Burn Wound Healing Considerations and Recovery Care Interventions

Original Editor - Stacy Schiurring based on the course by Diane Merwarth

Top Contributors - Stacy Schiurring

Burn Wound Healing Physiology

Please see this document for a growing list of wound care terminology and definitions.

Epithelialisation

"Epithelialization is a process of covering defect on the epithelial surface during the proliferative phase that occurs during the hours after injury. In this process, keratinocytes renew continuously and migrate upward from the basal to the differentiated layers. A continuous regeneration throughout homeostasis and when skin injury occurs is maintained by the epidermal stem cells ... Epithelialization is the most essential part to immediately reconstruct skin barrier in wound healing where keratinocytes undergo a series of migration, proliferation and differentiation."

Superficial partial thickness wounds:

• Epithelialisation occurs as the proliferative phase comes to an end and the remodeling phase begins
• Significant decrease in the amount of exudate released from the wound
• Risk of infection decreases
• Initial epithelial resurfacing is a thin, single layer of keratinocytes which will mature to a stratified, multi-cell layered structure that provides the barrier functions of the skin
• Skin appendages (hair follicles, sebaceous glands and sweat glands) eventually return to normal functioning
• No granulation tissue is generated and therefore these burn wounds generally heal without scar formation

Burn injuries of indeterminate depth or deep partial thickness wounds:

• Involves damage deeper into the dermal layer and may destroy many of the skin appendages. 
  • Full thickness burns eliminate all of the dermal appendages. 
• Healing of these burn injuries involve scar formation which never regains the normal structure and function of the skin, this is also true for areas of skin graft placement.

Burn Wound Care During Re-epithelialisation

"Care of the burn wound as it is re-epithelializing is critical to allow the new epidermis to resurface the burn and mature.  Any trauma or changes in the wound environment may delay or prevent ongoing epithelialization or cause deterioration of new epithelium." -Diane Merwarth, Physical Therapist, Wound Care Specialist

Wound Cleansing

• must be extremely gentle to avoid traumatising the new epithelium, a gentle rinsing and patting of the wound is sufficient

Dressing Selection and Techniques

• use of nonadherent dressings that minimize evaporative water loss while not causing a situation where the wound may be too wet. 
• decreasing dressing change frequency minimises the risk of causing trauma to the fragile new epithelium
  • ideally dressing changes should be undertaken every 3-5 days, depending on the dressing being used, unless there are infection concerns
• discontinue the use of silver-based dressings also facilitates the final re-surfacing of the burn wound
• protection of the wound margins, including the new epidermis, will help keep dressings from adhering and avoid potential periwound maceration
• dressing application should be discontinued when there is no drainage on the dressings and the wound area is visibly re-epithelialised

Table 1. Dressing Options During Re-epithelialisation Phase

	Benefits	Risks
petrolatum-based gauze dressing (eg Xeroform or Vaseline gauze)	provides an occlusive layer that maintains a moist environment rarely adherent to wound surface
Non-adherent Foam dressing	rarely adherent to wound surface up to 7-days
Hydrocolloids	provides an occlusive layer that maintains a moist environment rarely adherent to wound surface	May maintain too moist wound environment
Transparent Films	Allows for visual monitoring of wound	Do not absorb drainage Blistering potential May maintain too moist wound environment Adhesive poses risk of wound or periwound trauma with removal
Alginate dressings	When allowed to attach to wound bed, will create an occlusive environment gelling of wound dressing maintains moist environment

Burn Wound Complication: Maceration

Maceration is a common complication of burn wounds.  Prolonged exposure to excessive moisture effects periwound skin and causes it to be weakened and easily ruptured, due to:

• decreased elasticity and increasing brittleness of the epidermis
• decreased collagen density
• flattening of the basement membrane
• decreased binding of the basement membrane to the extra-cellular matrix
• impaired re-epithelialisation

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  Red skin demonstrates re-epitheliasation. Please note thee small raised hair follicles in the of re-epithelialisation.

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  Red and pink areas demonstrate re-epiithelialisation

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  Red and pink areas demonstrate re-epiithelialisation

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  White areas in periwound demonstrate maceration

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  White areas in periwound between toes demonstrate maceration

All photos provided by and used with kind permission from Diane Merwarth, PT

Prevention is the best intervention to avoid the complications associated with maceration: 

1. Appropriate dressing selection to manage drainage
2. Appropriate dressing change frequency
3. Protecting the periwound skin and any epithelial islands within the wound:
   • applying an ointment, paste, emulsifier or liquid polymer to protect the skin from moisture exposure. Example: zinc oxide paste, petrolatum or antibiotic ointment
   • placing a dressing or dry gause between the digits or skin folds

Clinical Pearl: Zinc Oxide Paste

Zinc oxide paste is a commonly used mineral paste in the treatment of skin irritations. It is inexpensive and readily available in most places. It can provide periwound protection against moisture and maceration. The thick white paste is opaque which makes determining the periwound condition difficult. The paste can affect the absorbency and adhesion of overlaying dressings.

