No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Burn Scar and Contracture Management
Abstract
Burns are wounds of the tissue architecture caused predominantly by thermal, electrical, or chemical injury. Their severity depends on the total body surface area involved and on the depth of the damage to the skin and underlying deep structures. Superficial injuries harbour the potential for self-regeneration due to the integrity of epidermal appendages within a preserved dermis.Deeper injuries destroy the ability of the tissues to heal by themselves due to loss of dermal integrity and blood supply. The direct consequences of deep burn injury or delayed healing are the formation of burn scars and contractures. These can cause severe functional deficit and cosmetic embarrassment that greatly affect the patient’s quality of life both physically and psychologically.In this chapter, we will be describing the abnormal features of burn scarring concerning the patient that need to be recognised and that may require appropriate assessment and management from the non-burn specialist.If the scars or contractures are complex or exceeding resources available, they may warrant appropriate referral to burn specialists within an expert and multidisciplinary scar management environment. The various choices for scar improvement will need to be tailored to the presenting physical or psychological concerns of the patient in a targeted consultation that evaluates the need for further escalation.The different options available for scar management that can guide the non-burn specialist to inform the patients and if necessary, refer them will be explained. These include multiple evidence-based alternatives in ascending order of complexity that range from basic skin-care practices, the use of modern technology, and light therapies such as laser to the most interventional treatments such as surgical reconstruction.KeywordsBurn scarBurn contractureScar assessmentScar scalesScar management
ResearchGate has not been able to resolve any citations for this publication.
Introduction
Hypertrophic scars (HTS) and keloids (K) cause significant morbidity and disfigurement. Care of HTS and keloids range from less invasive treatments, such as pressure garments and silicone products, to more invasive treatments, such as intralesional injections (ISI) of medication, and surgical excision. Laser-Assisted Drug Delivery (LADD) is becoming a more popular treatment for HTS and K. The ablative fractional laser creates microchannels in the skins which allows the delivery of drugs into deeper skin layers. We have conducted a systematic review of the literature to assess the effectiveness of LADD in the treatment of HTS and K.
Methods
A search was performed on PubMed between January 1998-August 2021 using the following keywords: Laser Assisted Drug Delivery, Laser Combined Drug Delivery, Laser Drug Delivery, Laser Drug, Hypertrophic, Burn, Keloid, Scar. Inclusion criteria was the use of LADD in HTS or K. Exclusion criteria were studies in animal models, case reports, reviews, and non-english articles. One article was excluded due to concerns of plagiarism.
Results
A total of 11 articles were included in the final review. One study found no difference in HTS outcomes between LADD of corticosteroids (CTS) and laser with topical petrolatum used as a control. Two prospective studies found that LADD of CTS led to improved HTS outcomes. Two split-scar studies found no difference in K outcomes between LADD of CTS and ISI of CTS. One prospective study assessed LADD of CTS in K and found statistically significant improvements in scar outcomes. A retrospective study looking at K outcomes found a 50% mean improvement when treated with LADD of CTS. A split-scar study found statistically significant better HTS outcomes with LADD of 5-FU compared to topical 5-FU alone. One study found no difference in HTS outcomes between LADD of CTS and 5-Fluorouracil (5-FU). Two studies assessed both HTS and K. The first study found that both LADD of 5-FU and LADD of CTS led to significantly better scar outcomes when compared to laser monotherapy. The other reported that HTS outcomes were significantly better with LADD of Botulinum toxin A and K outcomes were better with ISI of Botulinum Toxin A.
Conclusions
The use of LADD is effective in the setting of HTS. There is evidence that LADD of scar modulating agents to HTS lesions is more effective than topical delivery or ISI of the same agent. LADD shows promise as an alternative treatment for K as it displays similar efficacy as ISI.
Background
Silicone products, either as a sheet or in fluid form, are universally considered as the first line therapy in the prevention and treatment of hypertrophic scars and keloids. However, the study results have been questioned by different authors and there has never been a large systematic synopsis published on the efficacy of fluid silicone gels. This systematic review aims to elucidate the available evidence of the results obtained by fluid silicone gels and present a complete and comprehensive overview of the available literature as well as a meta-analysis of the pooled data.
Methods
A systematic search for articles concerning the use of silicone gel in the treatment and prevention of scars was performed on 3 different databases (Pubmed, Embase and Cochrane library) according to the PRISMA statement. Only RCT’s were included. Qualitative assessment was done by 2 separate reviewers using the Cochrane risk of bias (RoB 2) assessment tool. Revman 5.4.1 software was used for meta-analysis.
Results
The search yielded 507 articles. Two articles were identified through other sources. After deduplication and removal of ineligible records, 340 records were screened on title and abstract. Full text screening was done for 23 articles and ultimately 18 articles were included. A meta-analysis comparing fluid silicone gel to no treatment or placebo gels was conducted.
Conclusion
Studies on the effects of liquid silicone gels on hypertrophic scars are numerous and this systematic review shows that the use of liquid silicone gels is associated with both a prophylactic and a curative effect on scars. However, a considerable amount of the available ‘high evidence’ trials are at a high risk for bias and it is uncertain whether or not the effects of silicone gels are comparable to silicone sheets and if the additional components present in many silicone gels are partially responsible for their scar improving capacity.
Background:
In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.
Methods:
All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.
Results:
Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.
Conclusions:
Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.
Background
Cooling thermal burns with running water is a recommended first aid intervention. However, guidance on the ideal duration of cooling remains controversial and inconsistent across organisations.
Aim
To perform a systematic review of the evidence for the question; Among adults and children with thermal burn, does active cooling using running water as an immediate first aid intervention for 20 minutes or more, compared with active cooling using running water for any other duration, change the outcomes of burn size, burn depth, pain, adverse outcome (hypothermia) or complications?
Method
We searched Medline, Embase, Cochrane Database of Systematic Reviews and used ROBINS-I to assess for risk of bias. We used Grading of Recommendations, Assessment, Development and Evaluation methodology for determining the certainty of evidence. We included all studies that compared the selected outcomes of the duration of cooling of thermal burns with water in all patient ages. (PROSPERO registration number: CRD42021180665). From 560 screened references, we included four observational studies. In these studies, 48% of burns were cooled for 20 minutes or more. We found no benefit for a duration of 20 minutes or more of cooling when compared with less than 20 minutes of cooling for the outcomes of size and depth of burn, re-epithelialization, or the need for skin grafting. The evidence is of very low certainty owing to limitations in study design, risk of bias and indirectness.
Conclusion
The optimal duration of cooling for thermal burns remains unknown and future prospective research is required to better define this treatment recommendation.
Increased burn wound healing time has been shown to influence abnormal scarring. This study hypothesised that scar severity increases commensurate to the increase in time to healing (TTH) of the wound.
Wound healing and scar data from burn patients treated by the Burn Service of Western Australia at Royal Perth Hospital were examined. The relationship between TTH and scar severity, as assessed by the modified Vancouver Scar Scale (mVSS), was modelled using regression analysis. Interaction terms evaluated the effect of surgery and total body surface area – burn (TBSA) on the main relationship. Maximum likelihood estimation was used to account for potential bias from missing independent variable data.
The sample had a median age of 34 years, TTH of 24 days, TBSA of 3% and length of stay of five days, 70% were men and 71% had burn surgery. For each additional day of TTH, the mVSS score increased by 0.11 points (P ≤ 0.001) per day in the first 21 days and 0.02 points per day thereafter (P = 0.004). The relationship remained stable in spite of TBSA or surgical intervention. Investigation of the effect of missing data revealed the primary model underestimated the strength of the association.
