Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized controlled trials

The Role of Microsurgery in Burn Surgery

Acute burn reconstruction involves intricate strategies such as skin grafting and innovative technologies, addressing challenges in coverage and minimizing donor site morbidity. Despite being rarely used, flap reconstruction becomes necessary when critical structures are exposed, offering robust coverage and reducing complications. However, free flaps in acute burns face challenges, including a higher failure rate attributed to hyperinflammatory states and hypercoagulability. Surgical optimization strategies involve careful timing, patient preparation, and meticulous postoperative care. In delayed burn reconstruction, free flaps proved effective in functional and aesthetic restoration, with low flap loss rates and minimal contracture recurrence. Prefabricated and prelaminated flaps emerged as a solution for complex cases, ensuring the best functional and aesthetic possible outcomes in challenging facial burn reconstructions.

Carbon dioxide laser for precise and bloodless contouring of soft tissue ahead of skin grafting-A case example of technique and benefits

Scarring is a dynamic development as a result of the wound healing process. Post-burn scars are often hypertrophic in nature and thus exhibit a much thicker and firmer scar, often leading to contractures. Various strategies have been implemented by burns surgeons to endeavour to mitigate and improve such symptoms and appearances. Laser therapy in the control of hypertrophic scarring is of continual developing interest within this field. We demonstrate the advantageous, intra-operative use of a carbon dioxide laser for precise contouring of a burn scar prior to skin grafting in a 36 year-old female with hypertrophic scarring following a 65% total body surface area flash flame burn. This method provided a bloodless surgical field with no post-operative complications, good graft take and a favourable cosmetic outcome.

Pressure-garment therapy for preventing hypertrophic scarring after burn injury

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.

A bibliometric study: Relevant studies on scar laser therapy since the 21st century

To summarise research studies on scar laser therapy since the 21st century using bibliometric methods, and to speculate on the possible development in the future. The literature about scar laser therapy in Web of Science database was searched. CiteSpace and VOSviewer were used to analyse main countries, institutions, journals，subject hotspots and trends, etc. A total of 884 papers have been published since the 21st century. These publications were written by 653 authors from 515 institutions in 58 countries. The United States published 287 papers in this field and ranks first. Laser in Surgery and Medicine is the most widely published journal, with Shumaker as the core author. The main keyword clustering includes terms such as combination therapy, wound healing, fractional photothermolysis, experience, scar formation, etc. CiteSpace and VOSviewer were used to sort out and summarise the countries, institutions, authors, journals, research hotspots and frontier topics of related literature about scar laser therapy since the 21st century. The current situation of its application and basic scientific research in clinical treatments were summarised briefly. This provides a new idea for the development and research of scar laser therapy in the future.

Development and validation of a risk assessment scale for pathological scarring

To develop a risk assessment scale for pathological scarring and validate its psychometric properties. This was a methodological study. Researchers developed the scale based on a literature review, qualitative study and Delphi expert consultation. Subsequently, 409 patients participated in the study to test the psychometric properties of the scale. We evaluated construct validity, content validity, internal consistency reliability, and interrater reliability. The researchers developed a scale consisting of three dimensions and 12 items. Factor analysis extracted a total of four common factors that accounted for 62.22% of the total variance. The results revealed that the item-content validity index (I-CVI) ranged from 0.67 to 1, while the scale-content validity index (S-CVI) was 0.82. Internal consistency reliability: Cronbach's α of the items ranged from 0.67 to 0.76, while Cronbach's α of the whole scale was 0.74. Interrater reliability: the Kappa number was 0.73. The final scale showed adequate construct validity, content validity, and reliability. It is appropriate for use in research and clinical practice settings to identify patients with a risk of pathological scarring. Further study is needed to confirm the scale's validity and reliability in other settings and populations.

SMOOTH protocol: A pilot randomised prospective intra-patient single-blinded observational study for examining the mechanistic basis of ablative fractional carbon dioxide laser therapy in treating hypertrophic scarring

BACKGROUND

Burn injuries are the fourth most common type of trauma and are associated with substantial morbidity and mortality. The impact of burn injury is clinically significant as burn injuries often give rise to exuberant scarring. Hypertrophic scarring (HTS) is a particular concern as up to 70% of burns patients develop HTS. Laser therapy is used for treating HTS and has shown positive clinical outcomes, although the mechanisms remain unclear limiting approaches to improve its effectiveness. Emerging evidence has shown that fibroblasts and senescent cells are important modifiers of scarring. This study aims to investigate the cellular kinetics in HTS after laser therapy, with a focus on the association of scar reduction with the presence of senescent cells.

METHODS

We will conduct a multicentre, intra-patient, single-blinded, randomised controlled longitudinal pilot study with parallel assignments to achieve this objective. 60 participants will be recruited to receive 3 interventional ablative fractional CO2 laser treatments over a 12-month period. Each participant will have two scars randomly allocated to receive either laser treatment or standard care. Biopsies will be obtained from laser-treated, scarred-no treatment and non-scarred tissues for immune-histological staining to investigate the longitudinal kinetics of p16INK4A+-senescent cells and fibroblast subpopulations (CD90+/Thy1+ and αSMA+). Combined subjective scar assessments including Modified Vancouver Scar Scale, Patient and Observer Scar Assessment Scale and Brisbane Burn Scar Impact Profile; and objective assessment tools including 3D-Vectra-H1 photography, DermaScan® Cortex, Cutometer® and ColoriMeter®DSMIII will be used to evaluate clinical outcomes. These will then be used to investigate the association between senescent cells and scar reduction after laser therapy. This study will also collect blood samples to explore the systemic biomarkers associated with the response to laser therapy.

DISCUSSION

This study will provide an improved understanding of mechanisms potentially mediating scar reduction with laser treatment, which will enable better designs of laser treatment regimens for those living with HTS.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04736251.

A Review of Laser Therapies for the Treatment of Scarring and Vascular Anomalies

Significance: Laser use has become part of the gold standard of treatment as an effective adjuvant in multimodal therapy for pathologic scarring caused by burns, trauma, acne, and surgery, as well as vascular anomalies. Understanding indications and applications for laser therapy is essential for physicians to improve patient outcomes. Recent Advances: Since the 1980s, the medical use of lasers has continuously evolved with improvements in technology. Novel lasers and fractionated technologies are currently being studied in the hopes to improve treatment efficacy, while reducing complications. Recent advancements include acne treatment with novel picosecond lasers, new hypertrophic scar therapies with simultaneous laser and intense pulsed light use, and novel systems such as lasers with intralesional optical fiber delivery devices. In addition, optimizing the timing of laser therapy and its use in multimodal treatments continue to advance the field of photothermolysis. Critical Issues: Selecting the correct laser for a given indication is the fundamental decision when choosing a laser balancing effective treatment with minimal complications. This article covers the principles of laser therapy, the preferred lasers used for the treatment of scarring and vascular anomalies, and discusses the current evidence behind these laser choices. Future Directions: To optimize laser therapy, larger randomized control trials and split scar studies are needed. Continued advancement through better randomized controlled studies will help to improve patient outcomes on a broader scale.

