Scars are generally described as fibrous tissue areas that replace normal skin after some of the dermis is destroyed. A deep scar is one that is associated with damage to the epidermal and dermal skin layers, resulting in limitation of motion.

Scars may be a result of wound healing after injury or trauma, burns (thermal, radiation, electrical, or chemical), surgical procedures, lacerations, or less commonly, diseases including skin conditions.

Manifestations of the condition depend on the underlying cause. Initially, a scar is usually red or purple and, with time, it becomes white and glistening. Pain may be present when a superficial nerve is involved and the end of a nerve becomes bulbous. Scars can result in limitation of motion due to the depth of tissue injury and the amount of collagen laid down during the final phase of wound healing. If too much collagen is deposited, and it extends beyond the boundaries of the original injury, hypertrophic, keloidal, or cicatricial scars may develop. Examples of scar tissue include, but are not limited to the following types:

• Hypertrophic – An elevated, large, red, and hard scar that occurs when the body produces excess collagen tissue. This type of scar remains confined to the wound edges and regresses in time. Hypertrophic scars are similar to keloid scars since both are thick, red and raised. They remain within the boundaries of the original wound and improve on their own usually over the course of a year or so. Healing is helped by applying topical steroids or injections of steroids.

• Keloid – Keloid scars are shiny, hard and raised scar with an overproduction of scar tissue due to abnormal amounts of collagen deposit. This overgrowth forms in the skin following trauma or surgical incision, and is due to abnormal amounts of collagen deposit. Keloids commonly appear on the anterior chest, upper back, and deltoid regions. The areas may become tender and cause contractures because the tissue extends beyond the wound edges and assumes a tumor-like mass. Keloids are permanent without any tendency to subside, are more prone to develop in Blacks, Hispanics, and Native Americans and may recur after excision. Keloids occur in a small percentage of Whites.

• Cicatrix – A scar left by a healed wound that lacks color, is less elastic than normal tissue, and possibly causes a contracture that requires skin grafting.

Physical examination alone is usually adequate to diagnose many skin disorders including scars. However, if the underlying cause is disease or burns, diagnostic studies may have to be conducted to further evaluate the condition. Additional studies may include microscopic examinations, and culture and sensitivity tests. Areas affected may be outlined on a diagram to determine the extent of body surface involvement.

The extent of treatment depends on the amount of body surface area affected. Corticosteroid injections into the scar have been effective in some patients to shrink hypertrophic scars and keloids. In addition, surgical or laser therapy have been used to remove the scars, as well as specific medications that interrupt collagen development. Silicone gel (Sialastic) sheeting applied for 12 to 24 hours a day for two months has been found to prevent and treat hypertrophic scars and keloids. Finally, skin grafting may be used to cover imperfections from burns, trauma, or surgery, and to release severe contractures. Physical therapy may be necessary to preserve or improve range of motion.

Scars following skin disorders or surgery are usually noticeable and disfiguring, causing body image disturbances, which may require counseling. Deep scars may also prevent normal joint mobility and limit function.

• To properly evaluate disability, accurate measurements of scar size/area, and limitations in motion (if applicable), must be available.

• Unretouched color photographs can be helpful in determining extent or severity of disfigurement where appropriate. . When an examination report indicates that photographs have been taken of a scar or skin condition, consider the photographs when evaluating the condition.

• A deep scar is one associated with underlying soft tissue damage.

• For severe burn scars that have resulted in contractures with limitation of motion, consider entitlement to ancillary benefits.

• For the purposes of DCs 7801 and 7802, the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. Use midaxillary line to divide the anterior trunk from posterior trunk.

• A separate evaluation may be assigned for each affected zone of the body under this diagnostic code if there are multiple scars, or a single scar, affecting multiple zones of the body. Combine the separate evaluations under 38 CFR 4.25. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under the diagnostic code.