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Structure of the Skin

In order for you to understand how and why scarring develops, it is useful for you to know a little about the structure and function of normal skin.

The skin is the largest organ of the body and is essential for survival. It is divided into three layers. The outer layer is the epidermis, the dermis is in the middle and the innermost layer is referred to as the subcutaneous or fatty layer. Normally, the surface of the skin is smooth, punctuated only with hairs and pores for sweat.

The main function of the skin is to provide a protective barrier between you and the environment. The epidermis is made up of sheets of dead cells that act as a waterproof barrier. There are also cells inside the epidermis that protect you from ultra-violet light.

The dermis contains sweat glands and blood vessels, which help regulate body temperature. It also has nerve endings, which send the sensations of pain, itching, touch and temperature to the brain.  It contains hair follicles and also oil glands which help moisturise the skin. The main structural component of the dermis is called collagen, and this lies in flat organised layers.

The subcutaneous layer of the skin consists of fat, which provides insulation and helps to store calories.

The deeper the injury the more skin structures are destroyed, and their functions lost.

Wounds heal by forming scar tissue. Initially, the healed wound may appear flat and smooth, but if it has taken more than 21 days to heal, this is likely to change over the next three months.

As the wound heals, new connective tissue is formed. The blood supply to the new connective tissue is more rapid and greater than in normal skin, which makes the scar look red in colour. The increase in blood supply results in the connective tissue being formed at a much faster rate than it is broken down, and it becomes more adhesive. This results in the formation of bundles of collagen, which fuse together and push outwards making the scar appear raised, hard and lumpy. This type of scarring is called hypertrophic scarring.

Unfortunately, it is not possible to prevent hypertrophic scarring. It is, however, possible to minimise the effects and improve the appearance. A clinician will advise you on the most appropriate treatment options to facilitate this.

Massage and the use of moisturising cream are very important aspects of the ongoing care of your scar. One of the reasons for the use of moisturising cream is because your scar can become very dry, fragile and itchy. This is because the oil glands in your skin that usually provide moisture will have been damaged or destroyed during the injury. During the first six months after your injury, when the process of scarring is at its most active, application of moisturising cream and massage is especially important. It can improve the quality of the newly healed skin and reduce the risk of it breaking down, it keeps the skin supple which will make movement and function feel easier, and it can reduce itch.  

• Moisturising cream should be applied at least 2-3 times a day to clean skin.

• Whilst applying the cream, you should apply enough pressure to blanch the scar and be able to see the skin physically moving around.

• Take care with fragile scars over tight areas (including joints).

• Ensure that all of the cream has been massaged in, removing excess cream with a tissue or towel.

• Daily bathing or showering with a non-perfumed product and creaming after a bath will improve circulation and help soften and re-hydrate the skin.

The cream used should be free from perfumes, additives, and alcohol as these can irritate and dry your skin. It can also affect the elasticity of your pressure garments (if you need to wear them). Water-based or aqueous creams should not be used as they can dry out the skin.

These preparations make skin and surfaces slippery – particular care is needed when bathing.

IMPORTANT SAFETY INFORMATION: FIRE HAZARD WITH PARAFFIN-BASED EMOLLIENTS

Emulsifying ointment or 50% Liquid Paraffin and 50% white soft paraffin ointment in contact with dressings and clothing is easily ignited by a naked flame. The risk is greater when these preparations are applied to large areas of the body, and clothing or dressing become soaked in the ointment. Therefore, you will need to keep away from fire and flames, and do not smoke when using these preparations.

Hypersensitivity

Hypersensitivity occurs when the nerve endings in the dermis are damaged by the injury, and can cause an exaggerated, painful response to normally non-painful stimulus. It is quite common and can result in a variety of different sensations, often described as severe ‘pins and needles’, tingling, shooting or stabbing pains.

To desensitise the area:

• Start massaging at the point where there is normal sensation.

• Gradually move up to a point where the discomfort begins and massage that area until it eases and continue until you reach the most sensitive point.