Hypertrophic Scars of the Hand: The Role of Electrophotobiomodulation Theory as a Recent Line of Treatment

BACKGROUND

A more enduring strategy for the treatment of hypertrophic scars of the hand is still a challenge facing restorative dermatologists and plastic surgeons. Nonetheless, with the use of nonablative devices, intense pulsed light and different types of lasers have started to yield promising outcomes and are close to becoming an effective and dependable technique. The advances in radiofrequency energy have brought new life to optical-based frameworks. Radiofrequency current delivers an unadulterated heat effect according to the electrical response characteristics of each tissue. The purpose of this study was to assess the patient satisfaction, safety, and clinical efficacy of the use of electrophotobiomodulation (combined intense pulsed light and radiofrequency energy) in the treatment of postburn hypertrophic scars of the hand.

METHODS

This was a prospective clinical study that was performed on 56 patients who presented with postburn hypertrophic scars on the hands between March of 2013 and January of 2020.

RESULTS

The clinical appraisal showed excellent results in 33 patients (58.9%), good results in 18 patients (32.2%), fair results in five patients (8.9%), and no poor results.

CONCLUSION

The use of radiofrequency energy combined with intense pulsed light was effective for the treatment of hand scars on people with various skin tones.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The use of carbon dioxide and intense pulsed light laser for the treatment of hypertrophic burn scars: A case series

Introduction

Hypertrophic scarring is a common and debilitating consequence of burn scars. While there is limited evidence for current treatment options, laser therapy has been shown to be effective, low risk and minimally invasive. This study assesses the use of carbon dioxide lasers and intense pulsed light devices in the treatment of hypertrophic burn scars.

Methods

In this case series, patients were recruited from a hypertrophic burn scar waitlist and completed a Patient and Observer Scar Assessment Scale prior to and six weeks after laser therapy. The Nordlys (intense pulsed light) and CO2RE (carbon dioxide) systems from Candela Medical were used, with a range of settings used depending on the assessment of the burn scar. The differences between scores were calculated for the total Patient and Observer Scar Assessment Scale score, pain, itch, colour, stiffness, thickness, irregularity and the overall opinion of the scar. Statistical analysis was completed using a paired, two-tailed student T test.

Results

A total of 31 patients were recruited for this trial with a range of scar locations, surface areas and mechanism of burn injury. The calculated difference in mean showed a significant reduction for the overall Patient and Observer Scar Assessment Scale score (1.93, p < 0.0001), pain (1.39, p  =  0.0002), itch (1.84, p  =  0.0002), colour (1.97, p < 0.0001), stiffness (2.47, p < 0.0001), thickness (2.1, p < 0.0001), irregularity (1.89, p < 0.0001) and overall opinion (1.58, p  =  0.0003).

Conclusion

Current management options for hypertrophic scarring have limited evidence. Laser therapy presents a minimally invasive procedure that can be completed under topical anaesthetic and has shown to be effective following a single treatment of combined carbon dioxide laser and intense pulsed light device therapy.

Lay Summary

Many people will suffer a burn injury throughout their life and up to almost 3 out of 4 people with burn injuries will suffer from hypertrophic scars (a thickened, red and itchy scar). These scars cause distress both due to their appearance and their reduction of function, particularly over a joint or muscle. Laser therapy, in which different wave lengths of light (pulsed light) or gas (carbon dioxide) target the scar, has been found to be effective and have minimal side effects in the management of hypertrophic scars. While individual lasers have been assessed and found to be effective and low risk, the combined use of multiple lasers on the same scar has not been extensively studied. We studied the effectiveness of both light and gas laser therapies on hypertrophic scars. Patients with hypertrophic scars completed a questionnaire that focused on their perspective of their scar (pain, itch, stiffness, thickness, irregularity, overall opinion) prior to the treatment. The patients then underwent laser therapy (with local anaesthetic gel) with either pulsed light and/or carbon dioxide (gas) laser. The type of laser used was decided by the clinician performing the therapy depending on scar location and thickness. Patients then re-completed the subjective survey six weeks following the laser therapy, and the results compared. We learnt that laser therapy (both light, gas and a combination of both) are effective (and low risk) in reducing the subjective burden of the scar for the patient.

Hypertrophic scar management

Scarring has major psychological and physical repercussions. Scars are often considered trivial, but they can be disfiguring and aesthetically unpleasant and may cause severe itching, tenderness, pain, sleep disturbance, anxiety, depression and disruption of daily activities. It is more efficient to prevent hypertrophic scars than treat them; early diagnosis of a problem scar can considerably impact the overall outcome. Therefore, nurses need to be as knowledgeable about scar products as they are about wound products, and their responsibility should not end once the wound has healed. Appropriate management of the scar will ensure that the wound remains healed and that the patient is happy with the outcome. The nurse is ideally placed to ensure that scars are appropriately identified and treated as early as possible.

Cost-effectiveness of scar management post-burn: a trial-based economic evaluation of three intervention models

Optimal burn scar management has the potential to markedly improve the lives of children, but can require substantial healthcare resources. The study aimed to examine the cost-effectiveness of three scar management interventions: pressure garment; topical silicone gel; combined pressure garment and topical silicone gel therapy, alongside a randomised controlled trial of these interventions. Participants were children (n = 153) referred for burn scar management following grafting, spontaneous healing after acute burn injury, or reconstructive surgery. Healthcare resource use was costed from a health service perspective (6-months post-burn time-horizon). The mean total scar management cost was lowest in the topical silicone gel group ($382.87 (95% CI $337.72, $443.29)) compared to the pressure garment ($1327.02 (95% CI $1081.46, $1659.95)) and combined intervention $1605.97 ($1077.65, $2694.23)) groups. There were no significant between-group differences in Quality Adjusted Life Year estimates. There was a 70% probability that topical silicone gel dominated pressure garment therapy (was cheaper and more effective), a 29% probability that pressure garment therapy dominated combined therapy, and a 63% probability that topical silicone gel dominated combined therapy. In conclusion, topical silicone gel was the cheaper intervention, and may be favoured in the absence of clear clinical effect favouring pressure garment therapy or a combination of these management approaches.Trial registration: ACTRN12616001100482 (prospectively registered).

Topical application of an irreversible small molecule inhibitor of lysyl oxidases ameliorates skin scarring and fibrosis

Scarring is a lifelong consequence of skin injury, with scar stiffness and poor appearance presenting physical and psychological barriers to a return to normal life. Lysyl oxidases are a family of enzymes that play a critical role in scar formation and maintenance. Lysyl oxidases stabilize the main component of scar tissue, collagen, and drive scar stiffness and appearance. Here we describe the development and characterisation of an irreversible lysyl oxidase inhibitor, PXS-6302. PXS-6302 is ideally suited for skin treatment, readily penetrating the skin when applied as a cream and abolishing lysyl oxidase activity. In murine models of injury and fibrosis, topical application reduces collagen deposition and cross-linking. Topical application of PXS-6302 after injury also significantly improves scar appearance without reducing tissue strength in porcine injury models. PXS-6302 therefore represents a promising therapeutic to ameliorate scar formation, with potentially broader applications in other fibrotic diseases.

Regenerative effect of combined laser and human stem cell-conditioned medium therapy on hypertrophic burn scar

PURPOSE

This study aimed to determine the effect of combined treatment with non-ablative laser and human stem cell-conditioned medium (HSCM) on tissue regeneration after burn-induced hypertrophic scar (HTS) formation.

