The Psychological Impact of Scars in Children, Part III
The emotional and mental issues that a child can have about a scar are far-reaching and variable. This three-part series of articles has examined the psychological impact of scars in children from a variety of medical problems. The first part of this series focused on scars from dermatologic conditions, and the second was about scars from burns. This third and final installment will focus on scars from other medical and health issues, including accidents, cancer and more.
Children and adolescents experience a multitude of events that are often innocuous, from bumps on the head to scraped knees. There are other events, however, that can be more serious and potentially traumatic. Such events include cancer, surgery and more. These more significant events are also more likely to leave cutaneous scars that may serve as a negative reminder to the child about the inciting event or illness. For some children, these scars — and the role they may play as a reminder of a negative medical event — may lead to psychological distress.
“It’s very common to have scarring on the face from very simple injuries, and then deeper and/or more significant scarring that can happen from more significant trauma such as car accidents, serious bike injuries and dog bites. Dog bites are a very common cause,” explains Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at the University of California, San Diego (UCSD) School of Medicine and Rady Children’s Hospital, San Diego. “Scars can be functionally significant and deforming, and may have tremendous psychological effects beyond their physical injuries. For instance, there can be great emotional trauma from the events of traumatic abuse injuries, or dog attacks, and the scars represent much more than the physical changes.”
According to the literature, several events mentioned by Dr. Eichenfield are the most common causes of injury — and scarring — in children. About half of the dog bites that occur every year happen to a child, and the resulting scars may be significant.1-3 Cancer, which can cause scarring as a result of alopecia, IV lines and medical ports, is estimated to effect between 12,000 and 13,000 children in the United States every year.4-6 Unintentional injuries, which include car injuries and bike accidents, are also a frequent problem that can lead to scars; between 2001 and 2006, more than 55 million unintentional injuries occurred among children between 0 and 19, for an average of 9.2 million per year.7
Figures 1-3, left-right: (1) Dr. Cohen’s daughter was born with esophageal atresia and a tracheoesophageal fistula, requiring surgery. (2) Abdominal scars from Dr. Cohen’s daughter’s surgical procedure and 2 years with a feeding tube. (3) If his daughter becomes concerned, she may be treated, but right now the scar is not bothersome to her.
However, as was demonstrated in the first installment of this series, there is limited data about the psychological impact of scars in children.8 Dermatologists and other healthcare professionals have relied on existing literature about the psychological impact of the condition as it is happening and child development to work with children who have psychological issues that arise from scars.8 While there is slightly more information about the correlation between these other childhood illnesses and issues, the resulting scars and any related psychological issues, there is still a gap in the literature — and, therefore, in practice — about how to address these concerns. As a result, the same approach that is utilized in caring for children with psychological issues about scars from dermatologic conditions and burns — a combination approach with knowledge of the illness and of child development — may also be the best approach for these patients.
The literature consistently shows children are most likely to be the victims of a dog bite.1-3, 9,10 In particular, children between the ages of 5 and 9 are at the highest risk, especially male children.1-2,9 A number of factors are attributed to this, including the fact that children are smaller and therefore in closer proximity to the dog for such an accident, and the rough, hyper way in which children may play with dogs that may confuse the dog and cause it to act roughly in return.1-3,9,10
Dr. Eichenfeld considers dog bites to be a very common cause of scarring in children that can be both functionally significant and deforming and also have psychological impact beyond their physical state. In addition, he explains, the scars have much more significance tied to them than the physical aspect of the scars. One study that took place over 5 years at the Children’s Hospital of Philadelphia in Pennsylvania, described both physical and psychological scars from dog bites as “long-term reminders of these events.”3
Dr. Eichenfield and Dr. Andrew C. Krakowski, an assistant professor at UCSD and Rady Children’s and director of the Kids’ Scar Treatment and Revision (STAR) program at Rady, have treated patients with significant scars from dog bites, burns, oncology procedures and more and have seen a direct, significantly positive correlation between repair of the scars and a change in the child’s psyche.
“We had a young child from about an hour and a half away, in a rural community, who drove down to us — she had been bitten by her own dog on the face,” Dr. Krakowski explains. “She, basically, with tears in her eyes, allowed us to anesthetize her face so that she could have the procedure done, and it was pretty impressive. After the two treatments, she — and, more importantly, I think, her family and friends, who she hadn’t seen on a daily basis — noticed an improvement and commented on the fact that her scars looked better. The patient’s mother said that the child lit up.”
