The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring

A new CO2 laser technique for the treatment of pediatric hypertrophic burn scars: An observational study

Treatment of hypertrophic scars arising as a result of thermal burns in children is still a big problem. The results of the treatment are not satisfactory for patients and parents, and new methods of treatment are still investigated.We present the use of one of the most modern carbon dioxide (CO2) lasers (Lumenis Encore laser equipped with a Synergistic Coagulation and Ablation for Advanced Resurfacing module) in the treatment of hypertrophic scars in children after burns.From March to April of 2013, a group of 47 patients aged 6 to 16 years underwent 57 laser surgery treatments. The average time from accident was 7.5 years. The results of treatment were investigated in 114 areas. The assessed areas were divided into 2 groups: 9-cm area 1, where the thickness of the scar measured by physician was the lowest and 9-cm area 2, where the thickness of the scar was the biggest. The results were considered on the Vancouver Scar Scale (VSS) independently by the surgeon and by parents 1, 4, and 8 months after the procedure. In addition, ultrasound evaluation of the scar thickness before and after laser procedure was made.VSS total score improved in all areas assessed by both the physician and parents. The biggest change in total VSS score in area 1 in the evaluation of the investigator was obtained at follow-up after the 1st month of treatment (average 7.23 points before and 5.18 points after the 1st month after surgery-a difference of 2.05 points). Scar ratings by parents and the physician did not differ statistically (P < 0.05). In the ultrasound assessment, the improvement was statistically significant, more frequently for both minimum and maximum thickness of the scars (B-mode measures) (P < 0.05).The use of a CO2 laser in the treatment of hypertrophic scars in children is an effective and safe method. The use of a CO2 laser improves the appearance and morphology of scarring assessed using the VSS by both the parents and the physician. The treatment also reduced the thickness of scars evaluated by ultrasound.

The physical and physiological effects of vacuum massage on the different skin layers: a current status of the literature

Vacuum massage is a non-invasive mechanical massage technique performed with a mechanical device that lifts the skin by means of suction, creates a skin fold and mobilises that skin fold. In the late 1970s, this therapy was introduced to treat traumatic or burn scars. Although vacuum massage was invented to treat burns and scars, one can find very little literature on the effects of this intervention. Therefore, the aim of this review is to present an overview of the available literature on the physical and physiological effects of vacuum massage on epidermal and dermal skin structures in order to find the underlying working mechanisms that could benefit the healing of burns and scars. The discussion contains translational analysis of the results and provides recommendations for future research on the topic. An extended search for publications was performed using PubMed, Web of Science and Google Scholar. Two authors independently identified and checked each study against the inclusion criteria. Nineteen articles were included in the qualitative synthesis. The two most reported physical effects of vacuum massage were improvement of the tissue hardness and the elasticity of the skin. Besides physical effects, a variety of physiological effects are reported in literature, for example, an increased number of fibroblasts and collagen fibres accompanied by an alteration of fibroblast phenotype and collagen orientation. Little information was found on the decrease of pain and itch due to vacuum massage. Although vacuum massage initially had been developed for the treatment of burn scars, this literature review found little evidence for the efficacy of this treatment. Variations in duration, amplitude or frequency of the treatment have a substantial influence on collagen restructuring and reorientation, thus implying possible beneficial influences on the healing potential by mechanotransduction pathways. Vacuum massage may release the mechanical tension associated with scar retraction and thus induce apoptosis of myofibroblasts. Suggestions for future research include upscaling the study design, investigating the molecular pathways and dose dependency, comparing effects in different stages of repair, including evolutive parameters and the use of more objective assessment tools.

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.

Cutaneous Scar Prevention and Management: Overview of current therapies

Cutaneous scarring is common after trauma, surgery and infection and occurs when normal skin tissue is replaced by fibroblastic tissue during the healing process. The pathophysiology of scar formation is not yet fully understood, although the degree of tension across the wound edges and the speed of cell growth are believed to play central roles. Prevention of scars is essential and can be achieved by attention to surgical techniques and the use of measures to reduce cell growth. Grading and classifying scars is important to determine available treatment strategies. This article presents an overview of the current therapies available for the prevention and treatment of scars. It is intended to be a practical guide for surgeons and other health professionals involved with and interested in scar management.

