Pressure garments for use in the treatment of hypertrophic scars—a review of the problems associated with their use

Dose Effect in Adjuvant Radiation Therapy for the Treatment of Resected Keloids

PURPOSE

Surgical excision of keloids can result in an insidious cycle of tissue injury and repeat keloid formation unless combined with adjuvant therapy to halt this cycle. We present our results of postoperative radiation therapy for keloids with various dose regimens.

METHODS AND MATERIALS

A retrospective review of 124 patients with 250 keloid lesions treated with postoperative radiation therapy was analyzed. In this institutional review board-approved study, 125 keloids were treated to 20 Gy in 5 fractions and 125 keloids were treated to 12 to 16 Gy in 3 to 4 fractions. Local failure was defined as redevelopment of any clinically apparent keloid at the treated site. The median age was 34 years (14-84 years). Keloids were located on the ear (34%), neck/shoulder (19%), abdomen (13%), chest (10%), face (9%), breast (7%), extremities (4%), and back (3%). Median keloid size was 4 cm (0.5-20 cm).

RESULTS

At a median follow-up of 40 months, the recurrence rate for all lesions was 5.6%. Lesions treated to 20 Gy had a recurrence rate of 1.6% compared with 9.6% with <20 Gy and an odds ratio of 0.16 (P = .02). Upon univariate and multivariate analysis there were no differences in recurrence rate with respect to location, race, gender, age, previously treated lesions, and presence of multiple keloids. The lone predictor for improved control rate was the dose of 20 Gy in 5 fractions compared with less than that. Control rate for lesions treated to a biologically equivalent dose₂ of 35 to 36 Gy₂, 48 to 52.5 Gy₂, and 60 to 72 Gy₂ were 10% (P = .007), 8.9% (P = .16), and 1.6% (P = .02), respectively.

CONCLUSIONS

Surgical excision followed by immediate adjuvant radiation therapy for keloids provides excellent local control and cosmesis. Treatment with a biologically equivalent dose₂ > 60 (20 Gy in 5 fractions) yielded superior local control over lower dose regimens.

Patient Experience of Wearing Compression Garments Post Burn Injury: A Review of the Literature

This review was conducted to critically appraise the literature regarding the patient's lived experience of, and adherence to, wearing compression garments post burn injury. Scholarly articles were identified from searches of the following databases: Pubmed, Cochrane Central, CINAHL, PsycINFO, and OT Seeker. Combinations of key words including compression therapy/garment, pressure therapy/garment, burn(s), adherence, and patient experience were utilized. Retrieved studies were included in the review if they were written in English, reported on adult burn populations, and the patient's lived experience of wearing compression garments. Included studies were critically appraised and content analysis was completed on the results sections of the two qualitative studies. Nine studies investigating patient's lived experiences were retained: one systematic review, one randomized controlled trial, five cross-sectional surveys, and two qualitative studies. An adherence framework provided a conceptual basis to categorize reported patient's lived experiences. Results identified a strong focus on patient and treatment-related experiences with limited investigation of condition, patient-provider and health care system experiences. Minimal investigation has been completed regarding the impact of these patient's lived experiences on the adherence to wearing compression garments. Additional research using qualitative methods is required to gain a deep understanding of patient's experiences and perspectives of wearing compression garments and how these experiences influence on their adherence to wearing them. Identification of key experiences that lead to patients removing their compression garments may lead to modification of treatment and system approaches to better align with patients' needs and development of potential interventions that promote adherence.

Modern rehabilitation systems based on textiles

The article presents examples of rehabilitation solutions in which textiles play an important role. They are a fully functional garment, an element of clothing adapted to a given part of the body or a product intended for use in improving health. They are designed with the use of modern production technologies that utilize various raw materials to support the health aspects of the user with their structure and properties.

Recent Understandings of Biology, Prophylaxis and Treatment Strategies for Hypertrophic Scars and Keloids

Hypertrophic scars and keloids are fibroproliferative disorders that may arise after any deep cutaneous injury caused by trauma, burns, surgery, etc. Hypertrophic scars and keloids are cosmetically problematic, and in combination with functional problems such as contractures and subjective symptoms including pruritus, these significantly affect patients’ quality of life. There have been many studies on hypertrophic scars and keloids; but the mechanisms underlying scar formation have not yet been well established, and prophylactic and treatment strategies remain unsatisfactory. In this review, the authors introduce and summarize classical concepts surrounding wound healing and review recent understandings of the biology, prevention and treatment strategies for hypertrophic scars and keloids.

Impact of Moisture on the Pressure Delivering Potential of Pressure Garments

Pressure garments are the main method of treatment and prophylaxis for hypertrophic burn scars. The pressure they exert on the scarred skin prevents contractures forming, reduces the itchiness and pruritus associated with active hypertrophic scars, and is believed, by many, to hasten normalization of the scar tissue. The pressure exerted is believed to be critical to treatment success and can be predicted based on laboratory measurement of the fabric's tension profile. All previous research on the pressures delivered by pressure garments has been undertaken using dry fabrics in either laboratory or clinical conditions. However, many patients have complained of increased perspiration when wearing pressure garments, and many burn victims live and work in hot conditions where high levels of perspiration may be expected. This article investigated the impact of moisture content on fabric tension and thus the pressure exerting ability of pressure garments. Four different fabrics currently used in the construction of pressure garments were evaluated in seven different states of "wetness" from completely dry to completely saturated in water or artificial perspiration. Standard laboratory methods were used to measure the initial tension in fabrics and the tension after 11 cycles of extension. Pressures that would be exerted by these fabrics were calculated using the Laplace law. The results of this study showed that the tension, and therefore pressure delivering ability, of fabrics used in pressure garments was significantly reduced when they were wet but that the amount or type of "wetness" did not have a significant effect on pressure delivering ability.

