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Pressure Garment Therapy for the Management of Burn Scars

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

Top Contributors - Stacy Schiurring and Jess Bell

Burn Wound Hypertrophic Scars

Advancements in burn wound care at emergency departments and specialised burn centres have significantly improved survival rates for individuals with severe or massive burn wound injuries. Consequently, there's a growing emphasis on enhancing post-burn outcomes. Scar management is a major area of interest, with up to 70% of individuals developing hypertrophic scars following a burn injury.[1]

A hypertrophic scar presents as a raised, thickened area of skin that develops at the site of a burn wound injury. Initially, the scar may be red, pink, or darker than the surrounding skin, reflecting increased blood flow. Hypertrophic scars are usually confined within the margins of the original burn wound injury. These scars can feel firm or rubbery to the touch, and present with symptoms of pruritus (itching), pain and stiffness. There's also a risk of contracture formation if a burn occurs around a joint.[2]

"Hypertrophic scarring can be considered a systemic inflammatory illness regulated by local wound healing factors."[2] Patients who are at greater risk of hypertrophic scar formation include: (1) those who sustained deep partial or full thickness burn wound injuries,[3] (2) wounds with a delayed closure[2] of greater than three weeks,[4] or skin-grafted areas.[2] The severity of hypertrophic scar formation can be somewhat mitigated through timely wound closure. For more severe burns, this involves closure within the first three weeks after the burn injury, either by skin grafting or temporary coverage until a skin graft can be performed. In the case of smaller burns, it can be achieved by primary closure.[4]

"Hypertrophic burn scars pose a challenge for burn survivors and providers. In many cases, they can severely limit a burn survivor’s level of function, including work and recreational activities. A widespread modality of prevention and treatment of hypertrophic scarring is the utilization of pressure garment therapy."[2]

Burn Pressure Garment Therapy

Most wound care professionals who specialise in burn care recommend pressure garments as the first line of defence to minimise and potentially prevent hypertrophic scarring post-healing of a burn wound injury.[4][5] The evidence base for pressure garments is growing and there is sufficient evidence to support its use for scar management.[3]

The primary goal of pressure garment therapy is to apply consistent pressure to the scarred area, which can help flatten and soften hypertrophic scars, reduce redness, and minimise itching. This therapy is especially effective during the maturation phase of scar healing.[6]

Pressure garment therapy contraindications and precautions:[4]

  • pressure garment therapy is contraindicated in patients with latex allergy or an allergy to any garment component
  • precautions to monitor for include: rash or other skin reaction / sensitivity under the garment, or increased pain with wearing[4]

Evidence-based Findings for Burn Pressure Garment Therapy

  • Optimal benefits in scar reduction are achieved when pressure garments are worn for 24 hours a day, seven days a week:[7]
    • pressure garments for burn wound injuries are designed with low resting pressure, so the risk of developing an ischaemic injury is very low, even with prolonged or constant wearing.
  • Some evidence suggests that a garment pressure of approximately 15-25 mm Hg produces the best outcomes over hypertrophic scars (when pressure garment therapy is initiated within the first two months post-injury and garments are worn for at least 12 months).[3][8]
  • Evidence suggests that using silicone gel or gel sheets under a pressure garment may further improve hypertrophic scar height, pliability and overall appearance.[9][10]
  • For hand burns, early initiation of compression (even when the burn wounds are still open) is recommended to decrease oedema in the hands and the subsequent joint stiffness that can develop after burn healing.
  • Animal studies have found that pressure garment therapy can significantly decrease scar contracture. This is probably because of the mechanical forces exerted by the pressure garment. These forces administer pressures that decrease the risk of contractures across joints and help align collagen fibres during the remodelling phase of healing. They also help to reduce scar height and increase scar pliability as it matures.

Drawbacks of Burn Pressure Garment Therapy

The effectiveness of pressure garments is significantly influenced by the patient's adherence to their wearing schedule. Pressure garments tend to be difficult to don (put on) and doff (take off), and they can be hot to wear. Therefore, it is important to provide consistent and ongoing patient education on the importance and benefits of compliance with the pressure garment-wearing schedule.[4]

Management of Wounds Under Burn Pressure Garments

It is not appropriate to measure for, or wear, pressure garments over bulky wound dressings; the garments won't provide adequate pressure over a bulky dressing and their effectiveness will be limited once the dressings are no longer needed.

Burn pressure garments can, however, be worn over a low-profile dressing, such as a thin non-adherent foam dressing. This typically applies to small open burn wound areas or fragile areas of closed burn wounds that need protection. This allows the patient to start using pressure garments as soon as possible.

