Epidemiology of Burn Injury

The American Burn Association has led a long-term initiative to collect information from burn centers in the United States and Canada. Most individuals with burn are male, with a mean age of 33 years, and with burns affecting less than 10% of the total body surface area (TBSA). The most common etiologies of burn injuries are flames and scalds. Over 95% of burned individuals survived their hospitalization, with predictors for burn mortality including increasing age, higher TBSA, and the presence of inhalation injury. Increasing mortality in elderly individuals with burns is predicted by the inhalation injury, burn size, and increasing age, with 60 and 70 years being significant age thresholds ( Figures 26-1 and 26-2 ). With the large majority of burned individuals surviving their hospital stay, mortality may not be an outcome measure of choice for burn research in North America. The National Institute on Disability and Rehabilitation Research (NIDRR) has funded the Burn Model Systems project to research the long-term outcomes of burn survivors in the United States. Burn centers also admit individuals with other acute skin-related disorders and injuries, such as Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN), and necrotizing fasciitis, which adds to the complexity of care provided in these burn centers.

Effect of age on percent mortality at three discrete burn sizes.

(From Pruitt BA Jr, Goodwin CW, Mason AD: Epidemiological, demographic, and outcome characteristics of burn injury. In Herndon DN, ed: Total burn care , ed 2, New York, 2002, Saunders, with permission.)

Changes in the LD ₅₀ in individuals 21 years of age over time, illustrating the increased survival of individuals with large burns.

(From Pruitt BA Jr, Goodwin CW, Mason AD: Epidemiological, demographic, and outcome characteristics of burn injury. In Herndon DN, editor : Total burn care, ed 2, New York, 2002, Saunders, with permission.)

Burn epidemiology differs in the rest of the world, with approximately 90% of all burn deaths worldwide occurring in low- and middle-income countries. Intentional burn injuries, rare in the United States but seen most commonly in young men, are more common in young women in India and middle-aged men in Europe. Unintentional burn injuries are also more common in girls than boys, in low- to middle-income countries. Changing burn mortality in the future may be focused on improved treatments for inhalation injury and preventing burns in the elderly and in low- to middle-income countries.

Acute Physiatric Assessment of the Burned Individual

Because the majority of burns in the United States are less than 10% TBSA, many do not require surgical intervention. In the inpatient setting, the burn physiatrist may manage many different medical aspects of burn care as part of the larger burn team. There is a long-term shift of burn care to outpatient settings. In an outpatient setting, the modern burn physiatrist should be competent in managing small nonoperative burns independent of a surgical team, yet also recognize those individuals who may benefit from hospital admission, acute excision, and reconstruction of their wounds, and who may also benefit from scar reconstruction.

Size, location, and depth of burn injury are important predictors for complications and mortality, and should be assessed acutely. Assessment of TBSA may be calculated by using a clinical tool, such as a Lund and Browder chart ( Figure 26-3 ), by following the “rule of nines,” or by estimating for small focal burns (e.g., the palmar surface of the adult hand is approximately 1% TBSA).

The Lund and Browder method for calculation of burn size is reliable for different body proportions in children.

(From Artz CP, Moncrief JA, Pruitt BA: Burns: a team approach, Philadelphia, 1979, Saunders, with permission.)

High temperature thermal burns are divided into superficial, partial-thickness, and full-thickness injuries. Superficial wounds are red, painful, and have little exudate. A typical example of a superficial burn is sunburn. These burns injure the epidermis only, and healing typically occurs within 7 days. They do not require dressings or surgical interventions, and the risk of scarring is very low. These injuries are not usually managed in a specialized burn center.

Partial-thickness burn injuries are divided into superficial partial thickness and deep partial thickness. Superficial partial-thickness burns injure the superficial layers of the dermis and have mild to moderate wound exudate. Serous-filled blisters are typically present. These wounds are painful but typically heal within 7 to 14 days. The risk of scarring from this injury is low, but there might be pigmentation changes in the skin in the long term.

Deep partial-thickness burns injure the deeper layers of the dermis, have fewer blisters than superficial partial-thickness injuries, but have moderate to extensive exudates present. These wounds are painful but might heal within 14 to 28 days. Some deep partial-thickness injuries, however, do not heal in this time frame. The prolonged inflammatory wound healing seen in deep partial-thickness burn injuries significantly increases the risk of scarring and may be an indication for acute surgical intervention. This depth of burn may result in particularly painful recovery because of a combination of exposed cutaneous peripheral nerve endings and a different regenerative capacity from deeper dermal cell types that may result in more fibrosis in healing than more superficial dermal cells.