Cutaneous Scarring: Basic Science, Current Treatments, and Future Directions

Significance: Scarring of the skin from burns, surgery, and injury constitutes a major burden on the healthcare system. Patients affected by major scars, particularly children, suffer from long-term functional and psychological problems. Recent Advances: Scarring in humans is the end result of the wound healing process, which has evolved to rapidly repair injuries. Wound healing and scar formation are well described on the cellular and molecular levels, but truly effective molecular or cell-based antiscarring treatments still do not exist. Recent discoveries have clarified the role of skin stem cells and fibroblasts in the regeneration of injuries and formation of scar. Critical Issues: It will be important to show that new advances in the stem cell and fibroblast biology of scarring can be translated into therapies that prevent and reduce scarring in humans without major side effects. Future Directions: Novel therapies involving the use of purified human cells as well as agents that target specific cells and modulate the immune response to injury are currently undergoing testing. In the basic science realm, researchers continue to refine our understanding of the role that particular cell types play in the development of scar.

Comparative evaluations of hypertrophic scar formation in in vivo models

BACKGROUND AND OBJECTIVE

Hypertrophic scar (HTS) results from a connective tissue reaction to trauma, inflammation, surgery, or burn on skin. In spite of various techniques for wound generation, the degree of scar in animal models after healing is still unpredictable and less reproducible. The objective of the current study was to identify the appropriate method to create the maximal HTS tissue in a reliable manner by comparing three different methods in vivo.

MATERIALS AND METHODS

A 27 ICR mice were tested for the in vivo evaluations. Three different methods were applied to develop wounds on the back of each mice for quantitative evaluations on collagen formation: Group 1 (thermal burn), Group 2 (chemical burn), and Group 3 (physical punch). After injury, each lesion was photographed to examine physical variations in the wound areas. Histological analysis was conducted on days 0, 7, and 28 to assess the extent of the injury in the tissue and to quantitatively compare the amount of collagen formation after wound healing.

RESULTS

Compared with Groups 1 and 3, Group 2 demonstrated the largest wound area that gradually decreased with healing time. However, the minimal axial damage (along tissue depth) occurred to Group 2 at day 0 (183.7 ± 28.9, 38.1 ± 9.2, and 296.0 ± 81.7 µm for Groups 1, 2, and 3, respectively). After 28 days, all the groups showed the complete healing and accompanied a significant increase in the number of fibroblast and collagen generation with well-oriented and denser collagen fibers, in comparison with normal skin. Group 2 yielded twice thicker skin (both epidermis and dermis) than the other groups (970.8 ± 108.8 µm for Group 2 vs. 381.5 ± 30.8 µm for Group 1 and 442.9 ± 56.3 µm for Group 3; P < 0.001).

CONCLUSION

The proposed chemical burn can be the optimal method to create collagenous scar tissue in the mouse model. Further in vivo investigations with rat models will be performed to validate the current technique for laser scar treatment in terms of reliability and immunohistochemical responses. Lasers Surg. Med. 9999:XX-XX, 2017. © 2017 Wiley Periodicals, Inc.

Pathophysiologic Mechanisms and Current Treatments for Cutaneous Sequelae of Burn Wounds

Burn injuries are a pervasive clinical problem. Extensive thermal trauma can be life-threatening or result in long-lasting complications, generating a significant impact on quality of life for patients as well as a cost burden to the healthcare system. The importance of addressing global or systemic issues such as resuscitation and management of inhalation injuries is not disputed but is beyond the scope of this review, which focuses on cutaneous pathophysiologic mechanisms for current treatments, both in the acute and long-term settings. Pathophysiological mechanisms of burn progression and wound healing are mediated by highly complex cascades of cellular and biochemical events, which become dysregulated in slow-healing wounds such as burns. Burns can result in fibroproliferative scarring, skin contractures, or chronic wounds that take weeks or months to heal. Burn injuries are highly individualized owing to wound-specific differences such as burn depth and surface area, in addition to patient-specific factors including genetics, immune competency, and age. Other extrinsic complications such as microbial infection can complicate wound healing, resulting in prolonged inflammation and delayed re-epithelialization. Although mortality is decreasing with advancements in burn care, morbidity from postburn deformities continues to be a challenge. Optimizing specialized acute care and late burn outcome intervention on a patient-by-patient basis is critical for successful management of burn wounds and the associated pathological scar outcome. Understanding the fundamentals of integument physiology and the cellular processes involved in wound healing is essential for designing effective treatment strategies for burn wound care as well as development of future therapies. Published 2018. Compr Physiol 8:371-405, 2018.

Lower energy radial shock wave therapy improves characteristics of hypertrophic scar in a rabbit ear model

The aim of the present study was to investigate the effects of radial extracorporeal shock wave therapy (rESWT) on scar characteristics and transforming growth factor (TGF)-β1/Smad signaling in order to explore a potential modality for the treatment of hypertrophic scars (HS). The HS model was generated in rabbit ears, then rabbits were randomly divided into 3 groups: Lower (L)-ESWT [treated with rESWT with lower energy flux density (EFD) of 0.1 mJ/mm²], higher (H)-ESWT (treated with a higher EFD of 0.18 mJ/mm²) and the sham ESWT group (S-ESWT; no ESWT treatment). Scar characteristics (wrinkles, texture, diameter, area, volume of elevation, hemoglobin and melanin) were assessed using the Antera 3D^® system. The protein and mRNA expression of TGF-β1, Smad2, Smad3 and Smad7 was assessed by enzyme-linked immunosorbent assay and reverse transcription-quantitative polymerase chain reaction, respectively. The Antera 3D^® results indicated that wrinkles and hemoglobin of the HS were significantly improved in both of the rESWT groups when compared with the S-ESWT group. However, these changes appeared much earlier in the L-ESWT group than the H-ESWT. Scar texture was also improved in the L-ESWT group. However, rESWT did not influence HS diameter, area, volume of elevation or melanin levels. rESWT had no effect on TGF-β1 or Smad7 expression in either of rESWT groups. Although no difference was observed in Smad2 mRNA expression in the L-ESWT group, the Smad3 mRNA and protein expression significantly decreased when compared with the H-ESWT and S-ESWT groups. By contrast, Smad2 and Smad3 mRNA expression were upregulated in the H-ESWT group. These results demonstrated that rESWT with 0.1 mJ/mm² EFD improved some characteristics of the HS tissue. Downregulation of Smad3 expression may underlie this inhibitory effect. Inhibition of the TGF-β1/Smad signal transduction pathway may be a potential therapeutic target for the management of HS.