METHODS

Fourteen patients with HTSs on both sides of the same body part were subjected to three sessions of non-ablative laser treatment, with an interval of four weeks between each treatment. Following laser treatment, HSCM and normal saline were applied to the HTSs of the right (experimental) and left side (control), respectively. Over the next 6 days, HSCM and moisturizer were applied to experimental scars, while only moisturizer was applied to control scars. Skin characteristics were evaluated before laser treatment and on the seventh day after the third laser treatment.

RESULTS

No significant intergroup differences were noted in the initial evaluation (P > 0.05). We found significant differences between the pre- and post-treatment measurements of erythema (P < 0.001), trans-epidermal water loss (TEWL; P < 0.001), and Cutometer® parameters (all parameters; P <0^.05) of experimental scars. Control scars also showed significant differences between pre- and post-treatment measurements of thickness (P = 0.01), erythema (P < 0.001), TEWL (P < 0.001), and Cutometer® parameters (all parameters; P < 0.05). Changes (pre- to post-treatment) in scar thickness between the experimental (-0.003 ± 0.09) and control scars (0.04 ± 0.12) were significant (P = 0.01).

CONCLUSION

These results suggest that HSCM has a positive effect on short-term results when applied after laser treatment of hypertrophic scars.

Patient Satisfaction After Conservative Treatment for Burn Scars in Saudi Arabia

Background

Burn injury is a typical physical injury that occurs as a result of a thermal, electrical, or chemical stimulus. Burn injuries to the skin cause complicated issues, including scar marks, psychological impacts, and affect quality of life (QOL). The preferred treatment technique for burn scars is controversial, as attempts to control the contraction rate remain a challenge, often leading to a poor outcome. Thus, treating burn scar patients is one of the biggest challenges in reconstructive surgery. In this study, we aimed to assess the patients’ perception of pain and QOL after conservative treatment for burn scars in Saudi Arabia.

Methodology

This was a cross-sectional study conducted on Saudi Arabian patients who underwent conservative treatment for their burn scars. Information was obtained using a self-reported questionnaire which was distributed online using Google Forms on several social media platforms. MS Excel was used for data entry, while SPSS version 23 was used for data analysis.

Results

We collected 523 responses to our questionnaire. Among respondents, 70.2% were aged between 18-29 years and 62.1% were single. Most burns were on the upper limbs (74.2%), and 78% of burns were caused by a thermal stimulus (exposure to heat). In terms of emotional status, most respondents did not report significant emotional issues related to their burn scars with a mean emotional score of 12.5 out of 24. Overall, burn scars did not affect the respondents’ ability to work or independence in performing daily work. Regarding the impact of the burns on the patients’ appearance, 29.4% of respondents reported that their scars bothered them significantly, 64.2% reported that their appearance never bothered them, and 11.5% reported that they sometimes tried to forget how their appearance had been changed.

Conclusions

We found that conservative treatment of burn scars is effective in controlling the pain associated with the burns and can improve the patient’s ability to perform work and other daily activities. However, it did not completely improve the psychological distress associated with scars. Further investigations are required to understand the impact of adherence to conservative treatment for burn scars on the psychological status of patients.

Early Laser for Burn Scars (ELABS): protocol for a multi-centre randomised, controlled trial of both the effectiveness and cost-effectiveness of the treatment of hypertrophic burn scars with Pulsed Dye Laser and standard care compared to standard care alone [version 1; peer review: 2 approved]

This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact. This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.

Silicone gel sheeting for treating hypertrophic scars

BACKGROUND

Each year, in high-income countries alone, approximately 100 million people develop scars. Excessive scarring can cause pruritus, pain, contractures, and cosmetic disfigurement, and can dramatically affect people's quality of life, both physically and psychologically. Hypertrophic scars are visible and elevated scars that do not spread into surrounding tissues and that often regress spontaneously. Silicone gel sheeting (SGS) is made from medical-grade silicone reinforced with a silicone membrane backing and is one of the most commonly used treatments for hypertrophic scars.

OBJECTIVES

To assess the effects of silicone gel sheeting for the treatment of hypertrophic scars in any care setting.

SEARCH METHODS

In April 2021 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people with any hypertrophic scars and assessed the use of SGS.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment, data extraction and GRADE assessment of the certainty of evidence. We resolved initial disagreements by discussion, or by consulting a third review author when necessary.

MAIN RESULTS

Thirteen studies met the inclusion criteria. Study sample sizes ranged from 10 to 60 participants. The trials were clinically heterogeneous with differences in duration of follow-up, and scar site. We report 10 comparisons, SGS compared with no SGS treatment and SGS compared with the following treatments: pressure garments; silicone gel; topical onion extract; polyurethane; propylene glycol and hydroxyethyl cellulose sheeting; Kenalog injection; flashlamp-pumped pulsed-dye laser; intense pulsed light  and Gecko Nanoplast (a silicone gel bandage). Six trials had a split-site design and three trials had an unclear design (resulting in a mix of paired and clustered data). Included studies reported limited outcome data for the primary review outcomes of severity of scarring measured by health professionals and adverse events (limited data reported by some included studies, but further analyses of these data was not possible) and no data were reported for severity of scarring reported by patients. For secondary outcomes some pain data were reported, but health-related quality of life and cost effectiveness were not reported. Many trials had poorly-reported methodology, meaning the risk of bias was unclear. We rated all evidence as being either of low or very low certainty, often because of imprecision resulting from few participants, low event rates, or both, all in single studies. SGS compared with no SGS Seven studies with 177 participants compared SGS with no SGS for hypertrophic scars. Two studies with 31 participants (32 scars) reported severity of scarring assessed by health professionals, and it is uncertain whether there is a difference in severity of scarring between the two groups (mean difference (MD) -1.83, 95% confidence interval (CI) -3.77 to 0.12; very low-certainty evidence, downgraded once for risk of bias, and twice for serious imprecision). One study with 34 participants suggests SGS may result in a slight reduction in pain level compared with no SGS treatment (MD -1.26, 95% CI -2.26 to -0.26; low-certainty evidence, downgraded once for risk of bias and once for imprecision). SGS compared with pressure garments One study with 54 participants was included in this comparison. The study reported that SGS may reduce pain levels compared with pressure garments (MD -1.90, 95% CI -2.99 to -0.81;  low-certainty evidence, downgraded once for risk of bias and once for imprecision). SGS compared with silicone gel One study with 32 participants was included in this comparison. It is unclear if SGS impacts on severity of scarring assessed by health professionals compared with silicone gel (MD 0.40, 95% CI -0.88 to 1.68; very low-certainty evidence, downgraded once for risk of bias, twice for imprecision). SGS compared with topical onion extract One trial (32 participants) was included in this comparison. SGS may slightly reduce severity of scarring compared with topical onion extract (MD -1.30, 95% CI -2.58 to -0.02; low-certainty evidence, downgraded once for risk of bias, and once for imprecision). SGS compared with polyurethane One study with 60 participants was included in this comparison. It is unclear if SGS impacts on the severity of scarring assessed by health professionals compared with polyurethane (MD 0.50, 95% CI -2.96 to 3.96; very low-certainty evidence, downgraded once for risk of bias, and twice for imprecision). SGS compared with self-adhesive propylene glycol and hydroxyethyl cellulose sheeting One study with 38 participants was included in this comparison. It is uncertain if SGS reduces pain compared with self-adhesive propylene glycol and hydroxyethyl cellulose sheeting (MD -0.12, 95% CI -0.18 to -0.06). This is very low-certainty evidence, downgraded once for risk of bias, once for imprecision and once for indirectness. SGS compared with Gecko Nanoplast One study with 60 participants was included in this comparison. It is unclear if SGS impacts on pain compared with Gecko Nanoplast (MD 0.70, 95% CI  -0.28 to 1.68; very low-certainty evidence, downgraded once for risk of bias and twice for imprecision. There was a lack of reportable data from the other three comparisons of SGS with Kenalog injection, flashlamp-pumped pulsed-dye laser or intense pulsed light.

