Minor Burns and Scar Management Gabrielle Smith Lead Therapist Midlands Burn Care Network

1. Minor Burns and Scar Management Gabrielle Smith Lead Therapist Midlands Burn Care Network

2. Aims of Presentation • Decreasing the risk of scarring/oedema • Treatment for minor burns • range of movement • oedema management • prevention of intrinsic minus position • Factors affecting scarring • Recognising hypertrophic and keloid scars • Short term management • Long term management • Services available at designated burns services

3. Decreasing the Risk of Scarring/ Oedema • Dressings that continually promote the inflammatory response by not allowing the wound to heal, will prolong the healing time • More painful a dressing then the less likely to move consider this when dressing over joints • Do not make dressings too tight so that the patient is not able to move in the dressing

4. Range of Movement • Keep joints moving in extreme range of movement • Full extension, full flexion • Individual fingers not boxing gloved • Thumb able to mobilise • Pain limited to allow movement • Encourage to use with light Activities of Daily Living (ADL) • Benefits of moving – decreases oedema quickly • Knock on effect of not using the hand properly • Immobility of the hand can stiffen the wrist, elbow and shoulder • Consider the joints of either side of the injury • Little and often • Stretches, exercise programme

5. Intrinsic Minus Position • If hand is not mobilised, oedema can cause an intrinsic minus hand. • Intrinsic minus = hyperextension of MCP joints and flexion of the PIP and DIP joints commonly referred to as the claw hand deformity; • Dorsal skin drawn tight by increased fluid, causing the palmar arch to flatten • MCP’s drawn into extension or hyperextension which places the collateral ligaments in a shortened position • Concurrently PIP joints assume a flexed position

6. Beginning of Intrinsic Minus Hand

7. Exercise Programme • Maintain flexion/extension of wrist, elbow and shoulder • Isolated movements of MCP, PIP and DIP joints • Thumb opposition • Aim for composite fist with and without dressings • flat palm position

8. Factors Affecting Scarring • Healing time • 3 weeks • Infection • Genetic or previous history • Skin type and pigmentation • Age • Location of burn

9. Infection • Clean wounds heal quicker • Wound infection causes a delay in healing and therefore increases the risk of abnormal scarring

10. Genetic Factors • Abnormal scarring is 15 times more likely to occur in darker-skinned individuals. • Individuals with ginger hair and freckles are also at an increased risk of abnormal scars. • People with a previous personal history of keloid scarring are more likely to scar again in an abnormal fashion and those with a family history are also at an increased risk.

11. Fitzpatrick Classification Scale Skin Type/Skin ColourCharacteristics • I White; very fair; red or blond hair; blue eyes; freckles. Always burns, never tans • II White; fair; red or blond hair; blue, hazel, or green eyes. Usually burns, tans with difficulty • III Cream white; fair with any eye or hair colour; very common. Sometimes mild burn, gradually tans • IV Brown; typical Mediterranean caucasian skin. Rarely burns, tans with ease • V Dark Brown; mid-eastern skin types very rarely burns, tans very easily • VI Black; Never burns, tans very easily

12. Age • Younger people scar more than older people as they have a greater skin tension

13. Location • Some areas of the body are more likely to scar e.g. Sternum, shoulders, dorsum of the feet • Increased tension causes increased inflammation due to micro trauma causing the fibroblasts to secrete more collagen

14. What is a Scar? • A scar is formed as part of the healing process following damage to the skin as the body lays down collagen fibres • If the epithelial layer alone is damaged, there is often little or no scarring as it heals by regeneration. If the dermal layer is damaged then healing is by repair.

15. Hypertrophic Scars • Hypertrophic Scars are typically raised, red or pink and sometimes itchy but do not exceed the margins of the original wound. • Hypertrophic scars usually subside with time.

16. Keloid Scar • “ A scar that has grown beyond the boundaries of the original injury”

17. Short Term Management • Moisturise • Non-perfumed • E45, Diprobase, Aqueous Cream • Massage • Awareness of altered sensation • Pain • Small circular movements along the line of the scar, blanching the scar • Sun-care advice

18. Long Term Management • Silicones • In 2002, an International Advisory Panel on Scar Management published Clinical Recommendations on Scar Management, based on a qualitative overview of 300 published references and expert consensus on best practices. Silicone was recommended as first line therapy for prevention of scarring and first line treatment for the initial management of scarring.

19. Services Available in Designated Burns Services • Services Provided by designated burns services • Access to a MDT approach to burn care • Support groups • Clinical Psychology • Dietitians • Speech and Language Therapists • Social Workers • Interventions • Pressure garments • Silicones • Splinting • Psycho-social aspects of burn care

20. References • Aarabi. S., Longaker. M. and Gurtnr. G. (2007) Hypertrophic scar formation following burns and trauma; new approaches to treatment. PloS Medicine. 4, 9; 0001-007 • Bombaro. C., Engrav. L., Carrougher. G., Weichman. S., Faucher. L., Costa. B., Heimbach. D., Rivara. F. and Honari. S. (2003) What is the prevalence of hypertrophic scarring following burns? Burns. 29; 299-302 • Edwards. J. (2004) Scar management; what are the available options? Nursing in Practice. May/June. 69-71 • Enoch. S., Roshnan. A. and Shah. M. (2009) Emergency and early management of burns and scalds. British Medical Journal. April 338; 61037 • Linares. H. A. (1996) From wound to scar. Burns. 22, 5:339-352 • Papini. R. (2004) Management of burn injuries of various depths. British Medical Journal. 329: 158-160 • Patino. O., Novick. C., Merlo. A. and Benaim. F. (1998) Massage in hypertrophic scars. Journal of Burn Care Rehabilitation. 20, 3: 268-271 • Smith. F. R. (2005) Causes of and treatment options for abnormal scar tissue. Journal of Wound Care. 14, 2: 49-52

21. Thank you Any questions?