Current Concepts Burn Rehabilitation, Part II: Long-Term Recovery

This article summarizes current interventions for several of the most common challenges faced by patients during their rehabilitation from burn injury. These challenges include range of motion preservation through scar contracture management, achieving maximal independence through exercise and activities of daily living training, and psychological recovery through nonpharmacologic approaches pain and anxiety.

Current Therapeutic Approach to Hypertrophic Scars

Abnormal scarring and its accompanying esthetic, functional, and psychological sequelae still pose significant challe nges. To date, there is no satisfactory prevention or treatment option for hypertrophic scars (HSs), which is mostly due to not completely comprehending the mechanisms underlying their formation. That is why the apprehension of regular and controlled physiological processes of scar formation is of utmost importance when facing hypertrophic scarring, its pathophysiology, prevention, and therapeutic approach. When treating HSs and choosing the best treatment and prevention modality, physicians can choose from a plethora of therapeutic options and many commercially available products, among which currently there is no efficient option that can successfully overcome impaired skin healing. This article reviews current therapeutic approach and emerging therapeutic strategies for the management of HSs, which should be individualized, based on an evaluation of the scar itself, patients’ expectations, and practical, evidence-based guidelines. Clinicians are encouraged to combine various prevention and treatment modalities where combination therapy that includes steroid injections, 5-fluorouracil, and pulsed-dye laser seems to be the most effective. On the other hand, the current therapeutic options are usually empirical and their results are unreliable and unpredictable. Therefore, there is an unmet need for an effective, targeted therapy and prevention, which would be based on an action or a modulation of a particular factor with clarified mechanism of action that has a beneficial effect on wound healing. As the extracellular matrix has a crucial role in cellular and extracellular events that lead to pathological scarring, targeting its components mostly by regulating bone morphogenetic proteins may throw up new therapeutic approach for reduction or prevention of HSs with functionally and cosmetically acceptable outcome.

Biological Principles of Scar and Contracture

Hypertrophic scar and contracture in burn patients is a complex process. Contributing factors include critical injury depth and activation of key cell subpopulations, including deep dermal fibroblasts, myofibroblasts, fibrocytes, and T-helper cells, which cause scarring rather than regeneration. These cells influence each other via cellular profibrotic and antifibrotic signals, which help to determine the outcome. These cells also both modify and interact with extracellular matrix of the wound, ultimately forming hypertrophic scar. Current treatments reduce hypertrophic scar formation or improve remodeling by targeting these pathways and signals.

Influence of hand movement on skin deformation: A therapeutic glove design perspective

The fit of a therapeutic glove directly influences the hand function of the wearer as well as wear comfort. Static and dynamic hand dimensions and characteristics must be considered when designing a glove, as significant changes in hand shape, size, and skin surface morphology result from hand movements. The aim of this study is to investigate the skin relaxed-strain ratio at the dorsal side of the hand and its relationship to skin deformation behaviour during hand movements. The point cloud raw data of the right hands of 13 female participants (40-65 years, size M) were recorded using a 3D INFOOT scanner in three different hand postures. Twenty-two measurements of skin relaxed-strain ratios in each posture were calculated, and differences between them were identified using the Kruskal-Wallis H test. The results demonstrate that different hand postures cause substantial changes in hand geometry, especially in the metacarpal region. The findings of this study are valuable for the construction of functional tight-fitting therapeutic gloves with optimal fit, performance, and comfort.

Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for patient and physician alike. Laser treatment plays an important role in scar management with additional support from ancillary modalities. Subsequent to part 1: Burns scars, part 2 focuses on our strategies and literature review of treatment of keloid, hypertrophic, pigmented and acne scars where lasers are used in conjunction with other measures, and illustrated with case studies.

A clinical trial of tension and compression orthoses for Dupuytren contractures

STUDY DESIGN

Randomized clinical trial on 2 patient groups with Dupuytren's disease.

INTRODUCTION

Despite an unpredictable outcome, surgery remains an important treatment for Dupuytren's disease. Orthotic devices are a controversial noninvasive treatment method to influence the myofibroblasts in the nodules.

PURPOSE OF THE STUDY

To detect how much improvement 2 types of orthotic device (tension and compression) as only treatment intervention can provide on a Dupuytren's contracture. Is a compression orthosis better than a tension orthosis?

METHODS

Thirty patients with measurable flexion contractures of the fingers were identified. Both primary and recurrence cases were included. Patients were randomized in 2 groups of 15 patients. One group had a standard tension orthosis (Levame), the other group a newly designed silicon compression orthotic device. Patients were instructed to wear the orthotic devices 20 hours a day during 3 months. Data were collected at first visit and after 3 months of orthotic treatment. Primary outcomes were active extension deficit of each joint and total active extension (TAE) of the digit. Secondary outcome was patient satisfaction. Visual Analog Scale (VAS) score of function and esthetics (0-10 points) were recorded at the start and after 3 months.

RESULTS

Flexion contracture was reduced at least 5 degrees in all patients. After 3 months, TAE was significantly reduced in both groups (both P < .001).The mean change in TAE was 32.36° in the tension group and 46.47° in the compression group. Although reduction of TAE deficit was bigger in the compression group, this difference was not statistically significant (P = .39). VAS scale of esthetics and functionality was significantly increased in both treatment groups. The functional VAS scale after 3 months was 11% higher in the compression group than in the tension group (P = .03). A major complication of a tension orthotic is skin ulcers.

DISCUSSION

Too much tension may cause myofibroblast stimulation and disease progression, whereas continuous limited tension can improve flexion contractures. The idea of a compression device is based on the treatment concept of hypertrophic burn scars.

CONCLUSION

Tension and compression orthotic devices can be used as a nonoperative treatment of Dupuytren's disease in both early proliferative untreated hands and aggressive postsurgery recurrence. Although there is no statistically significant difference, compression orthoses appear to be more effective and are better tolerated. Nevertheless, adjustment of orthotic design and research on long-term results are needed.

LEVEL OF EVIDENCE

I (Randomized controlled trial, Therapeutic study).

