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Meikle B, Simons M, Mahoney T, Reddan T, Dai B, Kimble RM, Tyack Z. Ultrasound measurement of traumatic scar and skin thickness: a scoping review of evidence across the translational pipeline of research-to-practice. BMJ Open 2024; 14:e078361. [PMID: 38594186 PMCID: PMC11015304 DOI: 10.1136/bmjopen-2023-078361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 03/18/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVES To identify the ultrasound methods used in the literature to measure traumatic scar thickness, and map gaps in the translation of these methods using evidence across the research-to-practice pipeline. DESIGN Scoping review. DATA SOURCES Electronic database searches of Ovid MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature and Web of Science. Grey literature searches were conducted in Google. Searches were conducted from inception (date last searched 27 May 2022). DATA EXTRACTION Records using brightness mode (B-mode) ultrasound to measure scar and skin thickness across the research-to-practice pipeline of evidence were included. Data were extracted from included records pertaining to: methods used; reliability and measurement error; clinical, health service, implementation and feasibility outcomes; factors influencing measurement methods; strengths and limitations; and use of measurement guidelines and/or frameworks. RESULTS Of the 9309 records identified, 118 were analysed (n=82 articles, n=36 abstracts) encompassing 5213 participants. Reporting of methods used was poor. B-mode, including high-frequency (ie, >20 MHz) ultrasound was the most common type of ultrasound used (n=72 records; 61% of records), and measurement of the combined epidermal and dermal thickness (n=28; 24%) was more commonly measured than the epidermis or dermis alone (n=7, 6%). Reliability of ultrasound measurement was poorly reported (n=14; 12%). The scar characteristics most commonly reported to be measured were epidermal oedema, dermal fibrosis and hair follicle density. Most records analysed (n=115; 97%) pertained to the early stages of the research-to-practice pipeline, as part of research initiatives. CONCLUSIONS The lack of evaluation of measurement initiatives in routine clinical practice was identified as an evidence gap. Diverse methods used in the literature identified the need for greater standardisation of ultrasound thickness measurements. Findings have been used to develop nine methodological considerations for practitioners to guide methods and reporting.
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Affiliation(s)
- Brandon Meikle
- Centre for Children's Burns and Trauma Research, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
| | - Megan Simons
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
- Occupational Therapy, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Pegg Leditschke Children's Burns Centre, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Tamsin Mahoney
- Surgical, Treatment and Rehabilitation Services (STARS), Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Tristan Reddan
- Medical Imaging and Nuclear Medicine, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bryan Dai
- The University of Queensland, Saint Lucia, Queensland, Australia
| | - Roy M Kimble
- Centre for Children's Burns and Trauma Research, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
- Pegg Leditschke Children's Burns Centre, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Zephanie Tyack
- Children's Health Research Centre, The University of Queensland Faculty of Medicine, South Brisbane, Queensland, Australia
- Australian Centre for Health Service Innovation (AusHI), Centre for Healthcare Transformation, and School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
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Harris IM, Lee KC, Deeks JJ, Moore DJ, Moiemen NS, Dretzke J. Pressure-garment therapy for preventing hypertrophic scarring after burn injury. Cochrane Database Syst Rev 2024; 1:CD013530. [PMID: 38189494 PMCID: PMC10772976 DOI: 10.1002/14651858.cd013530.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Burn damage to skin often results in scarring; however in some individuals the failure of normal wound-healing processes results in excessive scar tissue formation, termed 'hypertrophic scarring'. The most commonly used method for the prevention and treatment of hypertrophic scarring is pressure-garment therapy (PGT). PGT is considered standard care globally; however, there is continued uncertainty around its effectiveness. OBJECTIVES To evaluate the benefits and harms of pressure-garment therapy for the prevention of hypertrophic scarring after burn injury. SEARCH METHODS We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, two other databases, and two trials registers on 8 June 2023 with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing PGT (alone or in combination with other scar-management therapies) with scar management therapies not including PGT, or comparing different PGT pressures or different types of PGT. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials for inclusion using predetermined inclusion criteria, extracted data, and assessed risk of bias using the Cochrane RoB 1 tool. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 15 studies in this review (1179 participants), 14 of which (1057 participants) presented useable data. The sample size of included studies ranged from 17 to 159 participants. Most studies included both adults and children. Eight studies compared a pressure garment (with or without another scar management therapy) with scar management therapy alone, five studies compared the same pressure garment at a higher pressure versus a lower pressure, and two studies compared two different types of pressure garments. Studies used a variety of pressure garments (e.g. in-house manufactured or a commercial brand). Types of scar management therapies included were lanolin massage, topical silicone gel, silicone sheet/dressing, and heparin sodium ointment. Meta-analysis was not possible as there was significant clinical and methodological heterogeneity between studies. Main outcome measures were scar improvement assessed using the Vancouver Scar Scale (VSS) or the Patient and Observer Scar Assessment Scale (POSAS) (or both), pain, pruritus, quality of life, adverse events, and adherence to therapy. Studies additionally reported a further 14 outcomes, mostly individual scar parameters, some of which contributed to global scores on the VSS or POSAS. The amount of evidence for each individual outcome was limited. Most studies had a short follow-up, which may have affected results as the full effect of any therapy on scar healing may not be seen until around 18 months. PGT versus no treatment/lanolin We included five studies (378 participants). The evidence is very uncertain on whether PGT improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, adverse events, and adherence. No study used the POSAS or assessed quality of life. One additional study (122 participants) did not report useable data. PGT versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, adherence, and other scar parameters. It is possible that silicone may result in fewer adverse events or better adherence compared with PGT but this was also based on very low-certainty evidence. PGT plus silicone versus no treatment/lanolin We included two studies (200 participants). The evidence is very uncertain on whether PGT plus silicone improves scars as assessed by the VSS compared with no treatment/lanolin. The evidence is also very uncertain for pain, pruritus, and adverse events. No study used the POSAS or assessed quality of life or adherence. PGT plus silicone versus silicone We included three studies (359 participants). The evidence is very uncertain on the effect of PGT plus silicone compared with silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. PGT plus scar management therapy including silicone versus scar management therapy including silicone We included one study (88 participants). The evidence is very uncertain on the effect of PGT plus scar management therapy including silicone versus scar management therapy including silicone, as assessed by the VSS and POSAS. The evidence is also very uncertain for pain, pruritus, quality of life, adverse events, and adherence. High-pressure versus low-pressure garments We included five studies (262 participants). The evidence is very uncertain on the effect of high pressure versus low pressure PGT on adverse events and adherence. No study used the VSS or the POSAS or assessed pain, pruritus, or quality of life. Different types of PGT (Caroskin Tricot + an adhesive silicone gel sheet versus Gecko Nanoplast (silicone gel bandage)) We included one study (60 participants). The evidence is very uncertain on the effect of Caroskin Tricot versus Gecko Nanoplast on the POSAS, pain, pruritus, and adverse events. The study did not use the VSS or assess quality of life or adherence. Different types of pressure garments (Jobst versus Tubigrip) We included one study (110 participants). The evidence is very uncertain on the adherence to either Jobst or Tubigrip. This study did not report any other outcomes. AUTHORS' CONCLUSIONS There is insufficient evidence to recommend using either PGT or an alternative for preventing hypertrophic scarring after burn injury. PGT is already commonly used in practice and it is possible that continuing to do so may provide some benefit to some people. However, until more evidence becomes available, it may be appropriate to allow patient preference to guide therapy.
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Affiliation(s)
- Isobel M Harris
- Biostatistics, Evidence Synthesis, Test Evaluation and prediction Models (BESTEAM), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kwang Chear Lee
- Department of Burns and Plastic Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan J Deeks
- Biostatistics, Evidence Synthesis, Test Evaluation and prediction Models (BESTEAM), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David J Moore
- Biostatistics, Evidence Synthesis, Test Evaluation and prediction Models (BESTEAM), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Naiem S Moiemen
- Department of Burns and Plastic Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Janine Dretzke
- Biostatistics, Evidence Synthesis, Test Evaluation and prediction Models (BESTEAM), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Radzikowska-Büchner E, Łopuszyńska I, Flieger W, Tobiasz M, Maciejewski R, Flieger J. An Overview of Recent Developments in the Management of Burn Injuries. Int J Mol Sci 2023; 24:16357. [PMID: 38003548 PMCID: PMC10671630 DOI: 10.3390/ijms242216357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.
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Affiliation(s)
- Elżbieta Radzikowska-Büchner
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Inga Łopuszyńska
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Wojciech Flieger
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4 Street, 20-090 Lublin, Poland;
| | - Michał Tobiasz
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Krasnystawska 52 Street, 21-010 Łęczna, Poland;
| | - Ryszard Maciejewski
- Faculty of Medicine, University of Warsaw, Żwirki i Wigury 101 Street, 02-089 Warszawa, Poland;
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A Street, 20-093 Lublin, Poland
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Kim EY, Hussain A, Khachemoune A. Evidence-based management of keloids and hypertrophic scars in dermatology. Arch Dermatol Res 2023; 315:1487-1495. [PMID: 36504113 DOI: 10.1007/s00403-022-02509-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/27/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
While normal, controlled wound-healing results in scars that are nearly imperceptible, hypertrophic scars (HTS) and keloids are the result of an abnormal wound-healing process that can leave unsightly, difficult-to-treat lesions. While such scars are classically associated with surgical incisions, they may also result from burns or accidental trauma to the skin. Several different measures can be taken to prevent the formation of scars or treat those that have already formed. Prevention focuses on reducing inflammation during the wound-healing process, and minimizing tension in the lesion when appropriate. Treatments range from non-invasive modalities such as pressure therapy, topicals, and symptom management, to invasive methods such as injections, lasers, and even surgery. While some treatments, such as corticosteroid injections, have been used in the treatment of HTS and keloids for decades, other newer therapies have only been described in case reports or are still in early phases of clinical trials. Because optimal scar management will not be the same for every patient, further investigation of newer agents and methods is warranted and may benefit a great number of patients. This paper will review the evidence-based management of scars, including current widely used treatment options and promising newly emerging therapies.
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Affiliation(s)
- Emily Y Kim
- Georgetown University School of Medicine, Washington, DC, USA
| | - Aamir Hussain
- MedStar Washington Hospital Center/Georgetown University Dermatology Residency Program, Washington, DC, USA
| | - Amor Khachemoune
- Department of Dermatology, Veterans Affairs Medical Center, SUNY Downstate, 800 Poly Place, Brooklyn, NY, 11209, USA.
- Department of Dermatology, Veterans Affairs New York Harbor Healthcare System, Brooklyn, NY, USA.
