Management of burn scars

Recommendations

Identify and Treat the Cause
1 Take a careful history asking about previous procedures or a family history of scarring. Level of Evidence
Not Assessed


Address patient-centered Concerns
2 Document and treat pain, itch, and psychological sequellae. Level of Evidence
Not Assessed


Provide Local Wound Care
3 Consider the early use of skin replacement to minimize hypertrophic scar formation in patients with burn wounds. Level of Evidence
Not Assessed
4 Consider the use of externally applied pressure therapy to prevent hypertrophic scar formation in patients with burns. Level of Evidence
Not Assessed
5 Consider use of silicone sheeting to manage established scars. Level of Evidence
Not Assessed
6 Consider static splinting to prevent scar contracture and loss of range of motion. Level of Evidence
Not Assessed
7 Use surgical interventions as necessary to manage hypertrophic scars and contractures. Level of Evidence
Not Assessed


Provide Organizational Support
8 Empower the team to provide excellent scar management care. Level of Evidence
Not Assessed


Background

Hypertrophic scar formation is an important clinical problem in managing burn patients. Individuals vary considerably in their potential for scarring, but burn scars can produce permanent functional loss and disfigurement. Physical deformity due to scar contracture can be disabling. Factors that influence scar formation include body are of the injury, age of the individual and skin pigmentation. Hypertrophic scar formation is thought to be inevitable when epithelialization takes longer than 2 weeks in individuals with darkly pigmented skin and in children, or longer than 3 weeks in other patient types. A variety of scar problems can be seen:

• Scar contracture: Scars crossing joints or skin creases at right angles may develop contractures when the scar is not fully mature. This type of scar is often hypertrophic and is typically disabling and dysfunctional.

• Hypertrophic scar: This type of scar is often red, inflamed, itchy and painful, and it typically occurs on the trunk and extremities. Hypertrophic scars do not extend beyond the boundary of the initial injury.

• Keloid scar: This type of scar extends past the boundary of the initial burn, and it is more common in people with darkly pigmented skin.

The main approach to limiting scarring after burns has been immediate skin replacement with split-thickness grafts or temporary skin replacements. Long-term improvement, however, has been modest. Massage, corticosteroid injection, pressure therapy, silicone dressings, splinting, and surgical scar revision have also been used to manage burn scars and limit hypertrophic scar formation. These approaches are largely empirical and have efficacy limitations.

• Corticosteroid injection: High pressure is required to inject directly into a hypertrophic scar. As these injections are painful, general anaesthesia may be required, especially in children. Corticosteroid injection is usually limited to localized and symptomatic areas of early hypertrophic scars, particularly in areas where a cosmetic result is important.

• Pressure: Use of pressure is recommended to prevent the development of hypertrophic scarring, but clinical trials have not determined the optimal pressure and duration of treatment. Pressure therapy can prevent scars but does little to remodel existing hypertrophic scars. A variety of techniques are available, but all are both complex and costly. Pressure garments must be tailored to individual patient needs and should be fitted as soon as possible after skin grafting. These garments have a lifespan of approximately 3 months. Acrylic face masks may be used for moderate-to-severe burns around the neck or face.

• Silicone gel sheeting: Silicone sheeting can significantly reduce established scars, even many years after injury. A 2-month trial can identify responders. Contractures that are detected early in development can be treated with silicone inserts and pressure.

• Splinting: Addition of a continuous-wear static splint to silicone inserts and pressure can maintain sustained stretch and improve outcomes in more developed contractures. Once full range of motion is achieved, splinting can be reduced to night-time wear until scar maturation is complete.

• Surgical intervention: Surgery may be considered for scar contractures that do not fully respond to pressure, silicone sheeting and splinting. Useful surgical techniques for burn reconstruction, including management of contractures, consist of excisional release and grafting, incisional release and grafting, Z-plasty, tissue expansion and use of free flaps.

Extreme pruritus frequently occurs with healing burn wounds. In most patients, pruritus responds to massage, moisturizers, and oral antihistamines. Intense pruritus may require corticosteroid injection into the scar.