Design, Manufacture and Testing of Capacitive Pressure Sensors for Low-Pressure Measurement Ranges

This article presents the design, manufacture and testing of a capacitive pressure sensor with a high, tunable performance to low compressive loads (<10 kPa) and a resolution of less than 0.5 kPa. Such a performance is required for the monitoring of treatment efficacy delivered by compression garments to treat or prevent medical conditions such as deep vein thrombosis, leg ulcers, varicose veins or hypertrophic scars. Current commercial sensors used in such medical applications have been found to be either impractical, costly or of insufficient resolution. A microstructured elastomer film of a polydimethylsiloxane (PDMS) blend with a tunable Young’s modulus was used as the force-sensing dielectric medium. The resulting 18 mm × 18 mm parallel-plate capacitive pressure sensor was characterised in the range of 0.8 to 6.5 kPa. The microstructuring of the surface morphology of the elastomer film combined with the tuning of the Young’s modulus of the PDMS blend is demonstrated to enhance the sensor performance achieving a 0.25 kPa pressure resolution and a 10 pF capacitive change under 6.5 kPa compressive load. The resulting sensor holds good potential for the targeted medical application.

The effectiveness of pressure therapy (15-25 mmHg) for hypertrophic burn scars: A systematic review and meta-analysis

Although pressure therapy (PT) represents the standard care for prevention and treatment of hypertrophic scar (HS) from burns, its practice is largely based on empirical evidence and its effectiveness remains controversial. To clarify the effect of PT (15-25 mmHg) for HS, we performed the systematic review and meta-analysis. Several electronic databases were screened to identify related randomized controlled trials (RCTs). 12 RCTs involving 710 patients with 761 HS resulting from burn injuries were included. Compared with non/low-PT, cases treated with PT (15-25 mmHg) showed significant differences in Vancouver Scar Scale score (MD = -0.58, 95% CI = -0.78--0.37), thickness (SMD = -0.25, 95% CI = -0.40--0.11), brightness (MD = 2.00, 95% CI = 0.59-3.42), redness (MD = -0.79, 95% CI = -1.52--0.07), pigmentation (MD = -0.16, 95% CI = -0.32--0.00) and hardness (SMD = -0.65, 95% CI = -1.07--0.23). However, there was no difference in vascularity (MD = 0.03, 95% CI = -0.43-0.48). Our analysis indicated that patients with HS who were managed with PT (15-25 mmHg) showed significant improvements. Due to limitations, more large and well-designed studies are needed to confirm our findings and the side-effects of the PT may also need to be evaluated.

The evidence for natural therapeutics as potential anti-scarring agents in burn-related scarring

Though survival rate following severe thermal injuries has improved, the incidence and treatment of scarring have not improved at the same speed. This review discusses the formation of scars and in particular the formation of hypertrophic scars. Further, though there is as yet no gold standard treatment for the prevention or treatment of scarring, a brief overview is included. A number of natural therapeutics have shown beneficial effects both in vivo and in vitro with the potential of becoming clinical therapeutics in the future. These natural therapeutics include both plant-based products such as resveratrol, quercetin and epigallocatechin gallate as examples and includes the non-plant-based therapeutic honey. The review also includes potential mechanism of action for the therapeutics, any recorded adverse events and current administration of the therapeutics used. This review discusses a number of potential 'treatments' that may reduce or even prevent scarring particularly hypertrophic scarring, which is associated with thermal injuries without compromising wound repair.

Interim pressure garment therapy (4-6 mmHg) and its effect on donor site healing in burn patients: study protocol for a randomised controlled trial

Background

Pressure garment therapy (PGT) is well accepted and commonly used by clinicians in the treatment of burns scars and grafts. The medium to high pressures (24–40 mmHg) in these garments can support scar minimisation, and evidence is well documented for this particular application. However, PGT specifically for burn donor sites, of which a sequela is also scarring, is not well documented. This study protocol investigates the impact of a low pressure (4–6 mmHg) interim garment on donor site healing and scarring. With a primary purpose of holding donor dressings in place, the application of the interim pressure garment (IPG) appears to have been twofold. IPGs for donor sites have involved inconsistent application with a focus on securing wound dressing rather than scar management. However, anecdotal and observational evidence suggests that IPGs also make a difference to some patient’s scar outcomes for donor sites. This study protocol outlines a randomised controlled trial designed to test the effectiveness of this treatment on reducing scarring to burn donor sites.

Methods/design

This study is a single-centre, single (assessor)-blinded, randomised control trial in patients with burns donor sites to their thighs. Patients will be randomly allocated to a control group (with no compression to donor sites) or to an experimental group (with compression to donor sites) as the comparative treatment. Groups will be compared at baseline regarding the important prognostic indicators: donor site location, depth, size, age, and time since graft (5 days). The IPG treatment will be administered post-operatively (on day 5). Follow-up assessments and garment replacement will be undertaken fortnightly for a period of 2 months.

Discussion

This study focuses on a unique area of burns scar management using a low-pressure tubular support garment for the reduction of donor site scars. Such therapy specifically for donor scar management is poorly represented in the literature. This study was designed to test a potentially cost-effective scar prevention for patients with donor sites to the thigh. No known studies of this nature have been carried out to date, and there is a need for rigorous clinical evidence for low-pressure support garments for donor site scar minimisation.

Trial registration

Australian New Zealand Clinical Trials Registry identifier ACTRN12610000127000. Registered 8 Mar 2010.

Compression therapy affects collagen type balance in hypertrophic scar

BACKGROUND

The effects of pressure on hypertrophic scar are poorly understood. Decreased extracellular matrix deposition is hypothesized to contribute to changes observed after pressure therapy. To examine this further, collagen composition was analyzed in a model of pressure therapy in hypertrophic scar.

MATERIALS AND METHODS

Hypertrophic scars created on red Duroc swine (n = 8) received pressure treatment (pressure device mounting and delivery at 30 mm Hg), sham treatment (device mounting and no delivery), or no treatment for 2 wk. Scars were assessed weekly and biopsied for histology, hydroxyproline quantification, and gene expression analysis. Transcription levels of collagen precursors COL1A2 and COL3A1 were quantified using reverse transcription-polymerase chain reaction. Masson trichrome was used for general collagen quantification, whereas immunofluorescence was used for collagen types I and III specific quantification.

