INTRODUCTION:

Burns is a devastating injury in the field of medicine. A burn occurs when there is injury to the body caused by heat, chemicals, electric current or radiation. Burns represent a worldwide public health issue, leading to around 180,000 fatalities annually. Most of these cases take place in countries with low to middle income, and nearly two-thirds are found in the WHO African and South-East Asia Regions. In India, annually, more than 1 million individuals suffer moderate to severe burn injuries¹.

The number of fatalities from burns has decreased in recent times thanks to improvements in medical treatment options, yet burn survivors continue to face challenges with scars, disabilities, and deformities that necessitate prolonged care.

Many burn survivors who are recovering from the acute phase of burn have a question if they would develop burn scars and it becomes difficult for the health care professionals to respond to it as it is unpredictable. Living with scars can be a challenging experience, especially in today's society, where there is a strong emphasis on beauty. However, steps can be taken to minimize the appearance of scars, and burn survivors can adopt a positive mindset when it comes to living with burns scar. In this article we will discuss about the classification of burn wound, phases of burn wound healing, types of burn scars, its prevalence, pathophysiology of burn scars, factors predicting burn scars, physical, psychological and social impact of burn scar, management of burn scar along with psychological and social interventions to help them live with burns.

Classification of burn wound:

The classification of burn wound is determined by the depth of the injury, and the occurrence of burns scar depends on the depth of the burn wound. More the depth of the burn wound, more the risk for developing the burn scar. Burn wound is classified as

1. First degree burns (superficial burns) which involves only the epidermis. It heals within 5-6 days without scarring

2. Second degree burns has two types. Superficial partial thickness burns involves the superficial layer of dermis and healing occurs within 2-3 weeks with minimal scarring and deep partial thickness burns involves the deep reticular dermis and it takes longer time for healing and scarring is unavoidable

3. Third degree burns (full thickness burns) involves the epidermis, dermis, occasionally subcutaneous tissue, connective tissues and muscles. It takes more than eight weeks to heal and require surgical treatment.

4. Fourth degree burns (deep burn necrosis) is also known as full thickness burns that involves the fat, fascia, muscles and bones^2,3.

Phases of burn wound healing:

Wound healing Phase:

The open wounds are replaced by skin that is lighter in colour. For individuals with darker skin, the initial replacement of a burn wound might be pink, which tends to fade over time. In general, quicker healing of a wound results in less scarring.

Scar Formation Phase:

Once the injury has healed, the skin undergoes changes during the following 3–4 months. It may become darker, firmer, and elevated. Scarring can pose an issue due to its appearance. Additionally, scars can cause the skin to become rigid and uncomfortable.

Scar Maturation Phase:

The maturation of scars can last from 1 to 2 years. Throughout this time, the affected skin slowly begins to resemble a more typical skin colour. Additionally, it becomes less firm and more even in texture.^4,5.

Occurrence of burns scar:

As the burn wound heals, scarring can develop. Burn survivors can become frustrated that they still have problem with scarring after their initial burn injury has healed. Studies indicate that burns that are less severe and heal within 14 days typically do not leave scars. More serious burns take about 14 to 21 days to heal and have a higher likelihood of scarring. Burns that require over 21 days to heal have a significantly elevated risk of scarring and might necessitate skin grafts. Burn scars can lead to both cosmetic and functional issues, which can restrict daily activities, hinder the ability to resume typical social roles, and negatively affect overall quality of life. Burn scars appear to have changes in the colour which may be hypopigmented or hyperpigmented. Texture of the burn scar may be thick, tough or fibrous to feel and can be shiny or smooth. Burn scar can be raised or indented. Scarring usually develops within the first few months after the burn, peaks around 6 months and will resolve or “mature” in 12-18 months. As scars mature they fade in colour, become flatter, softer and generally less sensitive. As the healing progresses, the areas affected by burns, the grafted sections, and the donor sites will undergo changes in color and texture. The process of scar "maturation" typically lasts between 6 to 18 months, although it can extend beyond that. Factors such as genetics, burn severity, size, age, and the location on the body influence the development and maturation of scars. Predicting who will experience scarring is challenging⁶.

