Mpox (monkeypox) is a viral illness recognized for causing a distinctive and potentially widespread rash. The skin lesions are a major concern, and scarring is a frequent outcome of mpox. The severity and likelihood of permanent marks are highly variable, depending on the individual and the characteristics of the lesion. Understanding how the virus affects the skin is the first step in managing expectations for long-term recovery.
The Progression of Monkeypox Skin Lesions
The development of the mpox rash follows a characteristic, staged evolution that determines the eventual risk of scarring. The lesions typically begin as macules (flat, discolored spots) before progressing into papules (small, raised bumps). These then become vesicles (small blisters filled with clear fluid), and finally pustules (firmer, deep-seated bumps filled with opaque, yellowish fluid).
The pustular stage, which can last five to seven days, is often accompanied by a central depression known as umbilication. Scarring is most likely during this phase because the lesion depth involves the dermis, the layer beneath the epidermis. The final stage is the formation of scabs or crusts, which last for one to two weeks before they naturally fall off and the skin begins to heal.
Factors Determining Scar Severity
Whether a lesion results in a noticeable scar is largely determined by the depth of the tissue destruction. Lesions confined to the epidermis heal without permanent textural change. However, the characteristic deep, firm nature of mpox lesions often means the infection extends into the dermis or even the subcutaneous tissue, leading to tissue loss that must be replaced by fibrotic, or scar, tissue.
Trauma to the lesions significantly increases the risk and severity of scarring. Scratching or picking at the lesions disrupts the healing process and extends tissue damage. This secondary injury can lead to more pronounced marks, frequently resulting in pitted or atrophic scars, which appear depressed below the surrounding skin.
Another major factor is the development of a secondary bacterial infection, or superinfection, within the lesions. When the skin barrier is compromised by the virus, bacteria can enter, leading to complications like cellulitis. The resulting increased inflammation and deeper tissue destruction cause more severe scarring, including the potential for hypertrophic scars, which are raised and thickened. Lesions in certain areas, such as the genital region and the face, also have a higher propensity for developing scars.
Managing Lesions to Minimize Scarring
Preventing permanent scarring is primarily focused on minimizing additional trauma and infection during the acute phase of the illness. The most important action is strict avoidance of scratching, picking, or manually removing scabs, as this is a direct cause of deeper tissue damage and secondary infection. Keeping fingernails trimmed short or wearing gloves, especially at night, can help prevent unintentional disruption of the lesions.
Maintaining hygiene is necessary to prevent bacterial superinfection, which worsens the inflammatory response and increases scarring risk. Lesions should be kept clean using a mild soap and water, followed by gentle drying. For pain and intense itching, cool compresses or sitz baths can offer soothing relief, making the impulse to scratch less frequent. It is important to allow scabs to detach completely on their own, as premature removal pulls away newly forming skin cells and can deepen the final scar.
Distinguishing Scars from Post-Inflammatory Changes
Once the lesions have fully healed and the scabs have fallen off, the skin often shows discoloration, which can be mistaken for permanent scarring. True scars involve a textural change, such as the depressed appearance of an atrophic scar or the raised surface of a hypertrophic scar, indicating permanent alteration of the underlying skin structure. These textural changes are the result of permanent loss or excess of collagen fibers in the dermis.
However, many of the dark or light spots that remain are actually temporary color changes known as post-inflammatory hyperpigmentation (PIH) or hypopigmentation. PIH appears as dark spots due to excess melanin production in response to the skin inflammation, while hypopigmentation results in lighter patches. Unlike true scars, these pigmentary changes typically fade significantly over several months, a process that can be aided by sun protection for the affected areas.