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Carney BC, Bailey JK, Powell HM, Supp DM, Travis TE. Scar Management and Dyschromia: A Summary Report from the 2021 American Burn Association State of the Science Meeting. J Burn Care Res 2023; 44:535-545. [PMID: 36752791 DOI: 10.1093/jbcr/irad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Indexed: 02/09/2023]
Abstract
Burn scars, and in particular, hypertrophic scars, are a challenging yet common outcome for survivors of burn injuries. In 2021, the American Burn Association brought together experts in burn care and research to discuss critical topics related to burns, including burn scars, at its State of the Science conference. Clinicians and researchers with burn scar expertise, as well as burn patients, industry representatives, and other interested stakeholders met to discuss issues related to burn scars and discuss priorities for future burn scar research. The various preventative strategies and treatment modalities currently utilized for burn scars were discussed, including relatively noninvasive therapies such as massage, compression, and silicone sheeting, as well as medical interventions such as corticosteroid injection and laser therapies. A common theme that emerged is that the efficacy of current therapies for specific patient populations is not clear, and further research is needed to improve upon these treatments and develop more effective strategies to suppress scar formation. This will necessitate quantitative analyses of outcomes and would benefit from creation of scar biobanks and shared data resources. In addition, outcomes of importance to patients, such as scar dyschromia, must be given greater attention by clinicians and researchers to improve overall quality of life in burn survivors. Herein we summarize the main topics of discussion from this meeting and offer recommendations for areas where further research and development are needed.
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Affiliation(s)
- Bonnie C Carney
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
- Department of Biochemistry, Georgetown University School of Medicine, Washington, DC, USA
| | - John K Bailey
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Heather M Powell
- The Ohio State University, Departments of Materials Science and Engineering and Biomedical Engineering, Columbus, OH, USA
- Scientific Staff, Shriners Children's Ohio, Dayton, OH, USA
| | - Dorothy M Supp
- Scientific Staff, Shriners Children's Ohio, Dayton, OH, USA
- The University of Cincinnati College of Medicine, Department of Surgery, Cincinnati, OH, USA
| | - Taryn E Travis
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
- The Burn Center, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
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Punsola-Izard V, Carnicero N, Ozaes-Lara E, Mendieta-Zamora J, Romera-Orfila G, Schultz KS, Llusà M, Casado A. A Cadaver Based Comparison of Two Elastic Tension Proximal Interphalangeal Joint (PIPJ) Extension Orthoses with Focus on Force Generation and Pressure Distribution. J Clin Med 2023; 12:jcm12082855. [PMID: 37109191 PMCID: PMC10145399 DOI: 10.3390/jcm12082855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/25/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Proximal interphalangeal joint flexion contracture is a frequent condition in hand therapy. Clinicians most frequently apply orthosis management for conservative treatment. Orthoses should apply forces for long periods of time following the total end range time (TERT) concept. These forces necessarily transmit through the skin; however, skin has physiological limitations determined by blood flow. Using three fresh frozen human cadavers, this study quantified and compared forces, skin contact surfaces and pressure of two finger orthoses, an elastic tension digital neoprene orthosis (ETDNO) and an LMB 501 orthosis. The study also investigated the effects of a new method of orthosis construction (serial ETDNO orthoses) that customizes forces to a specific finger position. We evaluated forces and contact surfaces for multiple ETDNO models tailored to the cadaver fingers in multiple PIP flexion positions. The results showed that the LMB 501 orthosis applied pressures beyond the recommended limits if applied for more than eight hours a day. This fact was the cause of time limited LMB orthosis application. This results also show that, at 30° of PIPJ flexion, straight ETDNOs created a mean pressure approaching the end of the recommended pressure limits. If the therapist modified the ETDNO design, the skin pressure decreased and reduced the risk of skin damage. With the results of this study, we concluded that for PIPJ flexion contracture, the upper limit of force application is 200 g (1.96 N). Forces beyond this amount would likely cause skin irritation and possibly skin injuries. This would cause a reduction in the daily TERT and limit outcomes.
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Affiliation(s)
- Vicenç Punsola-Izard
- Hand Therapy Barcelona Physical Therapy and Clinical Investigation Center, 08010 Barcelona, Spain
- Physiotherapy Department, Gimbernat School of Physical Therapy, 08174 Barcelona, Spain
| | - Nuria Carnicero
- Hand Therapy Barcelona Physical Therapy and Clinical Investigation Center, 08010 Barcelona, Spain
| | - Elena Ozaes-Lara
- Hand Therapy Barcelona Physical Therapy and Clinical Investigation Center, 08010 Barcelona, Spain
| | - Judit Mendieta-Zamora
- Hand Therapy Barcelona Physical Therapy and Clinical Investigation Center, 08010 Barcelona, Spain
- Physiotherapy Department, Gimbernat School of Physical Therapy, 08174 Barcelona, Spain
| | - Gemma Romera-Orfila
- Hand Therapy Barcelona Physical Therapy and Clinical Investigation Center, 08010 Barcelona, Spain
| | - Karen S Schultz
- Karen Schultz Hand and Upper Limb Strategies (KSHULS), Littleton, CO 80120, USA
| | - Manuel Llusà
- Unit of Human Anatomy and Embryology, University of Barcelona, 08036 Barcelona, Spain
| | - Aroa Casado
- Hand Therapy Barcelona Physical Therapy and Clinical Investigation Center, 08010 Barcelona, Spain
- Physiotherapy Department, Gimbernat School of Physical Therapy, 08174 Barcelona, Spain
- Department of Evolutionary Biology, Ecology and Environmental Sciences, University of Barcelona, 08007 Barcelona, Spain
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De Decker I, Beeckman A, Hoeksema H, De Mey K, Verbelen J, De Coninck P, Blondeel P, Speeckaert MM, Monstrey S, Claes KEY. Pressure therapy for scars: Myth or reality? A systematic review. Burns 2023; 49:741-756. [PMID: 36941176 DOI: 10.1016/j.burns.2023.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/09/2022] [Accepted: 03/07/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Hypertrophic scarring is a deviate occurrence after wound closure and is a common burn sequela. The mainstay of scar treatment consists of a trifold approach: hydration, UV-protection and the use of pressure garments with or without extra paddings or inlays to provide additional pressure. Pressure therapy has been reported to induce a state of hypoxia and to reduce the expression pattern of transforming growth factor-β1 (TGF-β1), therefore limiting the activity of fibroblasts. However, pressure therapy is said to be largely based on empirical evidence and a lot of controversy concerning the effectiveness still prevails. Many variables influencing its effectivity, such as adherence to treatment, wear time, wash frequency, number of available pressure garment sets and amount of pressure remain only partially understood. This systematic review aims to give a complete and comprehensive overview of the currently available clinical evidence of pressure therapy. METHODS A systematic search for articles concerning the use of pressure therapy in the treatment and prevention of scars was performed in 3 different databases (Pubmed, Embase, and Cochrane library) according to the PRISMA statement. Only case series, case-control studies, cohort studies, and RCTs were included. The qualitative assessment was done by 2 separate reviewers with the appropriate quality assessment tools. RESULTS The search yielded 1458 articles. After deduplication and removal of ineligible records, 1280 records were screened on title and abstract. Full text screening was done for 23 articles and ultimately 17 articles were included. Comparisons between pressure or no pressure, low vs high pressure, short vs long duration and early vs late start of treatment were investigated. CONCLUSION There is sufficient evidence that indicates the value of prophylactic and curative use of pressure therapy for scar management. The evidence suggests that pressure therapy is capable of improving scar color, thickness, pain, and scar quality in general. Evidence also recommends commencing pressure therapy prior to 2 months after injury, and using a minimal pressure of 20-25 mmHg. To be effective, treatment duration should be at least 12 months and even preferably up to 18-24 months. These findings were in line with the best evidence statement by Sharp et al. (2016).
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Affiliation(s)
- Ignace De Decker
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium.
| | - Anse Beeckman
- Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Henk Hoeksema
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Kimberly De Mey
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Jozef Verbelen
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Petra De Coninck
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Phillip Blondeel
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Marijn M Speeckaert
- Department of Nephrology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Stan Monstrey
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Karel E Y Claes
- Burn Center, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Plastic Surgery, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
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Clinical Utility of the Portable Pressure-Measuring Device for Compression Garment Pressure Measurement on Hypertrophic Scars by Burn Injury during Compression Therapy. J Clin Med 2022; 11:jcm11226743. [PMID: 36431220 PMCID: PMC9694806 DOI: 10.3390/jcm11226743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/19/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Compression therapy for burn scars can accelerate scar maturation and improve clinical symptoms (pruritus and pain). This study objectively verified the effect of pressure garment therapy in maintaining a therapeutic pressure range for hypertrophic scars. Sixty-five participants (aged 20~70 years) with partial- or full-thickness burns, Vancouver scar scale score of ≥4, and a hypertrophic scar of ≥4 cm × 4 cm were enrolled. Compression pressure was measured weekly using a portable pressure-monitoring device to regulate this pressure at 15~25 mmHg for 2 months. In the control group, the compression garment use duration and all other burn rehabilitation measures were identical except for compression monitoring. No significant difference was noted in the initial evaluations between the two groups (p > 0.05). The improvements in the amount of change in scar thickness (p = 0.03), erythema (p = 0.03), and sebum (p = 0.02) were significantly more in the pressure monitoring group than in the control group. No significant differences were noted in melanin levels, trans-epidermal water loss, or changes measured using the Cutometer® between the two groups. The efficacy of compression garment therapy for burn-related hypertrophic scars can be improved using a pressure-monitoring device to maintain the therapeutic range.
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Chen D, Li Q, Zhang H, Kou F, Li Q, Lyu C, Wei H. Traditional Chinese medicine for hypertrophic scars—A review of the therapeutic methods and potential effects. Front Pharmacol 2022; 13:1025602. [PMID: 36299876 PMCID: PMC9589297 DOI: 10.3389/fphar.2022.1025602] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022] Open
Abstract
Hypertrophic scar (HS) is a typical pathological response during skin injury, which can lead to pain, itching, and contracture in patients and even affect their physical and mental health. The complexity of the wound healing process leads to the formation of HS affected by many factors. Several treatments are available for HS, whereas some have more adverse reactions and can even cause new injuries with exacerbated scarring. Traditional Chinese Medicine (TCM) has a rich source, and most botanical drugs have few side effects, providing new ideas and methods for treating HS. This paper reviews the formation process of HS, the therapeutic strategy for HS, the research progress of TCM with its relevant mechanisms in the treatment of HS, and the related new drug delivery system of TCM, aiming to provide ideas for further research of botanical compounds in the treatment of HS, to promote the discovery of more efficient botanical candidates for the clinical treatment of HS, to accelerate the development of the new drug delivery system and the final clinical application, and at the same time, to promote the research on the anti-HS mechanism of multiherbal preparations (Fufang), to continuously improve the quality control and safety and effectiveness of anti-HS botanical drugs in clinical application.