Blisters

Blisters commonly develop when a patient begins wearing pressure garments. Pressure garments are very difficult to put on. Significant friction can be generated when an individual pulls the tight garment into place. This can lead to blister formation, particularly over fragile skin or bony prominences. It may be necessary to delay the initiation of pressure garment therapy in individuals who experience a significant amount of blistering. This will allow the burn wound injury to mature and better tolerate the friction associated with donning and wearing a pressure garment.[4]

Custom Pressure Garments versus Non-custom Alternatives

Burn wound injury experts agree that custom-fit pressure garments are the most effective[5] and are preferred over non-custom fit garments.

Custom-fit pressure garments are constructed based on measurements taken by the clinician or garment representative. Measurements must be precisely collected!

Please note that each company may have their own process for collecting body measurements. Therefore, it is important to stay in contact with a company representative to ensure the garment is suitable. Custom garments only need to cover areas where there are hypertrophic scars. Straps and anchors can be used to help secure the garment over the treatment area and ensure adequate pressures are applied. Company representatives can assist in designing an appropriate garment. Their role is to make sure the pressure garment will apply adequate pressure over the treatment areas and that the patient is not wearing a "garment where [they] don't need it."[4] Once produced, these garments cannot be returned.

Ideally, a burn survivor should have two sets of pressure garments. This allows them to launder one set while wearing the other to maintain a 24/7 wearing schedule. Custom pressure garments should be replaced every six months to ensure that the appropriate pressure is maintained.[4]

Custom pressure garments options:[4]

  • zippers can make it easier to don and doff the pressure garment
    • ideally, zippers should not be placed over areas of hypertrophic scarring
    • a lining can also be added under the zipper to prevent skin irritation
  • a silk lining can be added over the most sensitive areas, such as joint flexion areas
    • a silk lining can be added to the entire garment to decrease friction and for added comfort, but this will add significant cost
  • a silicone lining can be applied to various parts of the garment so that it's directly over the area of hypertrophic scarring
  • pockets for foam inserts can be added to fill gaps (e.g. skin folds, divots) and ensure proper garment fit to achieve effective pressure

Clinical Pearls: Tips for Custom Pressure Garments

It is best to contact the pressure garment manufacturer's representative for step-by-step instructions on measuring for a pressure garment or to request an in-person consultation.

For accurate circumferential measurements (e.g. of the arm, leg, finger, etc.), ensure the measuring tape fits snugly but is not too tight. Any soft tissue bulging on either side of the measuring tape indicates that the tape has been pulled too tight.

Hands and feet: most manufacturers recommend that you trace the patient's hand or foot on a piece of paper. Use a thin tracing implement so that the point is as close to the skin as possible to obtain an accurate measurement. When tracing, hold the tool perpendicular to the skin for the entire tracing to get the most accurate measurement.

Fingers and toes: the manufacturer will supply specific measuring devices for these areas. It is best practice to use these devices for the most accurate measurements.

When possible, include photos which show the location of a patient's burn scars. This allows the manufacturer to confirm that the garment is appropriate, with suitable features to provide the best possible compression.


However, there are times when a custom pressure garment is not an option, either due to the evolving nature of the burn wound injury or because of limited access to these often expensive medical garments. Alternative options for a custom pressure garment can include:[4]

  • tubular compression garments
  • off-the-shelf gloves or off-the-shelf stockings
  • yoga garments or bike shorts
  • elastic bandage wraps

Silicone gel or gel sheets can be applied under non-custom garments.

Limitations of non-custom pressure garments include:[4]

  • less durable compression over the life of the garment
  • decreased ability to apply the same amount of compression over the treatment area
  • cannot adjust the amount of pressure provided by the garment
  • less ideal fit
  • not designed to be worn the recommended 24 hours/day

Specialty Areas

Hands and feet: if there are areas of scarring between the digits that require pressure, adding web inserts or web spacers ensures adequate compression in the web space. If the tips of the digits are not burned, the tips of the pressure garment can be open.

Face: facial burns require a custom garment. Options include a full face mask if the whole front of the face is involved, or a mask with different parts open depending on the location of the burn injury. A chin strap may be needed to help hold headgear in place, or to apply adequate pressure to a burn scar on the chin.

Shoulders and hips: garments for areas like the axilla or groin may require additional components, such as a strap, to hold them in place. These straps help maintain optimal pressure over the treatment area while allowing non-burned areas to remain uncovered.[4]

Pressure Garment Care and Management

Appropriate garment care helps prolong the life and effectiveness of the pressure garment. Manufacturers recommend hand washing the garment daily in cool water with a mild detergent and allowing it to air dry completely. Avoid using a clothes dryer, as this can affect the material's elasticity and reduce its compression over time.