An increase in TTH within 21 days of injury is associated with an increase in mVSS or reduced scar quality. The results confirm that efforts should be directed toward healing burn wounds as early as possible.
Classic determinants of burn mortality are age, burn size, and the presence of inhalation injury. Our objective was to describe temporal trends in patient and burn characteristics, inpatient mortality, and the relationship between these characteristics and inpatient mortality over time. All patients aged 18 years or older and admitted with burn injury, including inhalation injury only, between 2004 and 2013 were included. Adjusted Cox proportional hazards regression models were used to estimate the relationship between admit year and inpatient mortality. A total of 5540 patients were admitted between 2004 and 2013. Significant differences in sex, race/ethnicity, burn mechanisms, TBSA, inhalation injury, and inpatient mortality were observed across calendar years. Patients admitted between 2011 and 2013 were more likely to be women, non-Hispanic Caucasian, with smaller burn size, and less likely to have an inhalation injury, in comparison with patients admitted from 2004 to 2010. After controlling for patient demographics, burn mechanisms, and differential lengths of stay, no calendar year trends in inpatient mortality were detected. However, a significant decrease in inpatient mortality was observed among patients with extensive burns (≥75% TBSA) in more recent calendar years. This large, tertiary care referral burn center has maintained low inpatient mortality rates among burn patients over the past 10 years. While observed decreases in mortality during this time are largely due to changes in patient and burn characteristics, survival among patients with extensive burns has improved.
Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.
The development of cutaneous pathological scars, namely, hypertrophic scars (HSs) and keloids, involves complex pathways, and the exact mechanisms by which they are initiated, evolved, and regulated remain to be fully elucidated. The generally held concepts that keloids and HSs represent "aberrant wound healing" or that they are "characterized by hyalinized collagen bundles" have done little to promote their accurate clinicopathological classification or to stimulate research into the specific causes of these scars and effective preventative therapies. To overcome this barrier, we review here the most recent findings regarding the pathology and pathogenesis of keloids and HSs. The aberrations of HSs and keloids in terms of the inflammation, proliferation, and remodeling phases of the wound healing process are described. In particular, the significant roles that the extracellular matrix and the epidermal and dermal layers of skin play in scar pathogenesis are examined. Finally, the current hypotheses of pathological scar etiology that should be tested by basic and clinical investigators are detailed. Therapies that have been found to be effective are described, including several that evolved directly from the aforementioned etiology hypotheses. A better understanding of pathological scar etiology and manifestations will improve the clinical and histopathological classification and treatment of these important lesions.
All deep second and third degree burns are at risk to develop hypertrophic scars which can severely undermine the quality of survival. To assess the severity of scarring, several technical devices or tools have been introduced to evaluate one or more aspects of the scar, enabling comparison of different treatment protocols and allowing an objective follow-up. The objective of this study was to review which tools can be used in objective burn scar assessment.
The Systematic literature search involving PubMed, the Web of Science (incl. Science Citation Index).
51 articles with burn scar assessment as main topic were found. Several characteristics of the scar can be assessed, such as color, metric features and elasticity, but none of the available tools covers the whole aspect of the scar. Especially subjective factors such as pain and itching cannot be assessed with those tools, in spite of their great impact on the patient's quality of life.
Scar tools enable objective and reproducible evaluation of scars, which is essential for scientific studies and medico-legal purposes, and in selected cases for the clinical follow-up of an individual patient. Further studies to evaluate these tools on scars are nevertheless required.
Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.
Introduction
Burn injuries remain common in the world, with an average of more than thousands of cases requiring medical attention each year. Singapore sees an average of 220 burns admissions annually. Given the high number of burn cases in Singapore, the authors identified that there is a need for more public awareness on first aid burn treatment. Acute management of burns can improve eventual patient outcome. The authors devised a simple mnemonic that can be used in burns education for first aid treatment, intended to be taught to trained personnel, who will have the first contact with these burn patients. The aim of the study was to assess the viability of implementing this mnemonic, B.U.R.N.S, to facilitate first aid education for burns.
Material and methods
In a pilot study, we first presented this mnemonic as a poster to 30 full-time burn care medical professionals. Feedback was then obtained from this group of medical professionals and used it to revise the mnemonic. The mnemonic was subsequently taught to 400 medical professionals, who are predominantly involved in the pre-hospital management of burns. They are then asked to reiterate the mnemonic to test the ease of remembering the mnemonic. Objective feedback was obtained with a 5-point scoring system.
Results
The results indicated a significant improvement in burn first aid knowledge after the implementation of the mnemonic, from a score of 3.67 to 4.77. The content was deemed as appropriate and easy to understand and recall, and participants were able to reiterate the content, and will recommend this mnemonic to be used for burns teaching for first aid.
Conclusion
The study results suggest that this B.U.R.N.S. mnemonic and visual aid is simple and easy to apply, especially for uniformed personnel, as these individuals may have the first contact with the burns victims, and it is important for them to render the appropriate burns first aid treatment. Overall, burns first aid awareness and education can be improved with the implementation of this mnemonic and poster.
Moving forward, we aim to integrate the B.U.R.N.S. into educational programmes in professional institutions involved in responding to burns (medical and nursing schools of Singapore), as well as in schools and public institutions, for educational purpose to raise public awareness. We wish to also be able to do so on an international level when courses are conducted.
Although there are numerous publications about the effect of fractional CO2 laser therapy for burn scars, the quantitative data about its efficacy and safety are sparse. The purpose of this meta-analysis was to assess the efficacy and safety of fractional CO2 laser therapy for the treatment of burn scars. Pertinent studies were identified by a search of PubMed, Embase and Web of Science up to 20 September 2020. Weight mean difference (WMD) was conducted to combine the results. A random-effect model was used to pool the results. Publication bias was estimated using Begg and Egger’s regression asymmetry test. Twenty articles were included in this meta-analysis. Our pooled results suggested that fractional CO2 laser therapy significantly improved the Vancouver Scar Scale (VSS) score (WMD = −3.24, 95%CI: −4.30, −2.18; P < 0.001). Moreover, the Patient and Observer Scar Assessment Scale (POSAS)-patient (WMD = −14.05, 95%CI: −22.44, −5.65; P = 0.001) and Observer (WMD = −6.31, 95%CI: −8.48, −4.15; P < 0.001) also showed significant improvements with the treatment of fractional CO2 laser therapy. Fractional CO2 laser significantly reduced the scar thickness measured with ultrasonography (WMD = −0.54, 95%CI: −0.97, −0.10; P < 0.001). For other outcomes, including pigmentation, vascularity, pliability, and height of scar, vascularity and relief, laser therapy were associated with significant improvements. However, only cutometer measures R2 (scar elasticity) (WMD = −0.06, 95%CI: −0.10, −0.01; P = 0.023) was significantly improved with the laser therapy, but cutometer measures R0 (scar firmness) (WMD = 0.03, 95%CI: −0.04, 0.09; P = 0.482) was not. The side effects and complications induced by fractional CO2 laser were mild and tolerable. Fractional CO2 laser therapy significantly improved both the signs and symptoms of burn scars. Considering the potential limitation, more large-scale, well-designed RCTs are needed to verify our findings.
Background
Triamcinolone acetonide (TAC) is widely used for hypertrophic scars and keloids; however, TAC has variable efficacy and safety in different individuals.
Purpose
To evaluate the efficacy and safety of intralesional TAC for treatment of hypertrophic scars and keloids.
Data sources
Searches of PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov prior to 25 March 2020.
Study selection
Randomized controlled trials in English that compared TAC with a placebo or other medications that are commonly used for intralesional injection in hypertrophic scars and keloids.
