Scar treatment

If your wound has healed on its own without a skin graft within two weeks then it is unlikely that you will develop scarring. The healed area will be red initially and gradually pale over several months. The skin may be dry and require moisturiser initially but you should be able to return to normal activity very quickly and have no long term difficulties.

If the wound takes longer than two weeks or has required a skin graft to the area then the risks of you developing some scarring is higher. For some people this scarring will cause no difficulties but they may develop into hypertrophic scars.

The reason for this is that it is likely to have been a deeper injury to the skin and therefore more of the skin structures are damaged. When the wound heals the connective tissue (collagen/scar tissue) is laid down to heal the wound. In burn wounds the inflammatory action that enables wound healing continues beyond the wound closure and can cause the area to become more irregular forming raised, thickened, sensitive, itchy and red scars. This type of scarring is called hypertrophic and can develop up to 3 months post wound healing.

There are other factors that can lead to higher risks of problem scars / hypertrophic scars after an injury. These include having an infection that causes the wound to deepen and healing to take longer, if the site of the injury is on areas that are more mobile particularly the chest and top of the shoulder. Your skin type and your genetics can also make you more likely to develop hypertrophic scars. There are a range of factors associated with hypertrophic scarring that make it important to treat:

• The appearance of scars can make people self-conscious and avoid returning to their normal activities.
• Scars across joints can cause problems with movement.
• Scars can be painful, tight, and uncomfortable.
• Scars can be very sensitive.
• Scars can be itchy and can lead to scratching and skin breakdown alongside causing difficulties with sleep.
• Scars can be dry and result in cracking or breakdowns in the skin.
• Scars are more sensitive to the sun and chemicals.

Scarring can take up to 2 years and sometimes beyond to mature so treatment may continue for this long.

Unfortunately it is not possible to prevent hypertrophic scarring. It is, however, possible to minimise the effects and improve the appearance through:

• Moisturising. 
• Massage. 
• Wearing a pressure garment. 
• Using silicone gels / sprays and sheets. 
• Carrying out exercises and stretches. 
• Using splints.
• Resuming your normal daily activities as much as you can.

Sometimes you may be referred to the burns doctors to assess for extra scar treatments, these may include:

• Medication.
• Steroid injections.
• Laser treatment.

• If you have dressings on and no surgery, and it is healed within two weeks, you are unlikely to need scar management input. Superficial burns normally heal without scarring.
• If you have dressings on and no surgery, and it is not healed within two weeks, you will need to be monitored at burns clinic as may require scar management.
• If you have had a skin graft, You will require a review from the scar management team as it is likely your burn was deeper, so the chances of scarring are higher.

Scars and skin graft donor sites require regular creaming to prevent the area from drying, cracking, and becoming sore. This can be because the oil glands in your skin that usually provide moisture can be damaged or destroyed during the injury and the surface layer that prevents water loss is damaged.

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.

Once your wound has healed we will advise you to start gentle massage called gliding. Before putting on your moisturiser place your fingers onto the scar and move in gentle circular motions – you are moving your skin not your fingers to prevent friction. Please ask your therapist to demonstrate. Spend a few minutes using this technique then apply your moisturiser. 

As the scar matures you can increase the pressure of the massage to help soften scars. Your therapist will guide you in this process as massaging too firmly initially can make scarring worse.

As discussed previously the new skin which has formed following the injury lacks the moisture needed. Silicone then acts to seal in the moisture and hydrate the scar. Silicone treatment aims over time to flatten, soften and pale your scar, alongside reducing discomfort. Silicone can be in the form of a sheet, liquid, spray or stick and if recommended by your therapist they will discuss with you the most appropriate type for your scar.

Precautions

• Some people find they are sensitive to silicone.
• If you have been given a silicone sheet it is important to build up wearing it daily from 4 hours on the first day of use by an additional 4 hours each day until the required time recommended by your therapist.
• Check your skin frequently for irritation or rashes over this period. Stop using the silicone and discuss further with your therapist if this does happen.
• If you know you have sensitive skin it may be advisable to patch test silicones away from your scar first to make sure your skin does not react.

