Scar massage for hypertrophic burns scarring—A systematic review

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.

Effect of intense pulsed light on immature burn scars: A clinical study

Introduction:

As intense pulsed light (IPL) is widely used to treat cutaneous vascular malformations and also used as non-ablative skin rejunuvation to remodel the skin collagen. A study has been undertaken to gauze the effect of IPL on immature burn scars with regard to vascularity, pliability and height.

Materials and Methods:

This study was conducted between June 2013 and May 2014, among patients with immature burn scars that healed conservatively within 2 months. Photographic evidence of appearance of scars and grading and rating was done with Vancouver Scar Scale parameters. Ratings were done for both case and control scar after the completion of four IPL treatment sessions and were compared.

Results:

Out of the 19 cases, vascularity, pliability and height improved significantly (P < 0.05) in 13, 14 and 11 scars respectively following IPL treatment.

Conclusions:

Intense pulsed light was well-tolerated by patients, caused good improvement in terms of vascularity, pliability, and height of immature burn scar.KEY WORDS: Burn scar, intense pulse light, vancouver scar scale     

Combination treatment utilizing fractional ablative and continuous wave CO2 lasers for hypertrophic burn scars

BackgroundHypertrophic scars are devastating outcomes of severe burn injuries, producing physical and mental burdens. Adequate treatment is of benefit to relieve these burdens. Laser therapy has shown scar reducing effects. In this study, we compared outcomes after combination of two different lasers or single laser treatment to treat severe hypertrophic burn scars.MethodsForty patients with hypertrophic burn scars were included in one of two therapeutic groups: continuous wave CO₂ laser and fractional ablative CO₂ laser group (group 1, n = 20) or fractional ablative CO₂ laser alone group (group 2, n = 20). Hypertrophic scars were evaluated by the observer-rated Vancouver Scar Scale (VSS) before and after treatment and by patient-completed questionnaires after treatment. Comparative analyses were performed before and after treatment, and time-dependent improvement was also analyzed.ResultsForty patients (54 hypertrophic scars) completed the laser treatment protocols. Group 1 exhibited significantly more improvement in VSS vascularity, pliability, and height indices than group 2 (p < 0.05). Time-dependent analysis of total VSS scores suggested that group 1 experienced more improvement during a shorter treatment period (p < 0.05). For patient-reported outcomes, group 1 noted better grades than group 2 in four indices, namely scar appearance, scar thickness, pain, and pruritus (p < 0.05).ConclusionEffective scar reduction was achieved using combination laser treatment, with significant improvement in multiple observer- and patient-reported outcomes. The shorter treatment period of the combination method can be a merit, as prolonged hypertrophic scars may increase morbidity. Nonetheless, cautious treatment protocols are necessary to avoid undesirable sequelae related to laser application.     

Reliability of scar assessments performed with an integrated skin testing device – The DermaLab Combo®

BackgroundThe DermaLab Combo^® is a device with potential to make objective measurements of key scar components – pigmentation, vascularity, pliability and thickness. This study assessed the inter-rater and test–retest reliability of these measurements.MethodThree raters performed scar assessments on thirty patients with burn scars using the DermaLab Combo^®. Measurements of pigmentation, vascularity, pliability and thickness were made and intra-class correlation coefficients (ICC) were derived for inter-rater and test–retest reliability.ResultsInter-rater reliability was found to be “excellent” in the ‘best’ and ‘worst’ areas of the index scar and normal skin for pigmentation (ICC: 0.94–0.98) and thickness (ICC: 0.86–0.96). Test–retest reliability was also “excellent” for pigmentation (ICC: 0.87–0.89) and thickness (ICC: 0.92–0.97) in all areas. Vascularity showed “good” to “excellent” inter-rater reliability (ICC: 0.66–0.84) in all areas however test–retest reliability was “low” (ICC: 0.29–0.42). Test–retest reliability was “excellent” for pliability (ICC: 0.76–0.91). Technical limitations were encountered making measurements in some scars for thickness, and in particular, pliability.ConclusionThe DermaLab Combo^® measured pigmentation, thickness and pliability with “excellent” reliability. If future studies provide protocols to improve test–retest reliability of vascularity measurements and obtain pliability measurements more successfully, the DermaLab Combo^® will be valuable device for scar assessment.     