Data extraction
Primary outcomes were reduction in scar height, vascularity, pliability, pigmentation, total scores on the Vancouver Scar Scale (VSS) or patient and observer scar assessment scale (POSAS), telangiectasia, and skin atrophy. Secondary outcomes included overall scar improvement.
Data synthesis
Fifteen trials met the inclusion criteria. In the short term, TAC was associated with a significant improvement in vascularity (MD: −0.22, 95% CI: −0.42 to −0.02) and pliability (MD: −0.25, 95% CI: −0.44 to −0.06) compared to verapamil. In the medium term, compared to TAC, 5-FU showed a significant improvement in scar height (SMD: 0.95, 95% CI: 0.15–1.75), while TAC led to a significant improvement in vascularity compared to 5-FU (MD: −0.45, 95% CI: −0.76 to −0.14). Compared to TAC, TAC+5-FU showed a significant improvement in pliability (SMD: 0.98, 95% CI: 0.17–1.78) and pigmentation (MD: 0.45, 95% CI: 0.12–0.78). Botulinum toxin type A resulted in significantly better pliability (SMD: 1.99, 95% CI: 0.98–3.00) compared to TAC. In the long term, compared to TAC, 5-FU led to a significant improvement in scar height (MD: 0.55, 95% CI: 0.17–0.93), but significantly less vascularity (MD: −0.35, 95% CI: −0.65 to −0.05). Compared to TAC, TAC+5-FU produced a significant improvement in scar height (MD: 1.50, 95% CI: 1.12–1.88), pliability (MD: 0.45, 95% CI: 0.10–0.80), and pigmentation (MD: 0.55, 95% CI: 0.24–0.86).
Conclusion
TAC may be beneficial for the short-term treatment of hypertrophic scars and keloids; however, 5-FU, 5-FU+TAC, and verapamil may produce superior results for medium- and long-term treatments. TAC injections at concentrations of 20 mg/ml or 40 mg/ml are more likely to result in skin atrophy compared to 5-FU or verapamil, and are more likely to cause telangiectasia than 5-FU, 5-FU+TAC, or bleomycin.
Introduction
Determining the efficacy of anti-scar technologies can be difficult as qualitative, subjective assessments are often utilized instead of systematic, objective measures. Perceptions regarding the reliability of instruments for quantitative measurements along with their high cost and increased data collection time may discourage their use, leading to use of scar scales which are relatively quick and low-cost. To directly evaluate the reliability of instruments for quantitative measurements of scar properties, instruments and two qualitative scales were compared by assessing a variety of cutaneous scars.
Methods
Scar height and surface texture were evaluated using a 3D scanner and a mold/cast technique. Scar color was evaluated by using a spectroscopy-based tool, the Mexameter®, and digital photography with image analysis. Scar biomechanics were evaluated using the BTC-2000™, Dermal Torque Meter (DTM®), and ballistometer®. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to qualitatively evaluate the same scar properties. Intraclass correlation coefficients (ICC) were used to determine inter- and intra-user reliability (poor, moderate, good, excellent) with all instruments and the kappa reliability statistic was used to asses inter-user reliability (poor, fair, moderate, good, very good) for VSS and POSAS. Time for measurement collection and post-collection analysis was also recorded.
Results
The Mexameter® was the most reliable method for evaluating erythema and pigmentation compared to digital photography and image processing, POSAS and VSS. Digital photography and analysis was more reliable than POSAS and VSS. Assessment of scar height was significantly more reliable when using a 3D scanner versus VSS and POSAS. The 3D scanner and mold-cast techniques also offered an additional benefit of providing an absolute value to scar height relative to the surrounding tissue. Intra-user reliability for all mechanical tests was moderate to good. Inter-user reliability was greater when using the BTC-2000™ and ballistometer® versus the DTM®. All quantitative measurements took less than 90 seconds for collection, with the exception of the mold/cast technique.
Conclusion
Non-invasive instruments allow scar properties to be quantitatively assessed with high sensitivity and as a function of time and/or treatment without the need for biopsy collection. Overall, the reliability of scar assessments was significantly improved when quantitative instruments were utilized versus scar scales. Quantitative assessment of color and biomechanics were swift, requiring less than 90 seconds per measurement while assessments of texture and height required additional analysis time post collection. With proper training of clinical staff and well-defined protocols for measurement collection, reliable, quantitative assessments of scar properties can be collected with little disruption to the clinical workflow.
The current evidence to support the use of massage for scar management is conflicting in the literature. The purpose of this study was to compare two scar massage protocols administered with pediatric burn survivors to determine if a more structured and standardized approach to scar massage could improve outcome. A retrospective review of the medical records of 100 children who received massage during the time period when two different protocol were implemented was conducted and data that was collected as part of the clinical exam regarding scar height, vascularity, pliability, itch and pain were extracted. Comparisons were made within subject for scar changes from baseline to follow up and between subjects receiving Protocol A and those receiving Protocol B for the same scar characteristics. Versions of the Vancouver Scar Scale were used to assess scars, while visual analogue scale, Itch Man Scale and Wong-Baker Faces Pain Scale were used to assess itch and pain. Results demonstrated improvements in itch and vascularity over time with both scar massage protocols. However, when comparing patients who received Protocol A to those who received Protocol B, there was no difference found in scar height, vascularity, pliability, itch or pain. Using commonly applied subjective scar assessment tools, we did not find clinically meaningful changes in scar characteristics with the implementation of a structured scar massage program compared to a general approach to massage. Further research is needed to better define the impact of massage on the recovery experience for burn survivors.
Background: Keloids are benign fibro-proliferative growths occurring after skin injury or spontaneously. Intralesional triamcinolone acetonide (TA) is their first-line therapy, but commonly associated with side effects or recurrence. Platelet rich plasma (PRP) is an autologous blood-derived product with promising results in improving wound healing with lower keloid occurrence.
Objective: To compare the efficacy of combined intralesional TA and PRP versus TA alone in keloids treatment.
Methods: Forty patients with keloids were divided randomly into two equal groups (A and B). Both groups received intralesional TA (20 mg/ml) for four sessions, 3 weeks apart. Group A patients received additional intralesional PRP 1 week after TA injections. Evaluation was done after 3 months of follow up by Vancouver scar scale (VSS) and verbal rating scale (VRS) for pain and itching.
Results: Both groups showed significant improvement in all parameters of VSS and VRS in comparison with baseline. Significantly better improvement in height, pigmentation, and pliability and overall VSS was detected in patients of group A. A significantly higher incidence of post-TA atrophy and hypopigmentation was observed in group B.
Conclusion: Combining intralesional PRP with TA could yield cosmetically better outcomes in keloid treatment with lower incidence of TA-induced side effects especially atrophy and hypopigmentation.
Thermal disease presents a major burden to individual patient morbidity, healthcare cost as well as to over all economy. Burns also also represent a significant per-patient utlilisation of finite healthcare resources. Secondary complications in these patients, such as multiple drug resistant organisms, may have a devastating effect.
Laser surgery has recently come of age as an optimal tool in the secondary reconstruction of burn injury, that is able to simultaneously address significant sheet scar tightness, hypertrophic, atrophic, and keloid complications, pruritus, microstomia, ectropion, skin graft honeycombing, and improve range of movement whilst reducing the risk of infection to <1%. Yet, cutaneous laser surgery is often underutilised due to the perceived concerns about the sustainability of a new service with relatively high startup cost. We present a dual methodology to explore this concern: an evidence-based background review of the last 5 years of current best evidence, and a 22-year cost-analysis comparison at an established, high volume UK Centre of reconstructive surgery.