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Affiliation(s)
- Daqin Chen
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qiannan Li
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Huimin Zhang
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fang Kou
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qiang Li
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chunming Lyu
- Experiment Center for Science and Technology, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Qinghai Province Key Laboratory of Tibetan Medicine Pharmacology and Safety Evaluation, Northwest Institute of Plateau Biology, Chinese Academy of Sciences, Shanghai, China
- *Correspondence: Chunming Lyu, ; Hai Wei,
| | - Hai Wei
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- *Correspondence: Chunming Lyu, ; Hai Wei,
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Syron-Jones D, Macintyre L. Pressure by design: How to improve the consistency of pressure garments in the clinical environment and implement a simple method for gathering evidence to establish efficacy. Burns 2022; 48:1172-1182. [PMID: 34887121 DOI: 10.1016/j.burns.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/15/2022]
Abstract
Pressure garments are used to treat scars after major trauma including burns. However, the ideal pressure for treatment is not known. Pressures exerted are not routinely measured and garments exert a wide range of pressures. Therefore, current treatment and its efficacy are variable. Pressure Garment Design Tools were introduced in 2012 but their application in hospitals has not been reported. A Garment Dimension and Pressure Calculator was used to audit pressures delivered by 8 pressure garments made for children using the hospital department's standard reduction factor. The tool was easy to use and showed that pressures exerted by standard garments ranged from 15 to 54 mmHg with highest pressures exerted on wrists. Results of our pilot study indicated that the Garment Dimension and Pressure Calculator was slightly quicker to use than our normal manual process for calculating garment dimensions and enabled easy auditing of past treatment. The Pressure Garment Design Tool was easy to use and calculated garments that exerted the mean target pressures of 15 mmHg and 25 mmHg, improving consistency. Pressures exerted by garments were difficult and time consuming to measure with the Picopress sensor. Pressure was not distributed evenly around the limbs and measurements were inaccurate on the smallest limbs.
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Affiliation(s)
- Dawn Syron-Jones
- Sheffield Children's Hospital, Ryegate Therapy Block, Tapton Crescent Road, Sheffield, S10 5DD, UK
| | - Lisa Macintyre
- School of Textiles and Design, Heriot-Watt University, Netherdale, Galashiels, TD1 3HE, UK.
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11
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Powell HM, Nedelec B. Mechanomodulation of Burn Scarring Via Pressure Therapy. Adv Wound Care (New Rochelle) 2022; 11:179-191. [PMID: 34078127 DOI: 10.1089/wound.2021.0061] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Significance: The physical and psychological sequalae of burn injuries account for 10 million disability-adjusted life years lost annually. Hypertrophic scarring (HSc) after burn injury results in reduced mobility, contracture, pain, itching, and aesthetic changes for burn survivors. Despite the prevalence of scarring and the number of scar therapies available, none are highly effective at preventing HSc after burn injury. Recent Advances: Recent studies modulating the mechanical environment surrounding incisional and excisional wounds have shown off-loading of tension to be a powerful strategy to prevent scar formation. Preclinical studies applying force perpendicular to the surface of the skin or using a combination of pressure both circumferentially and perpendicularly have shown substantial reductions in scar thickness and contraction after burn injury. Critical Issues: Though pressure therapy is highly effective in preclinical studies, outcomes in clinical studies have been variable and may be a result of differing therapy protocols and garment material fatigue. A recent adult clinical study reported a significant reduction in pressure after 1 month of use and significant reduction between 1 and 2 months of use, resulting in below therapeutic doses of pressure applied after only 1 month of use. Future Directions: To enhance efficacy of pressure garments, new low-fatigue materials must be developed for use in standard garments or garments must be redesigned to allow for adjustment to compensate for the loss of pressure with time. Additionally, measurements of applied pressure should be performed routinely during clinic visits to ensure that therapeutic doses of pressure are being delivered.
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Affiliation(s)
- Heather M. Powell
- Department of Materials Science and Engineering, The Ohio State University, Columbus, Ohio, USA
- Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio, USA
- Shriners Children's Ohio, Dayton, Ohio, USA
| | - Bernadette Nedelec
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
- Centre de recherche du Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
- Hôpital de réadaptation Villa Medica, Montreal, Quebec, Canada
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12
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Burn Wound Healing: Clinical Complications, Medical Care, Treatment, and Dressing Types: The Current State of Knowledge for Clinical Practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031338. [PMID: 35162360 PMCID: PMC8834952 DOI: 10.3390/ijerph19031338] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 02/01/2023]
Abstract
According to the World Health Organization (WHO), it is estimated that each year approximately 11 million people suffer from burn wounds, 180,000 of whom die because of such injuries. Regardless of the factors causing burns, these are complicated wounds that are difficult to heal and are associated with high mortality rates. Medical care of a burn patient requires a lot of commitment, experience, and multidirectional management, including surgical activities and widely understood pharmacological approaches. This paper aims to comprehensively review the current literature concerning burn wounds, including classification of burns, complications, medical care, and pharmacological treatment. We also overviewed the dressings (with an emphasis on the newest innovations in this field) that are currently used in medical practice to heal wounds.
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Abdlaty R, Fang Q. Skin erythema assessment techniques. Clin Dermatol 2021; 39:591-604. [PMID: 34809765 DOI: 10.1016/j.clindermatol.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Skin erythema may present owing to many causes. One of the common causes is prolonged exposure to sunrays. Other than sun exposure, skin erythema is an accompanying sign of dermatologic diseases, such as psoriasis and acne. Quantifying skin erythema in patients enables the dermatologist to assess the patient's skin health. Quantitative assessment of skin erythema has been the focus of several studies. The clinical standard for erythema evaluation is visual assessment; however, this standard has some deficiencies. For instance, visual assessment is subjective and ineffectual for precise color information exchange. To overcome these limitations, in the past three decades various methodologies have been developed in an attempt to achieve objective erythema assessments, such as diffuse reflectance spectroscopy and both optical and nonoptical systems. This review considers the studies published during the past three decades and discusses the performance, the mathematical tactics for computation, and the limited capabilities of erythema assessment techniques for cutaneous diseases. The achievements and limitations of the current techniques in erythema assessment are presented. The advantages and development trends of optical and nonoptical methods are presented to make the reader aware of the present technological advances and their potential for dermatological disease research.
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Affiliation(s)
- Ramy Abdlaty
- Biomedical Engineering, Military Technical College, Kobry-Elkobba, Cairo, Egypt
| | - Qiyin Fang
- Department of Engineering Physics, McMaster University, Hamilton, ONT, Canada.
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Zhou J, Fu C, Yang W, Gu W. A method for precise local pressurization in scar-repairing surgery. J Burn Care Res 2021; 43:240-248. [PMID: 34061950 DOI: 10.1093/jbcr/irab089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pressure Garment Treatment (PGT) is currently recognized as an effective method to prevent scar formation or treat scar hyperplasia. Research on PGT remains controversial. These controversies indicate that PGT lacks reliable evidence of evidence-based medicine. Different studies on PGT need to be conducted under the same 'gold standard' so that different studies can be compared. We consider this 'gold standard' to be that the pressure remains stable within a confidence interval during treatment. METHODS We calibrated and verified the reference value of the sensor using a cuff of sphygmanometer.A pressure adjustable pressure system was obtained by installing a soft tissue expander on the pressure garment.Local pressure was adjusted by charging and releasing air.Subsequently, the flexible pressure sensor was placed on the upper arm of the healthy volunteers. We validated the compression system on healthy volunteers' forearms and AO standard prostheses (forearms). RESULTS Reference value of the sensor was calibrated on No.1 volunteer. Measuring repeated on No.2 and No. 3. The measurement was very reproducible. The test results in the experimental group showed that the local pressure gradually increased with the increase of the inflation of the airbag. However, the pressure at the opposite position of the forearm changed little. CONCLUSIONS Real-time pressure monitoring and pressure adjustment enable the pressure to be maintained at a certain value. Our study provides a new idea for the production of elastic clothing with the function of pressure measurement and pressure regulation, which may promote the accuracy and reliability of PGT.
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Affiliation(s)
- Jinfeng Zhou
- Department of Burn and Plastic Surgery, Nanjing University of Science and Technology, Jiangsu, China
| | - Chen Fu
- School of Electronic and Optical Engineering, Nanjing University of Science and Technology, Jiangsu, China
| | - Wengbo Yang
- Department of Orthopaedics, Nanjing First Hospital, Nanjing Medical University, Jiangsu, China
| | - Wenhua Gu
- School of Electronic and Optical Engineering, Nanjing University of Science and Technology, Jiangsu, China
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15
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El Khatib A, Jeschke MG. Contemporary Aspects of Burn Care. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:386. [PMID: 33923571 PMCID: PMC8073568 DOI: 10.3390/medicina57040386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930-1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.
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Affiliation(s)
- Arij El Khatib
- Unité des Grands Brûlés, University of Montreal Medical Centre Sanguinet, 1051, Rue Sanguinet, Montréal, QC H2X 0C1, Canada
| | - Marc G. Jeschke
- Department of Surgery, Division of Plastic Surgery, Department of Immunology, Ross Tilley Burn Centre-Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, University of Toronto, 2075 Bayview Avenue, Rm D704, Toronto, ON M4N 3M5, Canada;
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Lee SY, Cho YS, Joo SY, Seo CH. Comparison between the portable pressure measuring device and PicoPress® for garment pressure measurement on hypertrophic burn scar during compression therapy. Burns 2021; 47:1621-1626. [PMID: 33632555 DOI: 10.1016/j.burns.2021.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/09/2020] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The current standard treatment for hypertrophic scars following burn injury is pressure garment therapy. The experimenters developed the novel portable pressure measuring device using silicon piezoresistive sensors. As PicoPress® is the most accurate (i.e., lowest variation and error) manometric sensor for pressure measurement, we sought to compare and examine the accuracy of the novel device regarding in vitro pressure measurements at the hypertrophic scar-pressure garment interface. METHODS The novel device was designed to operate in non-corrosive media, such as air. The device can use up to six pressure sensing points and was developed to adjust the number of pressure sensors according to the size of the scar. Pressure measurements were acquired through a readout circuit consisting of an analog-to-digital converter, a microprocessor, and a Bluetooth transmission module for wireless data transmission to an external device. All signals were converted into mean pressure expressed in millimeters of mercury (mmHg). The mean pressure values measured by the sensors were compared to those obtained from PicoPress®. 55 garment pressures recordings were obtained from the sensors over this study conducted in 2018-February 2020. We then analyzed the test-retest reliability using the intraclass correlation coefficients (ICC). PicoPress® was also employed in the same pressure garments for obtaining similar measurements. A two way random effects model ICC with 95% confidence intervals was used to compare the mean pressure values obtained from the silicon piezoresistive sensors to the PicoPress® measurements. RESULTS The test-retest reliability of the pressure sensors was close to the acceptable level for clinical use regarding stationary interface pressure measurement (ICC = 0.99, 95% CI 0.990-0.997). The mean pressure obtained from the silicon piezoresistive pressure sensors showed an accordance with the measurements from PicoPress® (ICC = 0.97, 95% CI 0.947-0.985). CONCLUSION The novel device may present a viable alternative to PicoPress® for garment pressure measurements. In addition, the novel device improves adaptability to the hypertrophic scar shape and size. Complementary characteristics such as wireless transmission to an external device may allow burn patients to continuously wear the device for real-time measurements during pressure garment therapy, thus improving existing devices including PicoPress®.