Patterns and predictors of burn scar outcome in the first 12 months after burn: The patient’s perspective

ObjectiveThis study aimed to provide insight into the patterns and factors that predict burn scar outcomes at 3, 6 and 12 months after burn.MethodsThe Patient and Observer Scar Assessment Scale (POSAS) was used to assess the scar formation of each patient. Structural equation modelling was used. The predictor variables used in this study were sex, three age categories, TBSA, depth of the wound and cause of the burn.ResultsThe POSAS patient total and individual item scores demonstrated a statistically significant decrease in the first 12 months after burn, except for the relief item. Male patients had a lower total and items scores (better scar quality) for pain and pruritus compared with female patients. Full thickness burns had a higher scores for pruritus, pliability, thickness and relief compared to the partial-thickness burns. Ages younger than 5 years, higher TBSA values and flame burns were predictors of various POSAS items at 3 and 6 months after burn.ConclusionThe POSAS patient total and individual item scores demonstrated a statistically significant improvement in the scar quality in the first 12 months after burn, except for the relief. Sex, age, depth of the wound, the percentage of TBSA and flame burns were predictors of various POSAS patient items at 3, 6 and 12 months after burn.     

The recovery of post-burn hypertrophic scar in a monitored pressure therapy intervention programme and the timing of intervention

Introduction

Pressure therapy used to be considered as the mainstay non-invasive treatment of hypertrophic scar. However, the maturation process of hypertrophic scar during pressure therapy process has seldom be reported. Moreover, although early application of pressure therapy after burn injuries is reco6mmended, minimal evidence exists to support it. This study aimed to examine the maturation trajectory of post-burn hypertrophic scars in a 6-month monitored pressure therapy intervention programme and investigate the difference in the trajectory between patients receiving early intervention and patients receiving late intervention.

A modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA): Inter-rater reliability of an innovative burn scar assessment method

Background

Current scar assessment methods do not capture variation in scar outcome across the burn scar surface area. A new method (mVSS-TBSA) using a modified Vancouver Scar Scale (mVSS) linked with %TBSA was devised and inter-rater reliability was assessed.

Method

Three raters performed scar assessments on thirty patients with burn scars using the mVSS-TBSA. Scoring on pigmentation, vascularity, pliability and height was undertaken for the ‘best’ and ‘worst’ areas of each scar. Raters allocated the total body surface area of the scar (%TBSA) to three mVSS categories (<5, 5–10, >10). Intra-class correlation coefficient (ICC) and weighted kappa statistic (k_w) were used to assess inter-rater reliability. The data were also analysed for clinically relevant misclassifications between pairs of raters.

Results

Total mVSS scores showed ‘fair to good’ agreement (ICC 0.65–0.73) in the ‘best’ area of the scar while there was ‘excellent’ agreement in the ‘worst’ scar area (ICC 0.85–0.88). The k_w of the individual mVSS components ranged from 0.44 to 0.84 and 0.02 to 0.86 for ‘best’ and ‘worst’ scar areas, respectively. Determination of scar %TBSA had ‘excellent’ reliability (ICC 0.91–0.96). Allocation of scar %TBSA to severity category <5 mVSS demonstrated ‘good to excellent’ reliability (ICC 0.63–0.80) and ‘fair to good’ reliability (ICC 0.42–0.74) for 5–10 mVSS category. However, misclassifications were observed for the total mVSS score in the ‘worst’ scar area and the allocation of scar %TBSA in the <5 mVSS category.

Conclusion

Inter-rater reliability of mVSS scores depends on the severity of the scar area being assessed. The mVSS-TBSA method of allocation of scar %TBSA to two broad mVSS categories, namely <5 and ≥5 mVSS, has ‘good to excellent’ reliability. The mVSS-TBSA has demonstrated utility for both clinical and research purposes; however, there is potential to misclassify scar outcome in some cases.     