Full-thickness burn injuries damage all of the epidermis and the dermis, and can extend into deeper structures. The area of the burned skin may have reduced somatic sensation, but there can be pain from underlying necrotic tissue, surrounding burns, or damage to nearby structures. These wounds typically appear pale with minimal exudate. Significant scarring is almost certain from ungrafted, full-thickness burn injuries, and acute surgical intervention to excise necrotic tissue and reconstruct the wound is indicated. A summary of burn depth and skin sections is shown in Figures 26-4 and 26-5 .

A superficial (first-degree) burn involves only the epidermis. A partial-thickness (second-degree) burn involves the superficial or deep dermis, and a full-thickness (third-degree) burn extends to subdermal tissues.

(From Achauer BM, Eriksson E: Plastic surgery indications, operations and outcomes, St Louis, 2000, Mosby, with permission.)

Cross-section of normal skin, illustrating the epidermis, the dermis, and the epidermal appendages (hair follicles, sweat, and sebaceous glands).

(From Achauer BM, Eriksson E: Plastic surgery indications, operations and outcomes , St Louis, 2000, Mosby, with permission.)

Electrical injuries also have special characteristics compared with thermal injuries. They are arbitrarily divided into high voltage (>1000 V) and low voltage (<1000 V). High-voltage injuries are usually work-related, whereas most low-voltage injuries occur at home. The total extent of soft tissue damage may be greater than expected based on the cutaneous injury observed, as electrical current will affect the tissues of the least electrical resistance, resulting specifically in significant peripheral and central nervous system damage. Although risks for myocardial necrosis and arrhythmias are present following an electrical injury, individuals who do not have an arrhythmia in the first 24 hours after injury do not appear at elevated risk for later arrhythmias. Survivors of high-voltage electrical injuries account for a large number of burn-related amputations and neuropathies, and have longer lengths of stay than individuals with thermal injuries. Both high-voltage and low-voltage injuries may be associated with impairments in function and complications with returning to work. Ocular complications of electrical injury, such as the development of cataracts or macular holes, may present late after injury.

Other acute wounds may be seen in the burn center. Frostbite may occur from environmental or industrial exposures to cold and the resultant wounds are more difficult to classify by depth than flame or hot contact burns. Other than rewarming, pain management, and a longer, nonoperative observation period, there is no convincing medical treatment that changes the outcome of frostbite injury. There is some early evidence that thrombolytic therapies have some benefit in the first 24 hours after injury. Challenging burns may occur after medical use of ionizing radiation as these wounds tend to arise at unpredictable times. The healing potential following a radiation burn is difficult to predict. Because there may be multiple wounds of varying depths within a single burn or areas of indeterminate depth, there may be a role for complementing physical examination of the injury with additional imaging, such as laser Doppler.

Acute Wound Care

Removal of necrotic material and the establishment of a clean, moist wound bed are the primary goals of acute wound management. There are a large number of commercially available products that are acceptable to use for management of acute burns. Unfortunately, few high-quality comparative studies have been performed on these products. Silver sulfadiazine remains a mainstay in burn care because of its low cost and the fact that many wounds heal quickly regardless of the wound treatment. Metaanalyses of the literature suggest superior healing outcomes from the use of biosynthetic, silver-based or hydrogel dressings compared with silver sulfadiazine. Although adequate wound healing for nonoperative burns is the ultimate goal, other considerations, such as cost and minimization of pain during dressing changes, should be taken into account when choosing a product.

Management of blisters remains controversial in burn care. However, in general, tense blisters associated with pain or limitation in function can be drained, allowing the separated epithelium to act as a temporary biological dressing that may reduce pain and functional limitation in the affected area.

The use of immersion hydrotherapy is no longer commonly practiced in modern burn centers. Immersion wound care in hydrotherapy tanks may result in lowering of core temperature or sodium, may be a source of gram-negative bacteria, such as Pseudomonas , and may cause cross-contamination of wounds. Also, the expense of draining and cleaning the tanks may be cost-prohibitive. The minimization of immersion hydrotherapy has been associated with a reduction in serious skin infections. Acute wound care is superior with local wound cleaning rather than with immersion hydrotherapy. The environment must be kept warm to avoid a significant drop in core temperature for individuals with large (>20% TBSA) burns.