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Affiliation(s)
- Seung Yeol Lee
- Department of Physical Medicine and Rehabilitation, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Yoon Soo Cho
- Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Republic of Korea
| | - So Young Joo
- Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Republic of Korea
| | - Cheong Hoon Seo
- Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Republic of Korea.
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17
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Huang PW, Lu CW, Chu KT, Ho MT. Assessing Thickness of Burn Scars Through Ultrasound Measurement for Patients with Arm Burns. J Med Biol Eng 2021. [DOI: 10.1007/s40846-020-00592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Abdlaty R, Hayward J, Farrell T, Fang Q. Skin erythema and pigmentation: a review of optical assessment techniques. Photodiagnosis Photodyn Ther 2020; 33:102127. [PMID: 33276114 DOI: 10.1016/j.pdpdt.2020.102127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/28/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Skin erythema may present due to many causes. One of the common causes is prolonged exposure to sun rays. Other than sun exposure, skin erythema is an accompanying sign of dermatological diseases such as acne, psoriasis, melasma, post inflammatory hyperpigmentation, fever, as well as exposure to specific electromagnetic wave bands. METHODS Quantifying skin erythema in patients enables the dermatologist to assess the patient's skin health. Therefore, quantitative assessment of skin erythema was the target of several studies. The clinical standard for erythema evaluation is visual assessment. However, the former standard has some imperfections. For instance, it is subjective, and unqualified for precise color information exchange. To overcome these shortcomings, the past three decades witnessed various methodologies that aimed to achieve erythema objective assessment, such as diffuse reflectance spectroscopy (DRS), and both optical and non-optical systems. DISCUSSION This review article reports on the studies published in the past three decades where the performance, the mathematical tactics for computation, and the capabilities of erythema assessment techniques for cutaneous diseases are discussed. In particular, the achievements and limitations of the current techniques in erythema assessment are presented. CONCLUSION The profits and development trends of optical and non-optical methods are displayed to provide the researcher with awareness into the present technological advances and its potential for dermatological diseases research.
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Affiliation(s)
| | - Joseph Hayward
- Juravinski Cancer Centre, Hamilton Health Sciences, Ontario, Canada
| | - Thomas Farrell
- Department of Medical Physics and Applied Radiation Sciences, McMaster University, Ontario, Canada
| | - Qiyin Fang
- Engineering Physics, McMaster University, Ontario, Canada
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19
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Tang KPM, Yick KL, Li PL, Yip J, Or KH, Chau KH. Effect of Contacting Surface on the Performance of Thin-Film Force and Pressure Sensors. SENSORS 2020; 20:s20236863. [PMID: 33266213 PMCID: PMC7729666 DOI: 10.3390/s20236863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/28/2020] [Accepted: 11/28/2020] [Indexed: 11/30/2022]
Abstract
Flexible force and pressure sensors are important for assessing the wear comfort of tightly fitting apparel. Their accuracy and repeatability depend on the sensor itself and the contacting surface. Measurements of the contact pressure on soft surfaces like human skin tend to be erroneous, which could be due to incorrect sensor calibrations. This study aims to examine the effects of human body parameters such as the hardness and temperature of the contacting surface by using a custom-made calibration setup and investigating the incorporation of rigid discs on the sensor surface. Two commercial force sensors, FlexiForce and SingleTact, and one pressure sensor, Pliance X, are used in the investigation. The findings reveal that adding rigid discs on both sides of the force sensors improves their sensitivity. Systematic calibration has been performed on the surfaces with different temperatures and hardness. The results show that FlexiForce and Pliance X tend to be affected by the changes in surface temperature and surface hardness. Prolonged testing time shows that the time dependence of SingleTact and Pliance X sensor is lower, which suggests that they are more suitable for lengthier evaluations in which interface pressure is exerted on the human body. In brief, sensor attachment and proper calibration should be thoroughly considered before using sensors for applications on soft surfaces, like the human body.
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Affiliation(s)
- Ka Po Maggie Tang
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; (K.P.M.T.); (P.L.L.); (J.Y.); (K.H.O.); (K.H.C.)
| | - Kit Lun Yick
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; (K.P.M.T.); (P.L.L.); (J.Y.); (K.H.O.); (K.H.C.)
- Laboratory for Artificial Intelligence in Design, Hong Kong Science Park, Taipo, Hong Kong
- Correspondence:
| | - Pui Ling Li
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; (K.P.M.T.); (P.L.L.); (J.Y.); (K.H.O.); (K.H.C.)
| | - Joanne Yip
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; (K.P.M.T.); (P.L.L.); (J.Y.); (K.H.O.); (K.H.C.)
| | - King Hei Or
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; (K.P.M.T.); (P.L.L.); (J.Y.); (K.H.O.); (K.H.C.)
| | - Kam Hong Chau
- Institute of Textiles and Clothing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; (K.P.M.T.); (P.L.L.); (J.Y.); (K.H.O.); (K.H.C.)
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Huang J, Dong R, Wang X, Yu N, Zhao R, Bai M, Zhang H, Wang Y, Long X. Keystone-designed perforator island flaps for reconstruction after chest keloid excision: A retrospective case series. J Cosmet Dermatol 2020; 20:937-942. [PMID: 32810907 DOI: 10.1111/jocd.13684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/05/2020] [Accepted: 07/21/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE We retrospectively evaluated the efficacy and safety of keystone-designed perforator island flaps for chest keloid reconstruction. METHODS We reviewed consecutive patients who received keystone flap reconstruction after chest keloid resection between January 2017 and February 2018. The patient demographic data, defect size, flap size, complications, and recurrence were recorded. RESULTS Thirty-eight patients were evaluated in this retrospective case series. After keloid resection, dimension of wound defects was 5.5-9.5 cm × 9.5-12.5 cm, with an average dimension of 7.3 cm × 10.7 cm. The dimension of keystone flaps was between 6-10 cm × 20-34.5 cm, with an average dimension of 7.5 cm × 25.5 cm. The flaps healed smoothly without any complication. There was no keloid recurrence with 15 months of follow-up. 89.4% of the patients had good outcome with no apparent scarring, and 10.6% patients had satisfactory outcome with localized scarring. CONCLUSIONS Keystone-designed perforator island flap is an effective and reliable method for reconstruction following chest keloid resection.
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Affiliation(s)
- Jiuzuo Huang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ruijia Dong
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaojun Wang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Nanze Yu
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ru Zhao
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Bai
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hailin Zhang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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21
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Nonsurgical Management of Hypertrophic Scars: Evidence-Based Therapies, Standard Practices, and Emerging Methods. Aesthetic Plast Surg 2020; 44:1320-1344. [PMID: 32766921 DOI: 10.1007/s00266-020-01820-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Accepted: 01/05/2007] [Indexed: 12/12/2022]
Abstract
Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.
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22
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Nischwitz SP, Rauch K, Luze H, Hofmann E, Draschl A, Kotzbeck P, Kamolz LP. Evidence-based therapy in hypertrophic scars: An update of a systematic review. Wound Repair Regen 2020; 28:656-665. [PMID: 32506727 PMCID: PMC7539946 DOI: 10.1111/wrr.12839] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023]
Abstract
Hypertrophic scars are still a major burden for numerous patients, especially after burns. Many treatment options are available; however, no evidence-based treatment protocol is available with recommendations mostly emerging from experience or lower quality studies. This review serves to discuss the currently available literature. A systematic review was performed and the databases PubMed and Web of Science were searched for suitable publications. Only original articles in English that dealt with the treatment of hypertrophic scars in living humans were analyzed. Further, studies with a level of evidence lower than 1 as defined by the American Society of Plastic Surgeons were excluded. After duplicate exclusion, 1638 studies were screened. A qualitative assessment yielded 163 articles eligible for evidence grading. Finally nine studies were included. Four of them used intralesional injections, four topical therapeutics and one assessed the efficacy of CO2 -laser. Intralesional triamcinolone + fluorouracil injections, and topical pressure and/or silicone therapy revealed significant improvements in terms of scar height, pliability, and pigmentation. This systematic review showed that still few high-quality studies exist to evaluate therapeutic means and their mechanisms for hypertrophic scars. Among these, most of them assessed the efficacy of intralesional triamcinolone injections with the same treatment protocol. Intralesional injection appears to be the best option for hypertrophic scar treatment. Future studies should focus on a possible optimization of infiltrative therapies, consistent end-point evaluations, adequate follow-up periods, and possibly intraindividual treatments.
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Affiliation(s)
- Sebastian P Nischwitz
- COREMED - Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Hanna Luze
- COREMED - Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Elisabeth Hofmann
- COREMED - Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Petra Kotzbeck
- COREMED - Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Lars-Peter Kamolz
- COREMED - Cooperative Centre for Regenerative Medicine, JOANNEUM RESEARCH Forschungsgesellschaft mbH, Graz, Austria.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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23
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Moortgat P, Anthonissen M, Van Daele U, Vanhullebusch T, Maertens K, De Cuyper L, Lafaire C, Meirte J. The effects of shock wave therapy applied on hypertrophic burn scars: a randomised controlled trial. Scars Burn Heal 2020; 6:2059513120975624. [PMID: 33312712 PMCID: PMC7716075 DOI: 10.1177/2059513120975624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION A wide variety of non-invasive treatments has been proposed for the management of hypertrophic burn scars. Unfortunately, the reported efficacy has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a new non-invasive type of mechanotherapy to treat wounds and scars. The aim of the present study was to examine the objective and subjective scar-related effects of ESWT on burn scars in the early remodelling phase. MATERIAL AND METHODS Evaluations included the Patient and Observer Scar Assessment Scale (POSAS) for scar quality, tri-stimulus colorimetry for redness, tewametry for trans-epidermal water loss (TEWL) and cutometry for elasticity. Patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group, and were tested at baseline, after one, three and six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks. RESULTS Results for 20 patients in each group after six months are presented. The objective assessments showed a statistically significant effect of ESWT compared with placebo on elasticity (P = 0.011, η2P=0.107) but revealed no significant effects on redness and TEWL. Results of the clinical assessments showed no significant interactions between intervention and time for the POSAS Patient and Observer scores. CONCLUSION ESWT can give added value to the non-invasive treatment of hypertrophic scars, more specifically to improve elasticity when the treatment was already started in the first three months after wound closure. LAY SUMMARY Pathological scarring is a common problem after a burn injury. A wide variety of non-invasive treatments has been proposed for the management of these scars. Unfortunately, the reported efficacy of these interventions has not been consistent, and especially in the first three months after wound closure, fragility of the scarred skin limits the treatment options. Extracorporeal shock wave therapy (ESWT) is a relatively new non-invasive therapy to treat both wounds and scars. The aim of the present study was to examine the scar-related effects of ESWT on burn scars in the early phase of healing.The scars were subjectively assessed for scar quality by the patient and an observer using the Patient and Observer Scar Assessment Scale (POSAS). Objective assessments included measurements to assess redness, water loss and elasticity. Forty patients were randomly assigned to one of two groups, the low-energy intervention group or the placebo control group (the device simulated the sound of an ESWT treatment but no real shocks were applied), and were tested at four timepoints up to six months. All patients were treated with pressure garments, silicone and moisturisers. Both groups received the ESWT treatment (real or placebo) once a week for 10 weeks.The objective assessments showed a significant improvement of elasticity in the intervention group when compared with placebo but revealed no significant effects on redness and water loss. Results of the clinical assessments showed no differences between the groups for the POSAS Patient and Observer scores.ESWT can give added value to the non-invasive treatment of pathological scars more specifically to improve elasticity in the early phase of healing.
