Classification of burns
Complications of burns
Mechanism of post-burn scar formation
Pressotherapy – an effective therapeutic method for post-burn scars
Associable therapy Codopress® + Codosil™ ADHESIVE
Yearly about 1% of our population gets burned. The number of Poles affected by burn injuries reaches even 400,000 patients a year. Mostly 50-80% of the burned are children in the 2-4-year-old age group.
Burns can be divided by depth:
- 1st degree – a superficial burn. Only the surface layers of the skin are affected. The symptoms include redness (erythema) and painfulness. The wound usually heals without any complications and scars.
- 2nd A degree – extends into superficial (papillary) dermis. Those wounds are usually very red with clear blisters and are extremely painful. After 2nd A injuries there might appear small discolorations or even scars.
- 2nd B degree – extends into deep (reticular) dermis. In those type of burns superficial epidermal and dermal necrosis might appear. Those wounds are very painful, without blisters, pale or pinkish, grey, bricky or even black. Moreover, they may leave nasty hypertrophied scars.
- 3rd degree – extends through entire dermis. These wounds are usually russet, brown, pale yellow or red.
- 4th degree – extends through skin, subcutaneous tissue and into underlying muscles, tendons, bones, joints.
In the 3rd and 4th degree burns the skin reproductive layer is impaired or completely damaged.
Complications of burns
Quite a frequent complication of burns are hypertrophied scars and joint contractures. The hypertrophied scars appear, among other things, as a result of the increase in blood flow, fibroblast development and collagen deposition as well as of chronic oedema. In all those cases, when strong redness of the scar does not disappear up to two months, and the scar gets thicker and thicker, a keloid scar is very likely to develop. Keloids have a lumpy structure, which is a result of increased metabolism. Their growth is stimulated by microphages and fibroblasts, evoking an overgrowth of collagen fibres. Those complications are inconvenient because they delimit the functioning of the motor apparatus and at the same time they blemish the affected person.
Prophylactically appropriate positioning of the body and joint immobilisation by means of splints or orthopaedic devices is practised. It has also been proven that the application of constant pressure, increasing the capillary pressure of vessels i.e. about 25-30 mmHg, has a beneficial influence on scar formation, and prevents the overgrowth to a large extent. A long-lasting pressure causes an oxygen deficiency in tissues, a deceleration in metabolism and a fibroblast reduction. An increase in the activity of a collagen-decomposing enzyme (collagenase) results in a visible scar reduction.
The pressure method in a post-burn scar treatment has been worldwide known for many years, and it is also commonly used in Poland. The pressotherapy is found to be the most effective method, though there are many alternative ones such as laser therapy, kriotherapy etc.
Apart from negative health effects, quite often the keloids are also harmful to patients’ mental state, resulting sometimes in social exclusion. In modern techniques, and medical procedures it is clearly stated that an effective post-burn treatment needs to be designed in such a way to reduce the keloid formation. An important element in modern treatment techniques is the application of compression combined with the activity of silicone dressings like e.g. CodosilTM ADHESIVE.
Mechanism of post-burn scar formation
Every wound has the possibility of self-healing. Superficial wounds, in which the topmost layer of the skin (the epidermis) is scraped off, heal without leaving any scars. At the beginning of the healing process the wound is cleansed, so there appear a lot of macrophages and histiocytes. The neoformation of capillaries is evoked, facilitating the appearance of multipotent cells – lymphocytes, which have the ability to turn into fibroblasts. A fibroblast is a type of a cell that synthesises the macromolecules building connective tissue. This cell synthesises tropocollagen, which by polymerisation creates collagen fibres. As those fibres get created, the involution of capillaries takes place, the activity of fibroblasts is lost, and the reepithalisation process is initiated.
In burns, when the epidermis, the papillary layer and the reticular layer get damaged, a stronger hyperplasia of vessels is observed. The widening of vessels, and the appearance of anastomoses causes blood to stop in the healing place, and provides a good access to nutrients; a lot of highly active fibroblasts appear as a result of the production of a great number of collagen fibres.
