If you went back in time, there would be plenty of differences you’d expect to see, but there would also be a lot of differences that would take you by surprise. (As L.P. Hartley wrote, “The past is a foreign country.”) I suspect that for most, one of these would be the sheer number of people who were scarred.

Specifically, scarred by smallpox.

Smallpox was a truly terrible disease. Thirty percent of those who caught it would die. Those who survived would almost certainly be marked with distinctive, pock-marked scarring on their skin. Many would be blinded. (Before smallpox was eradicated, 90% of the blind had been blinded by smallpox.)

I have two points here.

First: Vaccinations are good.

Second: Our view of the past is lilied by the Romantic paintings and Hollywood glamour through which we typically view it.

Can we take advantage of this when we’re worldbuilding?

Of course we can!

To start, if your game is set in any kind of pre-modern era (whether in the real world or otherwise), you can just make a point of including smallpox scars in your descriptions of NPCs.

More than that, though, you can use the inspiration of smallpox scars to introduce completely fantastical elements into a setting. For example, we could run down the list of D&D diseases and simply brainstorm the distinctive scars they might leave in their wake:

• Cackle fever could leave some of its victims with rictused atrophying around the corners of their mouth, locking them into a permanent laugh.
• Some of the victims of demon fever could be left with pale, reddish-grey hair.
• Even those who recover from slimy doom might have damaged sebaceous glands, resulting in their sweat having a thick, gelatinous quality.

(Not every disease, of course, leaves permanent scarring. You don’t need to overdo it here. A little can go a long way while also being more effective than a cavalcade of disease-signs.)

But that’s not all!

Look around your setting and ask yourself what other fantastical elements could leave their mark (literally) on the characters?

This is exactly what Frank Herbert does in Dune, for example, by having large amounts of Spice stain the iris and sclera, resulting in the distinctive blue “eyes of Ibad.”

So we can similarly imagine:

• Survivors of a werewolf attack having claw-scars marked silver from the dust sprinkled in them to fight off lycanthropy.
• The drug spacers take to prevent bone loss having the side effect of causing their iris to lose color, resulting in spacers being referred to by the slang/slur “white eyes.”
• Those living in an antimagic field developing chalky, flaking skin.

What type of mana-scar does a magic missile leave? Is it the same or different than a prismatic spray?

What about a wound inflicted by an elemental?

Does repeatedly jumping through a stargate leave a mark?

Something else to consider is what non-human scarring looks like. For example, Amazon river dolphins are born gray-skinned, but often look pink because (a) their wounds heal pink and (b) they fight each other so much, their entire bodies are usually covered in scars.

• Does an elf sunburn the same way a human does? Or does their skin turn a metallic copper or silver instead?
• Can serpent people lose (and regrow?) their tails like geckos?
• Would a tabaxi exposed to the sulfurous atmosphere of Avernus see its fur change color?
• When a tiefling is injured, do their wounds heal with a slightly more demonic/devilish appearance?
• Does a magically healed wound heal perfectly? Or does it leave a distinctive mana-scar? (Could the appearance of this scar differ depending on what type of magic was used?)

Tangentially, flamingos are pink because carotenoids in the brine shrimp they eat turn their feathers pink. So you can also invoke the effects of strange or limited diets.

Scars are badass and every scar tells a story — either about the character with the scar, the world as a whole, or both.

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