Hypertrophic Scarring and Contractures
Hypertrophic scarring is thought to be inevitable when epithelialization takes longer than two weeks in young children, or longer
|Wound Epithelialization Milestones|
|Wound healing time |
Early pressure treatment
>10 days Recommended for children
>14 days Recommended for patients of all ages
>21 days Mandatory for all patients
Application of pressure to burn wounds is generally recommended to minimize hypertrophic scarring, although optimal pressure and duration have not yet been determined in
Role of Surgery
Surgical excision and skin grafting beginning less than 72 hours after injury is beneficial and is indicated for nonscald full-thickness burns in children and in adults younger than 30 years of age. All other patients with suspected full-thickness burns should be observed for eight to 10 days, as nothing is lost by delaying surgical excision. It is also best to wait two weeks before assessing the need for surgery in children with hot-water scald burns because overly aggressive excision and skin grafting in this group has resulted in worse outcomes. Full-thickness burns less than 2 cm wide can be allowed to heal by contracture as long as they are in nonfunctional, noncosmetic areas and the skin is not thin (e.g., the ankle).
Coping with the Injury
After epithelialization occurs, no further dressing changes are required. However, patients should be instructed to use a nonperfumed moisturizing cream until natural lubricating mechanisms return. Use of preparations with a high lanolin content, thick waxes and ointments should be avoided. In addition, a sun block with a skin protection factor greater than 15 should be used to prevent hyperpigmentation until the wound loses its pink and red coloring. Depending on the depth of injury, it usually takes six months to two years for a burn wound to heal completely.
Itching is a common problem during the healing process. Pruritus is often triggered or worsened by environmental extremes (especially heat), physical activity and stress. The itching usually diminishes gradually and eventually stops after complete wound healing. Until then, a number of measures can be employed to control itching. Systemic antihistamines are usually tried first, with diphenhydramine used most frequently. Cyproheptadine and hydroxyzine are alternatives. Local measures include bicarbonate of soda baths and moisturizing lotions.
Many patients prefer to wear loose, soft, cotton clothing. In addition to helping patients cope with long-term physical discomfort, family physicians should be alert for psychologic issues. Patients who have sustained burns are at increased risk for anxiety, depression and posttraumatic stress disorder. Family dynamics can also change dramatically. Family members may be stricken with guilt, and patients are susceptible to dependency issues because of the additional help required for daily activities while healing is occurring.
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