Initial wearing schedule for silicone sheet

Silicone sheet

• Your sheet should be cut to size to cover the scar. It is self-adhesive but may require further fixation with a bandage or tape.
• You should wash your sheet twice daily with mild non-oily soap, rinse in warm water, allow to dry then reapply. Use two pieces and rotate between them whilst the washed sheet is drying. 
• Before reapplying, cleanse and dry your skin as normal, moisturise and ensure full absorption of the cream. 
• Your sheet should be worn for at least 12 hours a day and where possible up to 23 hours a day. 
• When the sheet begins to deteriorate and cleaning becomes difficult your gel should be replaced (a piece will last between 1-2 months). 
• The ongoing supply of your silicone treatment should be provided by your GP, these are expensive products so please take care of them and use then as advised.

Silicone gels

• Before being applied, your scar should be fully cleaned as normal. 
• Unless otherwise specified by your therapist then these should be applied twice a day once your moisturising cream has absorbed. 
• Silicone gels go a long way and only a thin layer is required for effective treatment, if they take longer than a minute to dry then you have put on too much.

These are elastic garments that can be off-the-shelf or made-to-measure. They are worn over your scar with the aim of achieving scars that are flat, soft, pale, and comfortable. They could be required to be worn up to 2 years post healing.

They work by applying appropriate levels of pressure to the scar which aims to restrict blood flow/reduce the scar inflammation and inhibit the growth of hypertrophic scar tissue by using constant compression to the area.

To achieve the best possible outcome it is important to wear the garment for 23 hours a day, removing it only to wash, apply moisturiser and change garments.

If your occupational therapist has assessed that pressure therapy is an appropriate treatment for you, they will take appropriate measurements and either fit an off-the-shelf product or send the measurements to an external provider who will make a bespoke garment. You may be required to attend a fitting appointment 2-3 weeks after being measured to check the best possible fit is achieved.

Your garment may require further alteration following this appointment but can then be sent to you in the post along with your repeat garments. If it is not your first garment we may measure you again and you will be asked to contact us to inform of us of the correct fit before being issued with your repeat garments.

After this you will be reviewed around every 3 months as the elasticity of your garments will reduce and optimum pressure is not achieved. It is important to attend your appointments to monitor the progress of scarring and fit of your garments in order to achieve the best results.

Your garment does not protect you from the suns UVA and UVB rays so high factor sun protection will need to be applied underneath the garment. It is also important to continue with recommended cream and massage whilst wearing a garment.

Care instruction and precautions

• Your garments are an expensive product so please take good care of your garments and follow the care instructions 
• Please contact your therapist if you notice any abnormal swelling, blueness, abnormal sensations or sore or broken skin.

Care instructions for made-to-measure garments

• Garments can be hand washed using a non-biological product or machine washed on a 30 degree wash cycle. Do not use fabric conditioner.
• Leave garments to air dry, please do not tumble dry as this will damage your garment.

Care instructions for off-the-shelf garments

• Garments can be washed on a 40 degree or lower cycle.
• Garments can be air dried or tumble dried.

Silontex

Your therapist may also recommend Silontex which is a fabric backed silicone gel sheet that is stitched into your pressure garment.

• It is only suitable to be worn on small areas of scarring. 
• It is washed in the same way as your pressure garment. 
• Silontex should not be used on unhealed areas or open wounds.

Scars are extremely sensitive to sunlight and exposure to the sun without sufficient protection will mean scars burn easily and could cause long term damage darkening the scar which could be irreversible. 

We recommend high factor sun cream with both UVA and UVB protection on scarred areas for 2 years post burn injury and also covering them with clothing to increase the protection.

Itching is unfortunately very common after a burn injury and can continue long after the wound has healed. It can be triggered by activity, heat, and manipulation of the scar.

What can I do?

• Apply moisturising cream regularly. 
• Creams can be cooled in the fridge prior to application which should have a soothing effect. 
• Extremes of temperature can make the itching worse particularly heat so avoid very hot baths or showers. 
• Try and cool, rather than scratch the area, use a fan or place a cold towel over the affected area.

If you are still experiencing problems after trying this advice then your therapist can discuss other options and may refer you to one of the burns consultants.

Hypersensitivity is caused by damage to the nerve endings due to injury of the skin. It can be painful and present as tingling, shooting/burning pain or a severe ‘pins and needles’. The nerve endings in the scar continue to send pain signals to the brain after the wound is healed when there is no longer a need to protect the area. 

If possible it is important to continue normal activity and to not be over protective of the sensitive area, you will not be damaging the area. Your therapist will discuss the techniques with you and which are most appropriate in how to manage the hypersensitivity specifically to your current symptoms.

