Observations of burn scars sustained by atomic bomb survivors; a preliminary study

A relatively high incidence of scar keloid and hypertrophic scar formation of a severe degree has occurred after healing of flash burns that probably were of deep second or third degree severity and in a people (Japanese), some of whom perhaps have a predisposition for the development of scar keloids. At this late date, the lack of complete, detailed, continuous studies and records on a large group of cases dating from the time of the occurrences of the injury and the large number of variables to be considered render impossible a complete evaluation and understanding of scar keloid formation. The inadequate treatment, poor nutrition, high incidence of severe infection and delayed healing should be considered as important contributing factors which affected the healing process to result in a high incidence of severe keloid or excessive scar formation. Scar keloids were found to occur in Japanese sustaining burns from other causes than the atomic bomb explosion. It would seem most probable that the scar keloids represent no peculiar effect of the atomic bomb explosion. Furthermore, it seems probable that a similar incidence of occurrence of scar keloids could have occurred in burns of the same severity from any other cause under similar conditions during the healing of the lesions in patients having the same general state of health.One gains the impression that the pathogenesis of keloids can be completely explained only by a better understanding of the detailed biophysical and biochemical processes which occur in the healing of skin lesions and how the initial conditions and possible later alterations in these steps influence the final result of the reparative process. Some individuals may be so constituted that they have a tendency to develop excessive amounts of scar tissue in the healing of wounds. The factors involved in the etiology of keloids are probably multiple.It is difficult to arrive at a differentiating working definition of scar keloids. It seems most probable that the differences between ordinary non-elevated scars, hypertrophic scars and scar keloids are only those of degree of amount of fibrous connective tissue produced during the healing process. From clinical data, histologic observations of various types of excised scars and reported experimental studies of the regeneration of skin in man, it would appear that the excess collagen production causing scar keloids and hypertrophic scars occurs when the lesion extends deep in the reticular layer of the dermis and, therefore, occurs usually in burns which extend to this depth initially, or later as a result of necrosis caused by infection or additional trauma. The necessity for early grafting of full thickness burns is again demonstrated. The necessity of preparation for the early care of burns in great numbers of casualties in the event of a catastrophe such as an atomic bombing of a populated area is obvious.