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WELSH CENTRE FOR BURNS
Patient Information Leaflet
Scar Management
Burns Outreach Service
Welsh Centre for Burns
Morriston Hospital
Swansea
First Published: January 2006
Version No: 2
Review Date: July 2012
Authors: JE, LB, SP – Burns Outreach Team
EB11
SA6 6NL
Contents
Page
Introduction
2.
Introduction
2.
Structure of the Skin
This booklet has been produced by the Burns Outreach
3.
Function of the Skin
Team to help you to manage your burn scars.
4.
Scar Formation
In order for you to understand how and why scarring
6.
Scar Massage
develops after a burn injury, it is useful for you to know a
9.
Hypersensitivity
little bit about the structure and function of normal skin.
10. Itching
14. Pressure Garments
Structure of the Skin
19. Silicone Gel
21. Skin Camouflage
22. Sun Exposure
23. Blisters
24. Extremes of Temperature
25. Don’t be a DNA
27. Summary
28. Support available
32. Key Worker contact details
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2
The skin is the largest organ of the body and is essential
to help moisturise the skin, and hair follicles. The main
for survival. It is divided into three layers. The outer layer
structural component of the dermis is called collagen and
is the epidermis, the dermis is in the middle and fat forms
this lies in flat, organised layers of connective tissue. The
the innermost layer. Normally, the surface of the skin is
upper layers of skin apply the pressure necessary to
smooth, punctuated only with hairs and pores for sweat.
promote this. As new collagen fibres form, the old ones are
broken down.
Function of the Skin
The innermost layer of the skin consists of fat, which
The main function of the skin is to provide a protective
provides insulation and helps to store calories.
barrier between you and the environment. The outermost
layer of the epidermis is made up of sheets of dead cells
The deeper the burn injury the more of these structures are
that act as a waterproof barrier. There are also special
destroyed and their functions are therefore lost.
cells inside the epidermis that protect you from ultra-violet
light.
Scar Formation
Wounds heal by forming scar tissue. Initially, the healed
The dermis contains sweat glands and blood vessels,
wound may appear flat and smooth. However, within the
which help regulate body temperature, and nerve endings
next three months, dramatic changes may take place.
which send sensations of pain, itching,
touch and temperature to the brain. It also contains
As the burn wound heals, new connective tissue is formed.
oil glands, which produce a substance called sebu
The blood supply to the new connective tissue
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3
is more rapid and greater than in normal skin, which makes
Unfortunately, it is not possible to prevent hypertrophic
the scar look red in colour.
scarring. It is, however, possible to minimise the effects
and improve the appearance through:
The increase in blood supply results in the connective
• Massage with moisturising cream.
tissue being formed at a much faster rate than it is broken
• The wearing of pressure garments and/or silicone
down, and it becomes more adhesive. This results in the
gels.
formation of whorles or bundles of collagen, which fuse
• Exercise.
together and push outwards making the scar appear
• Resuming your normal daily activities as much as you
raised, hard and lumpy. This type of scarring is called
can.
hypertrophic scarring.
Scar Massage
What are the benefits of scar massage?
Massage and the use of moisturising cream are very
important aspects of the ongoing care of your scar. One of
the reasons for the use of moisturising cream is because
your healed scar can become very dry and needs
moisturising. This is because the oil glands in your skin
that usually provide moisture are damaged or destroyed
during the burn injury.
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6
Moisturising cream should be applied at least three times a
Creaming and massage therefore improves the quality of
day to clean skin, massaging thoroughly for at least ten
the healed skin and helps to prevent skin breakdown.
minutes. The cream should be massaged into the scar
A further reason is to help reduce the extent of the scarring
using firm pressure, blanching the skin (being careful with
that has resulted from your injury, as the action of the
new, fragile scars). Take care over tight areas (including
massage helps to encourage the collagen fibres to realign
joints), stretching the scar during the massage process.
and flatten. Massage with cream also keeps the skin
Ensure that all of the cream has been massaged in,
supple and can reduce itching.
removing excess cream with a tissue.
What type of moisturising cream should I use?
How should I apply moisturising cream?
During the first six months after your injury, when the
process of scarring is at its most active, application of
moisturising cream and massage is especially important.