We report that fiscal viability for laser surgery services for secondary burn reconstruction is supported by: level 2 (one systematic review) level 4 evidence (2 studies) and level 5 evidence (expert reports). Evidence over 22 years from an established super-regional NHS laser centre shows that introduction of this service led to sustained and substantial cost saving, producing excellent surgical results at a fraction of the cost of traditional surgery.
Analysis of the potential dollar-effect of these advantages to the general population supports state investment in expertise and capital equipment as a medium to long-term cost saving strategy, which may also aid re-integrating patients into the workforce making a meaningful contribution to the economy.
Background:
Reconstructive surgery remains the main approach to address burn scar contractures. Ablative fractional resurfacing is an increasingly popular tool for severe burn scar management, but its effect on overall burns reconstructive case-mix, operating time and patterns of hospital admission have not been reported.
Methods:
Retrospective analysis of hospital administrative data from September 2013 to June 2017 was performed evaluating these effects of ablative fractional CO2 laser (CO2-AFL).
Results:
The total number of acute burn patients treated at CRGH increased substantially over this timeframe, resulting in 412 elective procedures including 82 before and 330 after introducing CO2-AFL. The proportion of traditional non-laser reconstructive procedures dropped considerably to 23.9% in about 2.5 years following CO2-AFL introduction. This change in approach had a profound effect on LOS with average LOS being 1.96days for non-laser and 0.36days for CO2-AFL-procedures (p<0.001). Anaesthetic times also decreased significantly, with median durations at 90min pre-laser and 64min post-laser introduction (p<0.001), and median anaesthetic times at 87min (non-AFL) and 57min (AFL procedures) (p<0.001).
Conclusion:
AFL profoundly affects elective reconstructive burn case mix with a replacement of conventional reconstructive operations in favour of AFL-procedures. This results in reductions of average LOS and anaesthetic times. Consequently, increased use of AFL in burn scar management could potentially reduce overall costs associated with burn scar reconstruction.
Objectives
At present, there are many therapies for treating keloids and hypertrophic scars, but there is still a lack of treatments that are relatively balanced in efficacy and safety. The study aims to evaluate comprehensively efficacy and safety of common therapies in keloids and hypertrophic scars.
Methods
The literature search was conducted up to May 2019. The traditional meta-analysis was performed on 17 therapies. Bayesian network meta-analysis was conducted on the four most common treatments. The outcome indicators were the numbers of patients with good-to-excellent effect, Vancouver Scar Scale (VSS) and adverse events.
Results
There was no significant difference in the efficacy of triamcinolone acetonide (TAC) compared with other monotherapies except for silicone gel sheet and neodymium-yttrium-aluminum-garnet in primary indicator. The combination therapies were superior to TAC, and the results were consistent after the pooled analysis (RR = 0.522, 95% CI 0.332–0.823). The level of VSS in TAC group was higher than that in 5-flurouracil (5-FU) and TAC + 5-FU group, but lower than that in verapamil (VER) group. And the patients treated with TAC were less safe than those treated with verapamil (P = 0.013). Surface under cumulative ranking ranked verapamil and TAC + 5-FU as the favorable efficacy therapies in terms of primary indicator and ranked TAC + 5-FU as the best therapy for VSS, while VER was ranked as the worst.
Conclusion
This meta-analysis showed that TAC + 5-FU may be the most effective therapy, while verapamil may be a better therapeutic strategy for safety.
Level of Evidence III
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Study objective:
First-aid guidelines recommend the administration of cool running water in the early management of thermal injury. Our objective is to analyze the associations between first aid and skin-grafting requirements in children with burns.
Methods:
This cohort study used a prospectively collected registry of patients managed at a tertiary children's hospital. Multivariate logistic regression models were used to evaluate the relationship between first aid and the requirement for skin grafting. Secondary outcomes included time to re-epithelialization, wound depth, hospital admission and length of stay, and operating room interventions. Adequate first aid was defined as 20 minutes of cool running water within 3 hours of injury.
Results:
In our cohort of 2,495 children, 2,259 (90.6%) received first aid involving running water, but only 1,780 (71.3%) were given the adequate duration. A total of 236 children (9.5%) required grafting. The odds of grafting were decreased in the adequate first aid group (odds ratio [OR] 0.6; 95% confidence interval [CI] 0.4 to 0.8). The provision of adequate running water was further associated with reductions in full-thickness depth (OR 0.4; 95% CI 0.2 to 0.6), hospital admission (OR 0.7; 95% CI 0.3 to 0.9), and operating room interventions (OR 0.7; 95% CI 0.5 to 0.9), but not hospital length of stay (hazard ratio=0.9; 95% CI 0.7 to 1.2; P=.48).
Conclusion:
Burn severity and clinical outcomes improved with the administration of cool running water. Adequate first aid must be prioritized by out-of-hospital and emergency medical services in the preliminary management of pediatric burns.
A rise in the current trend of corrosive substance attacks have been reported in the UK, causing devastating effects on victims. The optimal management of these patients requires the specialist skills of the burn multidisciplinary team (MDT) to address the resulting physical and psychological trauma experienced. However, burn care must commence in the pre-hospital setting. The public and first responders are invaluable resources in helping to limit the adverse effects of burns. Challenges of burn care outside the Burns Unit are not limited to the treatment of the injured patient and the rehabilitation of survivors. These challenges also encompass better education of the public and allied health professionals, as well as planning strategies to reduce the incidence of acid attacks. Prevention is always better than cure. This paper discusses the broadening of the MDT to improve outcomes in acid attacks by exploring the wider roles of the public, media, emergency services, police, legislation and better education.
Introduction
Although laser resurfacing has become an accepted treatment in the management of hypertrophic burn scars, no studies have directly compared different platforms, such as pulsed dye laser (PDL) or fractional CO2 laser (fCO2). We present the first rater-blinded study that compares these two modalities, using objective and subjective outcome measures, to determine the efficacy of laser therapy in burn patients with symptomatic, hypertrophic scars.
Methods
A rater-blinded, before-after cohort study was performed in 206 consecutive patients who underwent laser treatment of hypertrophic burn scars. A specific laser platform was chosen based on a pre-determined algorithm incorporating pruritis and vascularity, as well as stiffness and pliability, to guide the use of PDL or fCO2. A constant anchor spot was established prior to therapy and assessed using the Vancouver Scar Score and UNC5P. Data were collected by an independent, blinded rater, entered prospectively into a scar registry, and analyzed post hoc. PDL and fCO2 groups were compared by chi-square and Student’s T tests, with p values < 0.05 determined to be statistically significant.
Results
206 patients underwent 452 laser sessions, with 122 patients receiving PDL and 255 patients receiving fCO2. Median time from injury to first laser was 1.4 years. Median size of the burn was 8% of the total body surface area. PDL improved VSS from 9.03 to 7.48 (p<0.05) but nominally decreased UNC5P from 4.34 to 3.72 (NS). fCO2 improved both VSS from 8.33 to 6.93 (p<0.00001) and UNC5P from 3.89 to 2.65 (p< 0.01).
Conclusions
In this rater-blinded, before-after cohort study, PDL significantly improved objective measures of hypertrophic burn scars, but fCO2 lasers significantly improved both objective and subjective measures. These data strongly support previous clinical observations that fractional CO2 resurfacing may be more efficacious than pulsed dye laser, in the treatment of hypertrophic burn scars.
Applicability of Research to Practice
This study assists providers in determining what type of laser to use to treat hypertrophic burn scars.