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the clinical effectiveness of SGS in the treatment of hypertrophic scars. None of the included studies provided evidence on severity of scarring validated by participants, health-related quality of life, or cost effectiveness. Reporting was poor, to the extent that we are not confident that most trials are free from risk of bias. The limitations in current RCT evidence suggest that further trials are required to reduce uncertainty around decision-making in the use of SGS to treat hypertrophic scars.

A Single Institution Experience with Standardized Objective and Subjective Scar Evaluation While Undergoing Fractional Ablative Carbon Dioxide Laser Treatment

Laser treatment of burn scar has increased in recent years. Standard components of scar evaluation during laser scar revision have yet to be established. Patients who began laser scar revision from January 2018-2020, underwent at least three treatments, and completed evaluations for each treatment were included. Patients underwent fractional ablative carbon dioxide laser scar revision and pre- and post-procedure scar evaluations by a burn rehabilitation therapist, including Patient and Observer Scar Assessment Scale, Vancouver Scar Scale, our institutional scar comparison scale, durometry, and active range of motion measurements. Twenty-nine patients began laser scar revision and underwent at least three treatments with evaluations before and after each intervention. All patients improved in at least one scar assessment metric after a single laser treatment. After second and third treatments, all patients improved in at least three scar assessment metrics. Range of motion was the most frequently improved. Durometry significantly improved after a third treatment. Patients and observers showed some agreement in their assessment of scar, but observers rated overall scar scores better than patients. Patients acknowledged substantial scar improvement on our institutional scar comparison scale. Burn scar improves with fractional ablative laser therapy in a range of scar ages and skin types, as early as the first session. Improvements continue as additional sessions are performed. This work suggests baseline evaluation components for patients undergoing laser, and a timeline for expected clinical improvements which may inform conversations between patients and providers when considering laser for symptomatic hypertrophic scar.

Patient experience of scar assessment and the use of scar assessment tools during burns rehabilitation: a qualitative study

Background

Scar assessment plays a key role during burns aftercare, to monitor scar remodelling and patients’ psychosocial well-being. To aid assessment, subjective scar assessment scales are available that use health-care professionals’ and patients’ opinions to score scar characteristics. The subjective scales are more widely used in clinical practice over objective scar measures. To date, there is no research that considers patients’ views on scar assessment and the role of subjective and objective assessment tools. Therefore, the aim of this qualitative study was to explore patients’ perspectives on scar assessment and the utility of scar assessment tools during burns rehabilitation.

Methods

Semi-structured interviews were conducted with 10 adult burn patients who were being reviewed in clinic for scarring. Participants were recruited via their clinical care team and research nurses at the Queen Elizabeth Hospital, Birmingham, UK. Topics covered during interview included patient experience of scar assessment, the use of scar assessment tools and discussion surrounding important factors to be addressed when assessing scars. A thematic analysis using the Framework Method was conducted.

Results

Participants identified key subthemes that contribute towards the overarching theme of patient-centred scar assessment. These are: patient-led care; continuity in care; learning how to self-manage scarring; and psychological assessment. Links were demonstrated between these subthemes and the remaining themes that describe scar assessment strategies, indicating their potential patient-centred contributions. The subjective opinions of clinicians were found to be valued above the use of subjective or objective scar assessment tools. Scar assessment scales were perceived to be a beneficial method for self-reflection in relation to psychosocial functioning. However, minimal feedback and review of completed assessment scales led to uncertainty regarding their purpose. Patients perceived objective tools to be of primary use for health-care professionals, though the measures may aid patients’ understanding of scar properties.

Conclusions

Scar assessment tools should be used to support, rather than replace, health-care professionals’ subjective judgements of scarring. Adapting the way in which clinicians introduce and use scar assessment tools, according to patient needs, can support a patient-centred approach to scar assessment.

Comparison of Nd: YAG Laser and Combined Intense Pulsed Light and Radiofrequency in the Treatment of Hypertrophic Scars: A Prospective Clinico-Histopathological Study

INTRODUCTION

Hypertrophic scars are fibroproliferative disorders, seen after burn, trauma, and/or surgery. We aimed to compare the clinical and histopathological results of 1064-nm Nd:YAG laser and combined intense pulsed light and radiofrequency in the treatment of hypertrophic scars.

METHODS

Fifty patients with hypertrophic scars were included in this prospective, randomized study. Twenty-five patients were treated with Nd:YAG laser and 25 patients with combined intense pulsed light and radiofrequency (E-light). The scars were evaluated at baseline, during and at 3 months after the final treatment session using the Vancouver scar scale. Biopsy specimens from scars were obtained before, during, and 3 months after the final treatment session and were stained with hematoxylin and eosin stain, Masson's trichrome stain, and immunostaining procedures for collagen I, collagen III, and TGF-β1.

RESULTS

Significant improvements in the total Vancouver scar scale scores before and after the treatment in both groups (P < 0.001); however, a significant difference between both groups (P < 0.001), regarding the E-light, which showed better response than Nd:YAG laser. Hematoxylin and eosin and Masson's trichrome staining showed arrangement and thinning of collagen bundles and reduction in collagen density by in both groups, but the collagen bundles thinning and parallelism were more obvious in the E-light group. Significant decrease in the concentration of collagen I, collagen III, and TGF-β1 in the E-light group as compared with the laser group (P = 0.005, P = 0.003 and P < 0.001, respectively).

CONCLUSIONS

Both modalities were successful in the treatment of hypertrophic scars; however, a significant improvement in the clinical and histopathological findings was detected with the E-light method.

Patient- and Physician-Reported Outcome of Combined Fractional CO2 and Pulse Dye Laser Treatment for Hypertrophic Scars in Children

BACKGROUND

Hypertrophic scars are commonly seen in children and associated with pruritus, pain, functional impairment, and aesthetic disfigurement. Ablative fractional CO2 and pulse dye laser are emerging techniques to improve scar quality. Only limited data are available on children, nonburn scars, and patient-reported outcome. We aimed to investigate safety and outcome of repeated laser therapy for hypertrophic scars originating from burns and other conditions by means of patient- and physician-reported outcome measures.

METHODS

This was a retrospective before-after analysis of laser treatments in children with hypertrophic scars. Outcome was measured using Patient and Observer Scar Assessment Scale, Vancouver Scar Scale and Itch Man Scale. With respect to safety, laser- and anesthesia-related complications were analyzed.

RESULTS

Seventeen patients, aged 11.37 ± 4.82 years with 27 scars, underwent 102 distinct laser treatments, mainly combined CO2 and pulse dye laser (94%), with few CO2 only (6%). Vancouver Scar Scale total score before the first and after the first session decreased significantly from 7.65 ± 2.12 to 4.88 ± 1.73; Patient and Observer Scar Assessment Scale observer overall opinion also dropped from 5.88 ± 1.57 to 4.25 ± 1.70. Pruritus improved significantly. Patient age and timing of laser intervention did not have an impact on treatment response. Complications related to laser treatment were seen in 2% (wound infection, n = 2) and to anesthesia in 4% (insignificant n = 2, minor n = 1).