Donning and doffing pressure garments often require the assistance of one or two people due to the tight, compressive nature of the garment fabric. This can be especially true when the pressure garment has a zipper; one person will approximate the fabric while the other secures the zipper. The skin under the pressure garment should always be clean and dry when the garments are donned.

Skin care recommendations under pressure garments: the healed burn wound should be kept clean and dry. After cleaning, the area of the healed burn wound should be gently dried. Using a towel to "rub" the skin dry can cause blistering due to the sensitive nature of the skin. "Fanning" or allowing the area to air dry is preferred. Using lotion under pressure garments should be avoided, as it can affect the long-term elasticity of the garment.

Patient education is also extremely important. Providing consistent and frequent education on the benefits of pressure garments to help manage the appearance and quality of their scars will hopefully improve patient cooperation and personal accountability for wearing their pressure garments.

Current best practice recommends wearing pressure garments for "up to two years" following injury. At present, there is no research supporting when to discontinue wearing pressure garments. Therefore, it is important to maintain a relationship between a burn survivor and their wound care professional for guidance and recommendations.[4]

Resources

Optional Videos: Donning/Doffing Pressure Garments

This video shows several techniques for donning and doffing lower extremity compression stockings:

[11]

This additional video shares additional techniques and tools for donning and doffing lower extremity compression stockings:

[12]

The following video demonstrates how to don and doff an upper extremity compression stocking:

[13]

Examples of Patient Information about Burn Pressure Garments

References

  1. ↑ Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN. Hypertrophic scarring: the greatest unmet challenge after burn injury. The Lancet. 2016 Oct 1;388(10052):1427-36.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Atiyeh BS, El Khatib AM, Dibo SA. Pressure garment therapy (PGT) of burn scars: evidence-based efficacy. Annals of burns and fire disasters. 2013 Dec 12;26(4):205.
  3. ↑ 3.0 3.1 3.2 De Decker I, Beeckman A, Hoeksema H, De Mey K, Verbelen J, De Coninck P, Blondeel P, Speeckaert MM, Monstrey S, Claes KE. Pressure therapy for scars: Myth or reality? A systematic review. Burns. 2023 Jun 1;49(4):741-56.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 Merwarth, D. Management of Burn Wounds Programme. Burns Pressure Garment Therapy Course. Plus, 2024.
  5. ↑ 5.0 5.1 Carney BC, et al.  Scar management and dyschromia: a summary report from the 2021 American Burn Association state of the science meeting.  J Burn Care Res, 2023; 44(3): 535-545.
  6. ↑ Shirakami E, Yamakawa S, Hayashida K. Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence. Burns & trauma. 2020;8:tkz003.
  7. ↑ DeBruler DM, Baumann ME, Zbinden JC, Blackstone BN, Bailey JK, Supp DM, Powell HM. Improved scar outcomes with increased daily duration of pressure garment therapy. Advances in Wound Care. 2020 Aug 1;9(8):453-61.
  8. ↑ Syron-Jones D, Macintyre L. Pressure by design: How to improve the consistency of pressure garments in the clinical environment and implement a simple method for gathering evidence to establish efficacy. Burns. 2022 Aug 1;48(5):1172-82.
  9. ↑ Tian F, Liu Z. Silicone gel sheeting for treating hypertrophic scars. Cochrane Database of Systematic Reviews. 2021(9).
  10. ↑ De Decker I, Hoeksema H, Verbelen J, Vanlerberghe E, De Coninck P, Speeckaert MM, Blondeel P, Monstrey S, Claes KE. The use of fluid silicone gels in the prevention and treatment of hypertrophic scars: a systematic review and meta-analysis. Burns. 2022 May 1;48(3):491-509.
  11. ↑ YouTube. How To Put on Compression Stockings Easily- By a Lymphedema Physical Therapist. Available from: https://www.youtube.com/watch?v=-g-8b2TFD6Q [last accessed 24/Sept/2024]
  12. ↑ YouTube. How to Pick a Compression Donning Tool? Available from: https://www.youtube.com/watch?v=O5d_hjSs9mA [last accessed 24/Sept/2024]
  13. ↑ YouTube. Donning and Doffing mediven harmony Arm Sleeve. Available from: https://www.youtube.com/watch?v=BuhXtwgFb9M [last accessed 24/Sept/2024]
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