Desensitisation techniques include: 

(Please do not use these techniques until advised by your therapist)

Massage the hypersensitive area with moisturising cream:

• Start massaging the area (using small circular motions) at a point where there is normal sensation. 
• Gradually move up to a point where the discomfort begins and massage that area until the discomfort eases. 
• Then move up to a point where it feels sensitive and repeat the process. 
• Continue until you have reached the most sensitive point. 
• Carry out 3-4 times a day for approximately 10 minutes.

Stimulate the area with various textures:

• Graded textures can be used to stroke the hypersensitive area. Start with soft materials and work up to coarser textures e.g. cotton wool, felt, toweling, rough cloth, Velcro. 
• If your scar is on your hand or foot they can be immersed in a bowl of materials including: cotton wool, kidney beans, lentils, rice, or pasta. 
• Carry out 3-4 times a day for approximately 10 minutes. Make sure you are looking at the area whilst carrying out the treatment.

Sleep is essential for your health and wellbeing, protecting both your physical and mental health. 

Following a burn injury or trauma there may be many reasons why sleep can be affected including disruption to your sleep pattern, anxiety related to the injury, pain and discomfort and taking medications. 

If you are suffering from poor sleep some of the problems it can cause include:

• Increased pain and discomfort. 
• Restlessness, irritability, and changes in your behaviour. 
• Low mood. 
• Anxiety. 
• Lack of energy. 
• Poor motivation.
• Difficulty concentrating. 
• An increased risk of accidents.

If your scars have any of the following symptoms these can also affect the quality of your sleep:

• Tightness or contractures. 
• Pain. 
• Sensitivity. 
• Itch.

The treatments you are having for your scarring will slowly help improve these symptoms but while you are recovering there are other things you can consider to help improve your sleep.

• Try to stick to a regular routine of when you go to bed and when you get up. Doing so will help you to establish a reliable sleep-waking cycle, which is important for restful sleep. 
• Allow yourself time to switch off and unwind. Try engaging in relaxing activities such as reading a book, listening to restful music, or engaging in relaxation. 
• Initially after your injury you may need to nap during the day. If needed, try to keep the length of your nap short (limited to 30 minutes or less) to reduce the impact on your night-time sleep.
• If you find yourself tossing and turning for longer than 20 minutes, get up and try and do something to make yourself sleepy, such as read a book, complete a puzzle, have a milky drink, or try some relaxation. 
• Avoid food and drinks with caffeine in the evening as these act as stimulants and can keep you awake e.g. coffee/tea/some soft drinks/chocolate/some bakery products. 
• Try not to carryout activities such as surfing the web, playing video games just before bed time. The blue light from devices such as phones/tablets/televisions can impact on your ability to sleep by inhibiting the release of melatonin (a hormone that facilitates the onset of sleep). 
• Exercise is an important part of being physically tired and important for your recovery from your injury to aid sleep but do not do rigorous exercise close to your bed time as it can act as a stimulant, reducing your ability to sleep.
• Consider your bedroom environment, keep it free of clutter and it is usually better to keep it relatively cool as over-heating can increase itch in your scars. Using a fan can be helpful.
• If you sleep with a partner and your needs are different consider having separate duvets at different TOG levels. You can buy bedding that helps control your temperature so it is worth shopping around.
• If you have been advised that you need to position your affected limb, additional pillows can help, you may also want to consider a U or V shaped pillow that can add additional support to painful limbs.

Worry relating to your burn injury, symptoms, or unrelated stressors can all impact on your ability to get a good night’s sleep. Worry and anxiety keeps the brain active and activates the body’s stress response. If you find that worry prevents you from falling asleep or keeps you up at night you may wish to:

• Set time aside earlier in the day to write down your current worries and consider how you might tackle these. 
• Create a relaxing bedtime routine. 
• Note down any concerns that arise during the night and review these in the morning. Committing your worries to paper frees the mind to think of other things and reduces the likelihood of ongoing worry and rumination, which keeps the mind active. 
• Engage in calm (diaphragmatic) breathing or meditation. You may wish to consider listening to restful music, relaxation scripts or specific sleep apps such as Calm.

If you are having difficulty with sleep please talk to your therapist or your doctor as there may be other things that can help including medication or support from the burns psychology service.

There are many useful resources online about improving sleep please see some links below:

Sleep Recovery Tips After a Burn Injury | MSKTC

Home - The Sleep Council

Explore mental health

It is not uncommon for people to experience some appearance related concerns after a burn. 

Our skin camouflage service is available for free for those patients who have sustained a burn injury to their face or hands, for all other injury types and areas of the body there is a charge. 

