Laser management of hypertrophic burn scars:a comprehensive review

Hypertrophic scars often develop following burn-related injuries.These scars can be cosmetically unappealing,but associated symptoms of pruritus,pain and restricted range of motion can impair a person’s quality of life.Laser and light therapies offer a minimally invasive,low-risk approach to treatment,with a short postoperative recovery period.As laser technology developed,studies have shown decreased scar thickness,neuropathic pain and need for surgical excision,as well as improved scar pigmentation,erythema,pliability,texture,height and pruritus.In this review,we present the evolution of laser therapy for hypertrophic burn scars,how different types of lasers work,indications,perioperative considerations and guidelines for practice management.

Substance use and inhalation injury in adult burn patients:retrospective study of the impact on outcomes

Background:Substance use,alcohol use,and smoking use have all been associated with burn injury.Few studies have investigated associations with substances,alcohol,smoking,inhalational only burns,and patient outcomes.The purpose of the study was to identify risk factors for pulmonary failure in patients suffering inhalation injury,focusing on the impact of substance,alcohol,and cigarette use.Methods:This is a single-center retrospective analysis of 115 patients admitted to the Johns Hopkins Bayview Burn Center with inhalational injury from January 1,2010,through September 30,2018.Patients were excluded if they were under the age of 18 years or had burn involvement of the skin>5%.Primary outcome variables measured were if patients were intubated,length of total time intubated,substance use,alcohol use,and smoking use.Secondary outcome variables measured were types of substances used(amphetamines,barbiturates,benzodiazepines,cannabinoids,cocaine,methadone,codeine/morphine),total number of substances used,intensive care unit(ICU)length of stay(LOS),hospital LOS,secondary complications,and patient mortality.Analysis was performed with Fisher’s exact test and the Mann-Whitney U test.A sub-group analysis for each substance,alcohol,smoking,and control subgroup was compared to its respective sub-group without substance,alcohol,smoking,and control within the no intubation and intubation group.A sub-group analysis of substance use,alcohol use,smoking use,and control was further analyzed with binomial logistic regression within the intubation group.Results:Following inhalation injury,50/115(43%)patients required intubation.Forty-two of the 50(84%)patients intubated had substance use(p<0.001).Thirty-one of the 50(62%)patients intubated had history of smoking(p=0.038).Among the specific substances used,26/50(52%)patients intubated were using benzodiazepines(p<0.001)and 7/50(14%)patients were using cocaine(p=0.022).The lengths of intubation,ICU LOS,and hospital LOS with no substance use were shorter than with substance use(p<0.001).Following the adjusted sub-group analysis,patients with substance use(odds ratio(OR)6.4,95%confidence interval(CI)[2.5–16.3];p<0.001)and smoking use(OR 2.5,95%CI[1.2–5.1];p=0.013)were more likely to be intubated on admission than those without substance or smoking use.Conclusions:In patients admitted with an inhalational injury with less than or equal to 5%external burns,the presence of a substance and smoking use on admission provides a further risk of intubation and respiratory compromise.Substance use on admission poses a greater risk of longer intubation,ICU LOS,and hospital LOS.A higher potential for substance use should be suspected in this patient population with prompt treatment.

Prevalence and associated predictors for patients developing chronic neuropathic pain following burns

Background:Chronic pain,unrelated to the burn itself,can manifest as a long-term complication in patients sustaining burn injuries.The purpose of this study was to determine the prevalence of chronic neuropathic pain(CNP)and compare burn characteristics between patients who developed CNP and patients without CNP who were treated at a burn center.Methods:A single-center,retrospective analysis of 1880 patients admitted to the adult burn center was performed from 1 January 2014 to 1 January 2019.Patients included were over the age of 15 years,sustained a burn injury and were admitted to the burn center.CNP was diagnosed clinically following burn injury.Patients were excluded from the definition of CNP if their pain was due to an underlying illness or medication.Comparisons between patients admitted to the burn center with no pain and patients admitted to the burn center who developed CNP were performed.Results:One hundred and thirteen of the 1880 burn patients developed CNP as a direct result of burn injury over 5 years with a prevalence of 6.01%.Patients who developed CNP were a significantly older median age(54 years vs.46 years,p=0.002),abused alcohol(29%vs.8%,p<0.001),abused substances(31%vs.9%,p<0.001),were current daily smokers(73%vs.33%,p<0.001),suffered more full-thickness burns(58%vs.43%,p<0.001),greater median percent of total body surface area(%TBSA)burns(6 vs.3.5,p<0.001),were more often intubated on mechanical ventilation(33%vs.14%,p<0.001),greater median number of surgeries(2 vs.0,p<0.001)and longer median hospital length of stay(LOS)(10 days vs.3 days,p<0.001),compared to those who did not develop CNP,respectively.Median patient follow-up was 27 months.Conclusions:The prevalence of CNP over 5 years was 6.01%in the burn center.Older ages,alcohol abuse,substance abuse,current daily smoking,greater percent of total body surface area(%TBSA)burns,third degree burns,being intubated on mechanical ventilation,having more surgeries and longer hospital LOS were associated with developing CNP following burn injury,compared to patients who did not develop CNP following burn injury.