A systematic review of the quality of burn scar rating scales for clinical and research use

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.     

A comparison on the scar development when done through overlapping versus approximating seams techniques — A clinical trial

IntroductionSkin autografting is performed widely for deep burn wounds as an ideal coverage. Scaring at the site of grafting has been always a challenge for surgeons. Many methods have been proposed to lessen the probability of scaring, but conflicting results have been obtained. It is said that the suture type is important in the development of scaring. Seams technique has also been introduced to decrease scar after autografting.ObjectiveWe sought to compare two approximating (AP) and overlapping (OV) Seams technique to compare the development of scars.Methods and materialsPatients with deep burns of 10% to 50% TBSA who were candidates for grafting entered this double-blind randomized trial. One side of the graft was fixed with a stapler using the “approximating” technique and the other side was fixed by the “overlapping” technique with a 1–2 mm margin overlap. The Vancouver Scar Scale (VSS) standard was used to evaluate scar formation at the graft edges at six months. Data entered SPSS 16 and analyzed. A P-value below 0.05 was considered as statistically significant.ResultsThirty-six patients entered. Two (5.6%) were females and 34 (94.4%) males. The mean age of patients was 39.14 ± 8.53 years. The mean burn surface area percentage was 15.2 ± 2.84. Vascularity Scar index had no statistically significant difference between the overlapping and approximating techniques (P = 0.564). However, pigmentation (P = 0.014), pliability (P = 0.008) and the height indices (P < 0.001) were statistically significantly better in the approximating technique. The mean of total score of Vancouver was better in the approximating technique as well (P < 0.001).ConclusionWe compared two techniques of Seams between the normal skin and the graft edge for the first time. We showed that the AP method had a better Vancouver score compared to the OV regarding pigmentation, height, and pliability indices.     

Patient opinion of scarring is multidimensional: An investigation of the POSAS with confirmatory factor analysis

Introduction

Scarring is a significant consequence for patients following a burn. Understanding how patients perceive the physiological scar and define scar severity may provide valuable information regarding how the scar influences quality of life after burn. The Patient and Observer Scar Assessment Scale was the first scar assessment tool validated to include the patients’ evaluation of the scars physical qualities, following a burn. Validation studies of this tool have previously been conducted for a discrete scar-site after burn. The aim of this study was to assess the structural validity of the POSAS to capture the patients’ evaluation of the total area of burn scar(s).

Quantitative and qualitative dermal change with microfat grafting of facial scars

OBJECTIVE: To evaluate changes in dermal characteristics with subdermal fat grafting of cutaneous scars. DESIGN: Prospective cohort. METHODS: Fourteen patients with various scar types were treated with subdermal fat grafting over 30 months. Dermal elasticity, vascularity, pigmentation, patient perception and satisfaction, and observer assessment of scar characteristics were evaluated preoperatively and 1 year after treatment with validated objective and subjective measures. RESULTS: Significant improvements were observed in dermal elasticity, patient and observer perception of scar thickness, patient perception of stiffness, and observer perception of relief and pliability (P < 0.05). A trend toward significance was seen in observer assessment of height as evaluated by the Vancouver Scar Scale (P < 0.1). No significant differences were seen in quantitatively and qualitatively measured vascularity and pigmentation (P > 0.1). No significant difference in pain, pruritis, and irregularity were reported (P > 0.1). CONCLUSION: Although fat grafting represents a subdermal process, it appears to improve certain quantitative and qualitative dermal characteristics. Fat grafting does not appear to affect skin color, vascularity, or patient symptoms.     