Introduction
Corticosteroid injections rapidly reduce the volume of a pathologic scar. However, the downsides of corticosteroid injections include pain (caused by the injection itself) and difficulties associated with contraindications such as pregnancy, glaucoma, or Cushing’s disease. This problem can be overcome by using steroid tapes. The transcutaneous delivery using tape formulations is an alternative modality, which was first described in the dermatological literature in 1960’s. Despite early encouraging reports regarding the potential to be a useful adjunct in scar management, steroid tape is not widely used apart from a limited number of scar services worldwide.
Methods
Total 100 hypertrophic scars and keloid patients (50 pediatic and 50 adult patients) including post-burn scars who were treated after 2009 by using just fludroxycortide or deprodone propionate tapes and healed completely were enrolled to this study. These steroid tapes were changed every 24-48 h and cut so that they just cover the wound, with minimal attachment to healthy skin.
Results
All 50 adult patients over 18 years old used deprodone propionate tapes. 27 pediatric patients used deprodone propionate tapes, and 23 pediatric patients used fludroxycortide tapes. Stiffness of scars improved in all of cases. After improving stiffness of scars, heparinoid ointment were used and long-term follow-up were performed. About pediatric patients, total follow up term was short in a group of deprodone propionate tapes than that of fludroxycortide tapes.
Conclusions
In conclusion steroid tape administration appears to be a promising adjunct in scar management. It was suggested that many pediatric and older patients can be treated by steroid tapes alone because they have much thinner skin, which means that the steroids are easily absorbed. Moreover, it was considered that steroid tapes are a reasonable first-line therapy for severe hypertrophic scars and keloids. Further research should focus on attaining absorption data to guide steroid duration of treatment; studies comparing this to other adjuncts in scar management will aid in placing this adjunct in multimodal scar management protocols.
Applicability of Research to Practice
The submitted research is a clinical data analysis.It appears to be a promising modality in clinical practice.
Wound healing is a complex multistep process which is temporally and spatially controlled. In partial thickness wounds, regeneration is possible from the stem cells in the edges of the wound and from the remnants of the epidermal appendages (such as hair follicles and sebaceous glands). This study examines whether the mechanism of injury influences healing of wounds of similar depth. Burn and excisional wounds were created on the back of Hampshire pigs and harvested at 7, 14, 28, 44, 57 and 70 days after injury and processed for histology and immunohistochemistry. Quantitative analysis of re-epithelialisation, inflammatory response and thickness of the scar and semi-quantitative analyses of the architecture of the resultant scar were performed and subjected to statistical analysis. Results demonstrated a higher number of neutrophils, macrophages and lymphocytes present in the burn on day 7 compared to the excisional wounds. The inflammatory profile of burn wounds was higher than that of excisional wounds for the first month after injury albeit less marked than on day 7 after injury. Re-epithelialisation was markedly advanced in excisional wounds compared to burn wounds at day 7 after injury, corresponding to the higher number of hair follicles in the underlying dermis of excisional wounds at this time point. The thickness of the neo-epidermis increased with time and at day 70 after wounding, the neo-epidermis of the burn was significantly thicker than the neo-epidermis of the excisional scar. Interestingly, following partial thickness excision of skin, there was neo-dermal reformation albeit with an altered architecture, lacking the normal basket-weave pattern of collagen. The thickness of the dermis of partial thickness excisional scar was greater than that of the adjacent unwounded skin. The neo-dermis of the burn scar was even thicker, with the collagen arranged more compactly and disorganised compared to excisional scar and normal skin. This study provides evidence that the mechanism of injury does influence wound healing and the resultant scarring.
A large-scale online survey was designed to both inform and direct the development of an online community healthcare hub for people living with scarring. Focussed areas of questioning were generated to gather information on psychological symptoms, scar support and knowledge of wounds and healing. Simple statistical data was produced on the severity, aetiology and location of scarring. A secondary data analysis of the survey responses was conducted on more focussed themes. This survey was completed by 1034 people living with scars, 119 of which had burn scarring. The results highlight that patients with burn scars have higher levels of pre-existing psychological difficulties, carry a greater number of scars and experience more symptoms. A lack of support is identified for patients with scars once they have been discharged by their healthcare provider. The most popular forms of support were chosen as face-to-face interaction or online support. Key areas of support were found to be psychology particularly for help with acceptance or coping methods, wound care advice and meeting with other patients with scars. For these patients, key themes in the psychological impact of scarring include appearance-related concerns, social anxiety, acceptance and coping, experience of symptoms, skin viability and survivorship.
Aims:
Dermal preservation during acute burn excision is key to obtaining superior healing/scar outcomes, however, determining the most appropriate excision tool is an ongoing challenge. Novel tool development means the knife is no longer our only option, yet for the majority it remains the gold standard. This systematic review aims to evaluate evidence for burns excision approaches (knife/hydrosurgery/enzymatic).
Methods:
CENTRAL, EMBASE, MEDLINE (1946-2017) were searched with MeSH terms: 'debridement', 'burns', 'sharp', 'enzymatic', 'hydrosurgery'. Relevant randomised control trials (RCTs)/non-randomised controlled case series/trials were extracted/analysed. In vitro/burn non-specific studies were excluded. Main methodological parameters were intervention/excision efficacy.
Results:
Eighteen articles met inclusion criteria (n=7148): three were RCTs, involving comparator enzymatic (NexoBrid™ (EDNX)) or hydrosurgical (Versajet™) excision to surgical Standard of Care. Both showed statistically significant decreased need for excisional excision and auto-grafting by viable tissue preservation allowing spontaneous healing by epithelialisation.
Conclusion:
Level 1 Evidence comparing excision modalities for acute burns is sparse. Although early excision with a knife is still often considered best practice, there is no tool choice consensus or robust comparison with alternate, possibly superior, tools. EDNX or Versajet™ should be considered alternatively. Further RCTs are indicated, with regards final scar outcomes and to allow consensus within current evidence.
Objective:
The aims of this study are: firstly, to investigate if admission to specialized burn critical care units leads to better clinical outcomes; secondly, to elucidate if the multidisciplinary critical care contributes to this superior outcome.
Methods:
A multi-centre cohort analysis of a prospectively collected national database of 1759 adult burn patients admitted to 13 critical care units in England and Wales between 2005 and 2011. Units were contacted via telephone to establish frequency and constitution of daily ward rounds. Critical care units were categorized into 3 settings: specialized burns critical care units, generalized critical care units and 'visiting' critical care units. Multivariate logistic regression analysis and propensity dose-response analysis were used to calculate risk adjusted mortality.
Results:
Multivariate logistic regression analysis shows that admission to a specialized burn critical care service is independently associated with significant survival benefit compared to generalized critical care unit (adjusted OR for in-hospital death 1.81, [95% CI, 1.24, 2.66]) and 'visiting' critical care services (adjusted OR for in-hospital death 2.24 [95% CI, 1.49, 3.38]). Further analysis using propensity dose-response analysis demonstrates that risk-adjusted in-hospital mortality rate decreased as the dose of multidisciplinary care increased, with an adjusted odds ratio of 1 (specialized burn critical care units), 1.81 (generalized critical care units) and 2.24 ('visiting' critical care units).
Conclusions:
Admission to a specialized burn critical care service is independently associated with significant survival benefit. This is, at least in part, due to care being provided by a fully integrated multidisciplinary team.
Background and objective:
Burn scars are associated with significant morbidity ranging from contractures, pruritus, and disfigurement to psychosocial impairment. Traditional therapies include silicone gel, compression garments, corticosteroid injections, massage therapy, and surgical procedures, however, newer and advanced therapies for the treatment of burn scars have been developed. Lasers, specifically ablative fractional lasers, show potential for the treatment of burn scars.