Types of burn scars:

1. Hypertrophic scars:

Hypertrophic scars are elevated, firm and erythematous. The most frequent complication associated with a burn injury is hypertrophic scarring, which can restrict a survivor's functionality and impact their self-image. These scars are itchy and sensitive. They remain confined to the initial injury site. Over time, their appearance diminishes. 70% of the burn survivors develop hypertrophic scars as cited by Finnerty, Celeste C et al in 2016.But in a study done among 383 paediatric burn survivors, 17.2% of them developed hypertrophic scars^7,8.

2. Contracture scars:

A contracture scar is characterized as the abnormal consequence of prolonged scarring and continuous contraction of the scar tissue, leading to a reduction in the range of motion around the joints. It limits daily functioning and affects the health related quality of life after burns. In a systematic review on the prevalence of scar contracture, it was found to be 38-54%, but with a longer time after burn, the prevalence was lower⁹.

3. Keloid scars:

Keloid scars are raised, hard and shiny scars that can appear after burns. It can be skin coloured, pink, red, purple, brown or darker than the surrounding skin. It can be larger than the original wound and it can cause itching and be painful while they are growing¹⁰

Pathophysiology of burn scar formation:

The process of healing in burn injuries occurs through three interrelated phases. The inflammatory phase is initiated by injury, during which platelets, neutrophils, and macrophages secrete inflammatory mediators and cytokines that aid in attracting inflammatory cells, fibroblasts, endothelial cells, and epithelial cells. The proliferative phase entails the activation of fibroblasts, differentiation of myofibroblasts, and the deposition of the extracellular matrix (ECM). During this stage, myofibroblasts develop contractile abilities that allow them to tighten the wound and facilitate re-epithelialization. The third stage of healing involves the remodelling of the matrix, which encompasses the remodelling of scar tissue. In this stage, ongoing activation of myofibroblasts, an imbalance between the deposition and degradation of the extracellular matrix, and improper organization of newly created fibers can result in the formation of scars.

Myofibroblasts, which are cells derived from resting fibroblasts and various other cell types, have been shown to be crucial in the initiation and preservation of scar contracture. In typical acute wound healing, myofibroblasts have a temporary presence and are eliminated through apoptosis during the third phase of healing when the tissues are restored. In hypertrophic scars and keloids, myofibroblasts remain in elevated numbers for extended durations and encourage the production of α-smooth muscle actin (α-SMA), transforming growth factor-β1 (TGF-β1), and various other growth factors; they also maintain their contractile capabilities through a positive feedback loop involving TGF-β1^11,12. This leads to various types of burn scars formation.

Assessment of Scar quality:

Scars are evaluated based on specific parameters, including pigmentation, vascularity, thickness, pliability, height or depression, patient acceptability, and comfort. It helps in planning further management for burn scars. A variety of measuring tools have been developed, including the Vancouver Scar Scale (VSS), the Visual Analog Scale (VAS), and the Patient and Observer Scar Assessment Scale (POSAS).

Vancouver Scar Scale is a reliable objective assessment of burn scars. It pertains to the healing and maturation of wounds, as well as the cosmetic appearance and function of the healed skin. It pertains to the healing and maturation of wounds, as well as the cosmetic appearance and function of the healed skin. Pigmentation, vascularity, pliability and scar height are assessed. Normal skin has a score of 0 and increasing score being assigned to the greater pathological condition¹³.

The Patient and Observer Scar Assessment Scale (POSAS) includes two numeric scales, each with six items, that represent the perspectives of both the Patient and the Observer regarding various characteristics of scars, including colour, thickness, relief, pliability, pain, and itching. The features of the scar are evaluated on a numerical scale from 1 to 10, with 1 indicating a scar that resembles normal skin and 10 signifying the most severe scar possible.¹⁴

Factors predicting burn scar:

1. Patient characteristics:

a) Sex: Several studies have highlighted that females have increased incidence of burns and have poorer scar quality¹⁵.

b) Age: Older patients have less risk for pathological scarring. Research indicated that the likelihood of developing raised scars was lower in individuals over 45 years old, in contrast to those who are 30 years old or younger.

c) Skin type: Scar hypertrophy was more common in dark skinned patients. The Fitzpatrick classification of skin types consist of six categories, ranging from type I (very pale) to type VI (deeply pigmented dark brown to the darkest brown). Skin types V or VI are linked to a lower quality of scarring.

2. Injury characteristics:

A larger percentage of total body surface area burned, the presence of full thickness burns, complications related to wounds, and an extended duration of wound healing contribute to the risk of developing burn scars.

