Timing is everything
Kristina Stiles is a Clinical Nurse Specialist in Burns and Plastics. As the Head of Clinical Services at the Katie Piper Foundation, she is experienced in burn care and service development, leading the successful foundations and growth of the first UK-based residential, specialist burns rehabilitation centre.
In her latest blog, she considers the factors that lead to scarring and raises awareness of the treatment options available. She highlights the importance of treating a burn early in order to help support a patient’s journey to a better quality of life.
The practice of burns care is an extraordinary speciality. Those who commit their careers to burns set themselves an almost impossible challenge to support an injury, which cannot be easily defined due to its multiple aetiologies and cannot be simply estimated on its severity due to dependency on physical properties like size, depth and their relation to the emotional impact on the burn survivor.
Moreover, burns cannot be accurately assessed due to their dynamic nature and progression over time, they cannot be restored with a single operation by one team requiring the full armoury of many multidisciplinary specialities, and cannot be said to be fully “cured” due to reconstruction, rehabilitation and ongoing recovery throughout a person’s lifetime.
How can burns be defined?
Burns are defined and managed by the mechanism of injury ranging from flame, scald, contact, steam, radiation, electrical, chemical, to friction and frostbite. Each aetiology requires a definitive pathway of care. In clinical practice, burn severity is rather pragmatically calculated using the percentage total body surface area (%TBSA) burned (i.e. size of the burn) alongside the skin and underlying structures affected (i.e. depth of the burn). Additional parameters that are taken into consideration which are known to influence morbidity and mortality are age and presence of smoke inhalation injury. However, even a small %TBSA burn can have life-changing consequences for the burn survivor, especially when it affects functionally and aesthetically important areas such as a person’s face, eyes and hands.
Early intervention is key
Early appropriate interventions from the time of injury can influence a burn survivor’s outcome. Initial treatment aims to support life by following long established primary and secondary trauma surveys. Recommended steps include delivering first aid to prevent progression of depth and size, compensating for the damaged properties of skin by preventing heat loss, delivery of active warming, adequate analgesia, aseptic wound cleansing and atraumatic wound care regime.
Scar-free outcomes in burns are linked to the delivery of timely and appropriate first aid. Apart from the immediate physiological (i.e. biomechanical and microcirculatory) benefits, through removal of heat and oedema, and provision of pain relief to the burn wound, burns first aid is suggested to influence long term genetic (i.e. protein expression) changes as well. Twenty minutes of cooling a burn under running tap water has been shown to1:
- Reduce the negative burn progression resulting in faster healing
- Reduce the need for surgery and hence a hospital stay
- Result in less infective complications
- Reduce the likelihood of scarring
This is most beneficial if delivered immediately post-injury but remains effective up to 3 hours after burn. The lasting impact of a burn is dependent on the properties of the affected skin. Burn classification illustrates the extent of injury based on the structures and properties of the skin affected:
- In erythema (superficial reddening of the skin), the epidermis is inflamed and presents as hot to touch, reddened and painful area of skin, which sloughs off over a number of days and heals without a scar.
- In a superficial burn, the epidermal and upper dermal structures are involved with sensation and circulation remaining intact, often resulting in liquid-filled blisters, a painful red or pale-pink wound bed, which is likely to heal with minimal scarring utilising the conservative wound care approach.
- In deep dermal and full thickness burns, the epidermis, dermis and subcutaneous structures like tendon, muscle and bone may be unsalvageable and require specialist care. This type of burn often results in operative management and problem scarring and so can require a burn survivor’s life-long commitment to reconstructive surgery, rehabilitation and scar management. It is possible they will need to make a psychosocial and emotional adaptation following a life-changing injury.
Likelihood of scarring
Any burn that takes longer than 21 days to heal will result in a scar2. Whilst scarring is a natural outcome of wound healing, it has many unintentional consequences, which may influence a burn survivor’s quality of life. The scar has a maximum of 80% tensile strength of uninjured tissue with very different visual, structural and physical characteristics to normal skin. It means that the newly healed tissue will be weaker, less flexible, more fragile and more susceptible to injury.