Daily bathing with a non-perfumed bath moisturising
product such as oilatum, and creaming after a bath will
The cream used should be free from perfumes, additives
and alcohol as these can irritate and dry your skin. It can
also affect the elasticity of your pressure garments (if you
need to wear them). Your key worker will give you samples
of various creams to try. Water based or aqueous creams
should not be used as they can actually dry out the skin.
improve circulation and help soften and re-hydrate the skin.
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8
Itching
During the process of healing and your scar’s maturing,
Hypersensitivity
itching can be an irritating symptom.
Why do I get strange and sometimes painful feelings in
It is possible to soothe the itch, breaking the so-called “itch
some areas of my scarring?
Hypersensitivity occurs when the nerve endings in the
dermis are damaged by the burn injury, and can cause an
– scratch cycle”. The tips over-leaf enables skin dryness
and itch to be effectively managed.
exaggerated, painful response to normally non-painful
stimulus. It is quite common and can result in a variety of
What is the “itch – scratch cycle”?
different sensations, often described as severe “pins and
Scratching generally can cause scar break down. The
needles”, tingling, shooting or stabbing pains.
more your skin is damaged by scratching, the more it hurts
and itches, and the more you continue to scratch. This is
Your key worker will discuss with you in more detail how to
known as the “itch – scratch cycle”. Constant scratching
manage the hypersensitivity. In the meantime it is important
also triggers inflammation and makes the skin more likely
that you return to normal functional activities and not be
to get infected. So, it’s really important to try not to scratch.
over-protective of the sensitive area.
By relieving the itch, the itch – scratch cycle can be broken
and you’ll see the benefits, with a real improvement to your
scars.
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The “Itch – Scratch Cycle”
•
For best effect try using different formulations
together to find a combination that suits you – for
example gently apply emollient cream during the day and
use oil in the bath at night.
•
Avoid vigorous rubbing of your skin when massaging
in the cream, as this can trigger itching.
•
When washing and taking baths, use a bath oil
avoiding soaps, foam or bubble baths, all of which
Soothing the itch
•
can dry the skin.
Skin gets dry if it is allowed to dry out – keep it soft
by creaming regularly throughout the day.
•
Bath water should be tepid or warm as hot water can
make itching worse.
Emollient creams, bath oils, soap substitutes and lotions
are some of the different types of emollients to choose
from. Examples of these include: - E45 cream,
doublebase, oilatum and eucerin. There are also creams
and bath oils available that, as well as moisturising the
skin, contain an anti-itch ingredient which actively soothes
the itch e.g. balneum plus, E45 anti – itch. Your key
Beating the scratch
•
To avoid scratching pat or rub the skin over clothes
instead – if the itch is still troublesome pinch the skin.
•
Never tell a child to stop scratching as it will not work
– instead praise a child for not scratching.
worker will advise you on choice of creams.
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•
Cut fingers and toe nails short – this may help to limit
Pressure Garments
the damage from scratching.
• Keep a note of when itching is most frequent, and during
these times try the following tips to help distract you from
1. Clench your fists and count to 30
2. Keep your hands busy, i.e. write, draw or do a
4. Reduce exposure to heat – keep bedrooms on the
you will be given an “interim” (off-the-shelf) garment.
get used to the feel of wearing elasticated garments in
preparation for your custom-made ones. Measurements
cool side
Wear loose fitting or cotton clothes and pyjamas and
will then be taken and used to calculate a graduated
pressure designed for your individual needs. The garment
try to use cotton bed linen
At night cotton gloves/mittens help to stop children
will be manufactured in Ireland, and takes seven to ten
working days to be returned to the Burns Centre at
scratching
•
assessed and agree to wear a pressure garment, initially
These are made in soft lycra material and will help you to
puzzle
•
A pressure garment is a specifically designed elasticated
item of clothing worn over the scar. If you have been
the itch:-
•
What is a Pressure Garment?
Consider putting towels, cream or silicone gel
sheeting in the fridge
Morriston Hospital. It is the policy of the Burns Centre to
only order one garment to try at this stage.
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If the garment is found to fit well, a further order will be
When does the pressure garment have to be worn and for
made to provide you with spare garments (usually a total of
how long?
2 of each style), which will be mailed to your home
For optimum results you MUST comply with the following
address. A sample of the garments will be shown to you,
guidelines:
should you need this type of treatment.