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Affiliation(s)
| | - Mieke Anthonissen
- OSCARE, Antwerp, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Ulrike Van Daele
- OSCARE, Antwerp, Belgium
- University of Antwerp, Rehabilitation Sciences and Physiotherapy, Antwerp, Belgium
| | - Tine Vanhullebusch
- OSCARE, Antwerp, Belgium
- University of Antwerp, Rehabilitation Sciences and Physiotherapy, Antwerp, Belgium
| | - Koen Maertens
- OSCARE, Antwerp, Belgium
- Department of Clinical and Lifespan Psychology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lieve De Cuyper
- OSCARE, Antwerp, Belgium
- ZNA Stuivenberg, Burns Center, Antwerp, Belgium
| | - Cynthia Lafaire
- OSCARE, Antwerp, Belgium
- ZNA Stuivenberg, Burns Center, Antwerp, Belgium
| | - Jill Meirte
- OSCARE, Antwerp, Belgium
- University of Antwerp, Rehabilitation Sciences and Physiotherapy, REVAKI-MOVANT, Antwerp, Belgium
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Abstract
Keloids are pathological scars that grow over time and extend beyond the initial site of injury after impaired wound healing. These scars frequently recur and rarely regress. They are aesthetically disfiguring, can cause pain, itching, discomfort as well as psychological stress, often affecting quality of life. Many treatment modalities, including surgical and non-surgical, have been explored and have been reported to be beneficial; however, none have been absolutely satisfactory or optimal for the treatment of all keloid subtypes to date. This poses a major challenge to clinicians. Often, a combinational therapeutic approach appears to offer the best results with higher patient satisfaction compared to monotherapy. The aetiopathogenesis of keloids is not fully elucidated; however, with recent advances in molecular biology and genetics, insight is being gained on the complex process of scar formation and hence new therapeutic and management options for keloids. In this paper, we explore the literature and summarise the general concepts surrounding keloid development and review both current (corticosteroids, surgical excision, silicone-based products, pressure therapy, radiotherapy, cryotherapy, laser therapy, imiquimod and 5-fluorouracil) and emerging (stem cell therapy, mitomycin C, verapamil, interferons, bleomycin, botulinum toxin type A and angiotensin-converting enzyme inhibitors) treatments. Increased knowledge and understanding in this area may potentially lead to the discovery and development of novel therapeutic options that are more efficacious for all keloid types. LAY SUMMARY Keloids are problematic scars that are difficult to treat and manage. The aetiopathogenesis of keloids is not clear; however, recent advances in molecular biology and genetics are beginning to shed light on the underlying mechanisms implicated in keloid scar formation which will hopefully lead to the development of treatment options for all keloid types. This review summarises current and emerging therapies.
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Affiliation(s)
- Nkemcho Ojeh
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Ambadasu Bharatha
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Uma Gaur
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados, West Indies
| | - Andrew LeRoy Forde
- Pine Medical Centre, 3rd Avenue Belleville, St. Michael, Barbados, West Indies
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Prevalence and Risk Factors for Hypertrophic Scarring of Split Thickness Autograft Donor Sites in a Pediatric Burn Population. Burns 2019; 45:1066-1074. [DOI: 10.1016/j.burns.2019.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/31/2018] [Accepted: 02/07/2019] [Indexed: 11/19/2022]
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Kant SB, Colla C, van den Kerckhove E, Piatkowski de Grzymala A. Clinical effects of transparent facial pressure masks: A literature review. Prosthet Orthot Int 2019; 43:349-355. [PMID: 30860443 PMCID: PMC6557006 DOI: 10.1177/0309364619836023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Severe facial hypertrophic scars are known to severely impact emotional well-being. Pressure therapy by means of transparent face masks has been used for almost 40 years, but evidence about the clinical effects remains sparse. OBJECTIVES To provide a summary on the efficacy of transparent face masks in the treatment of facial hypertrophic scars. METHODS A literature search was conducted in PubMed, MEDLINE, and Cochrane databases through 1 January 2018. Articles describing the clinical effects of facial pressure therapy for remodeling the face after trauma or surgery with a validated tool were included. This review included studies of participants treated with facial hypertrophic scars, both minors and adults. RESULTS Three articles involving 33 patients were selected for inclusion. Two studies described statistically significant improvement in facial scars measured by durometer, ultrasound, and the Patient and Observer Scar Assessment Scale (POSAS). CONCLUSIONS Facial pressure masks have been shown to deliver significant improvement in facial scars, measured by both subjective and objective tools. However, only three studies could be included in this literature review. Also, because of considerable limitations of the studies, it remains difficult to draw substantial conclusions about the efficacy of transparent face masks. CLINICAL RELEVANCE This literature review provides a summary of the current evidence on the subjectively and objectively measured clinical effects of transparent face masks in the treatment of facial scars, highlighting the need for further research on this topic.
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Affiliation(s)
- Sander B Kant
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, The Netherlands,Sander B Kant, Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, P Debyelaan 25, 6229 HX Maastricht, The Netherlands.
| | - Carlo Colla
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, The Netherlands
| | - Eric van den Kerckhove
- Department of Plastic, Reconstructive, and Hand Surgery, Maastricht University Medical Center, The Netherlands,Department of Rehabilitation Sciences (Faber), Universitaire Ziekenhuizen Leuven, KU Leuven, Leuven, Belgium,Department of Physical Medicine and Rehabilitation and Burns Center, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
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Colla C, Kant SB, Van den Kerckhove E, Van der Hulst RRWJ, Piatkowski de Grzymala AA. Manual fabrication of a specialized transparent facial pressure mask: A technical note. Prosthet Orthot Int 2019; 43:356-360. [PMID: 30632878 PMCID: PMC6557004 DOI: 10.1177/0309364618820141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM The objective of this study was to describe the manual fabrication of a transparent facial pressure mask for treating facial deformities. The mask combines the use of a silicone inner liner and mechanical pressure in the facial region. TECHNIQUE A negative mold is formed by covering the face with plaster. Manipulation of soft tissue is a crucial part in this process. After hardening and removal of the negative mold, the positive mold is formed and dried. Next a rolled silicone sheet is placed over the positive mold in a vacuum environment. Subsequently, the silicones are vulcanized. Then the rigid outside of the mask is created. The silicone inner liner and outside shell are then affixed. DISCUSSION This described technique results in accurate facemasks with precise fitting. During therapy, the mask is adjusted multiple times to keep excellent fit, as remodeling of scars and deformities takes place. CLINICAL RELEVANCE Facemasks are a reputable therapeutic modality to reduce excessive facial scarring. They require excellent fitting to give pleasing results. To provide a better understanding of facemask therapy, this study describes the manual fabrication technique.
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Affiliation(s)
- Carlo Colla
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sander B Kant
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,Sander B Kant, Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands.
| | - Eric Van den Kerckhove
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,KU Leuven, Department of Rehabilitation Sciences, Faber, Universitaire Ziekenhuizen Leuven, Leuven, Belgium,Department of Physical Medicine and Rehabilitation and Burns Center, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - René RWJ Van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Moiemen N, Mathers J, Jones L, Bishop J, Kinghorn P, Monahan M, Calvert M, Slinn G, Gardiner F, Bamford A, Wright S, Litchfield I, Andrews N, Turner K, Grant M, Deeks J. Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study. Health Technol Assess 2019; 22:1-162. [PMID: 29947328 DOI: 10.3310/hta22360] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Eleven million people suffer a fire-related injury worldwide every year, and 71% have significant scarring. Pressure garment therapy (PGT) is a standard part of burn scar management, but there is little evidence of its clinical effectiveness or cost-effectiveness. OBJECTIVE To identify the barriers to, and the facilitators of, conducting a randomised controlled trial (RCT) of burn scar management with and without PGT and test whether or not such a trial is feasible. DESIGN Web-based surveys, semistructured individual interviews, a pilot RCT including a health economic evaluation and embedded process evaluation. SETTING UK NHS burns services. Interviews and the pilot trial were run in seven burns services. PARTICIPANTS Thirty NHS burns services and 245 staff provided survey responses and 15 staff participated in individual interviews. Face-to-face interviews were held with 24 adult patients and 16 parents of paediatric patients who had undergone PGT. The pilot trial recruited 88 participants (57 adults and 31 children) who were at risk of hypertrophic scarring and were considered suitable for scar management therapy. Interviews were held with 34 participants soon after recruitment, with 23 participants at 12 months and with eight staff from six sites at the end of the trial. INTERVENTIONS The intervention was standard care with pressure garments. The control was standard care comprising scar management techniques involving demonstration and recommendations to undertake massage three or four times per day with moisturiser, silicone treatment, stretching and other exercises. MAIN OUTCOME MEASURES Feasibility was assessed by eligibility rates, consent rates, retention in allocated arms, adherence with treatment and follow-up and completion of outcome assessments. The outcomes from interview-based studies were core outcome domains and barriers to, and facilitators of, trial participation and delivery. RESULTS NHS burns services treat 2845 patients per annum (1476 paediatric and 1369 adult) and use pressure garments for 6-18 months, costing £2,171,184. The majority of staff perceived a need for a RCT of PGT, but often lacked equipoise around the research question and PGT as a treatment. Strong views about the use of PGT have the potential to influence the conduct of a full-scale RCT. A range of outcome domains was identified as important via the qualitative research: perceptions of appearance, specific scar characteristics, function, pain and itch, broader psychosocial outcomes and treatment burden. The outcome tools evaluated in the pilot trial did not cover all of these domains. The planned 88 participants were recruited: the eligibility rate was 88% [95% confidence interval (CI) 83% to 92%], the consent rate was 47% (95% CI 40% to 55%). Five (6%) participants withdrew, 14 (16%) were lost to follow-up and 8 (9%) crossed over. Adherence was as in clinical practice. Completion of outcomes was high for adult patients but poorer from parents of paediatric patients, particularly for quality of life. Sections on range of movement and willingness to pay were found to be challenging and poorly completed. LIMITATIONS The Brisbane Burn Scar Impact Profile appears more suitable in terms of conceptual coverage than the outcome scales that were used in the trial but was not available at the time of the study. CONCLUSIONS A definitive RCT of PGT in burn scar management appears feasible. However, staff attitudes to the use of pressure garments may lead to biases, and the provision of training and support to sites and an ongoing assessment of trial processes are required. FUTURE WORK We recommend that any future trial include an in-depth mixed-methods recruitment investigation and a process evaluation to account for this. TRIAL REGISTRATION Current Controlled Trials ISRCTN34483199. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Naiem Moiemen
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan Bishop
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Philip Kinghorn
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Mark Monahan
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Melanie Calvert
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Fay Gardiner
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Amy Bamford
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan Wright
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ian Litchfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicole Andrews
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Karen Turner
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Margaret Grant
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jonathan Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Role of Early Application of Pressure Garments following Burn Injury and Autografting. Plast Reconstr Surg 2019; 143:310e-321e. [PMID: 30688890 DOI: 10.1097/prs.0000000000005270] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pressure garment therapy, used for reduction of postburn scarring, is commonly initiated after complete healing of the wound or autograft. Although some clinicians have suggested that earlier treatment may improve outcomes, the effect of early initiation of therapy has not been studied in a controlled environment. METHODS Full-thickness burns were created on red Duroc pigs, burn eschar was excised, and the wound bed was grafted with split-thickness autografts. Grafts were treated with pressure garments immediately, 1 week (early), or 5 weeks (delayed) after grafting with nontreated grafts as controls. Scar morphology, biomechanics, and gene expression were measured at multiple time points up to 17 weeks after grafting. RESULTS Grafts that received pressure within 1 week after grafting exhibited no reduction in engraftment rates. Immediate and early application of pressure resulted in scars with decreased contraction, reduced scar thickness, and improved biomechanics compared with controls. Pressure garment therapy did not alter expression of collagen I, collagen III, or transforming growth factor β1 at the time points investigated; however, expression of matrix metalloproteinase 1 was significantly elevated in the immediate pressure garment therapy group at week 3, whereas the delayed pressure garment therapy and control groups approached baseline levels at this time point. CONCLUSIONS Early application of pressure garments is safe and effective for reducing scar thickness and contraction and improving biomechanics. This preclinical study suggests that garments should be applied as soon as possible after grafting to achieve greatest benefit, although clinical studies are needed to validate the findings in humans.
