Burn Scar–Related Skin Cancers Associated With High Recurrence, Mortality Risk

Skin cancers arising from chronic burn scars were associated with substantial recurrence and mortality risks in a new systematic review, with squamous cell carcinoma emerging as the most common malignancy after an average latency period of 21.7 years.¹

Burn Scars and the Risk of Malignant Transformation

Burn scars are a risk factor for the development of various skin cancers through the malignant transformation commonly known as Marjolin's ulcer (MU).² Specifically, MU refers to any malignant tumor arising in a chronic burn scar, ulcer, or area of chronic inflammation, with a reported incidence of 0.77% to 2%.¹ Squamous cell carcinoma is the most frequent histological type of cancer resulting from burn scars, followed by basal cell carcinoma and melanoma, with the extremities, trunk, and scalp most frequently affected.³

Although the cause of this transformation is not fully understood, proposed mechanisms include that chronic wound irritation accelerates cellular proliferation. Another is that the loss of immunity cells in chronic scar tissue may allow malignant cells to go undetected.⁴

Although numerous studies have described MU, the researchers noted that considerable variability remains regarding its characteristics, prognosis, and treatment options.¹ They also highlighted the lack of large-scale synthesis of burn scar cancer evidence. To fill this gap, the researchers conducted a systematic review of the characteristics and prognosis of skin cancer arising from burn scars.

To do so, they searched all records in PubMed, Scopus, and Web of Science through January 18, 2024. Eligible studies included case reports, case series, and observational studies reporting histologically confirmed skin cancer arising from burn scars of any etiology: flame, scald, electrical, friction, or infection related. Two independent reviewers screened records and extracted data on patient demographics, burn and tumor characteristics, treatment, latency period, and clinical outcomes.

Burn Scar Malignancies Show High Recurrence, Mortality Rates

Of 5415 records identified, 211 studies met the inclusion criteria. Males comprised 53% of the cohort, and the mean age at burn injury was 21.0 years. Third-degree burns accounted for 89.4% of cases with documented burn severity. The lower limb was the most commonly affected anatomical site (33.6%), followed by the head, neck, or face (18.2%) and upper limb (10.2%).

The mean age at cancer diagnosis was 47.2 years, yielding a mean latency period of 21.7 years from burn injury to malignancy. This latency period is notably shorter than the 28- to 35-year latency estimates cited in past literature, a difference the researchers attribute to possible modern environmental carcinogen exposure or earlier detection through improved surveillance.

Squamous cell carcinoma was the most common malignancy, identified in 67.2% of cases, followed by basal cell carcinoma (3.8%) and a range of other malignancies (15.3%), including sarcomas, melanomas, and adnexal tumors.

Among the 675 patients with available outcome data, recurrence following excision occurred in 13.2% of cases. Meanwhile, postoperative mortality occurred in 6.96% of cases, with squamous cell carcinoma accounting for 63.8% of all deaths. Melanoma demonstrated a 100% recurrence rate across the 4 reported cases, whereas sarcoma recurred in 50%. Lymph node metastasis was identified in 7.56% of patients, with distant metastasis in 4.74%. In contrast, basal cell carcinoma showed comparatively favorable outcomes, with 9.4% recurrence and 3.1% mortality.

“This review highlights MU as a serious and aggressive malignancy arising in the context of burn injuries, associated with substantial morbidity and mortality, and characterized by distinct epidemiological and prognostic features,” the authors wrote. “…Integrating molecular diagnostics with standardized management protocols may improve outcomes for this historically neglected complication of burn injury.”

Standardization, Innovation Needed in MU Research

The researchers concluded by acknowledging several key limitations, including that the study was susceptible to publication bias toward more aggressive presentations since it predominantly draws on case reports and case series; as a result, it may overstate overall disease severity. Additionally, data on initial burn management, specifically whether wounds healed by secondary intention or skin grafting, were inconsistently reported across studies, prevented formal analysis of how early wound care decisions influence long-term malignant risk.

Considering both their findings and limitations, the researchers identified directions for future research.

“Future studies should establish international registries with standardized molecular profiling, validate immune checkpoint inhibitors in metastatic MU, and explore a standard risk stratification incorporating scar location, depth, and patient genetics predicting transformation risk,” they wrote.

References

1. Alhadlaq A, Kereet IM, Kamel B, et al. Characteristics and prognosis of skin cancer arising from burn scars: a systematic review. J Plast Surg Hand Surg. 2026;61:86-90. doi:10.2340/jphs.v61.45793
2. Lee HB, Han SE, Chang LS, Lee SH. Malignant melanoma on a thermal burn scar. Arch Craniofac Surg. 2019;20(1):58-61. doi:10.7181/acfs.2018.02103
3. Copcu E. Marjolin's ulcer: a preventable complication of burns?. Plast Reconstr Surg. 2009;124(1):156e-164e. doi:10.1097/PRS.0b013e3181a8082e
4. Bazaliński D, Przybek-Mita J, Barańska B, Więch P. Marjolin's ulcer in chronic wounds - review of available literature. Contemp Oncol (Pozn). 2017;21(3):197-202. doi:10.5114/wo.2017.70109