Principles of scar management
Adequate burn wound treatment is essential to minimize problematic scarring.
After the burn wound has healed and a scar is present, patients often experience scar-related problems. It is vital to first identify the scar-related problems before starting treatment. Therefore, scar management always starts with proper scar assessment.
Once you have identified the scar-related problems, you can make a treatment plan. This may focus on symptoms requiring non-invasive treatment, such as pain and itchiness, or on those requiring surgical treatment, including functional limitations such as limited range of movement due to contractures.
How to prevent scarring
Adequate burn wound treatment during the wound healing phase is essential to minimize problematic scarring, including contracture formation. Inflammation, infection, prolonged reepithelialization, extracellular matrix production, and remodeling may all influence scar formation.
There are a number of measures you can take to prevent problematic scarring, during the wound-healing phase and the maturation phase (one to two years after the burn injury).
Prevention during the wound-healing phase
Topical agents and dressings
Use adequate topical agents and wound dressings to establish a moist wound healing environment. This is especially important for superficial partial thickness burns.
Debride necrotic tissue adequately, either by mechanical debridement or surgical debridement. This is especially important for deep dermal burns.
Reduce the risk of infection through infection prevention and control, and daily dressing and cleaning of the wound.
Prevent the formation of granulation tissue and manage hypergranulation adequately.
Close wounds in a timely manner and perform surgery (often excision and skin grafting) when indicated. This is especially important for deep dermal partial thickness burns and full thickness burns.
The main factors influencing the timing of surgery are size and depth of the wound. Early excision, within a few days post-burn (up to a maximum of 10 days post-burn), is preferable to delayed excision for deep dermal burn wounds. For deep partial thickness burns, it is acceptable to wait two or three weeks until spontaneous healing has occurred.
Prevention during the maturation phase
A scar in the maturation phase is prone to sunburn, and high levels of UV radiation can increase the amount of the dark pigment melanin. Advise the patient to avoid sun exposure and to use sunscreen at regular time intervals, preferably SPF 50+, until the end of the maturation phase, up to two years after the burn injury. If sunscreen is not available, for example in resource-limited settings, advise the patient to limit the exposure of burned areas to direct sunlight by using an umbrella, covering the scar with clothing, or wearing a cap.
It can be beneficial to hydrate the scar – hydration can prevent or treat pruritus, normalize scar size and reduce pain. Patients can use any kind of moisturizer, such as body lotion, and choose the product they prefer. However, they should avoid using topical corticosteroids.
You should start specific measures to prevent the formation of contractures as early as possible to minimize contractures and achieve optimal range of motion (ROM). This should include a physiotherapy rehabilitation program with key components: stretching and mobilization, anti-contracture positioning, and splinting.
Stretching and mobilization
To attain and maintain ROM and help lengthen the scar, you should start stretching and mobilization as early as possible. In particular, if you have chosen delayed grafting, it is vital to start mobilization while waiting to begin grafting.
There are three types of mobilization: active, active assisted, and passive.
Active mobilization – the patient moves the antagonistic muscle group of the extremity. This can start as soon as the skin graft allows, usually a minimum of one week after surgery.
Active assisted mobilization – the patient moves the affected extremity, and uses the other hand to assist movement to maximize the ROM.
Passive mobilization – the physiotherapist moves the affected extremity when the patient is in a relaxed state.
After a burn injury, the burned body part will move into the most comfortable position by following the path of least resistance. This is usually a flexed position in the direction of the core, hence flexion contractures occur most often. Anti-contracture positioning counteracts this flexing tendency.
You should start anti-contracture positioning as early as possible in the rehabilitation program.
There are several common anti-contracture positions. It is possible to achieve this positioning actively or passively. Active positioning requires a highly motivated and consistently cooperative patient; passive positioning involves the use of splints. Note that it is important to follow the positioning regime during most of the day, except during exercise.
The most important indications for splinting during burn rehabilitation are tissue and skin graft protection, joint positioning, and tissue lengthening. Using splints forces the tissue to lengthen in a controlled state, and to follow the desired anatomical contour.
Splinting is not an alternative way to prevent contractures for skin grafting in large deep and full thickness burns.
Splinting without an exercise regime could still lead to contracture development.
In the early stages, the patient should be splinted day and night. When you have achieved the desired range of motion (ROM), you can gradually reduce the frequency of splinting.
There are two types of splints: static and dynamic splints.
Static splints immobilize the joint and should be worn during the night. However, the effect of mechanical tension on the wound during the healing process suggests that static splinting may counteract its own purpose by stimulating myofibroblast activity. Therefore, you must be alert and monitor scar development continuously.
Dynamic splints position the joint but allow mobilization against resistance and should be worn during the day, except when exercising.