Acute Pain Management

Acute burn pain is typically significant and is magnified by procedural pain associated with dressing changes, mobility, stretching, and surgery. Opioids remain the mainstay of acute pain management. Treatment requires frequent reassessment because an individual’s pain may change drastically around events, such as wound closure or participation in therapies. Adjuncts to opioids, such as distraction, hypnosis, or anxiolytics, may be used, particularly for the pediatric burned individual.

Acute Surgical Procedures in Burn Injuries

In full-thickness burn injuries, the damaged tissues are adherent to underlying structures. Wound edema and the fluids required for resuscitation after burn injury increase the risk for development of compartment syndrome, which must be monitored. Thick eschar on the trunk region can inhibit respiration and the surgical team can perform escharotomy (surgical incision through the eschar) to relieve this pressure. Escharotomies in the limbs and trunk typically are left open in the acute phase and will usually require skin grafting once the edema has resolved. Limbs requiring escharotomies should be elevated and splinted in a neutral position for 24 hours before initiating passive range of motion.

Early excision of necrotic tissue and eschar, combined with autologous, split-thickness skin grafting, has greatly improved survival after burn injury. This surgical approach reduces the inflammatory stimulation from the burn eschar and the risk of infection. Donor skin is removed from an unburned area of skin through the use of a powered dermatome ( Figure 26-6 ). The donor skin is then prepared and placed on the surgically prepared wound bed. The donor skin is held in place by staples, sutures, or, in some cases, dermal glues. A compressive postoperative dressing is then applied to the skin graft area, and an appropriate dressing is applied to the skin graft donor site. As only the epidermis and superficial dermis are harvested, the donor site is normally expected to heal spontaneously in 2 weeks. Much like other acute wounds, there are a large number of products available to dress the skin graft donor site. Individuals should be aware that the donor site area may be very painful postoperatively. The benefits of donor site products vary, with some more comfortable for individuals but slow healing, and others cheaper but more uncomfortable. Individual decisions are based on regional preferences.

Donor skin is removed from an unburned area of skin through the use of a powered dermatome.

The donor skin can be prepared by meshing, to broaden the area of wound covered. Meshing also allows for any blood or wound exudates to escape from underneath the skin graft. The donor skin can be applied as a sheet over areas of special function, such as the hands and face. Sheet grafts generally do not scar as much as meshed grafts, resulting in improved motion and aesthetic function. As there is no route of escape for wound exudates from beneath the unmeshed sheet graft, seromas or hematomas can form and even cause loss of the skin graft. Small fluid collections may be drained with a needle and the material rolled out to preserve the grafted skin. To improve adherence of the skin graft to the donor site, the grafted site is typically immobilized in the immediate postoperative phase. Early (1 to 4 days after surgery) initiation of therapies and mobilization improve individual function and reduce length of hospital stay.

Although lifesaving for individuals with severe burn injuries, split-thickness skin grafting results in abnormal skin as a result of the absence of the dermal appendages. Thus, the grafted skin is chronically dry, itchy, and mechanically inferior to normal skin. The grafted skin does not regenerate the dermal appendages, resulting in chronic impairments in skin function.

Other Acute Conditions Treated in the Burn Center

The expertise in managing large wounds and skin grafts present in burn centers results in referrals to provide care for other acute wound conditions. After excision of the affected tissue in necrotizing fasciitis or Fournier gangrene, the individual will typically require split-thickness skin grafting to address his or her wounds. The acute management afterward is very similar to that required in skin grafting after burn injuries.

Stevens-Johnson syndrome (<30% TBSA) or TEN (>30%), acute hypersensitivity reactions that result in wounds analogous to a partial-thickness burn injury, is associated with some drug exposures, such as carbamazepine, particularly in individuals with Asian ancestry. Ocular involvement requires consultation with an ophthalmologist. SCORTEN ( SCOR e of T oxic E pidermal N ecrosis) is a good prognostic tool to predict survival following Stevens-Johnson syndrome ( Table 26-1 ). The use of intravenous immunoglobulin or intravenous steroids remains controversial in this population. The main rehabilitation issues in this population are debility and neuropathy. Encouraging individuals to be up out of bed early will decrease the rate of complications.

Presence of Inhalation Injury

Inhalation injury associated with burns is a significant risk factor for morbidity, especially in children and older adults. Little has been documented regarding the incidence of hypoxic brain injury in burned individuals with inhalation injury, but the reduction of available oxygen, combined with toxic smoke components, such as carbon monoxide and cyanide, puts the burned individual with inhalation injury at risk for hypoxic brain injury. Burned individuals with inhalation injuries are at risk for developing pneumonia, adult respiratory distress syndrome, and multisystem organ failure, during the acute periods of recovery. Early tracheostomy in individuals likely to require prolonged intubation has not been shown to change pulmonary outcomes, but it does offer advantages for oral hygiene and management of facial burns. It is not known whether inhalation injury predisposes burned individuals to pneumonia in the rehabilitation setting and, as a result, routine oxygen monitoring during therapies varies among practitioners.

