Scar management

Scar Process

If a wound has healed within two weeks without a skin graft then it is unlikely to scar. The area may remain pink for some time but this will gradually pale over several months. It is important to keep the area well moisturised as it can become very dry and itchy. If a wound has taken longer than two weeks to heal or has required a skin graft there is an increased chance of developing scarring.

Hypertrophic scarring

Hypertrophic scars are the result of an imbalance in the production of collagen during the healing process. They are often red, raised, firm and itchy but they do not extend beyond the original boundary of the wound.

Keloid scars

A keloid scar is an overgrowth of tissue that occurs when too much collagen is produced during the scarring process. This causes the scar to continue to grow even after the wound has healed.

Scar management

If a wound has taken longer than two weeks to heal, it has been grafted or there are any other risk factors associated with scarring such as infection or family history your child will be referred to the scar management team.

It is important to treat such scarring due to a number of associated factors:

• Scars over joints can become tight and prevent movement
• Scars can be very dry and itchy
• Scars can be very sensitive

For more information, please view our scar management for children leaflet. 

Treatment

In order to minimise these affects a number of approaches and treatments may be used:

• Moisturising
• Massage
• Using silicone sheets and gels
• Pressure garments
• Splints
• Exercise and stretches

Moisturisation                         

Scars and skin graft donor sites require regular creaming to prevent the area from drying, cracking and becoming sore. This is because newly healed skin is unable to lubricate itself in the same way as undamaged skin. It is important to use a non-perfumed moisturiser to keep the area soft and supple and prevent itching. Perfumed creams can react with the newly healed sensitive scars. Your therapist can provide you with some samples of creams if needed. Moisturisers should be applied gently in thin layers while the scars are more fragile and should be done 2-3 times a day. It is important to fully cleanse the area each day to avoid build-up of cream and skin irritation.

Massage

When the wound has healed we will advise you to commence gentle massage. Place your fingers onto the scar and move in gentle circular motions - you are moving the skin not your fingers to prevent friction. Please ask your therapist to demonstrate. As the scar matures you can increase the pressure of the massage to help soften scars. Your therapist will guide you in this process.

• Scar Management after a Burn Injury - Children's Burns Trust (cbtrust.org.uk)  

Sun protection

 

As scars are extremely sensitive to sunlight and sun exposure it is very important they are protected from the sun. Complete sun block is recommended for at least two years following the injury. Once the scars have matured we still recommend the damaged area of skin is protected from the sun with at least a factor 30 sun cream. Your therapist can give you some sample sun creams to try.

Silicone therapy

 

As new skin which has formed following the injury lacks the moisture needed silicone acts by sealing in the moisture and hydrating the scar.  The aim of silicone is to flatten, soften and pale the scar in addition to reducing discomfort. They are most commonly used on small, stubborn scars or areas where it is difficult to apply pressure such as the face.  The use of silicone will need to be reviewed regularly to check the appropriateness and effectiveness of the treatment.

The most appropriate type of silicone for managing your child's scar will be chosen by the therapist. You will also be given a letter for your GP so you can get this on repeat prescription.

Silicone sheet(cica care/ dermatix)

• The sheet should be cut to size to cover the scar. The sheets are usually self-adhesive but they may require further fixation with a bandage or tape.
• The sheet should be washed daily in mild non oily soap, rinsed in warm water, allowed to dry, and then re-applied. At the same time the area of skin should be cleansed and dried as normal. Moisturising cream should still be used but needs to be fully absorbed before applying the sheet.
• The sheet should be worn for at least 12 hours a day and where possible worn 24 hours a day.
• Your child will need to build up the wearing time slowly (see wearing schedule below) to prevent the skin from reacting to the silicone.
• When the sheet begins to deteriorate and cleaning becomes difficult the piece should be replaced. Each piece should last for up-to 6 weeks.

Example of initial wearing schedule for silicone sheets

Day 1:     4 hours	Day 4:    16 hours
Day 2:     8 hours	Day 5:    20 hours
Day 3:     12 hours	Day 6:    23 hours

Silicone creams(scarsil, prosil, silgel, nourisil)

• Silicone gel should be applied to the scar twice daily
• Before being apllied/re-applied the scar should be fully cleaned as normal
• Continue to apply moisturising cream but allow this to fully absorb before applying the silicone gel

Precautions

• Silicone should not be used on unhealed/open wounds
• In some cases a rash may occur. If this happens, make sure you are fully cleaning the sheets and the skin regularly. Try and reduce the length of time it is being worn.
• If the rash persists discontinue use and contact the scar management team.

Silontex

This is a fabric backed silicone sheet that is stitched into a pressure garment.

• It is only suitable to be used on small areas of scarring
• It is washed in the same way as described for your pressure garment (see below)
• Silontex should not be used on unhealed or broken skin.

Pressure therapy(pressure garments)

Pressure garments are made-to-measure clothing, fitted accurately to apply pressure to the scarred areas with the aim of achieving scars that are flat, soft, pale and comfortable.

• The pressure garments should be worn up-to 23 hours a day unless otherwise advised. They should only be removed for bathing and creaming
• Initially you may need to slowly build up your child's tolerance to the required wearing time.
• Progress of the scarring and the fit of the garments need to be monitors carefully therefore regularly attending your child's appointments is essential to achieve the best possible outcome.
• You will need to return to the scar management clinic every two-three months for your child to be re-measured.
• Garments should normally be received within 7-10 days from order. Please contact the scar management team if the garment has not arrived.
• When new garments are received old garments should be thrown away as they are no longer effective
• It is still important to continue with cream and massage
• Garments do not protect from the sun's UVA rays so high factor sun creams still need to be applied underneath the garments.

Please view our information leaflet Bobby wears pressure garments, which explains pressure therapy to children.

Washing instructions

• All garments must be either hand washed using a mild soap product or washed in a delicate wash cycle
• Leave garments to air dry (to remove moisture you may wrap the garment carefully in a towel)Do not use a tumble dryer or fabric conditioner as this affects the elasticity of the garment
• If the garment has a foam pad insert, this needs to be washed and dried separately. 

Precautions

If any of the following problems occur please remove the garment and contact the scar management team as soon as possible:

• Changes in circulation causing blueness or swelling in your hands and feet
• Abnormal sensation/pins and needles
• Sore or broken skin
• Damage to your garment

Movement and exercise 

Physical activity is important to maintain or build joint range of movement, muscle strength and exercise tolerance. Please discuss any specific concerns with your physiotherapist. We are happy to advise on exercise, hobbies and leisure activities.