CONCLUSIONS

Combined laser therapy significantly improves quality, pain, and pruritus of hypertrophic scars in children. When provided by experienced laser and anesthesia teams, it is safe with a low rate of complications.

Umbilical cord-derived mesenchymal stem cells exert anti-fibrotic action on hypertrophic scar-derived fibroblasts in co-culture by inhibiting the activation of the TGF β1/Smad3 pathway

A hypertrophic scar (HS) is a severe fibrotic skin disease that causes disfigurement and deformity. It occurs after deep cutaneous injury and presents a major clinical challenge. The present study aimed to evaluate the effects of umbilical cord-derived mesenchymal stem cells (UCMSCs) on hypertrophic scar fibroblasts (HSFs), one of the main effector cells for HS formation, in a co-culture system and to investigate the potential underlying molecular mechanism. Cultured HSFs were divided into control and co-culture groups. The proliferation ability of HSFs was evaluated using cell counting kit-8 and the percentage of Ki67-positive fibroblasts was assessed by immunofluorescence. The apoptosis of HSFs was determined using a TUNEL assay and by assessing the expression of capase-3 via western blotting. A scratch wound healing assay was employed to examine the migration of HSFs. The expression levels of HS-associated genes (collagen type Iα 2 chain, collagen type IIIα 1 chain and actin α 2 smooth muscle) and proteins (collagen I, collagen III and α-smooth muscle actin) were measured by reverse transcription-quantitative PCR (RT-qPCR) and western blotting, respectively, to assess the pro-fibrotic phenotype of HSFs. The modulation of the transforming growth factor β1 (TGF β1)/Smad3 pathway in HSFs was evaluated by measuring the protein levels of TGF β1, Smad3 and phosphorylated Smad3 using western blotting, and the mRNA levels of TGFβ1 and several other target genes (cellular communication network factor 2, metalloproteinase inhibitor 1 and periostin) were measured by RT-qPCR. The proliferative and migratory ability of co-cultured HSFs was suppressed compared with controls, and no significant difference in apoptosis was observed between the two groups. The pro-fibrotic phenotype of co-cultured HSFs was inhibited due to a decline in expression levels of HS-associated genes and proteins. Furthermore, co-culture with UCMSCs inhibited the activation of the TGF β1/Smad3 pathway. In conclusion, the present study indicated that UCMSCs may exert an anti-fibrotic action on HSFs in co-culture through inhibition of the TGF β1/Smad3 pathway, which suggests a potential use for UCMSCs in HS therapy.

Ablative fractional laser treatment of hypertrophic burn and traumatic scars: a systematic review of the literature

Hypertrophic scars (HTS) following burns and other trauma and are associated with significant functional and psychosocial impairment. Ablative fractional lasers (AFLs) are increasingly being applied in the treatment of HTS supported by a rapidly expanding multidisciplinary base of literature. The multidisciplinary authors sought to evaluate existing literature, provide context and identify gaps, and make recommendations for a path forward. A systematic review was conducted to identify literature pertinent literature through September 2019. Retrospective cohort, randomized controlled trials, quasi-randomized controlled trials, observational prospective cohort, or case series with five or more subjects with hypertrophic scars incurred from burns and related trauma were considered. Twenty-two of the 23 evaluated studies documented statistically significant and/or meaningful qualitative improvements in nearly all outcome measures. Adverse events were generally infrequent and minor. Significant heterogeneity was observed among the studies included in this systematic review, precluding metaanalysis of pooled data. There is abundant existing literature on the use of AFLs in the management of HTS but study heterogeneity limits generalizability. Future studies should prioritize standardized protocols including assessments of function and quality of life.

Dipeptidyl Peptidase-4 Inhibitor Reduces the Risk of Developing Hypertrophic Scars and Keloids following Median Sternotomy in Diabetic Patients: A Nationwide Retrospective Cohort Study Using the National Database of Health Insurance Claims of Japan

BACKGROUND

Hypertrophic scars and keloids, which are abnormalities of fibrosis, often occur in surgical wounds; however, their exact cause and preventive measures are unknown. The administration of dipeptidyl peptidase-4 inhibitors to humans is expected to suppress fibrosis in wounds and minimize hypertrophic scar and keloid formation.

METHODS

This study aimed to verify the suppressive effect of dipeptidyl peptidase-4 inhibitors on the formation of hypertrophic scars or keloids using real world data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. It is a retrospective cohort study, and data were extracted from the National Database between April of 2013 and March of 2015. Patients who underwent median sternotomy were included in the study based on their claimed surgical codes. Subjects who were prescribed dipeptidyl peptidase-4 inhibitors constituted the treatment group; subjects who were not prescribed or administered dipeptidyl peptidase-4 inhibitors during that period constituted the nontreatment group.

RESULTS

Subjects included 5430 patients throughout Japan (3509 men and 1921 women). Of the 446 subjects who were treated with dipeptidyl peptidase-4 inhibitors within 1 year before the procedure, fewer than 10 (<2 percent) developed either hypertrophic scars or keloids. Of the 4984 subjects who were not treated, 152 (3.05 percent) were at significantly lower risk for hypertrophic scars and keloids (p = 0.04). A logistic regression analysis was performed to adjust for confounding factors, with history of hypertrophic scar formation as the explained variable.

CONCLUSION

This study revealed that dipeptidyl peptidase-4 inhibitors suppress the onset of hypertrophic scars or keloids after surgery in humans.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Assessment of laser-assisted delivery vs intralesional injection of botulinum toxin A in treatment of hypertrophic scars and keloids

Keloids and hypertrophic scars could impair the psychological, physical, and cosmetic aspects of the patient's quality of life. Unfortunately, there is no curative treatment available till now. This study aimed to evaluate the efficacy and safety of intralesional vs topical botulinum toxin A combined with Fractional CO₂ laser in the treatment of hypertrophic scars and keloids. Twenty patients with Keloids and hypertrophic scars were enrolled in the study. Each scar was divided into two halves, one subjected to intralesional injection of botulinum toxin type A once a month for 4 months and the other was subjected to four sessions of CO₂ laser therapy at 1 month interval followed by topical application of botulinum toxin A. Significant improvement was noted in Vancouver Scar Scale in hypertrophic scars in laser group than intralesional botulinum toxin A. In keloid cases, the improvement was significantly higher with intralesional botulinum toxin A. Clinical improvement showed significant negative correlation with scar duration and size. Botulinum toxin A is a promising treatment for hypertrophic scars and keloids. The use of fractional CO₂ laser as a mode of delivery enhanced the efficacy of botox in hypertrophic scars.

Efficacy of Silicone Gel versus Silicone Gel Sheet in Hypertrophic Scar Prevention of Deep Hand Burn Patients with Skin Graft: A Prospective Randomized Controlled Trial and Systematic Review

Burn injuries are burdensome to the public health system. Hypertrophic scars are the most common undesirable sequelae associated with burn scar contracture, resulting in reduced hand function. This study compared 2 different forms of silicone combined with pressure garment (PG) to determine the efficacy in hypertrophic scar prevention in hand burns.