If the appearance of your scar bothers you and you would like to cover it up as much as possible. Your therapist can make a referral to the skin camouflage service where a specialist can trial specific make-up to cover your scar. You may also be to access camouflage through the charity Changing Faces.

A burn injury or a scar does not just affect someone’s skin but can also influence how they think and feel.

Common experiences are feeling low or vulnerable, some can find that the burn incident is going over and over in their minds; they may experience flashbacks, distressing dreams or are avoiding situations which are reminders of the incident.

People cope in different ways but some find that it helps to talk to someone outside your family or friendship group. We have a burn psychologist within the team who can listen to you and provide support and possible management strategies as part of your rehabilitation. There is also a support service called Outlook which offers psychological support for people with appearance concerns, your therapist can discuss referral to them with you if required.

Once your wounds are fully healed you should be able to bath or shower as previously using your usual washing products. You may also be ready to return to work and start doing any sports or hobbies you did previously. 

You may need a graded return back to work due to reduced range of movement or stamina and are likely to require rest periods during the day dependent on the type of work you do. Please discuss this with your therapist or burns doctor if you require any advice.

Scar appointments at Southmead Hospital are held in Gate 24.

If you have an appointment booked that you can no longer attend or are unsure whether you need the appointment thathas been booked for you then please contact us to let us know. We also provide virtual appointments which can be completed via video call, we will discuss with you if this may be appropriate based upon your scarring and treatment provision.

Adult Burns Unit

Burns | North Bristol NHS Trust (nbt.nhs.uk)

Adult Burn Support UK

Adult Burn Support UK – Information, support and advice about burns in the UK

A support resource for adult burn survivors in the UK.

Email: info@adultburnsupportuk.org

Funded by Dan’s Fund for Burns national charity.

Dan’s Fund for Burns

Dans Fund For Burns – Giving burn survivors the help they need

Dan’s Fund for Burns is a national charity offering practical help to burn survivors in the UK. The charity identifies those most in need of help and provides it in a swift and practical way.

Changing Faces

Changing Faces | Visible Difference & Disfigurement Charity

Changing Faces is a charity for people and families who are living with conditions, marks, or scars that affect their appearance.

Katie Piper Foundation

www.katiepiperfoundation.org.uk

Offers a range of support, rehabilitation and scar management for burns survivors.

Outlook

Outlook | North Bristol NHS Trust (nbt.nhs.uk)

Psychological support for people with appearance concerns.

Talkscar 

A community sharing experiences and knowledge to make life with scars easier. 

talkscars (talkhealthpartnership.com)

Pressure garment manufacturers

Medigarments 

Medigarments Ltd – Designed Around You - Compression garments (jobskin.co.uk)

Juzo 

Juzo · Freedom in Motion

Medi (Duomed) 

Welcome to medi - I feel better. (mediuk.co.uk)

Lipoelastic 

lipoelastic.co.uk

Silicone sheet manufacturers

Cica-Care 

Products (smith-nephew.com)

Molnlycke (Mepiform) 

A world-leading provider of single-use surgical and wound care products | Mölnlycke (molnlycke.co.uk)

Silicone gel manufacturers

Scarsil 

ScarSil® Topical Gel. Scarsil gel – 15ml and 30ml (jobskin.co.uk)

Kelacote – Silicone Spray

Home - Alliance Kelo Cote

Nourisil 

Nourisil™ MD | Scar Gel | Scar Cream | Scar Removal (nourisilmd.co.uk)

Some examples of non-perfumed creams available (there are many others)

Alhydran 

Available through your GP or online purchase. 
ALHYDRAN CO UK 

Aveeno

Available through your local pharmacist, Boots or Superdrug. 
Buy Best Skin Care Products Online - AVEENO

Epaderm 

Available through your GP or Boots. 
Epaderm | Mölnlycke

QV 

Available through your GP or on Amazon. 
Products For Sensitive Skin | QV Skincare United Kingdom

Dermol and Doublebase 

Available through your GP. 
Dry Skin from Doublebase – clinically proven moisturising emollient (mydoublebase.co.uk)

CeraVe 

Available through your local pharmacist, Boots or Superdrug. 
Welcome to CeraVe: Your Skincare Expert | CeraVe

We would really appreciate your feedback about the service we have provided to help with your scarring. Once you have been discharged from our service you can access a short survey to provide your views and it will take no longer than 4 minutes.

Scar Management Feedback Form (office.com)