Polytrauma and Burns

It is estimated that approximately 5% of traumatically injured individuals will have a concomitant burn injury. Fractures outside of the burned area can be treated with standard fracture care. An individualized approach is necessary when the fractures occur in regions that also have burn injury. Individuals with a history of major trauma can have delayed diagnoses, including fractures or other neurologic and musculoskeletal injuries, which the physiatrist should consider during the ongoing assessment of the burned individual.

Catabolism and Metabolic Abnormalities

In all individuals with burn injuries greater than 30% TBSA, the physiatrist should anticipate a significant metabolic abnormality that results in loss of bone mineral density, lean body mass, and increased insulin resistance. These metabolic abnormalities indicate that individuals with large burn injuries have increased caloric and nutritional needs that should be addressed with early enteral feeding and supplementation. Progressive loss of lean body mass is associated with increasing loss of function and an increased incidence of medical complications, such as pneumonia and poor wound healing.

The management of the hypermetabolic state in individuals with a large TBSA burn has been improved with the use of anabolic agents, beta-blockers, and exercise. Oxandrolone is a synthetic testosterone analog that has been shown to reduce mortality and length of hospital stay. Lean body mass and bone mineral density might be improved by maintaining individuals on oxandrolone beyond their hospital discharge because the hypermetabolic state can persist beyond the time of wound closure. The typical dosage of oxandrolone for adult burned individuals is 10 mg twice a day and 0.1 mg/kg for children. Although human growth hormone (HGH) has shown some promise as an additional anabolic agent in burn injury, reports of increased mortality with the use of HGH in critically ill adults have limited research.

The stress response after burn injury is thought to be mediated by circulating catecholamines. An association of increased cortisol and catecholamine levels with infections and poor wound healing has been demonstrated in children. Beta-blockade is helpful in managing the increased catecholamines and the stress response to burn injury. The administration of propranolol, in doses high enough to reduce resting heart rate by 20%, has been shown in children to reduce the metabolic rate and help preserve protein and lean body mass. Beta-blockade might also have benefits for improving wound healing and preventing posttraumatic stress disorder (PTSD) in both adults and children.

Dysfunction in insulin action is also observed as part of the metabolic response to large burn injury. The mechanism for this is not entirely clear, but it can be related to insulin antagonists emanating from inflammatory cells in the burn region. Individuals with burn injuries greater than 40% TBSA and those over age 60 years should have close monitoring of blood glucose, with a goal of euglycemia in the acute phase. They might also need glucose monitoring for months to years after injury. Besides maintaining appropriate blood glucose levels, insulin has an added benefit to improving the metabolic state of the burned individual, thus minimizing lean body mass losses.

Mobilization and exercise should be initiated early in the burned individual. The frequency of active and passive therapeutic interventions by the rehabilitation team caring for acute care of burned individuals has increased over time. In the acute stages after a large burn, passive therapies, including splinting and positioning, should be initiated to minimize the risk of burn scar contracture, improve respiration, and reduce the risk of ventilator-associated pneumonias. As soon as the individual is able, active exercise should be started to help maintain function and to address the hypermetabolic state. Exercise is also an essential component for maximizing the benefits of anabolic hormones.

Nutrition and Swallowing in Burns

Enteral feeding should be instituted early for individuals unable to feed normally. This helps maintain gut immunity and motility, while providing the necessary calories and nutrients to counter the hypermetabolic response to burn injury. The total caloric requirements for adults with burn injuries can be estimated at 25 kcal/kg plus 40 kcal/1% TBSA burn/day. In addition to the changes in lipid and carbohydrate metabolism seen in individuals with a large burn injury, important changes in protein and amino acid metabolism are also of special importance. The administration of glutamine appears to have benefits in individuals with large burn injuries. Using body weight measurement to assess nutritional status can be difficult because of surgical procedures, dressings, and fluid changes. The serum prealbumin level can be very helpful as a marker of protein synthesis.