Ultrasound assessment of scald scars in Asian children receiving pressure garment therapy

BACKGROUND/PURPOSE: Scar formation after scald injury in children is managed commonly by application of pressure garment. The duration of the treatment depends on clinical assessment. The objective of the study was to evaluate the efficacy of the pressure garment therapy and to correlate the clinical assessment scar thickness with ultrasound measurement. METHODS: Prospective study of children with hypertrophic scars receiving pressure garment therapy was carried out between 1993 and 1998. The scars were mapped with paper cutting. Representative scar sites were scored clinically according to Vancouver General Hospital Burn Assessment Scale (pigmentation, vascularity, pliability, height, pain, itchiness). Blind to the clinical results, 2 radiologists measured the scar thickness of the same sites with ultrasonography (5 to 10 MHz transducer, General Electric LOGIQ 500). The correlation between the clinical scores and ultrasound measurement of scar thickness were analysed using analysis of variance (ANOVA). RESULTS: The median age of 58 children with scald injury (M:F = 36:22) was 2.8 years (0.5 to 15.8 years). The mean percentage of scald was 8.8% (24% had scald area >10%). In addition, there were 5 children with burn from naked flame and 9 children with keloid secondary to surgical incisions. With pressure garment therapy, the scar thickness reached a plateau 1 (1/2) years after the injury and began to decline gradually thereafter. The clinical estimation of scar thickness correlated well with the ultrasound measurement (ANOVA, P =.003, Adjusted R square = 0.99). The accuracy rate of clinical thickness estimation was 67%. Overestimation and underestimation accounted for 15% and 18%, respectively. There also was good correlation between total clinical score and the ultrasound measurement (ANOVA, P <.001). CONCLUSIONS: In children with scald injury, the pressure garment needs to be continued for a minimum of 1 year. Ultrasound measurement correlates well with overall score of the Vancouver General Hospital Burn Assessment Scale but not individual components of the scoring system except wound height.     

A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on post-traumatic hypertrophic scar among the Chinese population

BACKGROUND: This study aimed to determine the efficacy of silicone gel (Cica-Care) on severe post-traumatic hypertophic scars among the Chinese population. METHOD AND MATERIALS: A randomized clinical trial (RCT) was conducted on 45 Chinese patients with post-traumatic hypertrophic scars. Twenty-two subjects were placed in the experimental group with silicone gel sheeting (SGS) applied 24h per day for 6 months while all subjects were taught to massage the scar daily for 15 min serving as the control intervention. Scar assessments were conducted regularly to measure the changes in thickness, pigmentation, vascularity, pliability, itchiness and pain. RESULTS: Two-way repeated ANOVA showed a significant difference between MT group and SGS group on scar thickness. The post hoc comparison analysis showed that the difference was significant at the post-2-month (p=0.008) and post-6-month (p<0.001) intervention. The SGS group also showed changes in pigmentation which resembled normal skin but no statistical significance was found. Pain, itchiness and pliability were also improved after intervention. CONCLUSION: This study indicated that silicone gel sheeting (Cica-Care) was effective to reduce thickness, pain, itchiness and pliability of the severe hypertrophic scar among the Chinese population. The moisturization effect of the tough and hard scar might contribute to the reduction of the skin thickness after 6 month's intervention.     

Measurement of vascularity in the scar: A systematic review

BackgroundVascularity is an important parameter closely associated with the scar maturation. Reliable and accurate measurement of vascularity helps to monitor the scar change and adopt targeted interventions to prevent excessive scarring and achieve promising outcomes. However, there is no consensus on the assessment tools for the vascularity measurement in scars. This systematic review presents evidence on the available vascularity measurement tools.MethodsA systematic literature search was done using PubMed, CINAHL, Embase and Science Direct databases. Studies, which used non-invasive measurement tools and explored their clinimetric properties, were identified and included in this review.ResultsA total of 1458 articles were obtained, and 26 articles were finally included in this review. Subjective vascularity measurement scales include the Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale (VSS) and the modified Vancouver Scar Scale (mVSS) while objective vascularity measurement devices consist of the color-measuring device, the blood flow measuring device and the morphological imaging device.ConclusionSubjective scales are easy to use and have acceptable reliability to give a preliminary impression of the scar vascularity. Three types of objective devices are not equivalent and are mainly based on the blood flow and angiogenesis to quantify the scar vascularity.     

