Scabs and Scab-ology 101

Scabs: A word many find a bit repulsive. Plastic surgeon’s scabs are just as repulsive as a scab from any other surgeon and mean the same thing to the patient. There are several things every patient should know about scabs and their causation, so they can be treated appropriately and heal well not affecting the ultimate scar.

First and most important, do not pick scabs. Most people find themselves wanting to pick a dry scab- a normal feeling but try to fight it. Those who cannot seem to fight the urge may have a type of mental disorder related to Obsessive-compulsive Disorder called dermatillomania. A great word for your vocabulary, if you’re into that sort of thing, simply meaning “skin picker.” I guess if you pick compulsively you’re a dermatillomaniac and should consider not having plastic surgery with skin incisions.

A scab can be considered a “blood clot” on the surface of the skin. In other words, if a blood clot was exposed to air it would look something like a scab. They have the same basic components: platelets, fibrin, serum proteins and cellular debris. They are not free-floating, they are, through their fibrin and other protein components, integral to the damaged skin they protect. That is why if you pick your now protective scab off, it will bleed and probably become an infected scab when it reconstitutes itself. There will come a time between three and fourteen days that the skin has healed beneath the scab, but it continues to hang on-barely. It is at this point when professional pickers, such as myself, may remove the scab as it has served its purpose to protect and accelerate wound healing.

The point when the scab naturally separates can be accelerated by keeping the scab surface moist with Vaseline or a Vaseline product called Aquaphor. As a rule, it is best to keep all unhealed skin wounds moist, otherwise they desiccate and are more likely to become infected and leave a visible scar.

Hair-bearing skin represents a unique problem with respect to scabs and wound healing. As plastic surgeons, we rarely shave the hair to make an incision in hair-bearing skin. Rather, we separate the hair away from the scalp incisions in a surgery like a facelift. The problem of scabbing arises when the hair gets into the wound. Our own hair is read by the body as foreign material and reacts accordingly with inflammation and scabbing. If the sutures or staples are kept moist and protected with Aquaphor, the hair is less likely to get in the wound and cause scabbing. When it does, it is best to remove the staples, make sure the hair is out of the wound, remove any scabs and keep the hair out of the healing wound with Aquaphor. I have seen cases of exorbitant scab growth from hair “contamination” of the scalp incision behind the ear. This is rare but may require re-excision of the scar.

When scabs loosen prematurely due to picking or trauma, they may become infected deep to the scab in the wound proper. The scab remains attached but exudes purulent material and is usually reasonably obvious to the clinician. The scab should be debrided into the open wound, cleaned, debrided and left un-sutured. Scheduled dressing changes, antibiotic ointment and oral antibiotics should be given. The wound usually heals within a week or two as long there are no foreign bodies inadvertently left in the wound such as subcutaneous sutures. It can be expected that this part of the incision will not heal as nicely as the rest of the wound and may need revision after six months or so.

One of the important traits of an accomplished scab-ologist is the ability to tell the difference between a scab and congealed blood on the incision and skin. Both blood clots and scabs are made of similar material except the scab emanates from a wound opening and a clot is stuck on top of the skin and should be easily removed with peroxide. Blood clots beneath the skin are the enemy as the cause inflammation and swelling putting pressure on the wound closure. If a superficial clot is spotted early, it can be expressed out the unhealed incision without sequella. Deeper clots may need to wait until the clot is liquefied at a week or so to be aspirated by a large bore needle.

After committing this article to memory, we are now all trained scab-ologists.

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