Scarring has major psychological and physical repercussions – for example, scarring on the face and
visible regions of the body can be very traumatic to the patient, whether they are simple acne scars or large raised surgical or traumatic scars.
Hypertrophic scars
The development of hypertrophic scars is one of the most common and frustrating problems after burn injury, due to both the functional and aesthetic consequences (Van den Kerckhove et al., 2001). A hypertrophic scar presents as a deep red to purple colour, it becomes more elevated, firm, warm to the touch, hypersensitive and itchy as the scar progresses. It is more efficient to prevent hypertrophic scars than treat them. Mustoe et al. (2002) suggest that early diagnosis of a problem scar can considerably impact the overall outcome. For this reason all patients in our nurse led burn clinic are seen three weeks post healing. Usually if the patient is going to develop hypertrophic scarring, it will have occurred during this time. This is supported by Schmidt et al (2001), who suggest that hypertrophic scars appear between three to five weeks after trauma. These scars are characterised as being red and raised above the level of the surrounding tissue, often occur over a joint or skin crease and soften and flatten spontaneously with time and treatment (Carney 1993). There do seem to be a number of intrinsic factors that cause hypertrophic scar formation, such as; genetic predisposition, race, anatomical location of the burn, age and depth of the burn. Extrinsic factors are suggested to be; infection, type of wound intervention used and tension of the wound (Van den Kerckhove et al., 2001).
Silicone gels
Silicone gels were first developed as inserts in sporting footwear to prevent friction (Perkins et al., 1983) and have been used for management of scars since the early 1980s. Poston (2001) argues that it is a safe and effective management option; the gels adhere and mould to any body contour and are safely and painlessly applied and removed.
The mechanism of action of gel sheeting remains unknown despite several studies; pressure, temperature and oxygen tension, have all been investigated without success, but the moisture vapourisation rate has been found to be half of that of exposed scar tissue (Carney et al., 1994). The softening and flattening effect of gel sheeting may be due to hydration of the stratum corneum and/ or release of a low molecular weight silicone fluid (Sproat et al., 1992). However, Ahn et al. (1991) disagreed with the idea of silicone fluid being absorbed into the wound and stated that there was no evidence of silicone absorption. Musgrave et al. (2002) has recently revisited temperature as a potential mechanism of action, and demonstrated a raise of between 1-3 degrees centigrade, which they argue could promote increased collagen breakdown.
Silicone products vary considerably in composition, durability and adhesion, and this makes them more area specific. There are many gels available and a number of these are available on FP10, generally they are comfortable, durable, and easy to apply and remove, non-antigenic and non-toxic. The gels are self-adhesive or can be held in place by bandages, tape, tubular bandages or pressure garments.
Cica-Care
Cica-Care is a cured silicone gel laminated to an elastomeric silicone, and probably the best known of the silicone gels. It is slightly tacky and can be used on flat surfaces or where more pressure is required. It comes in two sizes and is available over the counter in most chemists. It does, however, seem to have a problem with reactions, In my clinical experience, a number of patients have experienced redness or excoriation underneath this gel, and for that reason it is not the first choice in my practice. Each piece will last anything from 14-28 days.
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Silgel
Silgel sheets are made from 100 per cent polysiloxane and come in a variety of sizes, including area specific, such as abdominal and submammary, as well as circular square and rectangular sheets. The formulation has changed recently and the sheets have become much thinner and don't have the useful backing they used to have, which facilitated taping the gel in place. The manufacturers suggest a number of benefits, including: ease of application, being thin and transparent, reduction in discomfort and irritation, softening of scars and contractures, permeability to water vapour and being 100 per cent pure. It is available in a number of sizes and specifically anatomical shapes such as abdominal, sub mammary and circular, which are very useful. Each piece will last from 1-2 months.
Mepiform
Mepiform is a thin flexible dressing consisting of a viscose non-woven fabric bonded to a semi-permeable polyurethane membrane. The inner surface of the non-woven is coated with a layer of soft silicone, which facilitates application and retention of the dressing to intact skin, but does not cause epidermal stripping or pain on removal. The dressing is waterproof but permeable to water vapour which allows for bathing and showering. The skin contact layer is protected by a plastic film that must be removed before use. The dressing should be cut to size, overlapping the scar onto good tissue by at least one centimetre. It is a very thin, discreet, flexible and compliable dressing and patients like it as it skin coloured, it is also excellent for difficult areas like the hands, face, feet, axillas etc. It comes in three sizes and lasts between 3-7 days.
Advasil
This is a sheet of medical grade silicone gel for the protection and management of hypertrophic scars. It is composed of translucent silicone gel and a smooth polyurethane outer layer to improve wear ability and patient compliance. The manufacturers suggest a number of benefits, which include: ability to cut dressing to conform to scar, conformability, washable, and self-adherence. This comes in one size only and will last up to 28 days.