Acquired Localized Hypertrichosis Following Pressure Garment and/or Silicone Therapy in Burn Patients

Hypertrichosis is characterized by excessive and abnormal hair growth anywhere on the skin and may develop after prolonged local irritation, such as application of a cast, injury, or a bite. Pressure garment/silicone therapy is often used to prevent hypertrophic scar formation. The adverse effects of gel sheet application include rash, skin breakdown, cessation of scar responsiveness, pruritus, contact dermatitis, and dry skin. We report on 7 burn patients who developed hypertrichosis following application of pressure garment/silicone therapy to prevent hypertrophic scarring.

Laser pretreatment for the attenuation of planned surgical scars: A randomized self-controlled hemi-scar pilot study

BACKGROUND

Nonsurgical scar attenuation options include compression garments, silicone gel, intralesional drug therapy, radiation therapy, laser, and light therapies. Laser application preceding surgical intervention has been shown to modify the wound-healing process and affect subsequent scar formation. The objective of this study was to evaluate the safety, efficacy, and final cosmesis of a single presurgical laser treatment on surgical scar formation.

METHODS

This was a randomized, controlled, intraindividual split-scar pilot study with blinded assessments of treated versus untreated planned incision sites. One half of each planned scar was treated by means of an Erbium glass, 1540 nm laser, 24 h before surgery, and the other half was not treated and served as the control. Clinical evaluations and the measurements of patient and physician POSAS scales were done at 1 and 12 months following surgery.

RESULTS

Eleven patients completed the study and were included in the analyses. Laser pretreatment showed a significant beneficial effect compared with no treatment. Both the patient and physician mean Patient and Observer Scar Assessment Scale scores were significantly lower for the laser-treated half of the scars compared with the control side (1.55 to 3.00, p = 0.02 and 2.28 to 4.42, p = 0.03). There was a highly significant interobserver correlation in the evaluation of the overall posttreatment changes (r = 0.904, p < 0.001).

CONCLUSION

A single presurgical laser treatment of a planned incision site is a simple, safe, and painless strategy to significantly improve the final scar appearance.

Exon skipping of TGFβRI affects signalling and ECM expression in hypertrophic scar-derived fibroblasts

BACKGROUND

In burn patients, wound healing is often accompanied by hypertrophic scar (HS) development, resulting in both functional and aesthetic problems. HSs are characterised by abundant presence of myofibroblasts that contribute to overproduction of extracellular matrix (ECM) that is regulated by the TGF-β signalling pathway. Studies have shown that inhibition of TGF-β receptors in fibrotic diseases reduces the fibrotic load. In the present study, we aim to inactivate ALK5, also known as TGF-β receptor I, in human HS fibroblasts by exon skipping using antisense oligonucleotides (AONs).

METHODS

HS biopsies were used to isolate and set up fibroblast monocultures. AONs targeting ALK5 were supplemented to the fibroblast cultures to induce exon skipping, while pharmacological ALK5 inhibition was induced using SB431542. AON delivery in HS fibroblasts was examined using immunofluorescence (IF), while TGF-β signalling downstream targets, such as Smad2/3, PAI-1, ACTA2, COL1A1 and COL3A1, were analysed using touchdown polymerase chain reaction (PCR), quantitative PCR (qPCR), IF or western blotting.

RESULTS

Our data clearly demonstrate that AONs were successfully delivered in the nuclei of HS fibroblasts and that functional exon skipping of ALK5 took place as confirmed with touchdown PCR and qPCR. In addition, exon skipping affected the expression of ECM-related genes, such as type I/III collagens, PAI-1 and CCN2. Moreover, AON treatment did not affect the migration of HS fibroblasts in a model for wound healing.

CONCLUSION

Exon skipping is a promising tool to modulate the TGF-β signalling pathway in HS. This would open a therapeutic window for the treatment of patients suffering from HSs.

Wnt4 negatively regulates the TGF-β1-induced human dermal fibroblast-to-myofibroblast transition via targeting Smad3 and ERK

Abnormal activation of Wnt signaling has been demonstrated in the wound healing process and the pathogenesis of fibrotic disorders, with Wnt4 specifically identified as having a key role in the pathogenesis of renal, pulmonary and liver fibrosis. Wnt4 also was found to be upregulated by transforming growth factor-β1 (TGF-β1) in fetal and postnatal murine fibroblasts and bone marrow mesenchymal cells, suggesting an underlying cooperation between Wnt4 and TGF-β1 in fibrosis. However, the specific roles of Wnt4 in TGF-β1-induced skin myofibroblast transition and hypertrophic scar formation remain unclear. In the present study, we first observed reduced Wnt4 expression in hypertrophic scar tissue compared with that in normal skin tissue. Following upregulation by TGF-β1, Wnt4 inhibited the TGF-β1-induced transdifferentiation of fibroblasts into myofibroblasts. Using fibroblast-populated collagen lattice contraction assays, we showed that the increased contractility induced by TGF-β1 was significantly blocked by exogenous Wnt4 and the α-smooth muscle actin (α-SMA) expression was decreased in fibroblasts in the collagen lattices. In addition, knockdown of Wnt4 resulted in further increases in α-SMA and collagen I expressions. Further investigation showed that Wnt4 could inhibit the autocrine effect of TGF-β1 as well as block the phosphorylation of Smad3 and ERK but not of AKT or JNK. Lastly, using hypertrophic scar-derived fibroblasts, we showed that the elevated α-SMA and collagen I levels were markedly reduced after treatment with Wnt4. Taken together, our results suggest that Wnt4 negatively regulates TGF-β1-induced fibroblast activation, which may represent a novel therapeutic strategy for the treatment and prevention of hypertrophic scars.

Fractional CO2 laser ablation of porcine burn scars after grafting: Is deeper better?

INTRODUCTION

Fractional CO₂ lasers have been used in clinical settings to improve scarring following burn injury. Though used with increasing frequency, the appropriate laser settings are not well defined and overall efficacy of this therapy has not been definitively established. As it has been proposed that for thick hypertrophic scars proportionally greater fluence and thus deeper ablation into the scar tissue would be most effective, the goal of this study was to examine the role of ablation depth on scar outcomes in a highly-controlled porcine model for burn scars-after grafting.

METHODS

Properties of laser ablated wells were quantified on ex vivo pig skin as a function of laser energy (20, 70 or 150mJ). Full-thickness burn wounds were created on the dorsum of red Duroc pigs with the eschar excised and grafted with a split-thickness autograft meshed and expanded 1.5:1. After four weeks of healing, sites were treated with either 20, 70, or 150mJ pulse energy from a fractional CO₂ laser at 5% density or left untreated as a control. Sites were treated every four weeks with three total sessions. Scar area, pigmentation, erythema, roughness, histology, and biomechanics were evaluated prior to each laser treatment at day 28, 56, and 83, as well as four weeks after the final laser treatment, day 112. Additional biopsies were collected at day 112 for gene expression analysis.

RESULTS

The depth of the laser ablated wells increased with increasing pulse energy while the width of the wells was smaller in the 20mJ group and not significantly different in the 70 and 150mJ groups. Scar properties (area, color, biomechanics) were not significantly altered by laser therapy at any of the laser energies tested versus controls. Average scar roughness was improved by laser therapy in a dose dependent manner with scars treated with 150mJ of energy having the smoothest surface; however, these changes were not statistically significant. Assessment of matrix metalloproteinase 9 gene expression showed a slight upregulation in scars treated with 70 or 150mJ versus control scars and scars treated with 20mJ pulse energy.

