pierard GE, Letawe C, Dowlati A, Pierard-Franchimont C. Effect of hormone replacement therapy for menopause on the mechanical properties of skin. J Am Geriatr Soc. 1995;43:662–665.
references.citation: Barel AO, Courage W, Clarys P. Suction method for measurement of skin mechanical properties: The Cutometer. In: Serup J, Jemec GBE, eds. Handbook of Non-Invasive Methods and the Skin. Boca Raton: CRC Press; 1995:335–340.
references.citation: Pederson L, Jemec GBE. Mechanical properties and barrier function of healthy human skin. Acta Derm Venereol. 2006;86:308–311.
references.citation: Pedersen LK, Jemec GB. Plasticising effect of water and glycerin on human skin in vivo. J Dermatol Sci. 1999;19:48–52.
references.citation: Pedersen L, Hansen B, Jemec GB. Mechanical properties of the skin: A comparison between two suction cup methods. Skin Res Technol. 2003;9:111–115.
references.citation: Serup J, Northeved A. Skin elasticity in localized scleroderma (morphoea): Introduction of a biaxial in vivo method for measurement of tensile distensibility, hysteresis, and resilient distension of diseased and normal skin. J Dermatol. 1985;12:52–62.
references.citation: Boyce ST, Supp AP, Wickett RR, Hoath SB, Warden GD. Assessment with the dermal torque meter of skin pliability after treatment of burns with cultured skin substitutes. J Burn Care Rehabil. 2000;21:55–63.
references.citation: Murray BC, Wickett RR. Correlations between Dermal Torque Meter, Cutometer, and Dermal Phase Meter measurements of human skin. Skin Res Technol. 1997;3:101–106.
references.citation: Bartell TH, Monafo WW, Mustoe TA. A new instrument for serial measurements of elasticity in hypertrophic scar. J Burn Care Rehabil. 1988;9:657–660.
references.citation: Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel for the prevention and treatment of hypertrophic scar. Arch Surg. 1991;126:499–504.
references.citation: Ballou SP, Mackiewicz A, Lysikiewicz A, Neuman MR. Direct quantitation of skin elasticity in systemic sclerosis. J Rheumatol. 1990;17:790–794.
references.citation: Schabauer AM, Rooke TW. Cutaneous laser Doppler flowmetry: Applications and findings. Mayo Clin Proc. 1994;69:564–574.
references.citation: Moncrieff M, Cotton S, Claridge E, Hall P. Spectrophotometric intracutaneous analysis: A new technique for imaging pigmented skin lesions. Br J Dermatol. 2002;146:448–457.
references.citation: Tehrani H, Moncrieff M, Philp B, Dziewulski P. Spectrophotometric intracutaneous analysis: A novel imaging technique in the assessment of acute burn depth. Ann Plast Surg. 2008;61:437–440.
references.citation: Junger M, Arnold A, Zuder D, Stahl HW, Heising S. Local therapy and treatment costs of chronic, venous leg ulcers with electrical stimulation (Dermapulse): A prospective, placebo controlled, double blind trial. Wound Repair Regen. 2008;16:480–487.
references.citation: Gerger A, Hofmann-Wellenhof R, Samonigg H, Smolle J. In vivo confocal laser scanning microscopy in the diagnosis of melanocytic skin tumours. Br J Dermatol. 2009;160:475–481.
references.citation: Nouveau-Richard S, Monot M, Bastien P, de Lacharriere O. In vivo epidermal thickness measurement: Ultrasound vs. confocal imaging. Skin Res Technol. 2004;10:136–140.
references.citation: MacDermid JC, Walton DM, Law M. Critical appraisal of research evidence for its validity and usefulness. Hand Clin. 2009;25:29–42.
references.citation: Falanga V, Bucalo B. Use of a durometer to assess skin hardness. J Am Acad Dermatol. 1993;29:47–51.
references.citation: Cheng W, Saing H, Zhou H, Han H, Peh W, Tam PK. Ultrasound assessment of scald scars in Asian children receiving pressure garment therapy. J Pediatr Surg. 2001;36:466–469.