The effects of conservative treatments on burn scars: A systematic review

A variety of conservative treatments for burn scars are available, but there is no clear consensus on the evidence. The purpose of this study was to summarize the available literature on the effects of conservative treatments of burn scars in adults. RCTs and CCTs were sought in three databases, reference lists of retrieved articles and relevant reviews. The Scottish Intercollegiate Guidelines Network scoring system was used to assess the quality of the selected studies. Information on the study characteristics, results and interventions was extracted. Twenty-two articles were included into the review and categorized in six topics: 5 on massage therapy, 4 on pressure therapy, 6 on silicone gel application, 3 on combined therapy of pressure and silicone, 3 on hydration and 1 on ultrasound. Pressure and silicone therapy are evidence-based conservative treatments of hypertrophic scar formation after a burn producing clinically relevant improvement of scar thickness, redness and pliability. Massage therapy could have a positive result on scar pliability, pain and pruritus, but with less supporting evidence. The use of moisturizers and lotions could have an effect on itching, but the findings are contradictory. Of all other non-invasive treatments such as splinting, casting, physical activity, exercise and mobilizations no RCTs or CCTs were found.

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.

The effects of electroacupuncture on analgesia and peripheral sensory thresholds in patients with burn scar pain

The aim of this study is to observe if the effects of electro-acupuncture (EA) on analgesia and peripheral sensory thresholds are transposable from the model of heat pain in volunteers to the clinical setting of burn scar pain. After severe burns, pathological burn scars (PPBS) may occur with excruciating pain that respond poorly to treatment and prevent patients from wearing their pressure garments, thereby leading to unesthetic and function-limiting scars. EA might be of greater benefit in terms of analgesia and functional recovery, should it interrupt this vicious circle by counteracting the peripheral hyperalgesia characterizing PPBS. Therefore we enrolled 32 patients (22 males/10 females) aged of 46±11 years with clinical signs of PPBS and of neuropathic pain despite treatment. The study protocol consisted in 3 weekly 30-min sessions of standardized EA with extra individual needles in accordance to Traditional Chinese Medicine, in addition of previous treatments. We assessed VAS for pain and quantitative sensory testing (QST) twice: one week before and one after protocol. QST measured electrical thresholds for non-nociceptive A-beta fibers, nociceptive A-delta and C fibers in 2 dermatomes, respectively from the PPBS and from the contralateral pain-free areas. Based on heat pain studies, EA consisted in sessions at the extremity points of the main meridian flowing through PPBS (0.300s, 5Hz, sub noxious intensity, 15min) and at the bilateral paravertebral points corresponding to the same metameric level, 15min. VAS reduction of 3 points or below 3 on a 10 points scale was considered clinically relevant. Paired t-test compared thresholds (mean [SD]) and Wilcoxon test compared VAS (median [IQR]) pre and after treatment, significant p<0.05. The reduction of VAS for pain reached statistical but not clinical relevance (6.8 [3] vs. 4.5 [3.6]). This was due to a large subgroup of 14 non-responders whose VAS did not change after treatment (6.6 [2.7] vs. 7.2 [3.8]). That subgroup exhibited significant differences in sensory thresholds when compared to the 18 responders (VAS from 7 [3] to 3 [1]). First, responders' thresholds for A-delta and C fibers in the PPBS area were significantly lower than those in the pain-free area before treatment but corrected after acupuncture (from respectively 60 [30] and 63 [10]% to 91 [11] and 106 [36]%). That might account for a nociceptive hypersensitivity in the PPBS that corrected after treatment. On the contrary, in non-responders nociceptive thresholds were similar in both the PPBS and the pain-free areas before treatment and did not change after EA. However, absolute values for thresholds in the pain-free areas where significantly lower for non-responders than for responders. The fact that non-responders had significant pain scores while presenting with lowered nociceptive thresholds even in the pain-free areas might evoke the possibility of a generalized supra-spinal hyperalgesia. The fact that acupuncture did not correct the pain nor the nociceptive thresholds in this subgroup requires further investigation. We also observed a statistically and clinically relevant reduction in VAS for pruritus for all patients - even those from the subgroup of non-responders to pain - that is worth to be mentioned and requires further studies to be confirmed. This observational study is the first that confirms the effects of acupuncture on analgesia and nociceptive thresholds in the clinical setting of burn pain only for patients presenting with a burn-localized but not a generalized hyperalgesia.

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.

Biology and principles of scar management and burn reconstruction

Hypertrophic scarring is extremely common and is the source of most morbidity related to burns. The biology of hypertrophic healing is complex and poorly understood. Multiple host and injury factors contribute, but protracted healing of partial thickness injury is a common theme. Hypertrophic scarring and heterotopic ossification may share some basic causes involving marrow-derived cells. Several traditional clinical interventions exist to modify hypertrophic scar. All have limited efficacy. Laser interventions for scar modification show promise, but as yet do not provide a definitive solution. Their efficacy is only seen when used as part of a multimodality scar management program.

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.

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 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.