3. Treatment characteristics:

An extended duration of hospitalization, the kind of skin substitute used, numerous surgical procedures, repeated surgeries on the wound, reconstructive operations, and the use of artificial ventilation increases the likelihood of scarring.¹⁶.

Physical problems with burn scars:

1. Burn scar can be dry leading to cracking or breakdown of the skin

2. It can be more sensitive to touch and their physical environment such as exposure to sun and certain bath and body products

3. It can lead to symptoms such as neuropathic pain¹⁷

Psychological problems with burn scars:

1. As the burn wound heals, burn survivor realizes that scars may be permanent and the body image has been altered.

2. Burn survivor experiences grief and has diminished body image and self esteem.

3. Psychological problems like post traumatic stress disorder, depression and anxiety occur which can become chronic if they are not treated appropriately¹⁷.

In a systematic review and meta analysis on the prevalence of anxiety among burn survivors, it was found to be 16.1%¹⁸. According to a 2 years prospective study of burn survivors, major depressive disorder was present in 8.5%, 5.9% and 4.2% at 6, 12 and 24 months post burn¹⁹. 42% of burn victims and 51% of the family members had Post traumatic stress disorder according to a study done by Hao Zheng in 2021²⁰.

Social impact of burn scars:

Burn survivors have social consequences due to burn scars. It has been studied that they face stigmatizing behaviour, develop body image dissatisfaction and exhibit anxiety and fear of social interaction due to burn scars¹⁷.

Care of Burn Scars:

Moisturizing and Massaging:

Massaging the scar with lotion helps to keep them moist, make them less sensitive, decrease itching and make stretching easier. Moisturizers can be used on all healed regions multiple times during the day. When using moisturizers, apply them in light layers and gently massage, as scars are delicate. As the scar matures, more pressure can be added to loosen the scar so that they are not stiff. Hot shower may remove natural oil from skin which makes it necessary to remoisturize it after shower.

Avoiding sun exposure:

Sun exposure can be avoided by planning activities in the early morning or late evening. Avoid exposure to sunlight. Scars that are discoloured and have not matured burn easily. Broad spectrum sunscreen with a SPF level greater than 30 can be used frequently to maintain sun protection and it can be reapplied every 2 hours.

Stretching:

Stretching of the burn wound scar should be performed to a maximum of five to six times per day. To make stretching easier, first moisturise the scars with a moisturizer.

Splint or cast can help position the scar in a stretched position.

Movement and activity can be improved by doing self care activities as much as possible²¹.

Treatment Options for burn scars:

There is no universally optimal treatment for the management of burn scars. Nonetheless, various treatment modalities are available that can significantly reduce, if not fully eradicate, the associated damage.

Nonsurgical treatments:

· Custom made inserts: This product is designed to be worn under gloves, compression bandages, or custom garments, which may enhance pressure on the scar and promote its maturation. It is offered in a range of materials, including soft foam and rubber-like substances, to accommodate various preferences and needs.

· Massage and stretching: These methods can enhance skin pliability and reduce the sensitivity of hypertrophic scar tissue, facilitating improved remodelling and aesthetic outcomes. Burn scar massage helps to relieve tissue and muscle fiber tension. It stimulates oxygen rich blood to circulate throughout the body. It helps to break down the internal scar tissue and underlying adhesions. It reduces edema and itching and promotes pliability and range of motion. It promotes healing of the burn scar²².

Systematic review and meta analysis on the effectiveness of scar massage revealed that scar massage improved the scar formation and reduced pain level, pruritus and anxiety among burn survivors with hypertrophic scars²³. In a systematic review done on efficacy of massage on burn scar management, nine out of ten studies show that scar massage was effective in reducing burn scar²⁴.

· Pressure garments : Pressure garments are customized to each burn survivor and helps to control scar maturity .It has to be worn for 24 hours, and has the potential to alleviate itching and discomfort, while also offering protection to the healing tissue. This is achieved by applying 20-25 mm of Hg pressure to the maturing scar. Pressure therapy causes a state of hypoxia and the expression pattern of transforming growth factor-β1 (TGF-β1) is decreased, which in turn restricts fibroblast activity. This contributes to the reduction of hypertrophic scarring. Evidences from systematic review of 17 articles showed that pressure therapy is capable of improving scar colour, thickness, pain and scar quality^25,26 .