Over-granulation and prolonged remodelling phase create persistent inflammation, excessive collagen synthesis and delay in wound healing, leading to pathological scars. This creates a permanent inflammatory cycle with an overproduction of the vascular and connective tissues, where collagen builds layers in a disorganised and haphazard fashion, leading to erythematous, bulky and aesthetically unsightly scar. Wounds across joint areas generate more mechanical tension and inflammation and are more likely to result in contractures. The scar maturation process sees a fully healed wound progress into a hyperaemic, hypertrophic, pruritic, painful, thick and inelastic scar which grows rapidly over many months reaching maturation at two years.
The treatment and prevention of scars
Most of the scar treatment options currently available are dedicated to management of scar characteristics: elasticity and pliability, vascularity, pigmentation and colour, height and thickness, texture and irregularity, contraction and degree of disfigurement. Scar prevention therapies aim to reduce the risk of shearing and tension through the use of non-invasive scar management modalities such as silicone-based products, hypoallergenic microporous tapes, pressure garments and manual or mechanical scar massage. Semi-invasive scar management techniques include microneedling and dermarolling, shockwave therapy, intralesional corticosteroid injections and laser resurfacing. Invasive scar surgery offers operative reconstruction for most severe and restrictive scarring.
Most common scars that result from burns and recommended therapies:
- Hypertrophic scars are most prevalent after burn injury. They remain within the borders of the wound with characteristic rapid growth phase within the first 12 months and gradual regression of scarring over months and years after. Non-invasive scar therapies are most effective in helping the scar to heal as is the longitudinal effect of time, however semi-invasive therapies, especially non-ablative and ablative fractional laser, have indicated promise in promoting rapid healing and remodelling response, which is the dynamic process of rebuilding the complex scaffold-like support structure around which the rest of the tissues heal.
- Keloid scars can develop post-injury or spontaneously and tend to experience excessive growth, which is persistent, travels outside the wound borders and does not result in spontaneous regression.
- Scar adhesions often affect surface area and pliability of a scar creating a feeling of tightness with reduced range of movement. Scar adhesions respond well to soft tissue techniques and vacuum massage, shockwave therapy and microneedling.
- Scar contractures are found over flexures creating a tense, thick and fibrous band of scar tissue which can be disfiguring and can restrict the range of movement. Manual stretching, tension-reducing taping, microneedling and scar revision surgery are the treatment options available.
- Scar hyperaemia is an indicator of the immaturity of the scar, which normally subsides independently over 6-12 months post healing. Scar vascularity (redness) most benefits from non-invasive scar management modalities, like pressure therapy, silicone therapy, manual and mechanical soft tissue techniques, as well as semi-invasive therapies like shockwave therapy, intralesional corticosteroid injections and vascular laser.
Scars can often present with hypo- or hyper-pigmentation, resulting in unsatisfactory aesthetic and visible difference. Scar pigmentation can be managed with fractional laser therapy, microneedling, scar camouflage, medical micropigmentation and medical tattooing treatments.
Scars can be inelastic and non-pliable, which can feel uncomfortable, stiff and tight with impact on the extent of movement and stretch. Scar elasticity is best treated with non-invasive techniques such as massage (to manipulate the tissue). Using non-perfumed moisturisers in the form of creams, gels or oils, such as Bio-Oil Skincare Oil, by applying deep massaging techniques regularly until sufficient relief of scar symptoms has been achieved can help maintain elasticity of scar tissue, especially those affecting joints and other high mobility areas. Other solutions such as silicone therapy, stretches, exercises and scar manipulation with a physiotherapist, positioning and splinting and semi-invasive therapies like microneedling and shockwave therapy can also help.
Poor scar texture is the most difficult scar characteristic to manage, as it affects the look and feel of the scar. Semi-invasive techniques like microneedling and ablative fractional laser are the most effective scar texture treatments to date.
By delivering prompt and appropriate first aid, the burn wound has the best chance to heal within 21 days without problem scarring1. If scarring does occur, appropriate treatment interventions should be respective of the scar maturation process by delivering the right care at the right time. By raising awareness of the scar treatment options available, burn survivors and patient with traumatic scars have an opportunity to access the care they require. By guiding our patients’ recovery we are supporting their journey to a better quality of life and a life worth living.
“A burn can be a life-changing injury, but it does not have to be life-ending.” – Katie Piper, Founder of The Katie Piper Foundation.
Resources for healthcare professionals:
Bio-Oil Professional has several free resources for healthcare professionals on the topic of scarring, free to download:
Resources for your patients:
1 Wood et al (2016), “Water First Aid Is Beneficial In Humans Post-Burn: Evidence from a Bi-National Cohort Study”