Methods:
Both MeSH and keyword searches of the PubMed, Medline and Embase databases were performed and relevant articles were read in full for the compilation of this review.
Results:
Fifty-one relevant observational studies, clinical trials, and systematic reviews published in English from 2006 to 2016 were reviewed and summarized.
Conclusion:
Laser therapy is effective for the treatment of burn scar appearance, including measures such as pigmentation, vascularity, pliability, and thickness. Ablative fractional laser therapy, in particular, shows significant potential for the release of contractures allowing for improved range of motion of affected joints. Patients may benefit from the use of lasers in the treatment of burn scars, and the safety profile of lasers allows the benefits of treatment to outweigh the risks. Laser therapy should be included in burn scar treatment protocols as an adjuvant therapy to traditional interventions.
Background
Scar massage is used in burn units globally to improve functional and cosmetic outcomes of hypertrophic scarring following a burn, however, the evidence to support this therapy is unknown.
Objective
To review the literature and assess the efficacy of scar massage in hypertrophic burn scars.
Methods
MEDLINE, PubMed, Embase, CINAHL and the Cochrane Library were searched using the key words “burn”, “burn injury”, “thermal injury” and “scar”, “hypertrophic scar” and “massage”, “manipulation”, “soft tissue mobilisation”, “soft tissue manipulation”. The articles were scored by the assessors using the Physiotherapy Evidence Database (PEDro) scale and outcome measures on range of motion (ROM), cosmesis (vascularity, pliability, height), pain scores, pruritus, and psychological measures of depression and anxiety were extracted.
Results
Eight publications were included in the review with 258 human participants and 15 animal subjects who received scar massage following a thermal injury resulting in hypertrophic scarring. Outcome measures that demonstrated that scar massage was effective included scar thickness as measured with ultrasonography (p = 0.001; g = −0.512); depression (Centre for Epidemiologic Studies — Depression [CES-D]) (p = 0.031; g = −0.555); pain as measured with Visual Analogue Scale (VAS) (p = 0.000; g = −1.133) and scar characteristics including vascularity (p = 0.000; g = −1.837), pliability (p = 0.000; g = −1.270) and scar height (p = 0.000; g = −2.054). Outcome measures that trended towards significance included a decrease in pruritus (p = 0.095; g = −1.157).
Conclusions
It appears that there is preliminary evidence to suggest that scar massage may be effective to decrease scar height, vascularity, pliability, pain, pruritus and depression in hypertrophic burns scaring. This review reflects the poor quality of evidence and lack of consistent and valid scar assessment tools. Controlled, clinical trials are needed to develop evidence-based guidelines for scar massage in hypertrophic burns scarring.
Intralesional (IL) corticosteroid therapy is a treatment for keloids. IL botulinum toxin type A (BTA) has been postulated in such an indication with controversial reports. To compare efficacy and safety of IL BTA to the IL corticosteroid therapy in treatment of keloids. Twenty-four patients with keloids were randomly divided into two equal groups: receiving IL steroid repeated every 4 weeks for six sessions (group A) and IL BTA 5 IU/cm(3) repeated every 8 weeks for three sessions (group B). Objective parameters (hardness, elevation, and redness), subjective complaints (itching, pain, and tenderness), patient satisfaction, and side effects were evaluated. There was a significant decrease in the volume of the lesions after treatment (P < 0.01), with a volume reduction of 82.7% and 79.2%, respectively, in both groups. A significant softening of lesions vs. baseline was observed (P < 0.01), with statistically significant improvement in softening in group A (P < 0.01). There was a significant decrease in height of lesions and in redness score compared with baseline (P < 0.01) with no significant difference in between both groups. All patients mentioned a significant reduction of their subjective complaints (P < 0.01) that were more significant in group B. Skin atrophy and telangiectasia were evident in three patients of group A. The efficacy and safety of the IL BTA were clearly evident in the current work from the rapid significant amelioration of the subjective complaints and the comparable significant improvement of the objective parameters as well as the volume of the keloids in comparison with the IL corticosteroids.
© 2015 Wiley Periodicals, Inc.
Significance: This paper discusses the history and developments of Silicone gel sheeting (SGS) scar therapy. Furthermore we review a breadth of literature to gain an insight into how and why topical silicone gels remain the favoured treatment of medical experts in scar management. We also analyse an ever increasing number of alternative therapies claiming to provide enhanced scar reduction performance.
Recent advances: Topical silicone gel treatments seem to remain the first point of clinical recommendation in scar management. SGS has been used in scar therapy for over 30 years, during which its efficacy has been the subject of numerous clinical evaluations.
Critical Issues: Whilst the exact mechanisms by which SGS improves hypertrophic scars, keloid development and recovery are yet to be fully agreed upon its ability to do so remains largely undisputed at present. However, there still is on-going deliberation over the exact mechanism of action of silicone in improving a scar. At present it is likely that through occlusion of the scar site and hydration of the wound bed, the over activity of scar-related cells is suppressed, and their activity normalised.
Future Direction: The clinical support of topical silicone gel products, relative to all alternative scar therapies, is considered the internationally recommended first-line form of scar management, and favoured by consensus among healthcare professionals. However, there still remains the need for further clinical evidence and a better understanding of the mechanism behind the benefit of silicone gel for use in the prevention of abnormal scarring.
Patients and clinicians use skin color attributes such as color uniformity, color distribution, and texture to infer physiologic health status. Normalization of skin color, surface texture, and height are important treatment goals in the treatment of scars. Skin color, structure, and response to trauma, vary with ethnicity. The incidence of hypertrophic and keloid scar formation is influenced by these inherent skin attributes. Skin type influences the response to various modalities including laser therapy and surgical intervention, and skin differences must be considered in treatment planning to achieve optimal results.
Burn injury is one of the most traumatic injuries a child or adolescent can experience. When a burn injury occurs, the child can suffer pain, uncertainty, fear, and trauma from acute treatment to rehabilitation and reintegration. He or she can also experience long-term psychosocial and psychological difficulties. The objective of the study was to compare health-related quality of life (HRQoL), psychopathology, and self-concept of children who have suffered a burn injury with a matched sample of healthy controls. Sixty-six children and adolescents with a burn injury, who were aged between 8 to 17 years, and a caregiver were recruited from six burn centers in Australia and New Zealand. Participants completed the Paediatric Quality of Life Inventory, the Strengths and Difficulties Questionnaire, and the Piers-Harris Self-Concept Scale (P-H SCS). Scores were compared with published normative data. As scarring and appearance are a distinct issue, the Paediatric Quality of Life Inventory cancer module perceived physical appearance subscale was also included. Pediatric burn survivors and their caregivers reported significantly higher emotional and behavioral problems and lower HRQoL, but no significant differences in self-concept compared with healthy counterparts. Pediatric burn survivors also reported significantly poorer perceived physical appearance than the matched pediatric cancer sample. Burned children reported lowered quality of life, particularly related to scarring and appearance; however, they reported normative self-concept. This may be because of self-concept being a psychological trait, whereas HRQoL is influenced by societal norms and expectations. Psychosocial support is necessary to build positive coping strategies and manage the unpleasant social experiences that may reduce quality of life.