• 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, towelling, 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 approx. 10 mins. Make sure you are looking at the area whilst carrying out the treatment.

Blisters

Newly healed skin is a lot thinner and more sensitive than normal skin. As a result of this, the development of small blisters is not uncommon within the first few months after healing. The blisters may occur from excessive irritation from clothing or accidental bumps or bruises. Maintaining a good skin care regime can help prevent blisters from forming. If you are concerned that the blister is not healing, contact your GP or Plastics Dressing Team for advice.

Itching can be an irritating symptom of the healing process, and scratching fragile skin can cause it to break-down. The more your skin is damaged by scratching, the more it hurts and itches, and the more you continue to scratch. This is known as the ‘itch – scratch cycle’. Constant scratching also triggers inflammation and makes the skin more likely to get infected, so it’s really important to try not to scratch. By relieving the itch, the itch– scratch cycle can be broken, and you will see the benefits with a real improvement to the appearance of your scars.  

To avoid scratching pat or rub the skin over clothes instead if the itch is still troublesome pinch the skin.

Never tell a child to stop scratching as it will not work, instead praise a child for not scratching.

Cut finger and toenails short to limit the damage from scratching.

Keep a note of when itching is most frequent, and during these times try the following tips to help distract you from the itch:

• Clench your fists and count to 30.

• Keep your hands busy, i.e. write, draw, or do a puzzle.

• Reduce exposure to heat, keep bedrooms on the cool side.

• Wear loose fitting or cotton clothes and pyjamas and try to use cotton bed linen.

• At night cotton gloves/mittens help to stop children scratching.

• Consider putting towels, cream or silicone gel sheeting in the fridge.

If your scarring is extensive, you may have difficulty regulating your body temperature. You may find it difficult to keep warm during cold weather. If so, you could try wearing layers of clothing for insulation, which you can remove easily once your body warms up. Many people with scarring also complain of increased stiffness in the injured areas in cold temperatures. You may need to perform extra stretching exercises to combat this.

In hot temperatures you will need to take several precautions to help prevent heat exhaustion or heat stroke. You will need to drink plenty of non-caffeinated drinks throughout the day. Additional suggestions for keeping cool include the use of a hand-held or electric fan, dampening garments with water, and keeping your moisturising cream in the fridge. Placing a cool pack on the head or wrist can help cool the entire body.

Sun Exposure

Scars and donor sites are extremely sensitive to UVA and UVB rays and will blister and peel more readily than normal skin. Direct sun exposure and the use of tanning beds should therefore be avoided for at least two years following the burn injury. Pressure garments and silicone gels do not provide protection from these harmful rays, so when you are outdoors in the sun, a factor 50 sun protection lotion with a five-star rating should be applied to the scars underneath the pressure garment or gel, and loose clothing should be worn over. When the scar has fully matured, exposure to the sun can gradually be increased, but we would advise that you continue to use high factor sun protection lotions long-term.

Hypertrophic Scar Treatments

There are numerous treatments available to help ensure the best possible functional and cosmetic outcome for your scarring, and those appropriate for you will be discussed with you by your clinician. These may include one of the following:

Silicone Therapy

Silicone acts to seal in the moisture and hydrate the scar. Over time it will help to flatten, soften, and pale the scar and can reduce discomfort. Silicone is available in the form of gel or sheets. The ongoing supply of silicone may be provided by your GP.

Silicone gel

• Before applying your scar should be cleaned

• Apply moisturising cream and allow to absorb fully before applying gel x2 daily or as directed by your clinician.

• Only a thin layer of gel is needed. If it takes longer than a minute to dry, then you have put too much on.

Silicone Sheets

• Build up wearing it daily from 4 hours on first day of use and then additional 4 hours each day until the required time as advised by your clinician.

• Stop using if you get any rash or irritation and inform your clinician.

• Wash gel sheet daily and pat dry.

• When the sheet loses its stickiness or deteriorates it needs replacing (one piece should last 1-2 months).

