Vita TU, Occupational Therapist and Project Manager
Sunshine Social Welfare Foundation
When burn wounds heal, the therapist will often be confronted to two issues when dealing with scars: a fragile surface that breaks and blisters easily, as well as scar contracture. If the slightest pressure and friction causes the surface of the scar to break, can pressure therapy interventions still be used? If we don’t use pressure therapy, won’t the scar continue to contract and become thicker? In a previous article Pressure garments and wounds. To use or not to use?, we clarified the specific considerations for using pressure garments when wounds are present. In this article, we’ll discuss the different options for pressure therapy for burn scars when scar stability is not optimal.
Scar stability: Why do scars break and blister easily?
Damage caused by burns to the epidermal and dermal structures will affect skin integrity. Rete pegs are the epidermal protrusions that point downward into the dermis and are partly responsible for skin integrity. In normal skin, their sunken and raised surfaces allow them to connect with the dermal papillae, which themselves are the protrusions of dermal connective tissue into the epidermal layer. However, the rete pegs of a newly healed scar are flatter, and the fixation of the epidermis to the dermis is unstable. As a result, transversal friction and shear between the epidermis and dermis will easily cause blisters. For example, when burn patients put on or take off pressure garments, the friction between the fabric and the skin may cause skin to break and blister. Repeated movements from exercises may also cause friction over joints, which will result in small wounds or blisters. We can see in Picture 1 how the surface of the scar is unstable and many wounds are present. However, as time passes and the process of healing continues, the surface of the scar will become more stable and be able to tolerate more tension and pressure.
What are the scar stability requirements for different pressure therapy options?
First of all, it’s important to know that there are many different options for pressure therapy to respond to different needs and situations.
The most common pressure treatment options for burn scars include:
Pressure garments
Everyone is familiar with pressure garments, which are made with elastic fabric. The tension from the elasticity of the fabric will create pressure on the scars. When putting on or removing garments, or during joint movement, friction will be generated by the movement of the fabric on the skin. If the scar is still in its “early unstable” phase, this friction may cause the skin to break or blister. However, the scar's surface will become stable over time, therefore for areas that require long-term pressure therapy to control scar hypertrophic growth, it is still more convenient to use pressure garments. We must pay attention to the fit of the garment and avoid excessive pressure. A pressure garment that is too tight may still cause wounds when the skin to rubs against fabric during joint movement.
Self-adherent elastic bandages
Because self-adherent elastic bandage like CobanTM is wrapped from distal to proximal, it will not cause friction on tissue as long as it’s not wrapped too tightly. Due to the design characteristics of the material, the stretchability of self-adherent elastic bandages has a good scar control effect, so it is suitable for both unstable and stable scars. The self-adherent elastic bandage is narrow in size and is suitable for use on small parts such as fingers, palms, toes, and soles. Moreover, its self-adhesive quality ensures better fixation. The downside is that each area (like fingers or toes) must be wrapped one by one, which is more time-consuming. Also, although the bandages can be reused a couple of times, they cannot be used repeatedly like regular elastic bandages, and are thus more expensive. This is why self-adherent elastic bandage is used as a temporary pressure therapy measure, while pressure garments are used for long-term needs.
Elastic bandages
The characteristics of elastic bandages (crepe elastic bandages) are similar to self-adherent elastic bandages, except that the size of elastic bandages is slightly wider and they are usually used on the upper limbs, lower limbs or trunk. The degree of pressure on the skin can be controlled by the degree of stretching during wrapping, so it is suitable for the unstable scar stage. However, if we continue using elastic bandages when the surface of the scar has become more stable, the scar control effect is usually insufficient, and it is recommended to use a pressure garment instead. Elastic bandages are not self-adhesive so physical activities during the day will cause the elastic bandages to fall off and they will need to be re-wrapped, sometimes several times a day.
Silicone gel sheets
Silicone gel sheets are another pressure therapy tool used in burn rehabilitation. In themselves, the sheets result in the occlusion and hydration of the scar site, which is believed to help with scar control. They usually require the use of pressure garments, elastic bandages, etc. to be fixed in place. When used underneath pressure garments or bandages, they can help compensate insufficient pressure on concave and flat surfaces of the body. Silicone gel sheets have poor air permeability. When using them, attention should be paid to skin allergies and skin maceration. Wounds on skin is a contraindication for use, so they are not recommended when the surface of the scar is unstable. Although silicone sheets have a good effect on softening scars, they cannot be used on large areas and are only suitable for local applications.
Otoform pressure inserts
Pressure inserts made of Otoform have the same breathability issues as silicone gel sheets, so their use must be avoided when the scar surface is unstable. Like silicone gel sheets, they are also suitable for local applications and must be used with other pressure therapy tools like pressure garments and bandages to be fixed in place. The difference is that Otoform pressure inserts must be made by hand, which is more time-consuming. If the insert is too thick or too large, it will be heavy and more difficult to fix in place.
This table compares the commonly used pressure therapy interventions.
To summarize…
Key points about options for pressure therapy for burn scars
Pressure garments:
Ideal for long-term scar management, despite potential friction-induced wounds during early unstable phases.
Proper fit is crucial to avoid excessive pressure and friction-related injuries.
Self-adherent elastic bandage:
Suitable for unstable and stable scars, offering good scar control due to their stretchability.
Ideal for small areas but may require time-consuming application and can be costly in the long term.
Elastic bandages:
Inexpensive and reusable. Effective for unstable scars but less so for stable scars or for long-term scar control.
Prone to unwrapping during physical activities, requiring frequent readjustments.
Silicone gel sheets:
Can promote scar softening and can be used alongside pressure garments or bandages to enhance pressure distribution.
Not recommended for unstable scars due to poor breathability and risk of skin allergies.
Otoform pressure inserts:
Like silicone gel sheets, they require stable scar surface for effective use.
Time-consuming to make and may be cumbersome if too thick or too large.
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