The reconstruction along with the scar formation takes place at the newly created fibroblasts’ expense, where gradually myofibroblasts – responsible for contractility – get distinguished, while mastocytes take care of the progressive maturation of the scar. Biochemical tests of a scarring process show that there is an increased collagen synthesis in comparison with a normal healing process, and there are also qualitative disorders connected with the increase in the number of mucopolysaccharide matrices, and the decrease in the number of lipids (mainly linolic acid) in the scar. It seems that the reason for this lies in the reduced amount of collagenase (a collagen-decomposing enzyme), resulting from the increase of 1 – antitrypsin and 2 – mucoprotein globulins. Those effects occur probably along with a toxic mitochondrial activity in the damaged cells. This activity takes place in burns from the first moment up to the 10th day of the healing process, when it is possible to notice that those symptoms stop, and a gradual comeback to a normal state, or also an objective steady growth takes place up to the 14th and after the 21st day, if any scarring complications appear.
Moreover, also the effect of the adrenal gland on scar fibroblasts, and their uncontested influence on scarring processes has been recognised. This is the base to examine possible mutual correlations between the prevalence of scarring complications and endocrinological changes in children. Obviously such a correlation takes place during a burn shock, and its further development is not known. Topical scar complications developing after a burn can be either of an aesthetic or of a functional type, or of both types simultaneously. From a histopathological point of view the cicatrical changes are of a hypertrophic, a contractile or a keloid type. Popularly it is said that this happens in 50% of burn cases; however, the factors indicating those changes has not been determined yet. Their impact on the early estimation of an actual scar development possibility is also not known. Especially when it goes about keloids – they are likely to develop even in 80% of places vulnerable to stretching or tension.
Pressotherapy – an effective therapeutic method for post-burn scars
An elastic pressotherapy as a preventive and therapeutic method started to evaluate in the 70s, and turned out to be very effective in the treatment of post-burn complications. This method involves using hypercompression (or just compression) to give constant pressure on keloids. This pressure on the scar gives an ischemic effect, which makes afferent vessels smaller, which results in the reduction of vessel embryos. On one hand, the scar will be supplied with less blood if we reduce the number of blood vessels, but on the other hand, depending on the diameter of the vessel embryos, the blood flow will be increased, and there will be no stasis, which will further influence the reduction of produced collagen fibres, and prevent the wound area from shrinking.
A correctly applied pressotherapy involves the use of strong pressure on the wound after finished epithelisation by means of different types of bandages made of natural latex. Such products are produced of latex threads covered with synthetic fibres.
Their application on the scar and the stable pressure they give can change and improve the content and the quality of various tissue elements. This change in the tissue components results in the qualitative improvement, weakening and decreasing the size of the scar, and at the same time due to the accompanying ischemia, the characteristic red colour of the scar is fading.
General rules for the use of pressotherapy:
- the pressure should be applied as soon as possible (from the moment of wound re-epithelisation, during the next 2-3 years – this is the estimated time for scar development), more or less 1 or 1,5 year;
- constant uninterrupted and long-lasting application of pressure on cicatrical places through an individual adjustment of special compression garments with compression level from 20-25 up to 50 mm Hg/cm2.
To reach the best results it is necessary to observe and control the entire process of the compression treatment, and to change the compression garment periodically since the knitted fabric loses its elasticity, or the patient’s size might change as well.
The time of the compression treatment is varied – optimally up to 2 years. If any topical complications appear such as skin irritation, intertrigo, skin breaks or patient’s psychical inconvenience – the pressotherapy should be temporarily interrupted and then repeated, trying to eliminate those symptoms. 
Compression levels in pressotherapy
Compression clothing is characterised by a precisely defined pressure level exerted on the patient’s body. The pressure is expressed in a unit – millimetre of mercury (mmHg). The efficiency depends on the size of the garment, which is to be individually adjusted to a given person after taking precise measures of the patient’s body. The effectiveness of the therapy is also affected by the choice of an appropriate compression level, which depends on the disorder type and its severity. It is highly important to choose the right compression level of a compression product, for too little pressure will bring no effect, and too big pressure can cause many undesirable side effects. The complications may start from very simple ones such as chafes, abrasions or maceration, up to more serious ones such as serous blisters or decubitus ulcers. Those and other side effects resulting from a wrongly chosen compression level, quite often make the patient break the therapy.