Pressure garments

• These are tight elasticated garments providing constant pressure worn over your scar with the aim of achieving scars that are flat, soft, pale, and comfortable and may need to be worn for up to 2 years or until the scar is matured.

• The fit of your garment will be reviewed/replaced every 3-6 months, depending on the type of garment provided.

• Garments need to be worn 23 hours a day removing them to wash affected area, apply moisturiser and change garments.

• Garments should be hand washed using non-biological powder. Do not use fabric softener. Leave to air dry and do not tumble dry.

• Pressure garments do not protect from the suns UVA and UVB rays so you will need to apply factor 50 suncream underneath the garment.

• Contact your clinician if you experience any sore or broken skin, abnormal swelling, blueness or altered sensations. 

Splints :

Made of a plastic material to treat joint contractures. To wear as advised by your clinician.

Exercises:

As advised by your clinician

Your treatment plan:

Everyone who experiences a burn injury and needs to undertake scar management reacts differently. Some people may find they adapt more quickly than expected, however others might find themselves struggling with a number of upsetting thoughts, feelings or behaviours. Common difficulties include body image issues and concerns about dealing with other people’s behaviours, comments and questions. These are normal and understandable and may resolve naturally in time with the support of family and friends.

However, for some people these difficulties do not fade with time or may emerge sometime after the original injury. For these people, support from the Clinical Psychologist may be useful. Please discuss with your Clinician if you would like to access the burns psychology service.

There are several national organisations that offer a range of services for burn survivors, a brief outline of each is listed below.

Changing Faces

Changing Faces supports people of all ages with disfigurements of all kinds, whether present at birth or acquired during an accident or illness, in achieving high self-esteem, access to the best health and social services, and equal rights and opportunities throughout their lives. They provide one-to-one counselling and advice, group workshops, self-help guides and videos.

See www.changingfaces.org.uk for more details.

The Katie Piper Foundation

The Katie Piper Foundation’s aim is to have a world where scars do not limit a person’s function, social inclusion or sense of wellbeing. They can provide intensive, comprehensive burns rehabilitation (post-acute care) in the UK and support burns survivors throughout their recovery to improve outcomes.

Visit the Katie Piper Foundation 

Dan’s Fund for Burns was formed in memory of Dan Miller, who died in the Bali bombing of 2002. It is now a leading aid organisation for burn survivors in the UK and aims to be a source of practical support and funding for specialist burns after-care. Visit Dan's fund for burns.

Dan’s Fund for Burns has also launched the Adult Burn Support UK (ABSUK) website, which offers a weekly moderated live online chat every Wednesday, 19:30 – 21:00.  The ABSUK Live Chat has been developed to provide the opportunity for those affected by burn injury to share their story, and give and receive mutual support in a real-time, safe and private forum.  To participate in the Live Chat you must register beforehand and then log in via Adult Burn Support UK

Support Available for Children and Parents

Supporting children with burns

Supporting children with burns is a website designed to support families of children and young people who have had a burn injury. The information of the website includes common experiences of parents, parent stories, stress management, how to support your child and their siblings, top tips from parents, links to helpful resources and exercises to assist coping.

Children’s Burns Trust

The Children’s Burns Trust is a national charity dedicated to providing rehabilitation support for burn injured children and their families, as well as prevention and awareness campaigns, for which there is little or no national funding. They also have a private Facebook group for parents across the UK to communicate and share experiences. Visit the Children's Burns Trust .

Here are the main members of the burns care team at Derriford Hospital which you may meet during your care:

Miss Jolita Zakaraite:       Trauma/burns consultant

Mr Duncan Mackenzie:    Trauma/burns consultant

Ishbel Penn:                     Burns outreach nurse.

Hayley Williams:              Plastic trauma nurse

Ruth Cornish:                  Plastic trauma nurse

Dena Slinger:                   Plastic trauma nurse

Jen Orchard:                    Advanced care practitioner

Sharron Barclay:              Advanced care practitioner

Aimee Howe:                    Physiotherapist

Janette Thornsby:           Occupational therapist

Lily Sanders:                    Trauma Coordinator