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422
J. Leon-Villapalos et al.
F . Atrophic immature burn scar with visible remaining
hypervascularity
F . Atrophic mature burn scar without visible
hypervascularity
maturation into immature, when erythema is still present
(Fig.20.1) or mature when this feature has subsided and cannot be elicited on palpation of the scar (Fig. 20.2). On
reaching maturation, characteristically the scar becomes flat
Chapter 20. Burn Scar andContracture Management
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F . Atrophic burn
scar
423
and asymptomatic and can progress to atrophy with a contour defect (Fig.20.3) in a process that may take a long time
to be completed.
Two main types of pathological scars can be identified
easily based on history and physical assessment: hypertrophic
and keloid scars [30]. Both types are the result of abnormal
fibroblast, myofibroblast, and collagen production but express
several individual peculiarities, even though both can be
symptomatic from the functional, cosmetic, and psychological
points of view.
Hypertrophic scars are common complications of burn
injuries [31] characterised by an initially raised pink or red
scar that enlarges within the first weeks of maturation and
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J. Leon-Villapalos et al.
F . Hypertrophic scar
F . Keloid scar
Chapter 20. Burn Scar andContracture Management
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425
causes symptoms such as pain and pruritus but stays within
the confinements of the original injury (Fig.20.4).
Keloids (Fig. 20.5) are overall much more problematic
entities in their management due to their potential for recurrence. In comparison with hypertrophic scars, keloids usually
appear, with a slow growth pattern within months of the
initial burn injury and extend beyond the margin of the initial
wound.
Scar Management Options
A recent seminal paper [32] on management options for
hypertrophic and keloid scars stated the following guidance:
• Conservative therapies should be administered on a case-
by- case basis.
• Treatment of hypertrophic scars depends on scar severity
with conservative management reserved for uncompli-
cated cases and surgery as first choice for the most severe
presentations.
• Small and single keloids can be treated with combination
of conservative therapies or radically by surgery with adju-
vant therapy.
• Patients should be offered long-term follow-up.
Scar massage is one of the most basic and accessible
options to provide relief to the patient’s symptoms and provide changes that are most noticeable in itch and vascularity
but without changes in the pliability, height, or other parameters in the scar scale. Even though patients report a noticeable and visible improvement, the lack of robust studies in
the literature means that the clinician, with appropriate education, can safely choose the type of massage agent (creams
vs ointments), the duration of the massage, and the technique
to apply it without incurring any potential damage to the
patient [33–35].
Silicone-based sheets and gels are useful therapeutic agents
to prevent and treat hypertrophic and keloid scars and con-
426
J. Leon-Villapalos et al.
stitute one of the main tenets of treatment in burn scar management [36]. The mechanism of action through which scar
improvement is elicited appears to be linked to scar hydration with suppression of the increased activity of the cellular
components of the scar [37].
Injection of scar-modulating substances represents one of
the most recognisable and minimally invasive therapeutic
options in the treatment of hypertrophic and keloid scars.
Even though a powerful anti-inflammatory effect can result
in the scar with reduction in hypertrophic and keloid scar
features with the use of injectable steroids such as triamcinolone acetate, the variability in individual response and the
potential for injection-site complications such as skin atrophy,
telangiectasia, and dyspigmentation suggest caution and
appropriate training in its use [38].
The use of 5-fluorouracil (5-FU) in combination with
triamcinolone acetate preparations appears to be associated
with a significant improvement in the treatment of hypertrophic scars and keloids compared with the use of injectable
steroid therapy alone [39]. Other injectable options that
modulate pathological burn scarring include botulinum toxin
[40], platelet-rich plasma (PRP) [41], and bleomycin [42].
The potential injection-site related complications of
injected steroids have opened the possibility of using other
therapeutic options that deliver steroid via transcutaneous
delivery [43] using steroid tapes, even though their use is more
limited than the injected form. Once these more conservative
approaches have been exhausted as suitable options of management for the scars, more complex approaches maybe necessary that require management within the environment of a
scar service. Ultimately, surgery may be required. This chapter will not be dealing in detail with the multiple reconstructive procedures available for reconstruction of complex
scarring causing contracture, functional limitation, and cosmetic embarrassment that may include all aspects of the
reconstructive ladder such as direct closure, skin grafting,
tissue realignment techniques (z-plasty), flap reconstruction,
and the use of dermal templates and tissue expansion. It is
Chapter 20. Burn Scar andContracture Management
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427
necessary, nevertheless, to describe the advantages that modern technology has brought into scar modulation.
One of the most outstanding outcome-changing technical
advancements for burn scars is the use of laser therapy, and
the generalised introduction within scar services of the use of
laser devices.
A review on the use of laser in the management of burn scars
[44] found that laser therapy is efficacious in changing many
abnormal scar scale parameters of pathological burn scarring
from both functional and cosmetic points of view. Functionally,
laser therapy may limit the number or complexity of the surgical
reconstructive procedures required to deal with complex scars
and contractures [45]. This may have improved cost-benefit
advantages [46]. Cosmetically, it may improve abnormal parameters of pigmentation, vascularity, pliability, and thickness.
Fractional carbon dioxide (CO2) laser has been found to
significantly improve parameters such as thickness, pigmentation, vascularity, pliability, height of scar, and relief of burn
scars [47]. It can be combined with other laser modalities
such as pulsed-dye laser for hypervascularity [48] or used as
a combination platform for delivery or injection of scarmodulating substances [49].
Micro needling offers an alternative to laser for atrophic,
minimally raised or hyperpigmented scars [50]
Conclusion
The management of burn scars starts at the time of injury and
requires a multidisciplinary and multimodal approach that
preserves dermis and ultimately minimises scarring. The nonburn specialist requires a thorough approach to the scar history in order to provide conservative therapies or refer to a
comprehensive scar management centre for escalation of
more advanced techniques.
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J. Leon-Villapalos et al.
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