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Liu B, Liu Y, Wang L, Hou C, An M. The effects of pressure intervention on wound healing and scar formation in a Bama minipig model. Burns 2019; 45:413-422. [DOI: 10.1016/j.burns.2018.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/16/2018] [Accepted: 09/05/2018] [Indexed: 01/16/2023]
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Wiseman J, Simons M, Kimble R, Tyack Z. Variability of pressure at the pressure garment-scar interface in children after burn: A pilot longitudinal cohort study. Burns 2019; 45:103-113. [DOI: 10.1016/j.burns.2018.08.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/10/2018] [Accepted: 08/30/2018] [Indexed: 11/29/2022]
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32
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Can a Cohesive Silicone Bandage Outperform an Adhesive Silicone Gel Sheet in the Treatment of Scars? A Randomized Comparative Trial. Plast Reconstr Surg 2019; 143:902-911. [PMID: 30601234 DOI: 10.1097/prs.0000000000005369] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of topical silicone to treat scars is widespread, and various studies have demonstrated its efficacy to treat scars. A new form of silicone application is a cohesive elastic bandage. The aim of this study was to compare the effects of this bandage versus an adhesive silicone gel sheet on scar elasticity after burn injury. METHODS A total of 60 patients were enrolled in a randomized, prospective, single-blind, single-center, comparative, parallel-group study. The participants were assigned randomly to one of two treatment arms: one for treatment with a cohesive silicone bandage, and the other with a silicone gel sheet. The color was measured objectively using a Chromameter, and the Cutometer was used to assess vertical elasticity. For subjective assessment of the scars, the authors used the Patient and Observer Scar Assessment Scale. RESULTS The results reveal that there were no significant differences between the two interventions for most subjective assessments and color measurements. However, the group that received treatment with the cohesive silicone bandage did seem to perform statistically significantly better than the silicone gel sheet group for vertical elasticity and the global score of the Patient and Observer Scar Assessment Scale (observer scale). This was probably because of the unique microstructure of the bandage that ensured a standardized pressure together with uninterrupted contact with the skin. CONCLUSIONS An elastic cohesive silicone bandage seems to outperform silicone gel sheets for vertical elasticity when treating hypertrophic burn scars. The authors recommend including timing of application and duration of application in future studies. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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33
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Duration of Scar Maturation: Retrospective Analyses of 361 Hypertrophic Scars Over 5 Years. Adv Skin Wound Care 2019; 32:26-34. [DOI: 10.1097/01.asw.0000547415.38888.c4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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34
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Wiseman J, Simons M, Kimble R, Tyack Z. Reliability and clinical utility of the Pliance X for measuring pressure at the interface of pressure garments and burn scars in children. Burns 2018; 44:1820-1828. [DOI: 10.1016/j.burns.2018.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 05/01/2018] [Accepted: 05/07/2018] [Indexed: 11/16/2022]
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35
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Li P, Li-Tsang CWP, Deng X, Wang X, Wang H, Zhang Y, Tan Z, He C. The recovery of post-burn hypertrophic scar in a monitored pressure therapy intervention programme and the timing of intervention. Burns 2018; 44:1451-1467. [DOI: 10.1016/j.burns.2018.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 12/09/2017] [Accepted: 01/08/2018] [Indexed: 12/14/2022]
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36
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Compression Garments for Medical Therapy and Sports. Polymers (Basel) 2018; 10:polym10060663. [PMID: 30966697 PMCID: PMC6404358 DOI: 10.3390/polym10060663] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/08/2018] [Accepted: 06/12/2018] [Indexed: 12/02/2022] Open
Abstract
Compression garments are elastic clothing with an engineered compression gradient that can be worn on limbs, upper, lower, or full body to use for therapy and sports. This article presents an overview and review on the compression garments and concentrates on the design of compression garments with an appropriate pressure for specific applications. It covers the types of compression garments, fibers and yarns, knitted fabric construction, garment design, an evaluation system, and pressure measurement and modeling. The material properties, fabric properties, pressure modeling, and the garment design system presents the prediction, design, and fabrication of the compression garments. Lastly, the research status and directions are discussed.
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37
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DeBruler DM, Blackstone BN, McFarland KL, Baumann ME, Supp DM, Bailey JK, Powell HM. Effect of skin graft thickness on scar development in a porcine burn model. Burns 2018; 44:917-930. [PMID: 29661554 DOI: 10.1016/j.burns.2017.11.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/16/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022]
Abstract
Animal models provide a way to investigate scar therapies in a controlled environment. It is necessary to produce uniform, reproducible scars with high anatomic and biologic similarity to human scars to better evaluate the efficacy of treatment strategies and to develop new treatments. In this study, scar development and maturation were assessed in a porcine full-thickness burn model with immediate excision and split-thickness autograft coverage. Red Duroc pigs were treated with split-thickness autografts of varying thickness: 0.026in. ("thin") or 0.058in. ("thick"). Additionally, the thin skin grafts were meshed and expanded at 1:1.5 or 1:4 to evaluate the role of skin expansion in scar formation. Overall, the burn-excise-autograft model resulted in thick, raised scars. Treatment with thick split-thickness skin grafts resulted in less contraction and reduced scarring as well as improved biomechanics. Thin skin autograft expansion at a 1:4 ratio tended to result in scars that contracted more with increased scar height compared to the 1:1.5 expansion ratio. All treatment groups showed Matrix Metalloproteinase 2 (MMP2) and Transforming Growth Factor β1 (TGF-β1) expression that increased over time and peaked 4 weeks after grafting. Burns treated with thick split-thickness grafts showed decreased expression of pro-inflammatory genes 1 week after grafting, including insulin-like growth factor 1 (IGF-1) and TGF-β1, compared to wounds treated with thin split-thickness grafts. Overall, the burn-excise-autograft model using split-thickness autograft meshed and expanded to 1:1.5 or 1:4, resulted in thick, raised scars similar in appearance and structure to human hypertrophic scars. This model can be used in future studies to study burn treatment outcomes and new therapies.
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Affiliation(s)
- Danielle M DeBruler
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH, United States
| | - Britani N Blackstone
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH, United States
| | - Kevin L McFarland
- Research Department, Shriners Hospitals for Children, Cincinnati, OH, United States
| | - Molly E Baumann
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States
| | - Dorothy M Supp
- Research Department, Shriners Hospitals for Children, Cincinnati, OH, United States; Department of Surgery, University of Cincinnati, Cincinnati, OH, United States
| | - J Kevin Bailey
- Department of Surgery, Division of Critical Care, Trauma and Burns, The Ohio State University, Columbus, OH, United States
| | - Heather M Powell
- Department of Materials Science and Engineering, The Ohio State University, Columbus, OH, United States; Department of Biomedical Engineering, The Ohio State University, Columbus, OH, United States.
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Lee HJ, Jang YJ. Recent Understandings of Biology, Prophylaxis and Treatment Strategies for Hypertrophic Scars and Keloids. Int J Mol Sci 2018; 19:ijms19030711. [PMID: 29498630 PMCID: PMC5877572 DOI: 10.3390/ijms19030711] [Citation(s) in RCA: 264] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/07/2018] [Accepted: 01/08/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Ho Jun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon 24253, Korea.
| | - Yong Ju Jang
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.
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39
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Wei Y, Wang Y, Zhang M, Yan G, Wu S, Liu W, Ji G, Li-Tsang CW. The application of 3D-printed transparent facemask for facial scar management and its biomechanical rationale. Burns 2018; 44:453-461. [DOI: 10.1016/j.burns.2017.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/17/2017] [Accepted: 08/09/2017] [Indexed: 11/30/2022]
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Carney BC, Liu Z, Alkhalil A, Travis TE, Ramella-Roman J, Moffatt LT, Shupp JW. Elastin Is Differentially Regulated by Pressure Therapy in a Porcine Model of Hypertrophic Scar. J Burn Care Res 2018; 38:28-35. [PMID: 28009695 DOI: 10.1097/bcr.0000000000000413] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Beneficial effects of pressure therapy for hypertrophic scars have been reported, but the mechanisms of action are not fully understood. This study evaluated elastin and its contribution to scar pliability. The relationship between changes in Vancouver Scar Scale (VSS) scores of pressure-treated scars and differential regulation of elastin was assessed. Hypertrophic scars were created and assessed weekly using VSS and biopsy procurement. Pressure treatment began on day 70 postinjury. Treated scars were compared with untreated shams. Treatment lasted 2 weeks, through day 84, and scars were assessed weekly through day 126. Transcript and protein levels of elastin were quantified. Pressure treatment resulted in lower VSS scores compared with sham-treated scars. Pliability (VSSP) was a key contributor to this difference. At day 70 pretreatment, VSSP = 2. Without treatment, sham-treated scars became less pliable, while pressure-treated scars became more pliable. The percentage of elastin in scars at day 70 was higher than in uninjured skin. Following treatment, the percentage of elastin increased and continued to increase through day 126. Untreated sham scars did not show a similar increase. Quantification of Verhoeff-Van Gieson staining corroborated the findings and immunofluorescence revealed the alignment of elastin fibers. Pressure treatment results in increased protein level expression of elastin compared with sham-untreated scars. These findings further characterize the extracellular matrix's response to the application of pressure as a scar treatment, which will contribute to the refinement of rehabilitation practices and ultimately improvements in functional and psychosocial outcomes for patients.