Zinc oxide paste is robust and adherent to the skin, fortunately it does not need to be completely removed at each dressing change. 

• The area can be gently wiped to remove the surface residue and crusted exudate
• If there is still adequate paste on the skin, it is not necessary to add more paste.  If there are areas of sparse coverage, more paste can be added. 
• When protection of the skin is no longer indicated, any resistant paste can be removed by applying a layer of petrolatum and wiping the skin after a few minutes.

Patients may have an allergy to this product. Please view this link for additional allergy information.

Post-healing Skin Care

After the skin has re-epithelialised, care of the new epithelium must be diligent.

• Moisture retention and hydration
  • It can take up to 1 year post re-epithelialisation for these functions to be restored following superficial partial thickness burn injuries
  • During the remodeling phase, hydrating creams or lotions can replace some of the moisture retention functions of the skin
  • General recommendations for moisturizing and or hydrating skin include using a non-irritating fragrance-free cream or lotion specific for moisturising the skin
• Avoid exposure to ultraviolet rays  
  • Increased the risk of developing skin cancer
  • Recommendations for protection from the sun include use of sun screen of at least 50 SPF, and wearing clothing or hat to cover the newly-healed skin
• Decrease friction on new skin
  • Bathing: avoid aggressive scrubbing of the new skin while washing and drying 
  • Application of moisturizers: done with minimal friction.  It is not necessary to completely rub the cream or lotion into the skin as it will be absorbed very quickly into the dry skin. 
  • Clothing selection: 
    • Avoid any tight clothing over area of burn wound
    • Avoid wearing any clothing made of rough fabric
    • Recommend well fitting shoes
    • Recommendations typically include loose, soft clothing. Socks should always be worn with shoes.
• Activity and nutrition  
  • A burn injury results in a persistent hyper-metabolic state which requires sufficient caloric intake to support metabolism. Recommendation for a dietician or nutritionist consultation.  
  • Fatigue is a common side effect of the energy requirements of this hypermetabolic state

Post Burn Wound Injury Care and Rehabilitation

Physical Rehabilitation

"The rehabilitation for patients with burn injuries starts from the day of injury, lasting for several years and requires multidisciplinary efforts."

Physical rehabilitation plays huge and vital role in improving functional independence and ability, maintain medical status, and have positive influence on emotional and psychological well-being. Physical rehabilitation in post-burn wound injury care can include:

• Maintaining range of movement
• Minimising development of contracture and the impact of scarring
• Prevention of deformity
• Maximising psychological well-being
• Maximising social integration
• Maximising functional ability and recovery
• Enhancing quality of life

Please read this article to learn more about post burn wound injury physical rehabilitation.

Burn Scar Management

"Hypertrophic scar formation is a significant debilitating factor following a burn injury.  For burn survivors who suffer deep-partial or full thickness injuries, development of hypertrophic scars is inevitable.  Damaged or destroyed extracellular matrix is unable to regenerate, and therefore can’t provide the components needed to regenerate the epithelium.  The excessive and prolonged inflammatory response that is normal to burn injuries results in the production of immature collagen." - Diane Merwarth, Physical Therapist, Wound Care Specialist

Hypertrophic scar characteristics generally include:

• elevated, firm , and erythematous in appearance
• pruritic (itchy) and tender for the patient
• limited to the site of the original burn wound injury
• grow in size by pushing out the scar margins

Additionally, because the epidermis is not regenerated, the normal functions of the skin are not restored:

• loss of sweat glands, which diminishes thermoregulation in the involved area
• sebaceous glands are not available to provide lubrication to the skin and hair follicles
• pliability/elasticity of the skin and soft tissue is severely diminished which directly contributes to scar contracture and limited functional ROM
• can be considered aesthetically unappealing by burn survivors
• coverage with a skin graft can mitigate some of the complications of hypertrophic scars

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All photos provided by and used with kind permission from Diane Merwarth, PT

Hypertrophic Scar Noninvasive Management

Hypertrophic scars are a dominant type of pathological scar formation after burns. Nowadays, hypertrophic scarring is described as “the greatest unmet challenge after burn injury.”

A 2023 report determined that there is no consensus for any single intervention in management of hypertrophic scars. As with all areas of rehabilitation practice, clinician experience and clinical reasoning play a huge role in setting and reassessing a burn injury care plan. Mentorship and coordination within the interdisciplinary care team should be used to support the wound care professional.