Dysphagia (see Chapter 3 ) can be a barrier to achieving adequate nutrition. Dysphagia can develop from inhaled irritants, mechanical complications of tube placement, or neurologic injury. Larger TBSA burns, higher number of days with a tracheostomy, and higher number of days on a ventilator are all associated with dysphagia after burn injury. An abnormal bedside swallowing assessment is predictive of abnormal barium swallowing studies, but there is still uncertainty regarding the best protocols for assessing swallowing in burned individuals. Although some very complex cases might have prolonged dysphagia, studies have described between 42% and 90% of individuals having normal swallowing function by the time of hospital discharge.

Peripheral Neuropathies

Approximately 10% of burned individuals will develop peripheral neuropathies from a variety of etiologies, such as direct thermal injury, electrical current, compression, and metabolic derangements. Several patterns of neuropathy are seen, including mononeuropathies, peripheral polyneuropathies, and patterns that resemble mononeuritis multiplex. Deeper and larger TBSA burns are more associated with axonal rather than demyelinating neuropathies. Mononeuropathies are seen with electrical injuries and flame burns. The pattern of peripheral polyneuropathy seen in those who have prolonged stays in intensive care units is similar to critical illness polyneuropathy.

The physiatrist performing electrodiagnostic testing on burned individuals should be mindful that the changes after burn injury can alter the results of both nerve conduction testing and electromyography. The increased skin thickness seen with hypertrophic burn scars can have an inverse relationship with the amplitude of the responses seen in nerve conduction testing. After large burn injuries there can be upregulation of nicotinic acetylcholine receptors in the muscle cell membrane that results in electrodiagnostic features suggestive of membrane instability or acute denervation. As a result, electromyographic studies must be interpreted with caution in the burned individual because these neuromuscular changes can be indistinguishable from true neuropathic changes.

Median sensory neuropathies are the most common peripheral nerve abnormality after burn injury. Conservative electrodiagnostic studies can help to define the extent of nerve injuries in burned individuals. Over the course of approximately 1 year, repeated nerve conduction tests typically show improvement in burn-related neuropathy, without requiring intervening surgical treatments. For burn-associated neuropathies not explained by compression or direct electrical injury, the mechanism leading to development and recovery is not well known.

Heterotopic Ossification

In individuals with burn injuries greater than 30% TBSA, there is a risk of development of heterotopic ossification (HO). The most common site of HO in burned individuals is the posterior elbow ( Figure 26-7 ). HO can develop in an unburned limb, but is more common in an affected limb, and can be associated with delayed wound closure over the elbow.

Heterotopic ossification of the posterior elbow.

The best treatment and prevention for HO in burns is still controversial. This is particularly the case regarding the use of bisphosphonates, with some evidence suggesting etidronate is not helpful. It is possible that etidronate is ineffective because of the significant postinjury inflammatory state seen in burn injury, and higher potency bisphosphonates might be more effective. Some physicians might be concerned regarding the potential development of osteonecrosis of the jaw with bisphosphonate administration, but this complication has been described primarily in individuals receiving zoledronate or pamidronate, and in the setting of cancer treatment. No osteonecrosis has been reported in osteoporosis trials using risedronate or alendronate. If used, therapies should be maintained in limbs affected by HO, and surgical resection should be considered when the bone is mature. HO can restrict the performance of activities of daily living or result in neurovascular compromise. Particularly of concern is loss of ulnar nerve function at the elbow.

Recurrence is common, even after resection and the use of postoperative continuous passive motion. Surgical resection, however, might have to be delayed in burns compared with other diagnoses to allow for adequate soft tissue coverage in the proposed surgical site. The timing of surgical resection is made based on the severity of functional deficit.

Hypertrophic Scarring

Hypertrophic scarring is the most common complication after burn injury, with a prevalence of 67%. Hypertrophic scarring, such as keloids, is a dermatoproliferative disorder. Hypertrophic scars are raised, red, painful, pruritic, and contractile and stay within the margins of the original injury. Keloid scars have some of the same characteristics as hypertrophic scars, but they also extend beyond the original injury and invade into local soft tissues. Hypertrophic burn scars tend to develop in the first few months of injury, while increasing in volume and erythema. After several months, they can regress, becoming less erythematous and flatter, but the skin never returns to its original state. Although there have been some advances in the prediction of wound healing, there is no accurate predictor of who will develop hypertrophic burn scars. Younger individuals, particularly adolescents, and those with darker skin pigmentation tend to have a higher incidence of hypertrophic scarring. Wounds with a prolonged inflammatory wound healing phase and those that are open longer than 3 weeks are more likely to develop hypertrophic scars ( Figure 26-8 ).

Hypertrophic scarring.

