A topic of significant discussion among internet-based support groups for burn survivors is the so-called “hidden burn”. Hidden burns are generally defined as the physical scars that can be covered with clothing. There is a strong voice that insists survivors with visible burns experience worse psychological trauma than those with hidden burns. Proponents believe that visible scars elicit a range of negative reactions from the general public, resulting in a social shunning. Self-image and body-esteem are therefore affected more harshly and the overall quality of life is worse. Reconstruction work to the head, neck and hands is also trickier and generally requires more surgeries. Longer and more frequent hospitals stays are known to have a detrimental effect on the psyche. While these anecdotal arguments seem to be valid, they do raise the question of whether the hypothesis can withstand empirical investigation.

Improving the survival rate of burn victims was the major focus during the latter half of the 20th Century. Now that so many seriously burned persons are surviving, consideration is finally being given to the inherent emotional issues in order to improve their functional quality of life. Research into the psychological effects felt by burn survivors has only seriously been undertaken during the past several years, so there is a dearth of material to examine. A mere 761 combined hits were elicited from a Google search for the terms “hidden burns” and “hidden scars”. Approximately 75 journal articles were reviewed that contained research relevant to the hypothesis: Do visible scars result in a greater psychological burden that hidden burns?

The term “hidden burns”, which appears to be something of a misnomer, needs to be addressed first. Not all burns result in scars. First and second-degree burns generally do not significantly scar if properly treated. However, even burns that do not leave obvious marks can result in psychological and physiological damage. Perhaps the term “hidden burns” would better describe the numerous changes that are secondary to a burn. These include, among others, damage to the nervous system, hypothalamus and psyche. Therefore, the term “ hidden burn” will be replaced with “non-visible”.

John Lawrence and James Fauerbach have completed a fair amount the pertinent research over the last few years. A team that they led published some interesting finding in 2004. There was evidence of a statistically significant, albeit it quite low, correlation between burn visibility and the social and emotional adjustment variables. They also failed to find strong relationships between the same variables with either scar visibility or severity indexes. They did, however, find that visible scarring correlated to stronger perceived stigmatization. The Visible and Non-Visible subject groups shared a similar prevalence of post-event depression. Lastly, the burn characteristics themselves (location, severity and T.B.S.A.) were found to account for approximately 20% of the aggregate emotional impact caused by burns. This was an extension of their 2003 work that found neuroticism was the most important factor in predicting Post-Traumatic Stress Disorder. They also determined that burn characteristics are less important than social and emotional variables in determining body esteem among burn survivors. The team’s 2005 study holds that rates of physical recovery are slowed by larger psychological burdens and psycho-social recovery is slower as well.

P.C. Esselman studied community integration after burn injuries. Martial status and social support were the most significant predictors of success, considerably more important than scar characteristics. Size, location and extent of the burn were only found to have a statistically significant impact on employment productivity. No discernible difference has been found between visible and non-visible scars in relation to self-reported Quality of Living (Cochran, 2004). One recent study (Meyer, et al., 2004) illuminates the impact of scars in one particular concealable area. Young adult females who suffered chest burns experienced more externalizing issues. The team of scientists led by Martin in 2003 had an interesting finding. Most burn survivors reported that the appearance of their scars visibly improved over a period of 18 months. However, they did not believe that others noticed the improvement. Baker’s 1996 research discovered that patients with more critical burns tended to recover better emotionally than ones with less serious burns. Of the visible body parts, only the hands were proven to have a greater psychological impact than non-visible wounds and even this finding was due to the stress of more difficult recuperations.

No reliable evidence exists to support the theory that visible scars are more emotionally traumatic than non-visible ones. Studies consistently prove that the location of scars is not a significantly affective variable. In fact, the only population that experiences greater psychological trauma in connection to scar location and size are the parents of children who are burnt. Mothers of children (Rizzone, 1994) with more visible and/or larger scars emotionally suffer much more. Adults who are burnt theoretically have a firmer self-image, while children are more susceptible to negative social influences. It would be interesting to assess the role that the mothers’ issues play in determining their children’s perception. Perhaps children and adult childhood survivors, whose parents left a negative perception, are the main defenders of the stated hypothesis.

There are a few valid explanations for the lack of a significant difference in the psychological burden between visible and non-visible scar burn survivors. One theory is that persons with visible scars are forced to deal with the disfigurement, grieve the loss and adapt to the new image. Persons who purposely hide their wounds would live in fear of discovery and might never effectively deal with the scars. This conviction holds that while visible and non-visible survivors experience different forms of psychological burden, the total emotional affect is equal in terms of burden. The visible vs. non-visible debate also fails if the scars are not covered. Many burn survivors are proud of their wounds and have sufficiently adjusted to the point that they don’t hide them. Therefore, their concealed scars are made as visible as those of people who cannot hide them. Another fact is that psychological trauma is rife among the burn community. Research consistently pegs the rate of emotional issues across the entire spectrum as being in the 70% range, with no real difference between the moderate or worse sub-groups. A decent majority of new burn survivors, regardless of size, location, age or sex will experience obvious psychological issues two years post-event. It is interesting to note that approximately half of all burn survivors had pre-existing psychological issues before the injuring event and as many as 10% of all critical burns were self-inflicted.


A review of the current research fails to prove that visible scars present a greater emotional burden. Scars are scars and all have a powerful impact. The most consistent variable in effectively adapting to the post-burn reality is social support. Time and again, clinical papers have shown that social support factors have a more powerful upshot on the emotional healing of burn survivors and impact on physical functioning. The victims that have successfully acclimated are survivors who are more prone to becoming “burn thrivers”. These people have ascended to the point that the visibility of their scars is no longer a consistent or stable factor. It is obvious that the focus on the psycho-social aspect of recovery must be maintained and the fruits of these efforts translated into developing programs that will provide the necessary supportive resources. More effort has to be funneled into developing positive psycho-social interventions that help survivors accept the physical effects, functionally recover, overcome the plethora of issues and build a strong, effective support system.

Mike Hodgkinson