• The pressure garment needs to be worn at least 22
hours a day
What are the benefits of wearing a pressure garment?
• Helps to reduce scar thickness
• Helps to improve the appearance of the scar
• Remove only for bathing, massaging and changing
garments for washing
• You may need to wear a garment for up to two years
– until the ‘scar maturation period’ is complete
• Prevents swelling
• Protects newly healed skin from blistering and
• If you have been provided with silicone gel the
garment must be worn directly over the gel, as
damaging
• Helps to prevent scar contracture (tightness)
• Helps to relieve the itching associated with healing
directed by your key worker
• If you have been provided with a splint, it may be
worn over the garment
scars
• Reduces the chances of needing surgery
• Improves quality of life
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How do I look after the pressure garment?
• Machine wash at maximum 40° or hand wash
(ideally) using mild detergent, preferably daily
As mentioned earlier, you will be reviewed every two to
three months, and it may be necessary to re-measure you
• Do not use bleaches
if you have grown, gained or lost weight. It is, however,
• Do not tumble dry
important that you contact your key worker immediately if
• Do not iron
there is a problem with your pressure garment so that an
• Do not dry clean
earlier appointment can be arranged.
• Dry flat or drip dry away from direct heat
• Protect garment for certain activities
• Protect from sun, i.e. cover pressure garment with
clothing
• Garments need replacing regularly (every 2-3 months
for children, 3 months for adults)
• If massaging with cream, ensure the area is dry
before applying garments (wait about 30 minutes for
cream to absorb)
• Never cut the garment
If you are unhappy with the fit, or the garment causes
soreness or skin breakdown, contact your key-worker
immediately
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18
Silicone Gel
When does the silicone have to be used and for how long?
• The silicone may have to be worn for up to two years,
What is silicone gel?
Silicone is a gel-like substance that comes as a sheet or in
a tube. It is thought that silicone gel hydrates the skin
through the gradual time release of silicone fluid to produce
or until the scar maturation period is complete.
• Your keyworker will provide you with wear and care
instructions specific to the gel you are using.
a soft, smooth, pale scar. There are many trade names
available, each with different properties. Your key worker
will prescribe the most appropriate gel for your scar.
You will be reviewed on a three monthly basis to check on
the progress of the scar and to provide you with a further
What are the benefits of wearing silicone gel?
supply of silicone. If you run out of silicone, contact your
• Softens and smoothes the scar
keyworker immediately and a further supply can be sent on
• Improves the cosmetic appearance of the scar
in the post.
• Flattens the scar
• Reduces the redness of the scar – changes it from
red to pink to normal skin colour
• Improves the texture of the scar
• Can be used beneath pressure garments and/ or
splints
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Skin Camouflage
Sun Exposure
Skin camouflage is a cream matched to the colour of your
Burn scars and donor sites are extremely sensitive to
normal skin, designed to conceal the discolouration of your
sunlight and will blister and peel more readily than
scar. It will not restore your skin to an even texture but
normal skin. Direct sun exposure should therefore be
does help to create a more natural look. It is specially
avoided for at least one year following the burn injury.
formulated to give the necessary cover with only a thin
Pressure garments do not provide sun protection, so
layer and is waterproof so can also been worn when
when you are outdoors in the sun a sun block lotion
swimming. Your key worker will be happy to discuss this
should be applied to the burn scars underneath the
with you as well as the other active treatments you are
pressure garment, and loose cotton clothing should be
receiving.
worn over the pressure garment. After a year, exposure
to the sun can gradually be increased.
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Blisters
Extremes of Temperature
Newly healed skin is a lot thinner and more sensitive than
If your burn injury was extensive, you may have difficulty
normal skin. As a result of this, the development of small
regulating your body temperature. If the weather is cold
blisters is not uncommon within the first few months after
you may have to wear many layers of clothing for
healing. The blisters may occur from excessive irritation
insulation. By layering clothing you can easily remove what
from clothing or accidental bumps or bruises. Maintaining
is no longer necessary once your body warms up. Many
a good skin care regime can help prevent blisters from
burn survivors complain of increased stiffness in the burned
forming. If you are wearing a pressure garment a small,
areas in cold temperatures. You may need to perform
non-stick dressing should be used to protect the blister
extra stretching exercises to combat this.
from further damage. Silicone gel should not be applied to
In hot temperatures you will need to take several
a blister. It can be re-applied once the blister has fully
precautions to help prevent heat exhaustion or heat stroke.
healed. If you are concerned that the blister is not healing,
You will need to drink plenty of non-caffeinated drinks
contact your GP or the Burns Centre for advice.
throughout the day. Additional suggestions for keeping
cool would include the use of a handheld or electric fan, or
dampening garments with water. Placing a cool pack on
the head or wrist can help cool the entire body.