RESULTS

Total collagen quantification using hydroxyproline assay showed a 51.9% decrease after pressure initiation. Masson trichrome staining showed less collagen after 1 (P < 0.03) and 2 wk (P < 0.002) of pressure application compared with sham and untreated scars. Collagen 1A2 and 3A1 transcript decreased by 41.9- and 42.3-fold, respectively, compared with uninjured skin after pressure treatment, whereas a 2.3- and 1.3-fold increase was seen in untreated scars. This decrease was seen in immunofluorescence staining for collagen types I (P < 0.001) and III (P < 0.04) compared with pretreated levels. Pressure-treated scars also had lower levels of collagen I and III after pressure treatment (P < 0.05) compared with sham and untreated scars.

CONCLUSIONS

These results demonstrate the modulation of collagen after pressure therapy and further characterize its role in scar formation and therapy.

Foot burns and diabetes: a retrospective study

BACKGROUND

Diabetes in conjunction with a foot burn can compound the challenges in wound healing; however, the impact of diabetes on outcomes of patients with foot burns has not been examined.

METHODS

A retrospective notes audit was conducted at the Concord Hospital Burns Unit for patients with foot burns who were admitted from 1(st) January 2012 to 31(st) December 2013. Data were collected for 15 subjects with foot burns and diabetes and 18 subjects with foot burns and no diabetes as a control group. Subjects were matched for percentage total body surface area of burns.

RESULTS

The mean inpatient and total lengths of stay for the diabetic group were 21.27 days and 64.80 days, which were significantly longer (P = 0.090 and P = 0.054) than the 9.61 days and 30.56 days in the control, based on a significance level of 0.10. The diabetic group was significantly older (P = 0.001), at 56.60 years versus 39.44 years in the control. Significantly (P = 0.033) more patients with diabetes were not working (n = 12/15 or 80.00 % versus n = 7/18 or 38.89 %) compared to the control. The diabetic group had higher rates of regrafting (n = 3/15 or 20.00 % versus n = 1/18 or 5.55 %) than the control and significantly (P = 0.013) more amputations (n = 5/15 or 33.33 % versus n = 0 or 0.00 %) compared to the control. Fewer patients with diabetes were prescribed pressure garments (n = 2/15 or 13.33 % versus n = 9/18 or 50.00 %), which was significant (P = 0.034). The increased age of patients in the diabetic group correlates with results from other studies. Healing time may be reflected by total length of stay, which was more than double for patients with diabetes, increasing demand and cost of inpatient and outpatient services.

CONCLUSION

This study highlights the importance of recognizing the potential for poorer outcomes for patients with diabetes and indicates the need for more burn prevention education and promotion in this 'at risk' patient group.

Burn Scar Biomechanics after Pressure Garment Therapy

BACKGROUND

The current standard of care for the prevention and treatment of scarring after burn injury is pressure garment therapy. Although this therapy has been used clinically for many years, controversy remains regarding its efficacy. The authors evaluated the efficacy of pressure garment therapy in a female red Duroc pig burn model in which wound depth could be tightly controlled.

METHODS

Full-thickness burn wounds were generated on female red Duroc pigs. At day 28 after burn, pressure garment therapy was applied to half the wounds (10 mmHg), with control wounds covered with garments that exerted no compression. Scar area, perfusion, hardness, and elasticity were quantified at days 0, 28, 42, 56, and 72 using computerized planimetry, laser Doppler, and torsional ballistometry. Scar morphology was assessed at days 28, 56, and 76 using histology, immunohistochemistry, and transmission electron microscopy.

RESULTS

Pressure garment therapy significantly hindered scar contraction, with control scars contracting to 64.6 percent + 13.9 percent original area at day 72, whereas pressure garment therapy scars contracted to 82.7 percent + 17.9 percent original area. Pressure garments significantly reduced skin hardness and increased skin strength by 1.3 times. No difference in perfusion or blood vessel density was observed. The average collagen fiber diameter was greater in control burns than in pressure garment therapy.

CONCLUSIONS

Pressure garment therapy was effective at reducing scar contraction and improving biomechanics compared with control scars. These results confirm the efficacy of pressure garments and highlight the need to further investigate the role of pressure magnitude and the time of therapy application to enhance efficacy for optimal biomechanics and patient mobility.

Chemical Burn Injury in Kumasi: The Trend and Complications following and Their Management

A chemical burn refers to irritation and destruction of human tissue caused by exposure to a chemical, usually by direct contact with the chemical or its fumes. The study investigated the trend and complications following chemical burns and their management.

Cen Y, Chai J, Chen H, Chen J, Guo G, Han C, Hu D, Huan J, Huang X, Jia C, Li-Tsang CW, Li J, Li Z, Liu Q, Liu Y, Luo G, Lv G, Niu X, Peng D, Peng Y, Qi H, Qi S, Sheng Z, Tang D, Wang Y, Wu J, Xia Z, Xie W, Yang H, Yi X, Yu L, Zhang G. Guidelines for burn rehabilitation in China

Quality of life and functional recovery after burn injury is the final goal of burn care, especially as most of burn patients survive the injury due to advanced medical science. However, dysfunction, disfigurement, contractures, psychological problems and other discomforts due to burns and the consequent scars are common, and physical therapy and occupational therapy provide alternative treatments for these problems of burn patients. This guideline, organized by the Chinese Burn Association and Chinese Association of Burn Surgeons aims to emphasize the importance of team work in burn care and provide a brief introduction of the outlines of physical and occupational therapies during burn treatment, which is suitable for the current medical circumstances of China. It can be used as the start of the tools for burn rehabilitation.

The Effect of Pressure Glove Tightness on Forearm Muscle Activity and Psychophysical Responses

OBJECTIVE

The impact of pressure glove tightness on maximum grip force, muscle activity, and psychophysical responses is investigated to facilitate the prescription of a suitable reduction factor (RF) for pressure treatment.

BACKGROUND

The wearing of pressure therapy gloves is often considered to hinder hand performance and cause discomfort, resulting in unsatisfactory treatment adherence during burn rehabilitation.

METHOD

A wear trial was carried out with 10 participants for three custom-made pressure gloves that consist of different RFs-10%, 15% and 20%-as well as for the bare hand. The surface electromyography of three forearm muscles was measured during tasks that involve moving marbles, buttoning a shirt, and typing. The psychophysical responses were also recorded.

RESULTS

The use of pressure gloves results in a reduction in the maximum gripping force. Gloves with tighter pressure contribute to lower perceived comfort and ease of hand motion. Increased glove tightness (with RFs of 15% and 20%) decreases muscle activity as compared to the bare-hand condition when buttoning a shirt. In terms of typing, the forearm muscle activity increases with high glove pressure (RF of 20%).

