Scar Management by pptfiles

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									Minor Burns and Scar Management

             Gabrielle Smith
Lead Therapist Midlands Burn Care Network
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
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
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
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
Beginning of Intrinsic Minus Hand
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
Factors Affecting Scarring
 Healing time
    3 weeks
    Infection
 Genetic or previous history
 Skin type and pigmentation
 Age
 Location of burn
Infection
 Clean wounds heal quicker
 Wound infection causes a delay in healing and
 therefore increases the risk of abnormal scarring
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.
Fitzpatrick Classification Scale
Skin Type/Skin Colour Characteristics
 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
Age
 Younger people scar more than older people as they
 have a greater skin tension
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
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.
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.
Keloid Scar
 “ A scar that has grown beyond the boundaries of the
 original injury”
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
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.
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
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
  Thank you

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