Silgel silicone oil
Another useful gel is Silgel oil, which can be massaged directly into the scar and is useful for areas like the face or if the patient cannot tolerate adhesives. The manufacturers suggest a number of benefits, which include; permeability, water repellent, allows application of facial cosmetics does not macerate skin and is 100 per cent pure.
Dermatix silicone gel
Dermatix is silicone in a liquid gel formulation. It can be applied to all areas of the skin, including the face, joints and flexures and dries rapidly to form an invisible sheet. Dermatix is an effective, convenient and discreet way to apply silicone gel. The manufacturers suggest a number of benefits, which include; ability to apply cosmetics over the gel, suitability for sensitive skin, including children, ease of use, and high patient acceptability.
Novogel
Unfortunately, some patients cannot tolerate silicone, and if this is the case, then Novagel can be used. This is a glycerine-based gel, which was originally developed as a wound product, but seems to work on scars, possibly by the principles of rehydration. It has the added benefit of being able to be placed on an unhealed wound, thus promoting early intervention. As glycerine is a natural substance it is less likely to cause skin irritation or reaction and is more cost-effective. It can be cut to size and held in place with adhesive tape or tubular bandage. It comes in a range of sizes as well as a thinner version specifically designed for scar management. Each piece will last 1-2 months
Application and skin care
Wear time of the gels should begin gradually with anything from 30 minutes to two hours on the first day, building up gradually until they are wearing them for almost 24 hours. All the gels should be applied to clean skin and skin should be washed daily. Apart from Mepiform, the gels should also be washed daily with unscented soap and water and patted dry. This helps to prevent a build up of sweat and dead skin cells. If this is not carried out, there have been instances of pruritis, sweating, odour and even breakdown of the scar (Van den Kerckhove et al., 2001). In particularly hairy areas, for example the chest, shaving may help with adhesion of the gel and therefore overall effectiveness.
In conclusion, the management of newly healed wounds to prevent scar formation is one of the most profound things a nurse can do for the patients' physical and mental well-being. Beldon (1999) adds that the overall results relate to the patients motivation to use the gel and their concordance with the treatment. Therefore, nurses need to be as knowledgeable about scar products as they are about wound products, and their responsibility should not end once the wound has healed. Appropriate management of the scar will ensure that the wound remains healed and that the patient is happy with the outcome. The nurse is ideally placed to ensure that the patient understands the reasons why silicone gels are applied and encourage the patients to continue there use as well as identifying when problem scars occur.
References
Ahn S.T., Monafo W.W., Mustoe T.A. (1991) 'Topical Silicone Gel for the Prevention and Treatment of Hypertrophic Scar'. Archives of Surgery, 126: 499-504.
Beldon P. (1999) 'Management of Scarring'. Journal of Wound Care, 8; 10: 509-512.
Carney S.A. (1993) 'Hypertrophic scar formation after skin injury'. Journal of Wound Care, 2; 5: 299-302.
Carney S.A., Cason C.G., Gowar J.P., Stevenson J.H., McNee J., Groves A.R., Thomas S.S., Hart N.B., Auclair P. (1994) 'Cica-care gel sheeting in the management of hypertrophic scarring'. Burns, 20; 2: 163-167.
Musgrave M.A., Umraw N., Fish J.S., Gomez M., Cartotto R.C. 'The Effect of Silicone Gel Sheets on Perfusion of Hypertrophic Burn Scars'. Journal of Burn Care and Rehabilitation, 23; 3: 208-214.
Mustoe T.A., Cooter D., Gold M.H., Hobbs R., Ramelet A., Shakespeare P.G., Stella M., Teot L., Wood F.M., Ziegler U.E. (2002) 'International Clinical Recommendations on Scar Management'. Plastic and Reconstructive Surgery, 110; 2: 560-571.
Perkins K., Davey R.B., Wallis K.A. (1983) 'Silicone Gel: a new treatment for burn scars and contractures'. Burns, 9: 201-204.
Poston J. (2000) 'The use of silicone gel sheeting in the management of hypertrophic and keloid scars'. Journal of Wound Care, 9; 1: 10-16.
Schmidt A., Gassmueller J., Hughes-Formella B., Bielfeldt S. (2001) 'Treating hypertrophic scars for 12 or 24 hours with a self-adhesive hydroactive polyurethane dressing'. Journal of Wound Care, 10; 5: 149-153.
Sproat J.E., Dalcin A., Weitaur N., Roberts R.S. (1992) 'Hypertrophic Sternal Scars: silicone gel sheeting versus Kenalog injection'. Plastic & Reconstructive Surgery, 90; 6: 988-992.
Van den Kerckhove E., Stappaerts K., Boeckx W., Van den Hof B., Monstrey S., Van der Kelen A., De Cubber J. (2001) 'Silicones in the rehabilitation of burns: a review and overview'. Burns, 27: 205-214.
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