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Affiliation(s)
- Bonnie C Carney
- From the *Firefighters' Burn and Surgical Research Laboratory, Washington, DC; †Department of Biochemistry, Georgetown University, Washington, DC; ‡The Burn Center, MedStar Washington Hospital Center, Washington, DC; and §Department of Biomedical Engineering, Florida International University, Miami
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Anthonissen M, Meirte J, Moortgat P, Maertens K, Daly D, Fieuws S, Lafaire C, De Cuyper L, Van den Kerckhove E. Influence on clinical parameters of depressomassage (part I): The effects of depressomassage on color and transepidermal water loss rate in burn scars: A pilot comparative controlled study. Burns 2018; 44:877-885. [PMID: 29395412 DOI: 10.1016/j.burns.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 08/23/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Depressomassage is a non-invasive massage technique using a mechanical suction device that is used in the treatment of traumatic or burn scars. Since color and transepidermal water loss (TEWL) are respectively the most important physical and physiological characteristic of hypertrophic scar formation, we wanted to investigate the effects of depressomassage on the recovery of color and TEWL in burn scars compared to the traditional physiotherapy. METHODS In this pilot comparative controlled study a total 43 burn patients were included and allocated into 2 groups. All patients received standard physical therapy, and the test group received additional depressomassage during 6 months. Color was assessed using the POSAS questionnaire (for color, vascularity and pigmentation) and the Minolta Chromameter. TEWL was measured using DermaLab. RESULTS Patients of both groups were evaluated at baseline, after 1, 3 and 6 months and after 1year. The evidence for a difference in evolution of color and TEWL between both groups in our study was minimal. CONCLUSIONS In practice, precise indications to begin depressomassage have to be kept in mind. Perhaps other scar abnormalities such as decreased elasticity, increased thickness, excessive pain or itching could be sufficient reasons to begin depressomassage and should be assessed.
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Affiliation(s)
- Mieke Anthonissen
- KU Leuven, Department of Rehabilitation Sciences, Leuven, Belgium; Oscare, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium; UZ Leuven, Department of Physical Medicine and Rehabilitation & Burns Center, Leuven, Belgium.
| | - Jill Meirte
- Oscare, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium; University of Antwerp, Department of Rehabilitation Sciences and Physiotherapy, Antwerp, Belgium
| | - Peter Moortgat
- Oscare, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium
| | - Koen Maertens
- Oscare, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium; Vrije Universiteit Brussel, Department of Clinical and Lifespan Psychology, Brussels, Belgium
| | - Daniel Daly
- KU Leuven, Department of Kinesiology, Leuven, Belgium
| | - Steffen Fieuws
- KU Leuven and Hasselt University, I-Biostat, Leuven, Belgium
| | - Cindy Lafaire
- Oscare, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium; ZNA Stuivenberg, Burns Center, Antwerp, Belgium
| | - Lieve De Cuyper
- Oscare, Organisation for Burns, Scar After-Care & Research, Antwerp, Belgium; ZNA Stuivenberg, Burns Center, Antwerp, Belgium
| | - Eric Van den Kerckhove
- KU Leuven, Department of Rehabilitation Sciences, Leuven, Belgium; UZ Leuven, Department of Physical Medicine and Rehabilitation & Burns Center, Leuven, Belgium; AZ Maastricht, Department of Plastic Surgery, Maastricht, The Netherlands
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Hall C, Hardin C, Corkins CJ, Jiwani AZ, Fletcher J, Carlsson A, Chan R. Pathophysiologic Mechanisms and Current Treatments for Cutaneous Sequelae of Burn Wounds. Compr Physiol 2017; 8:371-405. [PMID: 29357133 DOI: 10.1002/cphy.c170016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Caroline Hall
- Quality Skin Collaborative for Advanced Reconstruction and Regeneration (Q-SCARRTM), Dental Craniofacial Trauma Research Division, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
| | - Carolyn Hardin
- Quality Skin Collaborative for Advanced Reconstruction and Regeneration (Q-SCARRTM), Dental Craniofacial Trauma Research Division, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
| | - Christopher J Corkins
- Quality Skin Collaborative for Advanced Reconstruction and Regeneration (Q-SCARRTM), Dental Craniofacial Trauma Research Division, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA.,Clinical Division and Burn Center, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
| | - Alisha Z Jiwani
- Quality Skin Collaborative for Advanced Reconstruction and Regeneration (Q-SCARRTM), Dental Craniofacial Trauma Research Division, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA.,Clinical Division and Burn Center, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
| | - John Fletcher
- Quality Skin Collaborative for Advanced Reconstruction and Regeneration (Q-SCARRTM), Dental Craniofacial Trauma Research Division, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA.,Clinical Division and Burn Center, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
| | - Anders Carlsson
- Quality Skin Collaborative for Advanced Reconstruction and Regeneration (Q-SCARRTM), Dental Craniofacial Trauma Research Division, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA.,Clinical Division and Burn Center, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
| | - Rodney Chan
- Quality Skin Collaborative for Advanced Reconstruction and Regeneration (Q-SCARRTM), Dental Craniofacial Trauma Research Division, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA.,Clinical Division and Burn Center, US Army Institute of Surgical Research, Ft. Sam Houston, TX, USA
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A new treatment for reliable functional and esthetic outcome after local facial flap reconstruction: a transparent polycarbonate facial mask with silicone sheeting. EUROPEAN JOURNAL OF PLASTIC SURGERY 2017; 40:407-416. [PMID: 28989235 PMCID: PMC5610215 DOI: 10.1007/s00238-017-1306-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Facial flap surgery predominantly leads to good functional results. However, in some cases, it can cause unsatisfactory esthetic results. They include persistent erythema, pincushioning, and development of hypertrophic scars. Conservative, reliable treatment for facial flaps is lacking. Pressure and silicone therapy have proven to result in significant improvement in scar erythema, pliability, and thickness in postburn hypertrophic scars. By combining these therapies in a facial mask, the esthetic outcome of facial flaps could be improved. In this retrospective study, the efficacy of a unique transparent face mask containing silicone sheets on the esthetic outcome of postsurgical facial flaps is assessed. METHODS Twenty-one patients were assigned to facial pressure mask therapy after they underwent facial flap surgery between July 2012 and September 2015. Patients were treated for a mean duration of 46 weeks. The effects of pressure mask therapy were examined by means of the Patient and Observer Scar Assessment Scale (POSAS). RESULTS All POSAS components showed a reduction between start and end of therapy, while itchiness, pigmentation, pliability, thickness, and relief of the flap improved significantly (P < 0.05). Mean total and patient score showed significant reduction between start and end of therapy. CONCLUSIONS This study shows that a facial pressure mask layered with silicone results in noticeable flap improvement with a long-lasting result. Level of Evidence: Level III, therapeutic study.
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Pan R, Dos Santos BD, Nascimento LC, Rossi LA, Geenen R, Van Loey NE. School reintegration of pediatric burn survivors: An integrative literature review. Burns 2017. [PMID: 28624354 DOI: 10.1016/j.burns.2017.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The school is an essential context for children's social interaction with peers and to develop academic skills. Therefore, a fast reintegration can help children with burns to normalize their life. Thus, school reintegration is an important outcome after burns. The aim of this review was to systematically synthesize the literature addressing school reintegration programs of pediatric burns survivors. METHODS Five electronic databases were searched independently by two reviewers. The search yielded 13 eligible publications. A qualitative content analysis was conducted. RESULTS The two themes identified centered around (1) the roles, obstacles, and support for the different stakeholders (i.e., the child, parents and teacher) and (2) the contents of the school reintegration programs in which subthemes such as purpose, planning, essential elements, team, and effect were distinguished. The results show that return to school should start as soon as the child is admitted to the hospital and the program should acknowledge the different stakeholders' needs and tailor the program to these needs. CONCLUSION The review emphasizes the necessity of an integrated school reintegration program empowering both the child, the parents and the teachers and tailored to the child's specific situation. Furthermore, it offers recommendations for further improvement of the field.
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Affiliation(s)
- Raquel Pan
- Pontifical Catholic University of Minas Gerais at Poços de Caldas, Department of Nursing, Poços de Caldas, MG, Brazil.
| | - Bruna Domingos Dos Santos
- Psychiatric Nursing program, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
| | - Lucila Castanheira Nascimento
- Maternal-Infant and Public Health Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
| | - Lídia Aparecida Rossi
- General and Specialized Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
| | - Rinie Geenen
- Utrecht University, Department of Psychology, Utrecht, The Netherlands.
| | - Nancy E Van Loey
- Association of Dutch Burn Centers, Utrecht University, Department of Clinical & Health Psychology, Beverwijk, Utrecht, The Netherlands.
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Evidence-Based Scar Management: How to Improve Results with Technique and Technology. Plast Reconstr Surg 2017; 138:165S-178S. [PMID: 27556757 DOI: 10.1097/prs.0000000000002647] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Scars represent the visible sequelae of trauma, injury, burn, or surgery. They may induce distress in the patient because of their aesthetically unpleasant appearance, especially if they are excessively raised, depressed, wide, or erythematous. They may also cause the patient symptoms of pain, tightness, and pruritus. Numerous products are marketed for scar prevention or improvement, but their efficacy is unclear. METHODS A literature review of high-level studies analyzing methods to prevent or improve hypertrophic scars, keloids, and striae distensae was performed. The evidence from these articles was analyzed to generate recommendations. Each intervention's effectiveness at preventing or reducing scars was rated as none, low, or high, depending on the strength of the evidence for that intervention. RESULTS For the prevention of hypertrophic scars, silicone, tension reduction, and wound edge eversion seem to have high efficacy, whereas onion extract, pulsed-dye laser, pressure garments, and scar massage have low efficacy. For the treatment of existing hypertrophic scars, silicone, pulsed-dye laser, CO2 laser, corticosteroids, 5-fluorouracil, bleomycin, and scar massage have high efficacy, whereas onion extract and fat grafting seem to have low efficacy. For keloid scars, effective adjuncts to excision include corticosteroids, mitomycin C, bleomycin, and radiation therapy. No intervention seems to have significant efficacy in the prevention or treatment of striae distensae. CONCLUSION Although scars can never be completely eliminated in an adult, this article presents the most commonly used, evidence-based methods to improve the quality and symptoms of hypertrophic scars, as well as keloid scars and striae distensae.