One of the limitations of studying hypertrophic burn scarring is the lack of a widely accepted animal model for burn scarring. Although some progress has been made in creating thick scars in an excisional porcine wound model, there are no well-validated scar models in other species. Despite this, some progress has been made in the understanding of the development of hypertrophic burn scars. A key signal in scar development appears to be transforming growth factor-β (TGF-β). TGF-β is a ubiquitous protein and part of a larger family of proteins known as bone morphogenic proteins. It exists in a latent form that can be activated through a variety of inflammatory signals. TGF-β acts through a dimerized cell membrane receptor that activates the Smad signaling proteins to increase the expression of proteins related to increased extracellular matrix production. Beyond local inflammatory signals, there are also likely to be systemic effects on the development of hypertrophic burn scars, from bone marrow–derived fibrocytes that become present in burn wounds and scars. Over time, fibroblasts can develop an autocrine feedback loop between TGF-β and the Smad proteins that might perpetuate the excessive production of extracellular matrix. The overexpression of extracellular matrix alone does not entirely account for the development of hypertrophic scars. A balance of both extracellular matrix formation and remodeling of the matrix and new skin is necessary for normal wound healing. In dermatoproliferative disorders, an imbalance in both production and breakdown is present. Important components in the balance of burn scarring are likely to be also derived from keratinocyte signals. As an example, keratinocyte-derived stratifin has been demonstrated to activate matrix metalloproteinases, which can be an important component of extracellular matrix breakdown and reorganization.

Many treatment options are available for addressing the symptoms associated with hypertrophic burn scars, but none completely remove the scar. The best treatment is to prevent the scar through adequate wound care. When scars are present, early and aggressive treatment is indicated. The first-line treatment for any burn scar is regular moisturizer cream, applied several (four to six) times per day, avoidance of mechanical insults, and the minimization of direct heat and sun exposure. Deficiencies in skin, such as sweat and sebaceous glands, can cause scars to be dry and pruritic, and a moisturizer cream is helpful in managing these problems. Individuals with burn scars should also be instructed to minimize direct sunlight and heat exposure through the use of clothing and sunscreen.

Pressure garments have been used in burn scar treatment for decades. They are thought to improve the appearance of burn scars by making the scar flatter and less erythematous and by offering some environmental protection. Some evidence exists that pressure aids in remodeling hypertrophic burn scars. The overall clinical effectiveness is controversial, however; and in metaanalyses of research into pressure garment use, the overall effect seems small, with minor benefits on scar height but not necessarily on secondary measures of scar. If they are used, pressure garments should be prescribed with monitoring by the rehabilitation physician or therapist, for adequate fit and wear tolerance, because friction in the garment can create or perpetuate superficial wounds in the burn scar.

Silicone gel sheeting can also be used alone or in combination with pressure garments. If worn for 12 to 24 hours per day, silicone is thought to change hypertrophic burn scars through a combination of temperature and perfusion changes. Some evidence exists that silicone sheeting might be helpful in improving the volume in hypertrophic burn scars. Reviews note, however, that the evidence is weak for the use of silicone sheeting in the treatment or prevention of hypertrophic burn scars.

Intralesional corticosteroid injection can also be of some benefit in the treatment of hypertrophic burn scars. The injections are done with an injection tangential to the skin. The injection is usually painful, particularly when used on the face, and force is necessary to infiltrate the injectate into the fibrotic scar tissue. A combination of triamcinolone with other agents, such as 5-fluorouracil, or the addition of a second modality, such as pulsed dye laser treatment, may be considered to potentiate the effects of the intralesional steroid.

The use of pulsed dye laser in the treatment of hypertrophic scars is controversial. In some studies the use of laser resulted in the formation of new wounds and little clinically relevant benefit in the scar, whereas other studies have shown benefit with this type of laser for the treatment of burn-related hyperpigmentation. Pulsed dye laser appears to have some benefits compared with carbon dioxide or argon lasers, which have also been used to attempt to obliterate hypertrophic scars and keloids. Significant scar recurrence with carbon dioxide laser has been described. The use of pulsed dye laser in burn scar treatment is not yet routine in most North American burn centers. Some preclinical evidence supports the effect of interferon-α as a promising treatment for hypertrophic burn scars, but larger human studies have yet to be done.

Massage is routinely applied to hypertrophic burn scars, although the evidence for its effectiveness is lacking. Massage of hypertrophic burn scars can be applied by the therapist or individual, but the skin must be monitored for potential development of pain and superficial wounds in the scar.