Topical modalities for treatment and prevention of postsurgical hypertrophic scars

There is no universally accepted treatment regimen and no evidence-based literature to guide management of hypertrophic scars. This article summarizes the existing literature regarding topical treatments such as silicone gel sheeting and ointment, onion extract, vitamin E, pressure garment therapy, massage therapy, and topical imiquimod 5% cream in the management of hypertrophic scars.

Smoking and its effect on scar healing

Scar formation is influenced by several factors such as wound infection, tension, wound depth and anatomical localization. Hypertrophic scarring is often the result of an imbalance in the wound and scar healing process. The exact underlying pathophysiological mechanism remains unclear. Smoking has a higher risk of postoperative complications probably due to a diminished macrophage induction. Following our clinical impression that smokers without postoperative wound infections show esthetically better scars, we evaluated the scars after a reduction mammaplasty in smoking and nonsmoking patients in a prospective clinical trial. Between July 2006 and September 2007, 13 smokers and 30 non smokers with a reduction mammaplasty were included. They were recruited from Viecuri Medical Centre and Atrium Medical Centre in the Netherlands after written consent. Surgical data and data of the patients' condition were collected. Follow-up for erythema values of the scars was done with a colorimeter (The Minolta CR-300, Minolta Camera Co., Ltd., Osaka Japan) at 1, 3, 6 and 9 months postoperatively on four standardized postsurgical sites. ANOVA and Chi-square test were used for statistical analysis. In the smoking group, the scars were significantly less red compared to the nonsmoking group. No significant differences were found in BMI, resection weight and drain production between both groups. Although smoking is certainly not recommended as a preventive therapy to influence scar healing, this study confirms our assumption that smokers tend to have faster and less erythemateous scar healing to nonsmokers. Further research is needed to understand the mechanism of the effect of smoking on scars.

The effect of nano-scale topography on keratinocyte phenotype and wound healing following burn injury

Topographic modulation of tissue response is an important consideration in the design and manufacture of a biomaterial. In developing new tissue therapies for skin, all levels of architecture, including the nanoscale need to be considered. Here we show that keratinocyte phenotype is affected by nanoscale changes in topography with cell morphology, proliferation, and migration influenced by the pore size in anodic aluminum oxide membranes. A membrane with a pore size of 300 nm, which enhanced cell phenotype in vitro, was used as a dressing to cover a partial thickness burn injury in the pig. Wounds dressed with the membrane showed evidence of advanced healing with significantly less organizing granulation tissue and more mature epidermal layers than control wounds dressed with a standard burns dressing. The results demonstrate the importance of nanoscale topography in modulating keratinocyte phenotype and skin wound healing.

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 between laser-doppler imaging and colorimetry in the assessment of scarring: "a pilot study"

BACKGROUND

This cross-sectional pilot-study investigated the reproducibility of the LDI (Moor-LDI-B2; Moor Instruments) and the chromameter (Minolta chromameter CR-300) when used in scar assessment.

METHODS

Twenty-seven scars in 14 subjects were included between January and June 2003. One observer performed two times both measurements with 10 min apart. The intra-observer agreement is quantified by means of the intra-class correlations (ICC) and the standard errors of measurement (SEM) for both the LDI and the chromameter.

RESULTS

Ignoring one outlier, the ICC of the LDI = 0.856 and the SEM = 34.56. The chromameter shows a better reproducibility with an ICC of 0.93 and a SEM of 0.79.

CONCLUSION

This pilot-study with a limited number of measurements shows a moderate reproducibility of the LDI compared to the chromameter measurements, in the assessment of respectively flux and redness in scars.

Objective scar assessment tools: a clinimetric appraisal

BACKGROUND

Scars may lead to an array of cosmetic, psychological, and functional problems. Different scar features can be distinguished (i.e., color, thickness, relief, pliability, and surface area) that are clinically relevant and contribute to the quality and judgment of a scar. Today, objective evaluation of these scar features is indispensable for practicing evidence-based medicine (e.g., to evaluate the outcome of clinical trials). In this review, an overview and update are given on the most relevant noninvasive objective measurement tools for scar evaluation.

METHODS

A PubMed literature search was performed. Articles evaluating the clinimetric properties of noninvasive scar assessment tools were included. The selected objective measurement tools were then critically reviewed with respect to the clinimetric properties of reliability, validity, and feasibility.

RESULTS

In total, 75 articles were selected and 23 different noninvasive measurement methods were evaluated.

CONCLUSION

Based on the scar features color, thickness, relief, pliability, and surface area, the best measurement tools that are currently available were recommended.

Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies

Excessive scars form as a result of aberrations of physiologic wound healing and may arise following any insult to the deep dermis. By causing pain, pruritus and contractures, excessive scarring significantly affects the patient's quality of life, both physically and psychologically. Multiple studies on hypertrophic scar and keloid formation have been conducted for decades and have led to a plethora of therapeutic strategies to prevent or attenuate excessive scar formation. However, most therapeutic approaches remain clinically unsatisfactory, most likely owing to poor understanding of the complex mechanisms underlying the processes of scarring and wound contraction. In this review we summarize the current understanding of the pathophysiology underlying keloid and hypertrophic scar formation and discuss established treatments and novel therapeutic strategies.

Supportive treatment using a compression garment vest of painful sternal instability following deep surgical wound infection: a case report

INTRODUCTION

Sternal dehiscence and instability poses a significant cause of persistent pain and limited quality of life following hospital discharge for 0.2% to 5% of patients who have undergone median sternotomy for open heart surgery. We report a successful, conservative, supportive long-term therapy of painful sternal non-union using a customized compression garment vest.

CASE PRESENTATION

We report a case of painful sternal instability following open heart surgery in a 74-year-old Caucasian man. The complicating factors of obesity (body mass index of 40), renal failure, insulin-dependent diabetes mellitus and absolute arrhythmia with atrial fibrillation were present.

CONCLUSION

A number of studies have demonstrated the efficacy of surgical interventions for secondary sternal stabilization, but individual patients may reject this option or may be, for other reasons, no longer operable. The task of primary care physicians and other health care providers is to offer this group of patients an alternative option for pragmatic, inexpensive and effective supportive therapy, of which compression garments are an example.

The micrograft concept for wound healing: strategies and applications

The standard of care for wound coverage is to use an autologous skin graft. However, large or chronic wounds become an exceptionally challenging problem especially when donor sites are limited. It is important that the clinician be aware of various treatment modalities for wound care and incorporate those methods appropriately in the proper clinical context. This report reviews an alternative to traditional meshed skin grafting for wound coverage: micrografting. The physiological concept of micrografting, along with historical context, and the evolution of the technique are discussed, as well as studies needed for micrograft characterization and future applications of the technique.

Effect of different pressure magnitudes on hypertrophic scar in a Chinese population

INTRODUCTION

This study aimed to investigate the effect of different pressure magnitudes on treatment outcomes of hypertrophic scars, and determine pressure loss over time.

METHODS

A randomized clinical trial was adopted. 53 hypertrophic scar samples from 17 Chinese participants were recruited and randomly assigned into a high pressure group (20-25 mmHg) and low pressure group (10-15 mmHg) for a five-month intervention program. The scars were assessed objectively before intervention and monthly after intervention for thickness, color (redness, yellowness and lightness) and scar pliability. Pressure magnitude at each assessment was also measured. Two-way repeated ANOVA was used to compare for differences between groups.

RESULTS

The results showed that both levels of pressure produced reduction in scar thickness and redness, but the improvement in the high pressure group was statistically better than that of the counterpart (both p<0.05). Monthly pressure measurement revealed that pressure loss in the high pressure group was more severe. However, no major changes in other color parameters and pliability were observed for both the groups.

CONCLUSION

High pressure was demonstrated to be more effective for scar management, but it was also more prone to higher pressure loss. Pressure therapy integrated with regular monitoring of the interface pressure is suggested to improve its therapeutic efficacy.

The use of pressure and silicone in hypertrophic scar management in burns patients: a pilot randomized controlled trial

This pilot study investigates whether pressure and silicone therapy used simultaneously are more effective in treating multiple characteristics of hypertrophic scars than pressure alone. A pilot randomized controlled trial was conducted. Twenty-two participants with hypertrophic burn scars were randomized to receive Jobskin pressure garments and Mepiform silicone sheeting or Jobskin pressure garments alone. The Vancouver Scar Scale (VSS) was used to measure multiple scar characteristics at baseline, week 12, and week 24. No statistically significant difference was found in the rate of change of the VSS scores between the pressure therapy (PT) group and the pressure therapy and silicone group at week 12 or week 24; however, the mean scores of both groups reduced over 24 weeks. There were no statistically significant changes in the VSS subscores (scar height, vascularity, pliability, and pigmentation) from baseline to week 12 or week 24. A statistically significant relationship was observed between the VSS score and TBSA burned (<30%) in the PT group at baseline (P<.05), over 12 weeks (P<.05), and over 24 weeks (P<.05). Given the limitations of this study, especially the small sample size, further research is necessary before any firm conclusions can be drawn on this therapy approach. However, this pilot study has discussed the recurring issues in the research regarding these controversial treatments and has yielded potential for further investigation in a fully powered randomized controlled trial.