CONCLUSION

The forearm muscles are significantly affected by glove tightness in performing different daily tasks that required gripping, pinching, and typing. The increase of RF of pressure gloves causes negative impact on psychophysical response and handgrip strength. Glove tightness in relation to hand performance and comfort is important in prescribing an optimal pressure therapy glove for hypertrophic scar treatment.

APPLICATION

The findings give insight into the impacts of pressure glove tightness on muscle activity, thus providing a reference for glove development.

Revealing the dependence of cell spreading kinetics on its spreading morphology using microcontact printed fibronectin patterns

Since the dawn of in vitro cell cultures, how cells interact and proliferate within a given external environment has always been an important issue in the study of cell biology. It is now well known that mammalian cells typically exhibit a three-phase sigmoid spreading on encountering a substrate. To further this understanding, we examined the influence of cell shape towards the second rapid expansion phase of spreading. Specifically, 3T3 fibroblasts were seeded onto silicon elastomer films made from polydimethylsiloxane (PDMS), and micro-contact printed with fibronectin stripes of various dimensions. PDMS is adopted in our study for its biocompatibility, its ease in producing very smooth surfaces, and in the fabrication of micro-contact printing stamps. The substrate patterns are compared with respect to their influence on cell spreading over time. Our studies reveal, during the early rapid expansion phase, 3T3 fibroblasts are found to spread radially following a t≃¹·⁸ law; meanwhile, they proliferated in a lengthwise fashion on the striped patterns, following a t≃¹ law. We account for the observed differences in kinetics through a simple geometric analysis which predicted similar trends. In particular, a t² law for radial spreading cells, and a t¹ law for lengthwise spreading cells.

Mechanical cues in orofacial tissue engineering and regenerative medicine

Cleft lip and palate patients suffer from functional, aesthetical, and psychosocial problems due to suboptimal regeneration of skin, mucosa, and skeletal muscle after restorative cleft surgery. The field of tissue engineering and regenerative medicine (TE/RM) aims to restore the normal physiology of tissues and organs in conditions such as birth defects or after injury. A crucial factor in cell differentiation, tissue formation, and tissue function is mechanical strain. Regardless of this, mechanical cues are not yet widely used in TE/RM. The effects of mechanical stimulation on cells are not straight-forward in vitro as cellular responses may differ with cell type and loading regime, complicating the translation to a therapeutic protocol. We here give an overview of the different types of mechanical strain that act on cells and tissues and discuss the effects on muscle, and skin and mucosa. We conclude that presently, sufficient knowledge is lacking to reproducibly implement external mechanical loading in TE/RM approaches. Mechanical cues can be applied in TE/RM by fine-tuning the stiffness and architecture of the constructs to guide the differentiation of the seeded cells or the invading surrounding cells. This may already improve the treatment of orofacial clefts and other disorders affecting soft tissues.

Establishing a Reproducible Hypertrophic Scar following Thermal Injury: A Porcine Model

Background:

Our complete understanding of hypertrophic scarring is still deficient, as portrayed by the poor clinical outcomes when treating them. To address the need for alternative treatment strategies, we assess the swine animal burn model as an initial approach for immature scar evaluation and therapeutic application.

Methods:

Thermal contact burns were created on the dorsum of 3 domestic swine with the use of a branding iron at 170°F for 20 seconds. Deep partial-thickness burns were cared for with absorptive dressings over 10 weeks and wounds evaluated with laser and negative pressure transduction, histology, photographic analysis, and RNA isolation.

Results:

Overall average stiffness (mm Hg/mm) increased and elasticity (mm) decreased in the scars from the initial burn injury to 8 weeks when compared with normal skin (P < 0.01). Scars were thicker, more erythematous, and uniform in the caudal dorsum. The percent change of erythema in wounds increased from weeks 6 to 10. Histology demonstrated loss of dermal papillae, increased myofibroblast presence, vertically oriented vessels, epidermal and dermal hypercellularity, and parallel-layered collagen deposition. Immature scars remained elevated at 10 weeks, and minimal RNA was able to be isolated from the tissue.

Conclusions:

Deep partial-thickness thermal injury to the back of domestic swine produces an immature hypertrophic scar by 10 weeks following burn with thickness appearing to coincide with the location along the dorsal axis. With minimal pig to pig variation, we describe our technique to provide a testable immature scar model.

A histological study on the effect of pressure therapy on the activities of myofibroblasts and keratinocytes in hypertrophic scar tissues after burn

Although pressure therapy (PT) has been widely used as the first-line treatment for hypertrophic scars (HS), the histopathological changes involved have seldom been studied. This study aimed to examine the longitudinal effect of PT on the histopathological changes in HS. Ten scar samples were selected from six patients with HS after burn and they were given a standardized PT intervention for 3 months while 16 scar samples were obtained on those without PT. The scar biopsies were collected pre-treatment, 1 and 3 months post-intervention for both clinical and histopathological examinations. Clinical assessments demonstrated significant improvement in the thickness and redness of the scars after PT. Histological examination revealed that cell density in the dermal layer was markedly reduced in the 3-months post-pressurized scar tissues, while the arrangement of the collagen fiber was changed from nodular to wave-like pattern. The α-smooth muscle actin immunoreactivity was significantly decreased after 1-month pressure treatment. There was a significant reduction of myofibroblasts population and a concomitant increase in the apoptotic index in the dermal layer in the 3-months' post-pressurized scars. A significant negative correlation was found between the myofibroblasts population and the apoptotic index. The keratinocyte proliferation was found inhibited after PT. Results demonstrated that PT appeared to promote HS maturation by inhibiting the keratinocyte proliferation and suppressing myofibroblasts population, the latter possibly via apoptosis.

A portable automatic pressure delivery system for scar compression therapy in large animals

Compression therapy has long been a standard treatment for hypertrophic scar prevention. However, due to the lack of objective, quantitative assessments, and measurements of scar severity, as well as the lack of a self-operated, controllable, and precise pressure delivery technique, limited concrete evidence exists, demonstrating compression therapy's efficacy. We have designed and built an automatic pressure delivery system to apply and maintain constant pressure on scar tissue in an animal model. A force sensor positioned on a compression plate reads the imposed force in real-time and sends the information to a feedback system controlling two position actuators. The actuators move accordingly to maintain a preset value of pressure onto the skin. The system was used in an in vivo model of compression therapy on hypertrophic scars. It was shown that the system was capable of delivering a constant pressure of 30 mmHg on scar wounds for a period of two weeks, and that phenotypic changes were seen in the wounds.