The most popularly used compression level classification is the one used in Germany, Switzerland and Italy. In all types of classifications class 1 means the lightest compression, and class 4 the strongest compression. The values express compression given by a product at the ankle joint high. It is important to maintain a compression gradation given on the limb at the entire length of the product. In this case usually there is a rule applied to use 100% compression of the given class (from 1 to 4) at the ankle high (distal part of the product), up to 40% of the compression in the closer (proximal) part.
Producers use different classifications of compression; however, the one specified by the European Standardisation Commission distinguishes the following ones:
- class 1 – light compression (18-21 mmHg),
- class 2 – medium compression (23-32 mmHg),
- class 3 – strong compression (34-46 mmHg),
- class 4 – very strong compression (over 49 mmHg).
Efficient therapy with the application of compression garments Codopress®
The success of the therapy highly depends on appropriately chosen compression clothing. Compression garments Codopress® produced in Łódź (Poland) by Tricomed S.A. are used for the treatment of post-burn scars and in prophylactic rehabilitation of burns. Up till now over 20 thousand products Codopress® have been prepared, successively developing the product range, and improving the construction. The garment is produced of a highly elastic breathable knitted fabric of medical quality, composed of a polyurethane and polyamide yarn. This combination enables to obtain required parameters, and at the same time to provide high comfort for the user.
The manufacturing process makes it possible to produce the garment for every body part according to the compression class recommended by a doctor. The 1st class compression (18-21 mmHg) is the one most frequently used. It is remarkable that all compression products Codopress® are manufactured so that all seams are aside from all scars. Thanks to this the value of the therapeutic pressure is not changed in any way in this place.
The process of compression garment preparation:
- Get a referral from a specialist.
- Make an appointment with a person taking measures of the limb or other body parts.
- Once the garment is sewn it needs to be tried on to make sure that it fits perfectly.
- The patient is trained how to use and clean the product.
All compression garments should be worn permanently from 6 to 24 months after the wound healing process is finished, till visible cure effects appear (flattening, fading and softening). The entire therapy usually requires a few changes of the compression garments, along with the use up of the garment and the change of patient’s body size. It is important to remember to use the products only when the post-burn wound is fully healed.
Individually prepared Codopress® products:
- give appropriate compression on the scar,
- can be used with other types of therapy,
- cause no allergic reactions or skin irritations,
- release itching,
- prevent from joint contractures.
In specialised burn healing centres in Siemianowice (Poland) and Polanica Zdrój (Poland) – leading centres healing heavy burns – a wide range of patients were clinically examined. They tested the effectiveness of Codopress® products in the treatment of post-scar burns.
Clinics testing the Codopress® clothing included the Burn Treatment Ward of the Municipal Hospital No. 2 in Siemianowice Śląskie ran by S. Sakiel, MD, and the Plastic Surgery Hospital in Polanica Zdrój under the supervision of K. Kobus, PhD, Dr h. c. What is more in the National Medicines Institute under the direction of W. Zalewski, PD tests were carried out as for the irritating effect on the skin of the knitted textile used in the production of Codopress® products.
Materials and methods
Within 2 years compression products produced by Tricomed S.A. were tested in 40 patients at the age of 2 to 59 years old with the average burn area of 26%, and deep burns at the entire skin depth with the average area of 9%.
The patients were divided into two groups:
- in the first group (20 patients) the compression products were applied right after the wound was healed,
- in the second group (20 patients) the Codopress® products were applied after about 3 months after the wound was healed.
The evaluation concerned the face, the neck, the chest, the upper and lower limbs. Overall in the first group 24 places and in the second group 30 places were observed.
The tested products were evaluated as for their usefulness in the treatment of hypertrophied scars and keloids in 26 patients aged 3 to 58 years. Most of the hypertrophied scars and keloids were caused by hot fluids or fire. The entire healing period for a burn wound, starting from the application of the compression products, took a month up to 4 years. Before the application of pressotherapy, massages were applied. Body parts that were most often tested as for the usefulness of the compression products included: the knee and elbow joint, the buttocks, the hips, the shoulders, the chest, the upper and lower limbs.
