SCAR MANAGEMENT

Hypertrophic scarring is a difficult problem for burn patients (Image 7), and scar management is an essential aspect of outpatient burn therapy.

Perhaps the most virulent hypertrophic scarring is seen in deep dermal burns that heal spontaneously in 3 or more weeks; this seems especially true in areas of highly elastic skin (eg, the lower face, submental triangle, anterior chest and neck).

The wound hyperemia seen universally following burn wound healing should begin to resolve about 9 weeks after epithelialization. In wounds destined to become hypertrophic, increased neovascularization occurs with increasing (rather than decreasing) erythema after 9 weeks.

Available tools to modify the progression of hypertrophic scar formation are limited in number and effectiveness. These tools include scar massage, compression garments, topical silicone, steroid injections, and surgery. In some contractures over major joints, serial casting may be useful.

Conscientious scar massage can be effective in limited areas of scarring, and it is convenient since it can be performed by family members. Ideally, this technique is performed several times each day. Bland moisturizers, which minimize drying of recently healed burns and skin grafts, are applied . Evolving hypertrophic areas then are massaged in a firm and slow manner.
Despite the controversy over its use, compression garments seem to improve control of broad areas of hypertrophic scarring, particularly in young children in whom this process seems to be more severe.
- Compression garments should be worn 23 hours a day until wound erythema begins to abate, usually about 12-18 months after injury.
- In growing and young children, frequent refitting and replacement of compression garments are required. Garment fit must be verified after manufacture, as a poorly fitting garment is less effective and can be uncomfortable.
Topical silicone, applied to the healed wound as a sheet, is effective when applied to small areas of a troublesome hypertrophic scar.
- Having the silicone in place 24 hours a day is ideal, except during bathing.
- Some children develop a rash beneath the topical silicone, but this rash quickly resolves with removal of the silicone; in these patients, 12-hour or every-other-day application seems to help.
- Silicone sheets can be placed beneath compression garments or can be held in place by one of several elastic devices.
- Firm pressure is not required for the silicone to be effective.
For only localized and very symptomatic areas of early hypertrophic scars, especially if they are in highly cosmetic locations or are causing extreme pruritus, direct steroid injections can be useful .
- Limit the total dose so that systemic effects do not occur.
- These injections are painful, as they require high pressure to infiltrate the dense hypertrophic scars; in children, general anesthesia usually is required.
- Only localized and very symptomatic areas are treated in this fashion.
- Extreme pruritus is a frequent part of burn wound healing.
  - Pruritus typically begins shortly after the wound has healed, peaks in intensity 4-6 months after injury, and then gradually subsides in most patients. It can be especially troubling at night.
  - In most patients, it is adequately treated with massage, moisturizers, and oral antihistamines at night. Alternative approaches are available, although none works reliably for everyone.
  - In patients particularly troubled by pruritus, a sequential therapeutic trial of each maneuver often identifies one particularly helpful method: topical creams containing vitamin E, topical antihistamine creams, topical cold compresses, frequent application of moisturizing creams, or colloidal baths.
  - Localized highly pruritic scars often respond to a steroid injection.
  - In rare cases, pruritus becomes so intense that excoriations develop.
  - These wounds can become superinfected with Staphylococcus aureus, which further exacerbates the pruritus.
  - To allow healing of excoriated areas, some patients require admission for wound care and antibiotics to control the pruritus and infection.
  - Burn wound pruritus is a difficult but usually self-limited problem that begs for an effective solution.
Surgical excision or incision and autografting are useful maneuvers when other scar management tools are ineffective.