Role of silicone derivative plus onion extract gel in presternal hypertrophic scar protection: a prospective randomized, double blinded, controlled trial

Use of silicone derivative and onion extract had been reported in the prevention of hypertrophic scarring. Our experience showed the preventive use of silicone derivative plus onion extract gel on hypertrophic scars after median sternotomy. In a randomized, double blinded, placebo‐controlled study, 60 patients after median sternotomy incisions were separated into two groups. All patients were treated either with silicone derivative plus onion extract gel (Cybele^® scagel) or placebo gel twice daily for a total treatment period of 12 weeks. During each visit, pain and itching scores were graded by the patients and scar characteristics were observed by surgeons using the Vancouver scar scale. Pain and itch score values from patients' who applied silicone derivative plus onion extract gel was less than another group (P < 0·05). Pigmentation was significantly different between two groups (P < 0·05) and the reduction of scores on vascularity, pliability, height in treated group was not superior to the untreated group. No adverse events were reported by any of the patients. A silicone derivative plus onion extract gel is safe and effective for the preventing the hypertrophic scarring after median sternotomy.     

Genetic influence on scar height and pliability after burn injury in individuals of European ancestry: A prospective cohort study

After similar extent of injury there is considerable variability in scarring between individuals, in part due to genetic factors. This study aimed to identify genetic variants associated with scar height and pliability after burn injury. An exome-wide array association study and gene pathway analysis were performed on a prospective cohort of 665 patients treated for burn injury. Outcomes were scar height (SH) and scar pliability (SP) sub-scores of the modified Vancouver Scar Scale (mVSS). DNA was genotyped using the Infinium^® HumanCoreExome-24 BeadChip. Associations between genetic variants (single nucleotide polymorphisms) and SH and SP were estimated using an additive genetic model adjusting for age, sex, number of surgical procedures and % total body surface area of burn in subjects of European ancestry. No individual genetic variants achieved the cut-off threshold of significance. Gene regions were analysed for spatially correlated single nucleotide polymorphisms and significant regions identified using comb-p software. This gene list was subject to gene pathway analysis to find which biological process terms were over-represented. Using this approach biological processes related to the nervous system and cell adhesion were the predominant gene pathways associated with both SH and SP. This study suggests genes associated with innervation may be important in scar fibrosis. Further studies using similar and larger datasets will be essential to validate these findings.     

Patient satisfaction after fractional ablation of burn scar with 2940 nm wavelength Erbium-Yag laser

Objective

Fractional laser therapy is a new treatment with potential benefit in the treatment of burn scars. We sought to determine patient satisfaction after burn scar treatment with the Erbium-Yag laser.

The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized controlled trial

ObjectiveTo evaluate the effect of burn rehabilitation massage therapy on hypertrophic scar after burn.MethodOne hundred and forty-six burn patients with hypertrophic scar(s) were randomly divided into an experimental group and a control group. All patients received standard rehabilitation therapy for hypertrophic scars and 76 patients (massage group) additionally received burn scar rehabilitation massage therapy. Both before and after the treatment, we determined the scores of visual analog scale (VAS) and itching scale and assessed the scar characteristics of thickness, melanin, erythema, transepidermal water loss (TEWL), sebum, and elasticity by using ultrasonography, Mexameter^®, Tewameter^®, Sebumeter^®, and Cutometer^®, respectively.ResultsThe scores of both VAS and itching scale decreased significantly in both groups, indicating a significant intragroup difference. With regard to the scar characteristics, the massage group showed a significant decrease after treatment in scar thickness, melanin, erythema, TEWL and a significant intergroup difference. In terms of scar elasticity, a significant intergroup difference was noted in immediate distension and gross skin elasticity, while the massage group significant improvement in skin distensibility, immediate distension, immediate retraction, and delayed distension.ConclusionOur results suggest that burn rehabilitation massage therapy is effective in improving pain, pruritus, and scar characteristics in hypertrophic scars after burn.     

Burn scar assessment: A systematic review of objective scar assessment tools

Purpose

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.

Basic procedures

The Systematic literature search involving PubMed, the Web of Science (incl. Science Citation Index).

Main findings

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.

Conclusions

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.