The results of the carried out tests indicated that in hypertrophied scars and keloids treated with the compression products sweeping changes were noticed. The itch observed in 8 cases retreated after 3 weeks. The colour of fresh scars changed from bloody pale into flesh-like in 17 patients after 4 weeks. The height of the scar was reduced from average 4 mm at the beginning (measured from the healthy skin) up to 0-2 mm. The best results were observed in fresh scars, which were 4 weeks old. In the case of older scars those effects were visible after a longer period of time.
There were no allergic reactions noted. Washing by means of commonly available washing agents and an all-day-long utilisation did not affect the elasticity of the tested products. The best medicinal results were observed on tights, lower legs and forearms. The patients had no objection to wearing the compression garments. All in all compression products Codopress® undoubtedly contribute to faster rehabilitation of patients with after-burn deformations.
The summary of test results
While wearing Codopress® products for a few months the following conclusions were made:
- the scars were getting flatter,
- the extremely red colour was gradually fading,
- no allergic reactions to the material in Codopress® products were observed,
- in the same patients comparing not pressed scar places with the ones pressed by means of Codopress® clothing there were visible differences in form of hypertrophies and hard scars in the not pressed places,
- the application of the compression clothing just after the wound was healed brought better effects than in patients who used the products after hypertrophied scars appeared. 
- The tested products Codopress® are very useful in the prophylaxis and treatment of hypertrophied scars.
- Compression garments need to be tailored according to the measured body dimensions of the wearer in order to provide high efficiency.
- An early application (just after the wound is healed) of tailor-made compression products guarantees the best efficiency of the scar treatment.
- Constant wear of the clothing (13 hours a day) 1 to 2 years changed only if it is worn up or the patient’s size has changed:
- prevents the development of hypertrophied scars,
- causes the reduction and, in most cases, the regression of keloids,
- improves the final aesthetic look.
- Pressotherapy enables to continue physical rehabilitation and does not constrain the patient’s activity after the burn.
- The knitted fabric used in Codopress® products causes no irritating reactions.
Associable therapy Codopress® + Codosil™ ADHESIVE
Silicone dressings adjunctive to scar treatment by means of pressotherapy have gained in popularity in the past 10 years. Their application decreases the growth of small blood vessels in a scar, and as a result the scar gets more elastic and flatter.
Many specialists recommend the associable therapy, combining a few methods individually adjusted to a given patient. One of them is compression therapy joined with dressings meant for scar treatment. The dressing used for this type of combined therapy is CodosilTM ADHESIVE.
CodosilTM ADHESIVE is a soft multi-layer product designed for the treatment and rehabilitation of hypertrophied scars and keloids. Adhesive silicone layer is in the direct contact with the scar surface. The outer side of the dressing is secured with an anti-adhesive protection layer.
- releases the itching and pain,
- does not present irritating and sensitising properties,
- is susceptible to folding,
- reveals sticky properties which makes it possible to stick to the skin’s surface repeatedly,
- is meant for multiple use,
- is easy to store and apply.
The silicone dressing can be applied as a preventive agent when the wound is fully closed (8-10th day) or when first symptoms of a hypertrophied scar appear. The earlier the dressing is applied, the bigger the chance to completely heal the wound.
The dressing is used only on skin that is not broken, remembering to make the dressing 1 cm bigger than the scar size. Prophylactically it should be worn 12 hours a day. In patients using the compression products Codopress® along with the silicone dressing CodosilTM ADHESIVE there were visible healing effects observed: flattening, fading and softening of the scar. Moreover, the motor activity is improved and the risk of contractures is limited.
CodosilTM ADHESIVE is recommended to be used:
- in rehabilitation of hypertrophied scars and keloids,
- as prophylaxis in people with hypertrophied scar and keloid tendencies,
- after cosmetic treatment of scars in aesthetic plastic surgery.
 Babiana Mossakowska, PhD, Professor, Presoterapia u dzieci (Pressotherapy in children).
 A. Nawrocki, doc., PhD, and others, Ocena kliniczna – Opracowanie technologii i ocena artykułów medycznych do zastosowania w chirurgii plastycznej (Clinical evaluation – The compilation of technologies and the evaluation of medical products to be applied in plastic surgery).