Paediatric post-burn scar management in the UK: a national survey

Thermal injuries affect 250,000 people annually in the United Kingdom. As burn survival improves, good scar management is paramount to help individuals living with the resultant scars lead a life without restrictions. Post-burn hypertrophic scars can limit growth in children, interfere with function and cause psychological problems. In the current literature there is great variation in post-burn scar management across the world and in the evidence available for the efficacy of these management modalities. The aim of this study was to investigate the variances if any, in the management of post-burn scarring in children across the UK. A telephone survey of UK paediatric burn services was conducted to obtain information on post-burn scar management and advice given to patients/carers. Of the 19 burn services that participated, all advised moisturising of scars but with variable emphasis on massaging. Silicones and pressure therapy were used by 18 services but commencement of use varied from soon after healing to onset of hypertrophic scarring. Laser therapy, ultrasound therapy and steroid therapy were used sporadically. This study highlights the common modalities of post-burn scar management in children across the UK. However, there is marked variation in timing and selection of the commonly used modalities. Although this study did not investigate the outcomes of scar management, it clearly identifies the need for a well-designed multi-centred study to establish evidence-based best practice in the management of post-burn scarring in children as these modalities are time consuming and not without potential complications. Evidence based practice could potentially lead to significant financial savings to the health service.

Acute surgical management of hand burns

A hand represents 3% of the total body surface area. The hands are involved in close to 80% of all burns. The potential morbidity associated with hand burns can be substantial. Imagine a patient carrying a pan of flaming cooking oil to the doorway or someone lighting a room-sized pile of leaves and branches doused with gasoline. It is clear how the hands are at risk in these common scenarios. Not all burn injuries will require surgical intervention. Recognizing the need for surgery is paramount to achieving good functional outcomes for the burned hand. The gray area between second- and third-degree burns tests the skill and experience of every burn/hand surgeon. Skin anatomy and the size of injury dictate the surgical technique used to close the burn wound. In addition to meticulous surgical technique, preoperative and postoperative hand therapy for the burned hand is essential for a good functional outcome. Recognizing the burn depth is paramount to developing the appropriate treatment plan for any burn injury. This skill requires experience and practice. In this article, we present an approach to second- and third-degree hand burns.

The effect of pressure and fabrication of pressure therapy gloves on hand sensitivity and dexterity

Pressure therapy gloves always affect the function and performance of hands but the effect is often neglected. In this study, fabrication and reduction factors (RFs) of pressure therapy gloves on hand dexterity and comfort perception are assessed by goniometer, Semmes-Weinstein monofilaments and Purdue Pegboard, as well as through daily activity tasks. A subjective rating scale was also used to record comfort perception. The repeated-measures multivariate analysis of variance and Friedman tests were used to compare hand function tests and comfort sensation results when different glove prototypes were worn in terms of fabrics and RFs. The results show that even though both fabric types and RFs of pressure gloves exert no significant effect on the tactile sensitivity of fingertips, the active range of motion and dexterity of the fingers in carrying out daily tasks and comfort perception are considerably affected. The adoption of a high RF of 20% in making of glove patterns can impact negatively on both hand functions and comfort perception, thus leading to unsatisfactory treatment adherence. Strong associations were found between the comfort performance and fabric properties, including surface roughness, bending rigidity, thermal conductivity and moisture retention. It has been suggested that fabric choice, anticipated fabric tensile behaviour and surface and thermal properties should also be taken into consideration when prescribing pressure therapy glove for treatment of hypertrophic scars.

Update on hypertrophic scar treatment

Scar formation is a consequence of the wound healing process that occurs when body tissues are damaged by a physical injury. Hypertrophic scars and keloids are pathological scars resulting from abnormal responses to trauma and can be itchy and painful, causing serious functional and cosmetic disability. The current review will focus on the definition of hypertrophic scars, distinguishing them from keloids and on the various methods for treating hypertrophic scarring that have been described in the literature, including treatments with clearly proven efficiency and therapies with doubtful benefits. Numerous methods have been described for the treatment of abnormal scars, but to date, the optimal treatment method has not been established. This review will explore the differences between different types of nonsurgical management of hypertrophic scars, focusing on the indications, uses, mechanisms of action, associations and efficacies of the following therapies: silicone, pressure garments, onion extract, intralesional corticoid injections and bleomycin.

Updated scar management practical guidelines: non-invasive and invasive measures

Hypertrophic scars and keloids can be aesthetically displeasing and lead to severe psychosocial impairment. Many invasive and non-invasive options are available for the plastic (and any other) surgeon both to prevent and to treat abnormal scar formation. Recently, an updated set of practical evidence-based guidelines for the management of hypertrophic scars and keloids was developed by an international group of 24 experts from a wide range of specialities. An initial set of strategies to minimize the risk of scar formation is applicable to all types of scars and is indicated before, during and immediately after surgery. In addition to optimal surgical management, this includes measures to reduce skin tension, and to provide taping, hydration and ultraviolet (UV) protection of the early scar tissue. Silicone sheeting or gel is universally considered as the first-line prophylactic and treatment option for hypertrophic scars and keloids. The efficacy and safety of this gold-standard, non-invasive therapy has been demonstrated in many clinical studies. Other (more specialized) scar treatment options are available for high-risk patients and/or scars. Pressure garments may be indicated for more widespread scarring, especially after burns. At a later stage, more invasive or surgical procedures may be necessary for the correction of permanent unaesthetic scars and can be combined with adjuvant measures to achieve optimal outcomes. The choice of scar management measures for a particular patient should be based on the newly updated evidence-based recommendations taking individual patient and wound characteristics into consideration.