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Tyack Z, Simons M, Kimble RM, Muller MJ, Leung K. The reproducibility and clinical utility of the 3D camera for measuring scar height, with a protocol for administration. Skin Res Technol 2017; 23:463-470. [PMID: 28271550 DOI: 10.1111/srt.12357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study aimed to determine the reproducibility and clinical utility of a 3D camera for measuring burn scar height in adults. METHODS Participants from a larger prospective longitudinal study were included. Reproducibility data were collected using an immediate test-retest interval and a 1-2 week test-retest interval and included reliability and agreement. The LifeViz™ 3D camera was used to measure scar height. Reproducibility was tested using the Intraclass Correlation Coefficient (ICC), percentage agreement within 1 mm between test and retest, standard error of measurement, smallest detectable change (SDC) and Bland Altman limits of agreement. RESULTS Burn scar images from 55 adult participants were included. Intra-rater reliability was acceptable using an immediate retest interval (maximum and minimum height ICC=0.85, 0.86 respectively). Agreement using an immediate retest interval was borderline acceptable (maximum and minimum height SDC=1.11, 0.69 respectively) to detect changes of close to 1 mm. Reproducibility was largely not acceptable using a 1-2 week test-retest interval (eg, maximum and minimum height ICC=0.34, 0.68 respectively; maximum and minimum height SDC=2.66, 1.16). The clinical utility of the camera was supported for scars over relatively flat areas and well-defined border margins. A protocol for administration of the camera was developed. CONCLUSION The 3D camera appears capable of detecting gross changes or differences in scar height above the normal skin surface, in adults with scars over relatively flat areas and well-defined border margins. However, further testing of reproducibility using a shorter test-retest interval than 1-2 week retest is recommended to confirm the suitability of the device for measuring changes or differences in scar height.
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Affiliation(s)
- Z Tyack
- Centre for Children's Burns and Trauma Research, Level 7, Children's Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia.,School of Allied Health, Australian Catholic University, Banyo, QLD, Australia
| | - M Simons
- Centre for Children's Burns and Trauma Research, Level 7, Children's Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia.,Department of Occupational Therapy, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
| | - R M Kimble
- Centre for Children's Burns and Trauma Research, Level 7, Children's Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia.,Department of Paediatric Surgery, Urology, Neonatal Surgery, Burns and Trauma, Lady Cilento Children's Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, St Lucia, QLD, Australia
| | - M J Muller
- Royal Brisbane and Women's Hospital, Professor Stewart Pegg Adult Burns Unit, Herston, QLD, Australia.,Burns Trauma Critical Care Research Centre, The University of Queensland, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - K Leung
- Centre for Children's Burns and Trauma Research, Level 7, Children's Health Research Centre, The University of Queensland, South Brisbane, QLD, Australia.,Department of Paediatric Surgery, Urology, Neonatal Surgery, Burns and Trauma, Lady Cilento Children's Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland, St Lucia, QLD, Australia
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Wiseman J, Simons M, Kimble R, Ware R, McPhail S, Tyack Z. Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children: study protocol for a randomised controlled trial. Trials 2017; 18:72. [PMID: 28209175 PMCID: PMC5314463 DOI: 10.1186/s13063-017-1820-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 01/26/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Abnormal scar development following burn injury can cause substantial physical and psychological distress to children and their families. Common burn scar prevention and management techniques include silicone therapy, pressure garment therapy, or a combination of both. Currently, no definitive, high-quality evidence is available for the effectiveness of topical silicone gel or pressure garment therapy for the prevention and management of burn scars in the paediatric population. Thus, this study aims to determine the effectiveness of these treatments in children. METHODS A randomised controlled trial will be conducted at a large tertiary metropolitan children's hospital in Australia. Participants will be randomised to one of three groups: Strataderm® topical silicone gel only, pressure garment therapy only, or combined Strataderm® topical silicone gel and pressure garment therapy. Participants will include 135 children (45 per group) up to 16 years of age who are referred for scar management for a new burn. Children up to 18 years of age will also be recruited following surgery for burn scar reconstruction. Primary outcomes are scar itch intensity and scar thickness. Secondary outcomes include scar characteristics (e.g. colour, pigmentation, pliability, pain), the patient's, caregiver's and therapist's overall opinion of the scar, health service costs, adherence, health-related quality of life, treatment satisfaction and adverse effects. Measures will be completed on up to two sites per person at baseline and 1 week post scar management commencement, 3 months and 6 months post burn, or post burn scar reconstruction. Data will be analysed using descriptive statistics and univariate and multivariate regression analyses. DISCUSSION Results of this study will determine the effectiveness of three noninvasive scar interventions in children at risk of, and with, scarring post burn or post reconstruction. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12616001100482 . Registered on 5 August 2016.
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Affiliation(s)
- Jodie Wiseman
- Centre for Children’s Burns and Trauma Research, Centre for Children’s Health Research, The University of Queensland, Brisbane, QLD Australia
| | - Megan Simons
- Pegg Leditschke Children’s Burns Centre, Lady Cilento Children’s Hospital, Brisbane, QLD Australia
| | - Roy Kimble
- Centre for Children’s Burns and Trauma Research, Centre for Children’s Health Research, The University of Queensland, Brisbane, QLD Australia
- Pegg Leditschke Children’s Burns Centre, Lady Cilento Children’s Hospital, Brisbane, QLD Australia
| | - Robert Ware
- UQ Child Health Research Centre, The University of Queensland, Brisbane, QLD Australia
| | - Steven McPhail
- School of Public Health and Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD Australia
- Centre for Functioning and Health Research, Metro South Health, Buranda, QLD 4102 Australia
| | - Zephanie Tyack
- Centre for Children’s Burns and Trauma Research, Centre for Children’s Health Research, The University of Queensland, Brisbane, QLD Australia
- Centre for Functioning and Health Research, Metro South Health, Buranda, QLD 4102 Australia
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Ai JW, Liu JT, Pei SD, Liu Y, Li DS, Lin HM, Pei B. The effectiveness of pressure therapy (15-25 mmHg) for hypertrophic burn scars: A systematic review and meta-analysis. Sci Rep 2017; 7:40185. [PMID: 28054644 PMCID: PMC5215680 DOI: 10.1038/srep40185] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/02/2016] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Jin-Wei Ai
- Evidence-Based Medicine Center, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
- Department of Plastic Surgery, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
| | - Jiang-tao Liu
- Department of Plastic Surgery, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
| | - Sheng-Duo Pei
- School of Life Sciences, Central China Normal University, Wuhan 430079, P.R. China
| | - Yu Liu
- Department of Plastic Surgery, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
| | - De-Sheng Li
- Department of Plastic Surgery, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
| | - Hong-ming Lin
- Department of Plastic Surgery, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
| | - Bin Pei
- Evidence-Based Medicine Center, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
- Department of Plastic Surgery, Xiangyang Hospital, Hubei University of Medicine, Xiangyang 441000, P.R. China
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Mohammadi AA, Eskandari S, Johari HG, Rajabnejad A. Using Amniotic Membrane as a Novel Method to Reduce Post-burn Hypertrophic Scar Formation: A Prospective Follow-up Study. J Cutan Aesthet Surg 2017; 10:13-17. [PMID: 28529415 PMCID: PMC5418975 DOI: 10.4103/jcas.jcas_109_16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Several studies have shown that the application of amniotic membrane as a biological dressing in the management of burns is accompanied by rapid re-epithelialisation. In this follow-up study, we aimed to evaluate the possible role of amniotic membrane as an adjunct to split thickness skin grafting on reducing itching and severity of hypertrophic scar formation. Materials and Methods: From October 2013 to January 2015, in a prospective follow-up study, 54 patients (108 limbs) with second and third degree burns, covering 4%–15% of total body surface area (TBSA), were included in the study. All patients needed split-thickness skin grafts for burn-wound coverage. Selected patients had symmetric burns on two (upper or lower) extremities. Then, in every patient, the extremities were randomly divided into two groups: In one limb, the skin graft was traditionally fixed with skin staples (control group) and in the other limb, the skin graft was covered with an amniotic membrane (amnion group). Therefore, in every patient, the graft was covered with an amniotic membrane in one extremity and fixed with skin staples in the other extremity. Finally, after 6 months, the degree of itching and hypertrophic scar formation was compared between the two groups. Results: The study group was composed of 108 limbs in 54 patients (27 males and 27 females) with a mean age of 23.54 ± 4.9 years and burn 9.03 ± 2.69% TBSA. The patients were divided into two groups: 54 limbs in amnion group and 54 limbs in control group. In 59.25% of the cases, patient had less itching in the extremity covered with amniotic membrane. Furthermore, in 64.81% of the cases, patients had less hypertrophic scar formation in the extremity covered with amniotic membrane. These differences were statistically significant (P < 0.001). Conclusions: Amniotic membrane used as an adjunct in split thickness skin grafting is a novel modality which significantly reduces scar formation and itching that can be greatly distressing to burn patients. However, still more prospective well designed studies are needed to prove it.
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Affiliation(s)
- Ali Akbar Mohammadi
- Plastic and Reconstructive Surgery Ward, Burn and Wound Healing Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shima Eskandari
- Department of Anesthesiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Ghoddusi Johari
- Department of General Surgery, Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ata'ollah Rajabnejad
- Vascular and Endovascular Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Sorg H, Tilkorn DJ, Hager S, Hauser J, Mirastschijski U. Skin Wound Healing: An Update on the Current Knowledge and Concepts. Eur Surg Res 2016; 58:81-94. [PMID: 27974711 DOI: 10.1159/000454919] [Citation(s) in RCA: 596] [Impact Index Per Article: 74.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 12/05/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The integrity of healthy skin plays a crucial role in maintaining physiological homeostasis of the human body. The skin is the largest organ system of the body. As such, it plays pivotal roles in the protection against mechanical forces and infections, fluid imbalance, and thermal dysregulation. At the same time, it allows for flexibility to enable joint function in some areas of the body and more rigid fixation to hinder shifting of the palm or foot sole. Many instances lead to inadequate wound healing which necessitates medical intervention. Chronic conditions such as diabetes mellitus or peripheral vascular disease can lead to impaired wound healing. Acute trauma such as degloving or large-scale thermal injuries are followed by a loss of skin organ function rendering the organism vulnerable to infections, thermal dysregulation, and fluid loss. METHODS For this update article, we have reviewed the actual literature on skin wound healing purposes focusing on the main phases of wound healing, i.e., inflammation, proliferation, epithelialization, angiogenesis, remodeling, and scarring. RESULTS The reader will get briefed on new insights and up-to-date concepts in skin wound healing. The macrophage as a key player in the inflammatory phase will be highlighted. During the epithelialization process, we will present the different concepts of how the wound will get closed, e.g., leapfrogging, lamellipodial crawling, shuffling, and the stem cell niche. The neovascularization represents an essential component in wound healing due to its fundamental impact from the very beginning after skin injury until the end of the wound remodeling. Here, the distinct pattern of the neovascularization process and the special new functions of the pericyte will be underscored. At the end, this update will present 3 topics of high interest in skin wound healing issues, dealing with scarring, tissue engineering, and plasma application. CONCLUSION Although wound healing mechanisms and specific cell functions in wound repair have been delineated in part, many underlying pathophysiological processes are still unknown. The purpose of the following update on skin wound healing is to focus on the different phases and to brief the reader on the current knowledge and new insights. Skin wound healing is a complex process, which is dependent on many cell types and mediators interacting in a highly sophisticated temporal sequence. Although some interactions during the healing process are crucial, redundancy is high and other cells or mediators can adopt functions or signaling without major complications.
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Affiliation(s)
- Heiko Sorg
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Alfried Krupp Krankenhaus Essen, Essen, Germany
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