Hypertrophic Scarring and Contractures
Hypertrophic scarring is thought to be inevitable when epithelialization takes longer than two weeks in young children, or longer

than three weeks in all other patients.

Application of pressure to burn wounds is generally recommended to minimize hypertrophic scarring, although optimal pressure and duration have not yet been determined in

controlled trials. A variety of techniques are used, but all are complex and costly. Therefore, family physicians often refer patients at risk for scarring to a burn specialist. Because pressure prevents scars but does not treat them once they develop, referral should be initiated promptly at the first sign of hypertrophic scarring or if a wound misses certain epithelialization milestones (Table 3). Although pressure does little to remodel existing hypertrophic scars, the application of silicone gel sheeting has been found to significantly reduce established scars as late as 12 years after injury. A two-month trial of the continual use of silicon gel sheeting on established scars distinguishes responders from nonresponders. Side effects of pruritus and rash can be minimized by washing the scar and applying silicon gel daily. Scar contractures result in disfigurement and disability. If detected early, a contracture can be treated with silicone inserts and pressure. If the contracture is more developed, a continuously worn static splint is added to maintain sustained stretch. Once full range of motion is achieved, splinting can be reduced to nighttime use until the scar fully matures. Surgical intervention should be considered if the contracture is not completely reduced.

Role of Surgery
Surgical excision and skin grafting beginning less than 72 hours after injury is beneficial and is indicated for nonscald full-thickness burns in children and in adults younger than 30 years of age. All other patients with suspected full-thickness burns should be observed for eight to 10 days, as nothing is lost by delaying surgical excision. It is also best to wait two weeks before assessing the need for surgery in children with hot-water scald burns because overly aggressive excision and skin grafting in this group has resulted in worse outcomes. Full-thickness burns less than 2 cm wide can be allowed to heal by contracture as long as they are in nonfunctional, noncosmetic areas and the skin is not thin (e.g., the ankle).

Coping with the Injury
After epithelialization occurs, no further dressing changes are required. However, patients should be instructed to use a nonperfumed moisturizing cream until natural lubricating mechanisms return. Use of preparations with a high lanolin content, thick waxes and ointments should be avoided. In addition, a sun block with a skin protection factor greater than 15 should be used to prevent hyperpigmentation until the wound loses its pink and red coloring. Depending on the depth of injury, it usually takes six months to two years for a burn wound to heal completely.

Itching is a common problem during the healing process. Pruritus is often triggered or worsened by environmental extremes (especially heat), physical activity and stress. The itching usually diminishes gradually and eventually stops after complete wound healing. Until then, a number of measures can be employed to control itching. Systemic antihistamines are usually tried first, with diphenhydramine used most frequently. Cyproheptadine and hydroxyzine are alternatives. Local measures include bicarbonate of soda baths and moisturizing lotions.

Many patients prefer to wear loose, soft, cotton clothing. In addition to helping patients cope with long-term physical discomfort, family physicians should be alert for psychologic issues. Patients who have sustained burns are at increased risk for anxiety, depression and posttraumatic stress disorder. Family dynamics can also change dramatically. Family members may be stricken with guilt, and patients are susceptible to dependency issues because of the additional help required for daily activities while healing is occurring.