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Children – On the occasion of a child not attending their
Don’t be a DNA
first appointment, the parent/carer(s) will be telephoned
Having been reviewed by a member of the Burns Outreach
and a second appointment agreed. If the child fails to
Team, you have agreed to start treatments for your burn
attend again, their health visitor will be informed and the
scars, and will be offered regular appointments so that your
process repeated. In the event that the child does not
progress can be monitored.
attend on the third occasion, it will be discussed with the
A DNA is someone who Did Not Attend their outpatient
appointment, and did not advise us beforehand. The clinic
was ready, your key worker was waiting but the patient was
health visitor whether social services will be informed. The
child will be offered a final fourth appointment. In the event
they do not attend they will be discharged, and a letter sent
to the General Practitioner, Consultant and Health Visitor
a DNA.
It is the policy of the Burns Outreach Team that in the case
If you have been given an appointment which is unsuitable,
of:-
change it now by telephoning the number at the back of
Adults – you will be sent an outpatient appointment
this booklet.
(O.P.A.). A second O.P.A. will be sent if you DNA.
If you fail to attend for the second time, your Consultant
and General Practitioner will be informed, and you will be
discharged.
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26.
Summary
Support Available
Your key worker will work with you and your Consultant
throughout the scar maturation period to help you choose
the best treatment plan for you and to monitor your
response. However, despite all of the treatments that are
available, no scar will ever disappear completely. As
mentioned, we can put you in touch with other services
such as counselling, cosmetic camouflage and voluntary
support groups at any time during your treatment, or on
discharge from the service, if you feel that this would be
beneficial.
Welsh Dragon Burns Club
Dyfed Ward
Welsh Centre for Burns
Morriston Hospital
Swansea SA6 6NL
01792 703622
www.welshdragonburnsclub.co.uk
This club is open to any child between 7-17 years old who
has a scar resulting from a burn injury. The cost of
running the club is met through fund raising activities,
which means that every child who wants to attend can.
The club provides the opportunity to attend burns camp,
family fun days and day trips, and so build a network of
friends who share similar experiences in life.
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28.
Changing Faces Cymru
Dan’s Fund for Burns
PO Box No. 562
PO Box 54394
Swansea SA8 9AD
London W2 7HJ
0845 4500 240
020 7262 4039
www.changingfaces.org.uk
www.dansfundforburns.org
Email: [email protected]
Email: [email protected]
Changing Faces supports people of all ages with
Dans Fund for Burns was formed in memory of Dan Miller
disfigurements of all kinds, whether present at birth or
who died in the Bali bombing of 2002. It is now a leading
acquired during an accident or illness, in achieving high
aid organisation for burn survivors in the UK and aims to be
self-esteem, access to the best health and social services,
a source of practical support and funding for specialist
and equal rights and opportunities throughout their lives.
burns after-care.
They provide one-to-one counselling and advice, group
workshops, self-help guides and videos.
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Key worker contact details:
Burns Survivors Association – UK
416 Outwood Common Road
Billericay
Essex
Liz Brown, Clinical Nurse Specialist
(For patients outside Swansea/ Neath Port Talbot)
01792 703628
01277 631086
www.burnsurvivorsassociation.org.uk
Janine Evans, Advanced Practitioner Occupational
Therapist
This is an independent association for burn survivors, their
Claire Poole, Specialist Occupational Therapist
families and friends. It aims to provide information on
(For patients within Swansea/ Neath Port Talbot)
professional contact points, link existing local support
01792 703980/ 703982
groups and promote exchange of information and best
practices in support services.
Sue Price, Advanced Practitioner Occupational Therapist
(For patients outside Swansea/ Neath Port Talbot)
01792 703628
Available 8:30am – 4:30pm, Monday - Friday
A telephone answer machine service is available on these
lines.
31.
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