• Silicone Gel.
  • Silicone gel (pieces of thin, flexible medical grade silicone, can come in a sheet or as a self-drying gel) can be placed over hypertrophic scars. These products may decrease post-burn pruritis, dryness, and pain.
  • They can be used alone or underneath pressure garments, splints, or casts.Scar quality improvements may be more significant when silicone use is combined with pressure garment therapy (see below) when used on hand injuries.
  • Mechanism of treatment is based in silicone's ability to restore the skin's barrier function by reducing transepidermal water loss. Restoration of this barrier can take at least a year in deep-thickness burn wounds.
  • Despite a lack of strong evidence, many burn care algorithms and protocols include silicone as the first or primary therapy in scar management
  • The American Burn Association states there are "no clear benefits to using gels versus gel sheets or nonsilicone versus silicone products with respect to the treatment effect, but there appear to be fewer adverse reactions when using silicone gels compared to gel sheets."
  • Some patients may have an allergy or sensitivity to silicone, therefore skin checks should be performed frequently
• Massage therapy.
  • Recent research states that massage therapy can provide significant short-term improvement on burn scars, but no long-term benefit was appreciated.
  • May have some positive effects on patient reported pruritis, pain, and vascularisation, but no current evidence shows a lasting effect on scar height or thickness.
• Pressure garment therapy (PGT).
  • PGT has been extensively studied for management of burn scars, and is considered the mainstay noninvasive treatment for hypertrophic scars
  • Mechanism of treatment theorises that the mechanical forces applied by the pressure garments decreases scar contracture and reorganises collagen deposition during the remodeling phase.  
  • PGT has been found to be capable of improving scar colour, thickness, pain, and scar quality 
  • Wearing schedules for pressure garments have not been standardised, with research suggesting a wearing schedule anywhere from 4 hours blocks to a continuous 23or 24 hours/day, with garments being removed for bathing purposes. .
  • Ideal pressure for PGT also varies in the research: some reports show the ideal pressure exerted by garments is 15-25 mmHg, while other studies recommend a pressure that equals or exceeds capillary closing pressure (40 mmHg)
  • Garment fatigue (garment in need of replacement) significantly decreases the effectiveness of PGT
  • Outcomes are directly affected by poor patient adherence.  Reasons reported for poor adherence include:
    • • Garments are uncomfortable or hot to wear as scheduled
      • Garments can be difficult to don and doff
      • Cost is a significant deterrent to obtaining and replacing fatigued garments

• Corticoid-embedded dissolving microneedles (CEDMN).
  • CEDMN provide minimal to painless skin penetration and direct dermal drug delivery using a hyaluronic acid dressing onto which the microneedles are implanted.  As the microneedles dissolve, they release the embedded corticosteroid, which has been found to be effective in reducing the thickness of hypertrophic scars. 
  • This intervention holds great promise as being superior to intralesional steroid injections, which can be extremely painful and have a limited area of effectiveness.
• Serial casting.
  • A small study in 2023 found recovery of full ROM using serial casting
  • Once full ROM is achieved, a night-time splint was used to maintain ROM.
  • Casting protocol included therapeutic interventions to the joint at each cast change:

• • • Moist heat
    • AROM with end-range stretching
    • Joint glides
    • Progressive resistive exercises

Hypertrophic Scar Surgical Management

If functional limitation or aesthetic concerns continue after maturation, surgery can be considered. 

1. Scar contracture release
2. Scar debulking
3. Cosmetic surgery

There is abundant research and case reports studying various interventions intended to improve outcomes related to hypertrophic scars.  Unfortunately the outcomes of these studies and reports are widely variable.

Burn Wound Injury Special Concern: Post-burn Pruritus

Pruritus, or itching, is a common and significant complication of burn injuries and can greatly affect a burn survivor's quality of life and psychosocial well-being. 

• Onset may occur within a few days after burn injury and can persist for years after healing
• Prevalence of pruritus immediately after burn is 80–100%, prevalence rate continues to be approximately 40% 12-years post-burn injury
• Sensory discomforts can include: prickling, burning sensation, numbness, and stinging that occur in the post-burn state. It can be disruptive to sleep and ability to complete daily activities

When considering treatment for pruritus, it is important to determine if there are underlying factors that may be contributing to the itching.  If the burn survivor has any of these factors, they should be addressed first before other pruritus interventions are initiated. These factors can include (1) an allergy or sensitivity to their current drug therapy, (2) an underlying dermatological disorder, or (3) they may be developing a neuropathy. 

When the pruritus is directly related to the burn injury, the mechanism for this is not well understood therefore there is no accepted consensus for treatment. Treatments reported to show some success include:

1. Topical treatment with creams, lotions or emollients to restore the barrier function
2. Systemic treatment
   • Antihistamines
   • Gabapentin
   • Gabapentin in combination with Pregabalin (this combination was found superior to either used alone)
3. Antidepressents
   • Somewhat effective for patients with pruritis who also suffer from depression or anxiety
4. Extracorporeal Shock Wave Therapy
5. Physical treatment
   • Compression
   • Massage

Resources

Clincial Resources:

• Burn Physiotherapy and Occupations Therapy Guidelines (New South Wales Government)
• Practice Guidelines for the Application of Nonsilicone or Silicone Gels and Gel Sheets After Burn Injury (American Burn Association, 2015)

Patient/ Care Provider Education

• Burn Care at Home Handout Example (Trauma Burn Center, University of Michigan Health System)
• Eating Well for Wound Healing Handout Example (National Institutes of Health)
• Energy Conservation Handout Example (NHS Foundation Trust, Blackpool Teaching Hospitals)