Genetic risk factors for hypertrophic scar development

Hypertrophic scars (HTSs) occur in 30 to 72% patients after thermal injury. Risk factors include skin color, female sex, young age, burn site, and burn severity. Recent correlations between genetic variations and clinical conditions suggest that single-nucleotide polymorphisms (SNPs) may be associated with HTS formation. The authors hypothesized that an SNP in the p27 gene (rs36228499) previously associated with decreased restenosis after coronary stenting would be associated with lower Vancouver Scar Scale (VSS) measurements and decreased itching. Patient and injury characteristics were collected from adults with thermal burns. VSS scores were calculated at 4 to 9 months after injury. Genotyping was performed using real-time polymerase chain reaction. Logistic regression was used to determine risk factors for HTS as measured by a VSS score >7. Three hundred subjects had a median age of 39 years (range, 18-91); 69% were male and median burn size was 7% TBSA (range, 0.25-80). Consistent with literature, the p27 variant SNP had an allele frequency of 40%, but was not associated with reduced HTS formation or lower itch scores in any genetic model. HTS formation was associated with American Indian/Alaskan Native race (odds ratio [OR], 12.2; P = .02), facial burns (OR, 9.4; P = .04), and burn size ≥20% TBSA (OR, 1.99; P = .03). Although the p27 SNP may protect against vascular fibroproliferation, the effect cannot be generalized to cutaneous scars. This study suggests that American Indian/Alaskan Native race, facial burns, and higher %TBSA are independent risk factors for HTS. The American Indian/Alaskan Native association suggests that there are potentially yet-to-be-identified genetic variants.

Up-to-date approach to manage keloids and hypertrophic scars: a useful guide

Keloids and hypertrophic scars occur anywhere from 30 to 90% of patients, and are characterized by pathologically excessive dermal fibrosis and aberrant wound healing. Both entities have different clinical and histochemical characteristics, and unfortunately still represent a great challenge for clinicians due to lack of efficacious treatments. Current advances in molecular biology and genetics reveal new preventive and therapeutical options which represent a hope to manage this highly prevalent, chronic and disabling problem, with long-term beneficial outcomes and improvement of quality of life. While we wait for these translational clinical products to be marketed, however, it is imperative to know the basics of the currently existing wide array of strategies to deal with excessive scars: from the classical corticotherapy, to the most recent botulinum toxin and lasers. The main aim of this review paper is to offer a useful up-to-date guideline to prevent and treat keloids and hypertrophic scars.

Are “Smart Pressure Monitored Suits” “Smarter” than Conventional Garments in Clinical Applications?*

Objective/Background

There is still no standardized regime to prescribe pressure garments with quantifiable pressure dosage to patients with different medical conditions. This study aimed to examine the efficacy of a newly developed system [a smart pressure monitored suit (SPMS)] for pressure intervention when compared with the conventional method of pressure garment production (conventional garment or CG). The SPMS is designed with a set of standard methods of measurements and computerized pattern drafting software (YUKA) to adjust the pressure range through computation of the percentage of strain directly on the drafted pattern. The CG was fabricated by occupational therapists in clinical settings.

Methods

A selected group of patients who required pressure therapy intervention was recruited through convenience sampling. They were provided with both a SPMS and a CG, each to be worn for 1 month. The interface pressure levels of both garments were measured before the implementation. Patients’ feedback was collected using a standardized questionnaire on the comfort of wear, elasticity, and durability of the garments.

Results

There was a significant difference in the deterioration of pressure between the SPMSs and the CGs (p < .05) before and after 1 month of wear. The satisfaction on overall efficacy of the SPMSs was significantly higher than that of CGs (p < .05).

Conclusion

This standardized system using a SPMS appeared to provide a more accurate and consistent pressure range and long-lasting effect to the patients. It also appeared to be more efficient and effective in terms of production and fabrication.

Management of Hypertrophic Burn Scar: A Comparison between the Efficacy of Exercise-Physiotherapy and Pressure Garment-Silicone on Hypertrophic Scar

Purpose

Our study aims to investigate the effectiveness of other treatment methods for burn related scarring and to determine the possibility of their routine administration in similar clinical settings.

Methods

Through a prospective study, 66 patients were enrolled to receive either the conventional pressure garment therapy (PGT) and Silicone (control group) or exercise and physiotherapy (case group). Patients were visited regularly to be examined for the status of their scars’ regression, limbs’ dysfunction, and joint motion. Then, these two groups were compared to determine the efficacy of exercise and physiotherapy as an alternative to the conventional treatment with PGT.

Results

After about 20 months follow-up, decreased articular range of motion (ROM) was: 16 (51.5%) cases compared to 5 (15%) of controls had mild, 11 (35.5%) of the cases compared to 13 (39.5%) of the controls had moderate; and 4 (13%) of the cases compared to 15 (45.5%) of the controls had severe decreased ROM which revealed statistically significant difference (P<0.01). At the same time, Vancouver Scar Scale score was: 15 (48%) of the cases and 6 (18%) of the controls had mild Scar Scale, 12 (39%) of the cases and 14 (42.5%) of the controls had moderate score and 4 (3%) of the cases and 13 (39.5%) of the controls had severe score which revealed a statistically significant difference (P<0.05).

Conclusion

Our study showed that physical therapy andexercise are more effective than PGT, in management of burn hypertrophic scar, hence could be an alternative in cases that conventional therapy cannot be used for any reason.

Management of keloids and hypertrophic scars: current and emerging options

In the context of growing aesthetic awareness, a rising number of patients feel disappointed with their scars and are frequently seeking help for functional and aesthetic improvement. However, excessive scarring following surgery or trauma remains difficult to improve despite a plethora of advocated treatment strategies as frequently observed in daily clinical routine. It is thus still preferable to prevent scarring by minimizing risk factors as much as possible. Hence, it remains crucial for the physician to be aware of basic knowledge of healing mechanisms and skin anatomy, as well as an appreciation of suture material and wound closure techniques to minimize the risk of postoperative scarring. Next to existing, well known prophylactic and therapeutic strategies for the improvement of excessive scarring, this article discusses emerging techniques such as intralesional cryotherapy, intralesional 5-fluorouracil, interferon, and bleomycin. Some of them have been successfully tested in well-designed trials and already have extended or may extend the current spectrum of excessive scar treatment in the near future. Innovative options such as imiquimod 5% cream, photodynamic therapy, or botulinum toxin A may also be of certain importance; however, the data currently available is too contradictory for definite recommendations.