CONCLUSION

The current study demonstrated that the properties of the ablative well (depth and width) are not linearly correlated with laser pulse energy, with only a small increase in well depth at energies between 70 and 150mJ. Overall, the study suggests that there is little difference in outcomes as a function of laser energy. Fractional CO₂ laser therapy did not result in any statistically significant benefit to scar properties assessed by quantitative, objective measures, thus highlighting the need for additional clinical investigation of laser therapy efficacy with non-treated controls and objective measures of outcome.

Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children: a randomized controlled trial

Objective:

To determine the effectiveness of silicone and pressure garments (alone and in combination) in children receiving scar management post-burn.

Design:

Multicentre, parallel-group, randomized controlled trial.

Setting:

Hospital outpatient clinics, colocated research centre, or the participant’s home.

Participants:

Children (0–18 years) referred for burn scar management.

Interventions:

Participants were randomized to (1) topical silicone gel only, (2) pressure garment therapy only, or (3) combined topical silicone gel and pressure garment therapy.

Main measures:

Primary outcomes included scar thickness and itch intensity at the primary end-point of six months post-burn injury. The outcome assessor and data analyst were blinded for scar thickness.

Results:

Participants (N = 153; silicone n = 51, pressure n = 49, combined n = 53) had a median (inter-quartile range) age of 4.9 (1.6, 10.2) years and percent total body surface area burn of 1% (0.5%, 3%) and were 65% male. At six months post-burn injury, intention-to-treat analysis identified thinner scars in the silicone (n = 51 scar sites) compared to the combined group (n = 48 scar sites; mean difference (95% confidence interval) = –0.04 cm (–0.07, –0.00), P = 0.05). No other between-group differences were identified for scar thickness or itch intensity at six months post-burn.

Conclusion:

No difference was identified in the effectiveness of silicone and pressure interventions alone. No benefit to a combined silicone and pressure intervention was identified for the prevention and management of abnormal scarring in children at six months post-burn injury, compared to the silicone or pressure interventions alone.

Efficacy of Compression Gloves in the Rehabilitation of Distal Radius Fractures: Randomized Controlled Study

OBJECTIVE

The aim of this study was to examine the outcomes of wearing made-to-measure compression gloves after distal radius fracture.

DESIGN

In a randomized controlled trial, adults who were about 6 wks post distal radius fracture were recruited and divided into a comparison control group (n = 15), who received standard rehabilitation twice a week for half an hour, and an intervention group (n = 17), who additionally used compression gloves. All treatments were conducted at a single rehabilitation clinic. Outcomes assessed were wrist and finger range of motion, grip strength, swelling, pain, and activities of daily living (using the Patient Rating Wrist Evaluation). The intervention group underwent additional objective dynamic assessments of range of motion with and without the gloves.

RESULTS

The intervention group demonstrated reduced swelling, pain, and analgesic use; increased wrist range of motion; better scores for specific hand functions; and greater participation in activities of daily living compared with the comparison group.

CONCLUSION

This randomized controlled trial shows that using compression gloves during the rehabilitation phase after distal radius fracture improves daily functioning and reduces adverse symptoms. These improvements, which are important in their own right, are also expected to aid in preventing the development of chronic conditions and disability.

EVIDENCE LEVEL II

Un-blinded prospective comparative study.

Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study

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.

Beneath the Surface: A Review of Laser Remodeling of Hypertrophic Scars and Burns

Significance: Hypertrophic scars, keloids, and burn injuries of the skin have a significant impact on patients' lives and impact the health care system tremendously. Treating skin wounds and lesions can be challenging, with a variety of choices available for treatment. Scar and burn managements range from invasive, surgical options such as scar excision to less invasive, nonsurgical alternatives such as laser therapy or topical drug application. Recent Advances: Laser treatment has become increasingly popular, with a growing body of research supporting its use for scars and burns. Numerous methods are available for the treatment of these skin diseases, including different nonsurgical laser therapies. Critical Issues: To date, the optimal treatment method for scars, keloids, and burn injuries of the skin has not yet been established, although it is an area of increasing clinical concern. Future Directions: This review provides an updated summary of the treatment of scars and burn wounds of the skin using different laser treatments, including the most recent technologies. It addresses their indications, mechanisms of action, differences, efficacies, and complications.

Effectiveness of interventions for optimising adherence to treatments for the prevention and management of scars: protocol for a systematic review and meta-analysis

INTRODUCTION

Treatments used in the management of scarring following wounds of the skin can be complex and time consuming, and patients may experience difficulties adhering to these treatments. Therefore, the aim of this systematic review is to identify the types of interventions that have been used to optimise adherence to treatment for preventing or reducing skin scars in adults and children and to determine the effectiveness of these interventions.

METHODS AND ANALYSIS

Databases (PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and OTSeeker) will be searched using the developed search strategy to identify eligible randomised trials. Adults and children using scar treatments to prevent or manage scarring as a result of a dermal wound (which may occur following burn injury, surgery, lacerations, piercings, vaccinations, acne and other conditions affecting the skin) will be included. Any intervention with the potential to effect adherence will be included. Titles and abstracts located through searching will be screened by two independent reviewers. Full text of studies will also be screened to determine eligibility for final inclusion. Two reviewers will assess the quality of included studies using the Cochrane 'risk of bias' tool. Data extraction forms will be developed and two reviewers will extract the data. A third reviewer will be used at each stage to ensure consensus is achieved. Meta-analysis and meta-regression will be completed if appropriate, otherwise a narrative synthesis of results will be undertaken.

ETHICS AND DISSEMINATION

No ethical approval is necessary for this systematic review as no patients will be directly involved. Results of this systematic review will be disseminated through journal publications and relevant conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018095082.

Risk factors for hypertrophic burn scar pain, pruritus, and paresthesia development

Hypertrophic scar pain, pruritus, and paresthesia symptoms are major and particular concerns for burn patients. However, because no effective and satisfactory methods exist for their alleviation, the clinical treatment for these symptoms is generally considered unsatisfactory. Therefore, their risk factors should be identified and prevented during management. We reviewed the medical records of 129 postburn hypertrophy scar patients and divided them into two groups for each of three different symptoms based on the University of North Carolina "4P" Scar Scale: patients with scar pain requiring occasional or continuous pharmacological intervention (HSc pain, n = 75) vs. patients without such scar pain (No HSc pain, n = 54); patients with scar pruritus requiring occasional or continuous pharmacological intervention (HSc pruritus, n = 63) vs. patients without such scar pruritus (No HSc pruritus, n = 66); patients with scar paresthesia that influenced the patients' daily activities (HSc paresthesia, n = 31) vs. patients without such scar paresthesia (No HSc paresthesia, n = 98). Three multivariable logistic regression models were built, respectively, to identify the risk factors for hypertrophic burn scar pain, pruritus, and paresthesia development. Multivariable analysis showed that hypertrophic burn scar pain development requiring pharmacological intervention was associated with old age (odds ratio [OR] = 1.046; 95% confidence interval [CI], 1.011-1.082, p = 0.009), high body mass index (OR = 1.242; 95%CI, 1.068-1.445, p = 0.005), 2-5-mm-thick postburn hypertrophic scars (OR = 3.997; 95%CI, 1.523-10.487, p = 0.005), and 6-12-month postburn hypertrophic scars (OR = 4.686; 95%CI, 1.318-16.653, p = 0.017). Hypertrophic burn scar pruritus development requiring pharmacological intervention was associated with smoking (OR = 3.239; 95%CI, 1.380-7.603; p = 0.007), having undergone surgical operation (OR = 2.236; 95%CI, 1.001-4.998; p = 0.049), and firm scars (OR = 3.317; 95%CI, 1.237-8.894; p = 0.017). Finally, hypertrophic burn scar paresthesia development which affected the patients' daily activities was associated with age (OR = 1.038; 95%CI, 1.002-1.075; p = 0.040), fire burns (OR = 0.041; 95%CI, 0.005-0.366; p = 0.004, other burns vs. flame burns), and banding and contracture scars (OR = 4.705; 95%CI, 1.281-17.288, p = 0.020).