Color measurements are an essential part of scar evaluation. Thus, vascularization (erythema) and pigmentation (melanin) are common outcome parameters in scar research. The aim of this study was to investigate the clinimetric properties and clinical feasibility of the Mexameter, Colorimeter, and the DSM II ColorMeter for objective measurements on skin and scars. Fifty scars with a mean age of 6 years (2 months to 53 years) were included. Reliability was tested using the single-measure interobserver intraclass correlation coefficient. Validity was determined by measuring the Pearson correlation with the Fitzpatrick skin type classification (for skin) and the Patient and Observer Scar Assessment Scale (for scar tissue). All three instruments provided reliable readings (intraclass correlation coefficient ≥ 0.83; confidence interval: 0.71-0.90) on normal skin and scar tissue. Parameters with the highest correlations with the Fitzpatrick classification were melanin (Mexameter), 0.72; ITA (Colorimeter), -0.74; and melanin (DSM II), 0.70. On scars, the highest correlations with the Patient and Observer Scar Assessment Scale vascularization scores were the following: erythema (Mexameter), 0.59; LAB2 (Colorimeter), 0.69; and erythema (DSM II), 0.66. For hyperpigmentation, the highest correlations were melanin (Mexameter), 0.75; ITA (Colorimeter), -0.80; and melanin (DSM II), 0.83. This study shows that all three instruments can provide reliable color data on skin and scars with a single measurement. The authors also demonstrated that they can assist in objective skin type classification. For scar assessment, the most valid parameters in each instrument were identified.
Background. The treatment of keloids and hypertrophic scars has been difficult and a recent French study showed that bleomycin has been useful in the treatment of these lesions.Objective. To determine the effectiveness and safety of bleomycin in the treatment of hypertrophic scars and keloids when this drug is administered through multiple superficial punctures.Methods. We applied bleomycin to keloids and hypertrophic scars in 13 patients using a multiple-puncture method on the surface of the skin. All patients were given bleomycin at a concentration of 1.5 IU/ml. Clinical response after treatment was classified according to the following scale: complete flattening (100%), highly significant flattening (>90%), or significant flattening (75–90%).Results. The clinical response was very positive in all cases: complete flattening in six cases, highly significant flattening in six cases, and significant flattening in one case. Two patients presented a recurrence as a small nodule 10 and 12 months after the last infiltration.Conclusions. These clinical findings show that administration of bleomycin in keloids and hypertrophic scars shows promise and needs further investigation.
Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly.
To review the regimens and efficacy of scar massage.
PubMed was searched using the following key words: "massage" in combination with "scar," or "linear," "hypertrophic," "keloid," "diasta*," "atrophic." Information on study type, scar type, number of patients, scar location, time to onset of massage therapy, treatment protocol, treatment duration, outcomes measured, and response to treatment was tabulated.
Ten publications including 144 patients who received scar massage were examined in this review. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment protocols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from one treatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score.
The evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it.
Introduction:
Scar rating scales have the potential to contribute to better evaluation of scar properties in both research and clinical settings. Despite a large number of scars assessment scales being available, there is limited information regarding the clinimetric properties of many of these scales. The purpose of the review was to inform clinical and research practice by determining the quality and appropriateness of existing scales. This review summarises the available evidence for the clinimetric properties of reliability, validity (including responsiveness), interpretability and feasibility of existing scales.
Methods:
Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1990 onwards were used to identify English articles related to burn scar assessment scales. Scales were critically reviewed for clinimetric properties that were reported in, but not necessarily the focus of studies.
Results:
A total of 29 studies provided data for 18 different scar rating scales. Most scar rating scales assessed vascularity, pliability, height and thickness. Some scales contained additional items such as itch. Only the Patient and Observer Scar Assessment Scale (POSAS) received a high quality rating but only in the area of reliability for total scores and the subscale vascularity. The Vancouver Scar Scale (VSS) received indeterminate ratings for construct validity, reliability and responsiveness. Where evidence was available, all other criteria for the POSAS, VSS and the remaining 17 scales received an indeterminate rating due to methodological issues, or a low quality rating. Poorly defined hypotheses limited the ability to give a high quality rating to data pertaining to construct validity, responsiveness and interpretability. No scale had empirical testing of content validity and no scale was of sufficient quality to consider criterion validity.
Conclusions:
The POSAS, with high quality reliability but indeterminate validity, was considered to be superior in performance based on existing evidence. The VSS had the most thorough review of clnimetrics although available data received indeterminate quality ratings. On the basis of the evidence, the use of total scores has not been supported, nor has the measurement of pigmentation using a categorical scale.
Scarring is the major hindrance to the healing of all tissues. Unfortunately, our knowledge about the factors that regulate scarring is quite limited. Even worse is the fact that there have been few gains in the treatment of pathologic scarring. This review sets the stage for the supplement on scar formation that provides the latest knowledge on the pathophysiology and treatment of scar formation.
The goal of this concise review is to provide an overview of some of the most important resuscitation and monitoring issues and approaches that are unique to burn patients compared with the general intensive care unit population.
Consensus conference findings, clinical trials, and expert medical opinion regarding care of the critically burned patient were gathered and reviewed. Studies focusing on burn shock, resuscitation goals, monitoring tools, and current recommendations for initial burn care were examined.
The critically burned patient differs from other critically ill patients in many ways, the most important being the necessity of a team approach to patient care. The burn patient is best cared for in a dedicated burn center where resuscitation and monitoring concentrate on the pathophysiology of burns, inhalation injury, and edema formation. Early operative intervention and wound closure, metabolic interventions, early enteral nutrition, and intensive glucose control have led to continued improvements in outcome. Prevention of complications such as hypothermia and compartment syndromes is part of burn critical care. The myriad areas where standards and guidelines are currently determined only by expert opinion will become driven by level 1 data only by continued research into the critical care of the burn patient.
A reliable, objective, and universal method of assessing burn scars does not exist in today's burn literature. Such a method is necessary to provide a descriptive terminology for the comparison of burn scars and the results of treatment. The method should be applicable to patients both within an institution and between burn centers. A burn scar assessment has been devised based on physical parameters. These relate to the healing and maturation of wounds, cosmetic appearance, and the function of the healed skin. Pigmentation, vascularity, pliability, and scar height are assessed independently, with increasing score being assigned to the greater pathologic condition. Normal skin has a score of 0. Seventy-three patients were assessed by three separate occupational therapists and the findings subjected to statistical analysis for interrater reliability. For each parameter a Cohen's kappa statistic of approximately 0.5 +/- 0.1 indicates a statistically significant agreement between observers. These values were found to improve with time. This appears to be a useful tool for the assessment of burn scars, allowing objective comparison of the same scar by different observers.
The subjective assessment of scar appearance is a widely used method in the evaluation of burn outcomes and the efficacy of treatment methods. The purpose of this study is to design a numeric scar-rating scale with better interrater reliability than has previously been reported. The rating scale assesses scar surface, thickness, border height, and color differences between a scar and the adjacent normal skin. Eight raters were trained with use of a standardized set of photographs that provide examples of the scores to be assigned to each level of severity of each scar characteristic. The raters then rated 10 photographs of different scars, referring to the teaching set of pictures for comparison. The intraclass correlation (interrater reliability) was 0.94, 0.95, 0.90, and 0.85 for scar surface, border height, thickness, and color, respectively. This rating system has proved to be a useful tool for the evaluation of scar surface, thickness, border height, and color.
Wound healing in adult human skin results in varying degrees of scar formation, ranging clinically from fine asymptomatic scars to problematic hypertrophic and keloid scars, which may limit function and restrict further growth. At present, no good objective method of clinically assessing scars exists, which is problematic for the evaluation of scar prevention or treatment regimens. Similarly lacking are histologic correlates of what we consider good and bad clinical scars. The objective of this study was to quantitatively assess human scarring (1) clinically, by developing a comprehensive rating scale, (2) photographically, using an image capture system and a scar assessment panel, and (3) by histologic analysis following scar excision. We assessed 69 scars, with a wide clinical range of severity, in patients who were undergoing surgery, for whatever reason, that involved removal of an old scar. Preoperatively, patients had their scars assessed, clinically using our newly developed scale and photographically using a computerized image capture system. These photographs were then sent to a panel for assessment using similar criteria to those used clinically. Assessment of scars from photographs correlated well with the clinical scar evaluation, indicating its potential utility in multicenter scar prevention/treatment trials. Following excision, scars were processed and analyzed for histology. We also found a strong correlation between the macroscopic and microscopic appearance of scars, particularly between the clinical appearance and histologic scores of features in the epidermis and papillary dermis. This suggests that our clinical scale is a sensitive instrument in scar assessment, allowing validated quantification of the severity of a wide range of scars.
