Skin scar preconceptions must be challenged: importance of self-perception in skin scarring

Greater objective scar severity and visibility should intuitively cause greater psychosocial distress for patients. Previous research is contradictory and has employed non-validated scar severity measures whilst neglecting patient-rated severity. The aim of this study was to assess the effects of objective and patient-rated scar severity, scar type and location on psychosocial distress. Skin scars were quantitatively assessed on two independent occasions using the 'Manchester Scar Scale' (MSS) - a validated measure. Scars were scored twice independently. Patients also rated their scars (from 'very good' [zero] to 'poor' [four]) and good completed the Derriford Appearance Scale (DAS24) and Dermatology Life Quality Index (DLQI). Eighty-two patients, with an average+/-SD (range) age of 34+/-15 (16-65) years were recruited. Mean psychosocial questionnaire scores were: DAS24 45.5+/-17.8 (15-91); DLQI 7.5+/-6.7 (0-26). Participants had 1.9+/-1.5 (1-8) scars with an MSS score of 31.3+/-24.0 (6.6-162.0) and subjective score of 2.6+/-1.2 (0-4). Correlation between psychosocial distress and objective severity was not significant (DAS24 0.14 p=0.11; DLQI 0.16 p=0.06). Correlation between psychosocial distress and subjective severity was significant (DAS24 0.48 p<0.0001; DLQI 0.46 p<0.0001). Patients with non-visible scars experienced greater psychosocial distress than patients with visible scars (DAS24 9.7 p=0.046; DLQI 4.2 p=0.014). Scar type was unrelated to psychosocial distress. Patient-rated scar severity and scar visibility are correlated with psychosocial distress rather than clinician's objective severity rating or scar type. Although counter-intuitive, results are consistent with research into other disfiguring conditions and patient self-assessment should therefore form an integral part of clinical assessment.