Flavones hydroxylated at 5, 7, 3' and 4' ameliorate skin fibrosis via inhibiting activin receptor-like kinase 5 kinase activity

Skin fibrosis is mainly characterized by excessive collagen deposition. Studies have recently identified a number of flavonoids with variable structures that have the potency of inhibiting collagen synthesis and thus attenuating organ fibrosis. In this study, we found that flavones with 5, 7, 3', 4' hydroxy substitution reduced collagen expression most efficiently. Among those flavones, luteolin, quercetin, and myricetin were selected for follow-up. In vivo, the three compounds ameliorated skin fibrosis and reduced collagen deposition. Further analysis showed the compounds had significant inhibition on the proliferation, activation and contractile ability of dermal fibroblasts in vitro and in vivo. More importantly, we revealed that luteolin, quercetin, and myricetin selectively downregulated the phosphorylation of Smad2/3 in TGF-β/Smads signaling via binding to activin receptor-like kinase 5 (ALK5) and impairing its catalytic activity. We also found flavones with 5, 7, 3', 4' hydroxy substitution showed stronger affinity with ALK5 compared with other flavonoids. Herein, we identified at least in part the underlying molecular basis as well as the critical structures that contribute to the antifibrotic bioactivity of flavones, which might benefit drug design and modification.

Novel pharmacotherapy for burn wounds: what are the advancements

INTRODUCTION

The prognosis for severe burns has improved significantly over the past 50 years. Meanwhile, burns have become an affliction mainly affecting the less well-developed regions of the world. Early excision and skin grafting has led to major improvements in therapeutic outcomes.

AREAS COVERED

The purpose of this article is to survey the use of pharmacotherapy to treat different pathophysiological complications of burn injury. The author, herein, discusses the use of drug treatments for a number of systemic metabolic disturbances including hyperglycemia, elevated catabolism, and gluconeogenesis.

EXPERT OPINION

Advancements in personalized and molecular medicine will make an impact on burn therapy. Similarities between severe burns and other critically ill patients will lead to cross-fertilization between different medical specialties. Furthermore, advances in stem cells and tissue regeneration will lead to improved healing and less lifelong disability. Indeed, research in new drug therapy for burns is actively progressing for many different complications.

Advances in the treatment of traumatic scars with laser, intense pulsed light, radiofrequency, and ultrasound

Traumatic scarring is one of the most common complications after soft tissue injury caused by burns and trauma, which affects tens of millions of people worldwide every year. Traumatic scars diminish the quality of life due to disfigurement, symptoms of pain and itch, and restricted motion. The pathogenesis and pathophysiology of traumatic scar remain elusive. The management for traumatic scars is comprised of surgical and non-surgical interventions such as pressure therapy, silicone, corticosteroid, and radiotherapy, which are chosen by clinicians based on the physical examinations of scars. Recently, great progress in treating traumatic scars has been achieved by the development of novel technologies including laser, intense pulsed light (IPL), radiofrequency, and ultrasound. The aim of this review article was to summarize the advances of these technologies for traumatic scars intervention.

Endostatin inhibits fibrosis by modulating the PDGFR/ERK signal pathway: an in vitro study

Accumulating evidence indicates that endostatin inhibits fibrosis. However, the mechanism is yet to be clarified. The aim of this study is to evaluate the effect of endostatin on platelet-derived growth factor-BB (PDGF-BB)- or transforming growth factor β1 (TGF-β1)-induced fibrosis in cultured human skin fibroblasts, and to further examine the molecular mechanisms involved. Human dermal fibroblasts were cultured in Dulbecco's modified Eagle's medium (DMEM) and serum-starved for 48 h before treatment. Cells were grouped as follows: "PDGF-BB", "PDGF-BB+ endostatin", "TGF-β1", "TGF-β1+endostatin", "endostatin", and "blank control". The fibroblasts were stimulated with either TGF-β1 or PDGF-BB for 72 h in order to set up the fibrosis model in vitro. The cells were co-cultured with either TGF-β1 or PDGF-BB and endostatin and were used to check the inhibiting effect of endostatin. A blank control group and an endostatin group were used as negative control groups. The biomarkers of fibrosis, including the expression of collagen I, hydroxyproline, and α-smooth muscle actin (α-SMA), were evaluated using an enzyme-linked immunosorbent assay (ELISA) and Western blot. The expression of phosphorylated PDGF receptor β (p-PDGFRβ), PDGFRβ, phosphorylated extracellular signal-regulated kinase (p-ERK), and ERK was detected using Western blot and immunofluorescent staining was used to explore the mechanisms. Both PDGF-BB and TGF-β1 significantly up-regulated the expression of collagen I, hydroxyproline, and α-SMA. Endostatin significantly attenuated both the PDGF-BB- and TGF-β1-induced over-expression of collagen I, hydroxyproline, and α-SMA. PDGF-BB and TGF-β1 both promoted the expression of PDGFR, ERK, and p-ERK. Endostatin inhibited the expression of PDGFR and p-ERK but did not affect the expression of total ERK. Endostatin inhibited hypertrophic scar by modulating the PDGFRβ/ERK pathway. Endostatin could be a promising multi-target drug in future fibrosis therapy.

Novel Stereoscopic Optical System for Objectively Measuring Above-Surface Scar Volume-First-Time Quantification of Responses to Various Treatment Modalities

BACKGROUND

Current approaches use subjective semiquantitative or cumbersome objective methodologies to assess physical characteristics of hypertrophic and keloid scars.

OBJECTIVE

This pilot study aimed to evaluate the accuracy and feasibility of a new stereoscopic optical and high-resolution 3-dimensional imaging system, for objectively measuring changes in above-surface scar volume after various interventions.

METHODS

Feasibility and accuracy were assessed by monitoring the above-surface scar volume of 5 scars in 2 patients for 5 successive months. Above-surface scar volume and Vancouver Scar Scale scores and the investigator and patient volume improvement assessment scores were assessed before and 12 weeks after last intervention.

RESULTS

Scar volume measured by the imaging system correlated significantly with the gold standard (actual weight). The greatest volume reduction followed a combination of cryotherapy and intralesional triamcinolone acetonide and 5-fluorouracil injections in Patient 1 and a combination of pulse dye laser and intralesional triamcinolone acetonide injections in Patient 2.

CONCLUSION

The new stereoscopic optical system is a valid, accurate, and practical objective method for assessing scar volume and for monitoring treatment response. It is more sensitive and accurate than semiquantitative objective scales. Further studies with a higher number of patients and scars are required to increase the measurement validity of the system.