The treatment of keloids and hypertrophic scars has been difficult and a recent French study showed that bleomycin has been useful in the treatment of these lesions.
To determine the effectiveness and safety of bleomycin in the treatment of hypertrophic scars and keloids when this drug is administered through multiple superficial punctures.
We applied bleomycin to keloids and hypertrophic scars in 13 patients using a multiple-puncture method on the surface of the skin. All patients were given bleomycin at a concentration of 1.5 IU/ml. Clinical response after treatment was classified according to the following scale: complete flattening (100%), highly significant flattening (>90%), or significant flattening (75-90%).
The clinical response was very positive in all cases: complete flattening in six cases, highly significant flattening in six cases, and significant flattening in one case. Two patients presented a recurrence as a small nodule 10 and 12 months after the last infiltration.
These clinical findings show that administration of bleomycin in keloids and hypertrophic scars shows promise and needs further investigation.
Hypertrophic scarring after burns remains a major problem and is considered to be "common". Pressure garments are commonly used as treatment even though there is little sound data that they reduce the prevalence or magnitude of the scarring. In 1999 we began a study of the efficacy of pressure garments on forearm burns. After studying 30 patients, mainly white adults, we found no hypertrophic scar in either those treated with pressure or without. This prompted us to review the literature on the prevalence of hypertrophic scarring after burns and found only four articles with a relatively small number of patients and only three geographical locations. It became clear that the prevalence of hypertrophic scarring is really unknown. We then did a retrospective study of 110 burn survivors and counted all hypertrophic scars of all sizes and locations in all races and found the prevalence hypertrophic scarring to be 67% which conflicts with the published reports and our prospective study and suggests that further research is necessary. We concluded that a worldwide, prospective survey is necessary to establish the prevalence of hypertrophic scarring after burns. In this article we are calling for and offering to organize this survey.
At present, various scar assessment scales are available, but not one has been shown to be reliable, consistent, feasible, and valid at the same time. Furthermore, the existing scar assessment scales appear to attach little weight to the opinion of the patient. The newly developed Patient and Observer Scar Assessment Scale consists of two numeric scales: the Patient Scar Assessment Scale (patient scale) and the Observer Scar Assessment Scale (observer scale). The patient and observer scales have to be completed by the patient and the observer, respectively. The patient scale's consistency and the observer scale's consistency, reliability, and feasibility were tested. For the Vancouver Scar Scale, which is the most frequently used scar assessment scale at present, the same statistical measurements were examined and the results of the observer scale and the Vancouver scale were compared. The concurrent validity of the observer scale was tested with a correlation to the Vancouver scale. Furthermore, the authors examined which specific characteristics significantly influence the general opinion of the patient and the observers on the scar areas. Four independent observers have each used the observer scale and the Vancouver scale to assess 49 burn scar areas of 3 x 3 cm belonging to 20 different patients. Subsequently, the patients completed the patient scale for their scar areas. The (internal) consistency of both the patient and the observer scales was acceptable (Cronbach's alpha, 0.76 and 0.69, respectively), whereas the consistency of the Vancouver scale appeared not to be acceptable (alpha, 0.49). The reliability of the observer scale completed by a single observer was acceptable (r = 0.73). The reliability of the Vancouver scale completed by a single observer was lower (r = 0.69). The observer scale showed better agreement than the Vancouver scale because the coefficient of variation was lower (18 percent and 22 percent, respectively). The concurrent validity of the observer scale in relation to the Vancouver scale is high (r = 0.89, p < 0.001). Linear regression of the general opinions on scars of the observer and the patient showed that the observer's opinion is influenced by vascularization, thickness, pigmentation, and relief, whereas the patient's opinion is mainly influenced by itching and the thickness of the scar. Such an impact of itching and thickness of the scar on the patient's opinion is an important and novel finding. The Patient and Observer Scar Assessment Scale offers a suitable, reliable, and complete scar evaluation tool.
Objective measurement of burn scar response to treatment is important to facilitate individual patient care, research, and service development. This work examines the validity and reliability of the tonometer as a means of quantifying scar pliability. Ten burn survivors were recruited into the study. Triplicate measures were taken for each of four scar and one normal skin point. The pliability score from the Vancouver Scar Scale also was used as a comparison. The tonometer demonstrated a high degree of reliability (intraclass correlation coefficients 0.91-0.94). It also was shown to provide a valid measure of pliability by quantifying decreased tissue deformation for scar (2.04 +/- 0.45 mm) compared with normal tissue (3.02 +/- 0.92 mm; t = 4.28, P = .004) and a moderate correlation with Vancouver Scar Scale scores. The tissue tonometer provides a repeatable, objective index of burn scar pliability. Using the methods described, it is a simple, clinically useful technique for monitoring an individual's scar.
The relationship between burn depth, healing time and the development of hypertrophic scarring (HTS) is well recognised by burn surgeons but is seldom mentioned in the published literature. We studied 337 children with scalds whose scars were monitored for up to 5 years. Overall HTS rates were found to be: under 10 days to healing=0%, 10-14 days=8%, 15-21 days=20%, 22-25 days=40%, 26-30 days=68% and over 30 days=92%. In the conservatively treated group the HTS rates are: under 10 days=0%, 10-14 days=2%, 15-21 days=20%, 22-25 days=28%, 26-30 days=75% and over 30 days=94%. If skin grafting is undertaken there is a much higher incidence of HTS in the 10-14 days group: 10-14 days=33%, 15-21 days=19%, 22-25 days=54%, 26-30 days=64% and over 30 days=88%. We conclude that there is a low risk of HTS formation in scalds healed before 21 days, and that surgery should be reserved for scalds likely to take more than 21 days to heal.
The depth of a burn wound and/or its healing potential are the most important determinants of the therapeutic management and of the residual morbidity or scarring. Traditionally, burn surgeons divide burns into superficial which heal by rapid re-epithelialization with minimal scarring and deep burns requiring surgical therapy. Clinical assessment remains the most frequent technique to measure the depth of a burn wound although this has been shown to be accurate in only 60-75% of the cases, even when carried out by an experienced burn surgeon. In this article we review all current modalities useful to provide an objective assessment of the burn wound depth, from simple clinical evaluation to biopsy and histology and to various perfusion measurement techniques such as thermography, vital dyes, video angiography, video microscopy, and laser Doppler techniques. The different needs according to the different diagnostic situations are considered. It is concluded that for the initial emergency assessment, the use of telemetry and simple burn photographs are the best option, that for research purposes a wide range of different techniques can be used but that, most importantly, for the actual treatment decisions, laser Doppler imaging is the only technique that has been shown to accurately predict wound outcome with a large weight of evidence. Moreover this technique has been approved for burn depth assessment by regulatory bodies including the FDA.
Combined intralesional triamcinolone acetonide and platelet rich plasma versus intralesional triamcinolone acetonide alone in treatment of keloids
- E S Hewedy
- Bei Sabaa
- W S Mohamed
- D S Hegab
- ES Hewedy