As with some other issues that cause scarring in children, there is limited literature about the psychological impact of scars from cancer. One study that does address this link shows bodily changes were of significant impact for childhood cancer survivors, particularly because they are visible.11 The survivors in this study who underwent surgical treatment called the surgical scars “ugly” and reported hiding the scars when meeting new people.11 Some patients had plastic surgery as a way to hide their scars.11
Two other studies provide limited evidence for the psychological impact of cutaneous cancer scars. Agha and colleagues found scarring from oncological procedures was associated with psychological problems in 15% to 16% of childhood cancer survivors.12 A separate study from researchers in Hungary showed that scar formation following surgical or radiotherapy resulted in psychological problems.13
Unintentional physical injuries in the pediatric population are one of the leading causes of morbidity in the United States.7,14 The lack of literature on the link between scarring and the psychological impact in children, this time in the context of unintentional injuries, continues to be an issue.
“Every day, every dermatologist in the United States deals with scarring, but there is a disconnect between what we’re doing in practice versus what’s in the literature,” explains Bari Cunningham, MD, of the Comprehensive Dermatology Group in Encinitas, CA. “There is a gap, and there’s definitely a need for more understanding and awareness.”
The prevention of unintentional injury in children, however, is a topic that is discussed extensively. The focus is on public health campaigns, in-school interventions and other modalities for reducing these unintentional injuries, although some articles do address the possible psychological implications of these accidents. According to an article in the British Journal of School Nursing, “the psychological scars for children, their families and friends can be long-lasting.”15
Talking to Patients
A one-on-one approach with pediatric patients who are having psychological issues about a scar is one of the most successful approaches to these situations, according to the dermatologists who have worked with these patients.
“Direct engagement in discussions with not only the parent, but also the child, is key,” explains Joel Cohen, MD, FAAD, the director of AboutSkin Dermatology and DermSurgery in Colorado. “Doctor-patient communication plays as important a part, or sometimes an even bigger part, as physical diagnosis. The important thing is to make people feel comfortable with themselves, and, if we can improve the appearance of scars significantly, than I think it’s the right choice to make if the kiddo is really bothered by it.”
There are two themes that overlap from the first and second part of this series: the need to talk directly to the child to ensure that his or her thoughts and feelings are not being misrepresented or misinterpreted by the parent and to be aware that the nature of the injury that led to the scar can significantly influence the child’s resulting issues.8,16
“I try to make it known to the children that, if they aren’t educated about it and they don’t have the verbal tools to explain it, then we have the time to talk about it, and phrase it in a way that they feel comfortable talking about it,” Dr. Cunningham, who is board-certified in both dermatology and pediatric dermatology, explains. “Give them the tools to answer those questions and encourage them to be very upfront about it.”
Talking to pediatric patients in this manner can help the dermatologist make clinical decisions.
“The question comes up of WHEN, or at what age, is it appropriate to treat a child with a laser?” Dr. Cohen explains. “In my mind, it’s when the child becomes very conscious of it and they are also mature enough to understand the treatment. Usually they become more concerned about their scars because other kids start asking about it... And, obviously, these other kids don’t know it’s not the right thing to do. So when a child is very concerned about the appearance of their scar and understands the treatment and the importance of sitting still and following instructions, then we usually go ahead with initiating treatment with various laser modalities (usually starting with non-ablative fractional treatments or pulsed dye laser). I always try to get good photos ahead of time, so that we can document improvement along the way. Like adults, kids do recognize improvement in side-by-side photos and need to start seeing that as a rationale to continue.”
Drs. Eichenfield and Krakowski have treated pediatric patients with scars from a variety of these kinds of conditions who are dealing with related psychological issues. From what they’ve seen, interventions to reduce or eliminate scarring, like laser surgery, correlate directly to an improvement in the child’s psychological wellbeing.
“We have several children who’ve been recovering from congenital surgeries, we’ve had children who have been bitten by dogs on the face, scars from hemangioma surgery, port-a-caths, and the results are translating,” Dr. Krakowski explains. “It’s not an overnight process — this is a marathon and not a sprint. This is not a silver bullet that will remodel overnight. It’s a process that occurs over 6 to 12 months, which, I think, is both a boon and a bane, because what’s happening is real – it just requires the time and the invested interest of those of us in it to see it through from start to end. In that sense, it’s very promising. By addressing the scar, treating it with a number of modalities that we now have — you can make an improvement and see the psyche change as well.”
Dr. Eichenfeld referred back to the child who was treated for the dog bite scars as a great example of this success.
“The child was so happy that she was getting these compliments and that the scar was less noticeable,” he explains. “This is a case of new technology that can really change a life."