References

Essential Publications
1 Photodamaged skin Quality Indicator
 Type: Systematic review
Samuel M, Brooke RCC, Hollis S, Griffiths CEM. Interventions for photodamaged skin. Cochrane Database of Systematic Reviews 2005, Issue 1.
In this systematic review of many single and double blind RCTs, there is a large scope of interventions pertaining to photodamaged skin. There is conclusive evidence that topical tretinoin improves the appearance of mild to moderate photodamage on the face and forearms, in the short term. However, erythema, scaling/dryness, burning/stinging and irritation may be experienced initially.
2 Silicone gel sheeting Quality Indicator
 Type: Systematic review
O’Brien L, Pandit A. Silicone gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database of Systematic Reviews 2006, Issue 1.
This is a good systematic review of RCTs and quasi RCTs, non-randomized trials. No differences were found between treatment with silicone gel sheeting versus control for improvement in scar colour, appearance, elasticity or relief of itching or pain in persons with keloid or hypertropic scars. Generally the reviewed studies were of poor quality indicating the need for further rigorous investigation of this topic.
3 Keloids and Hypertrophic Scars Quality Indicator
 Type: Systematic review
Leventhal, D, Furr M, Reiter D. Treatment of Keloids and Hypertrophic Scars. Arch Facial Plast Surg. 2006; 8:362-368
Review examined studies that measures success rate of various therapies and found a mean rate of 60% from all the studies. Additional research needs to be done to determine whether factors such as location, depth and duration of lesion, patient ethnicity, or prior response to therapy have any influence on treatment outcome.
4 Topical negative pressure Quality Indicator
 Type: Systematic review
Wasiak J, Cleland H. Topical negative pressure (TNP) for partial thickness burns. Cochrane Database of Systematic Reviews 2007, Issue 3.
Review examined studies measuring the rate of change in wound area and adverse treatment events No conclusive evidence was recovered. As a result, this study highlights the need for better quality RCTs on TNP as sample size was limited and the methodology to detect differences was inadequate.
5 Early excision of burns Quality Indicator
 Type: Systematic review
Ong YS, Samuel M, Song C. Meta-Analysis of Early Excision of Burns. Burns 2006; 32(2): 145-50.
This is a detailed systematic review with specific conclusions stating that patients receiving early excision treatment had significantly higher blood transfusion requirements (SMD 1.65 95% CI 0.51-2.80), but shorter hospital stays (WMD 8.89, CI 14.28-3.5). The need for better studies is however communicated as a number of out comes (wound healing time, duration of sepsis, operating room hours and long term morbidity) could not be pooled because of differences in outcome definition or the absence of relevant data.
6 Internet sites for burn scar management Quality Indicator
 Type: Systematic review
Bohacek L, Gomez M, Fish JS. An Evaluation of Internet Sites for Burn Scar Management. J Burn Care Rehab 2003; 24: 246–251.
This paper rated Internet sites for burn scar management. Highly ranking sites may be useful for health care professionals, administrators, patients and their families. Future work in this area is required because digital and computer technology appears infinite to the public, and healthcare professionals struggle to remain aware of the material that may influence their patient’s opinions and knowledge.
7 Silicone Quality Indicator
 Type: Systematic review
Fette A. Influence of Silicone on Abnormal Scarring. Plastic Surgical Nursing 2006; 26(2): 87-92.
This is a systematic review of prospective studies that received a low rating for quality, since the methodological rigour of individual studies was not considered. Despite this, occlusive silicone cream treatment versus petroleum jelly was successfully tested in split and full-thickness skin grafts, resulting in significantly less pigmentation and hardness (78%), less marginal scar hypertrophy (37%), redness (26%), and in an even narrower marginal scar (22%). Nonetheless, a reliable and validated animal model would be essential for further well-structured research.
8 Silicone gel sheeting Quality Indicator
 Type: RCT
Li-Tsang CW, Lau JC, Choi J, Chan CC, Jianan L. A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population. Burns 2006; 32(6): 678-683.
This study offers a comprehensive analysis into the addition of silicone gel sheeting (SGS) treatment to post-traumatic hypertrophic scar protocol among Chinese individuals as it was effective to reduce thickness, pain, itchiness and pliability of the scar. Scar thickness was significantly less in the SGS group than in the MT group at 2 months (p = 0.008) and 6 months (p < 0.001). There was no statistically significance between pain and itchiness between the two groups. The scars in the SGS group became softer, more pliable and the improvement between the two groups were significant in 2 months (p = 0.008), 4 months (p = 0.004) and 6 months (p < 0.001).
9 Negative pressure closure Quality Indicator
 Type: RCT
Llanos S, Danilla S, Barraza C, Armijo E, Pineros JL, Quintas M, Searle S, Calderon W. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann.Surg. 2007; 244(5): 700-705.
This randomized, double-masked, controlled trial examines the benefits of negative pressure closure (NPC) for both healing, as it diminishes the loss of split thickness skin grafts (STSG) area, and decreased hospital stay. The medium loss of STSG in experimental NPC patients was 0.0 cm² versus 4.5 cm² in the control group (p = 0.001). The medium hospital stay was 13.7 days in the experimental NPC group versus 17 days in the control group (p < 0.001).
10 Skin substitutes Quality Indicator
 Type: RCT
Boyce ST, Kagan RJ, Greenhalgh DG, Warner P, Yakuboff KP, Palmieri T, Warden GD. Cultured skin substitutes reduce requirements for harvesting of skin autograft for closure of excised, full-thickness burns. Journal of Trauma-Injury Infection & Critical Care 2006; 60(4): 821-829.
The data obtained from this prospective study suggests that cultured skin substitutes (CSS) provide medical benefits and reduced complications for closure of burn wounds greater then 50% TBSA. The ratio of closed wound: donor skin areas for CSS at post-operative day 28 was significantly greater than for conventional 4:1 meshed autografts (p < 0.01). The percentage of total body surface area closed with CSS at post-operative day 28 was significantly less then AG (P < 0.05).
11 Topical morphine Quality Indicator
 Type: RCT
Welling A. A randomized controlled trial to test the analgesic efficacy of topical morphine on minor superficial and partial thickness burns in accident and emergency departments. Emergency Medicine Journal 2007; 24(6): 408-412.
This placebo-controlled RCT examined the potential benefits of topical morphine on superficial burns and chronic inflammatory wounds and found it to be ineffective. There were no significant differences between the pain scores found among the three treatments (p = 0.217), but the morphine group was administered the greatest amount of analgesia.


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