Acute surgical vs non-surgical management for ocular and peri-ocular burns:a systematic review and meta-analysis

Background:Burn-related injury to the face involving the structures of the eyes,eyelids,eyelashes,and/or eyebrows could result in multiple reconstructive procedures to improve functional and cosmetic outcomes,and correct complications following poor acute phase management.The objective of this article was to evaluate if nonsurgical or surgical interventions are best for acute management of ocular and/or peri-ocular burns.Methods:This systematic review and meta-analysis compared 272 surgical to 535 non-surgical interventions within 1 month of patients suffering burn-related injuries to 465 eyes,253 eyelids,90 eyelashes,and 0 eyebrows and evaluated associated outcomes and complications.The PubMed,Embase,Cochrane Library,Web of Science,and Scopus databases were systematically and independently searched.Patient and clinical characteristics,surgical and medical interventions,outcomes,and complications were recorded.Results:Eight of the 14,927 studies queried for this study were eligible for the systematic review and meta-analysis,with results from 33 of the possible 58 outcomes and complications using Preferred Reporting Items for Systematic Reviews and Meta-analysis(PRISMA)and Cochrane guidelines.Surgery was associated with standard mean differences(SMD)0.44 greater visual acuity on follow-up,SMD 1.63mm shorter epithelial defect diameters on follow-up,SMD 1.55 mm greater changes in epithelial diameters from baseline,SMD 1.17 mm^(2) smaller epithelial defect areas on follow-up,SMD 1.37 mm^(2) greater changes in epithelial defect areas from baseline,risk ratios(RR)1.22 greater numbers of healed epithelial defects,RR 11.17 more keratitis infections,and a 2.2 greater reduction in limbal ischemia compared to no surgical intervention.Conclusions:This systematic review and meta-analysis found that compared to non-surgical interventions,acute surgical interventions for ocular,eyelid,and/or eyelash burns were found to have greater visual acuity on follow-up,shorter epithelial defect diameters on follow-up,greater changes in epithelial diameters from baseline,smaller epithelial defect areas on follow-up,greater changes in epithelial defect areas from baseline,greater numbers of healed epithelial defects,more keratitis infections,and a greater reduction in limbal ischemia,possibility preventing the need of a future limbal stem cell transplantation.

Surgical outcomes in adults with purpura fulminans:a systematic review and patientlevel meta-synthesis

Background:Cutaneous manifestations of purpura fulminans(PF)present many challenges for clinicians and surgeons.In a state of septic shock complicated by limb ischemia,surgical interventions are necessary to control the pathological cascade and improve patient outcomes.The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults.Methods:This systematic review and meta-analysis compared 190 adult patients with etiologies,signs and symptoms,and surgical outcomes associated with cutaneous manifestations of PF.The PubMed,EMBASE,Cochrane Library,Web of Science,and Scopus databases were systematically and independently searched.Patient and clinical characteristics,surgical interventions,outcomes,and complications were recorded.Results:Seventy-nine studies were eligible for the systematic review,and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis(PRISMA)and Cochrane guidelines.A total of 71/190(38%)cases reported surgical debridement.Fasciotomies were reported in 12/190(6%)cases and 20 procedures.Amputations were reported in 154/190(81%)cases.Reconstruction was reported in 45 cases.Skin grafts were applied in 31 cases.Flaps were used for reconstruction in 28 cases.Median(IQR)surgical procedures per patient were 4(4,5)procedures.Infectious organisms causing PF were 32%Neisseria meningitidis(n=55)and 32%Streptococcus pneumonia(n=55).Coagulase-negative Staphylococcus(95%confidence interval(CI)(8.2–177.9),p=0.032),Haemophilus influenza(95%CI(7.2–133),p=0.029),Streptococcus pneumonia(95%CI(13.3–75.9),p=0.006),and West Nile Virus(95%CI(8.2–177.9),p=0.032)were associated with significantly more extensive amputations compared to other organisms.Conclusion:This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism.Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF.The majority of cases were not treated in a burn center.The most common surgeries were amputations,with below-the-knee-amputations being the most common procedure.Skin grafting was the most commonly performed reconstructive procedure.The most common complications were secondary infections.Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus,Haemophilus influenza,Streptococcus pneumonia,and West Nile Virus.Interpretation of findings should be cautioned due to limited sample data.