· Silicone gel treatments: Thin layers of medical-grade silicone can be utilized either on their own or beneath clothing or casts to alleviate itching and dryness. They are long-lasting and comfortable for extended wear.

· Intralesional injection: Intralesional pharmacologic treatments for hypertrophic scars and keloids include triamcinolone acetonide and fluorouracil which is administered weekly or monthly for four to six months to improve burn scar characteristics²⁷.

· Laser therapy:

Laser therapy has shown to be effective in treating burn scars and is more effective than topical treatments, and it can be combined with surgical procedures. Carbon dioxide laser resurfacing is the most commonly utilized method for minimizing scar thickness, enhancing texture irregularities, and addressing contractures ²⁸

· Novel treatments :

Polyherbal ointment made of neem, tea tree oil and Katphala has been found to have predominant antimicrobial activity and helps to promote wound healing and thereby reduce the risk of scar formation²⁹. Moringa Olifera has efficacy in promoting burn wound healing according to a recent study ³⁰. Ointment of 10% Siam weed ethanol extract has antioxidant and anti-inflammatory activity thus helps in the burn wound healing process³¹.

Surgical treatments:

While it is not possible to completely eradicate scars, surgical options are available that can reduce their visibility and enhance mobility in areas affected by contractures.

· Skin grafts: Healthy skin is placed over the burnt area to help in the better healing. Skin grafts can be either split-thickness skin grafting which are thin and involve removing the epidermis and a shallow dermis layer from the donor site or full-thickness skin grafts which removes the entire epidermis and dermis layer from the donor site³².

· Skin flaps: A skin flap consisting of skin, fat and muscles are attached to the burnt area which is the recipient site along with the blood vessels and it helps in the healing process³³.

· Tissue expansion: A silicone balloon is utilized to expand healthy skin so that it can be utilized to substitute burned scar tissue^34,35.

· Scar release surgery: Burn tissues can become stiff and leads to contracture scars which necessitates scar release surgeries to improve the functional ability and appearance.

Burn scar reconstruction aims to improve or restore physical function, confidence, and body image. Like acute burn care, burn scar reconstruction requires thoughtful, coordinated approaches along the continuum of burn injury, recovery, and rehabilitation³⁶. Bioresources from plant and animal helps in wound healing and restores skin integrity³⁷. Appropriate burn management helps in optimizing the burn scar by providing better wound healing³⁸ .

Interventions to manage psychological problems with burn scars:

1. Encourage burn survivors to get connected with friends and family and ask for support.

2. Assist them in accepting the injury and the changes and also understand that recovery proceeds at a slow pace

3. Encourage them to stay active and exercise regularly.

4. Help them to return to the normal routine as soon as possible.

5. Encourage them to seek support from professional organisations.

6. Connect them with other burn survivors and seek peer support.

7. Psychotherapy by trained mental health professionals can help to overcome problems like body image disturbances, anxiety, depression, post traumatic stress disorder etc

8. Cognitive Behavioural therapy is an effective intervention to overcome psychological issues

9. Encourage burn survivors to practice stress management.

10. Motivate the burn survivors to utilize the coping skills.

11. Encourage them to improve communication and social skills

12. Seek medications for depression, anxiety or insomnia if it could not be managed by other interventions³⁹

Interventions to manage social impact of burn scars:

Barbara Kammerer Quayle suggested strategies for a burn survivor to feel confident when entering new social situations. Burn survivors should be encouraged to follow the techniques.

Do self talk so that the burn victim tells himself/herself that he/she loves and accepts himself or herself and he/she can do it

Have friendly, warm and enthusiastic tone of voice

Have eye contact with people

Have a confident posture

Have a smile that makes them look confident and approachable.⁴⁰

CONCLUSION:

Burn scars can have devastating consequences in terms of physical, psychological and social wellbeing of the burn survivor. They face enormous challenges and living with burns becomes difficult. As health care professionals, we need to identify the needs and the problems of the burn survivors and assist them in the rehabilitative journey. It will enhance their quality of life and help them live a productive and satisfied life.

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Received on 15.12.2024 Revised on 12.01.2025

Accepted on 05.02.2025 Published on 22.02.2025

Available online from March 20, 2025

Int. J. Nursing Education and Research. 2025;13(1):53-58.

DOI: 10.52711/2454-2660.2025.00012

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