A burn is a really common kind of traumatic wound, whose healing process can be pathological, v the appearance of a hypertrophic or keloid scar. Intralesional corticosteroid infiltration is a an approach of selection for dealing with pathological scars. Therefore, considering the well-known risk that hypertrophic scar after a burn, might it be exciting to apply topical corticoid in a precautionary manner? The writer of an write-up published in 20141 questioning this exact same question and conclude the ” Theoretically, subject corticosteroids might reduce pathological scar by diminish inflammation and activation that fibroblasts. However, there space no studies examining this hypothesis”.
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Despite the lack of studies on this subject, us will know the reason of this exciting reflection. To this end, we begin with a brief introduction to burns.
How space burns classified?
Depending on the depth of skin involvement, burns are classified in various degrees:First degree: only the epidermis is affected. Usually just erythema occurs and also heals without leaving a scar.Second degree: affect epidermis and dermis with the formation of a blister. Relying on the depth of the affection of the dermis, lock are split into superficial and also deep, generally the bottom of the blister being red in the former and also whitish in the latter. The risk of occurring a hypertrophic or keloid scar is greater the depth the involvement.Third degree: it suggests a necrosis of all the skin layers. Graft coverage need to be performed to protect against contracture and hypertrophy.
In addition to the depth of the affectation, to measure its severity, that is extension, location, type of burn, age and associated pathologies of the patient must be taken right into account.
We will certainly now emphasis on a kind of burn the we generally encounter in our day-to-day lives, superficial second-degree burns.
What is the healing procedure after a burn?
As in any type of wound, after ~ the damage produced by a burn, a procedure begins in which the cells and molecules affiliated vary end time. Therefore, come facilitate its study, the healing procedure is separated into phases, although these phases in reality overlap (see write-up “Brief outline of wound healing”)
In the inflammatory phase, macrophages are an initial responsible for creating a pro-inflammatory environment, publication cytokines such together IL-1 and TNF, and they connect in phagocytosing bacteria and destroying devitalised tissue. Later, in the proliferative phase, macrophages identify to secrete expansion factors (TGFb1 and 2, PDGF) the stimulate the proliferation of fibroblasts and also their production of collagen (type III collagen), as well as the proliferation of endothelial cells for the development of brand-new vessels. In the final or remodeling phase, apoptosis of the cells created for the proliferation of new wound tissue occurs and also type III collagen is degraded to form type i collagen. This collagen is organized in different ways than common skin collagen, but over time the appearance and function of the scar have the right to be improved.
If excessive scar tissue has actually been produced, a hypertrophic scar (red, raised, that intensifies months after wound production and also improves spontaneously end the following 1-2 years) or a keloid (extends past the limits of the initial wound and also does not boost without treatment) might develop.
With respect to other types of wounds, burns room injuries v a high risk of pathological healing, largely if over there is deep dermis involvement. This higher incidence of hypertrophic or keloid scars in burns appears to be linked with the extreme and lengthy inflammation that usually occurs in this kind of wounds and the consequent extreme proliferation the fibroblasts and also collagen production.
Why and how must topical corticosteroids be applied to stop pathological scarring?
Topical corticosteroids decrease the synthesis and also release of inflammation mediators (including prostaglandins and cytokines such together IL-1 and TNF), reduce the release of growth determinants that wake up fibroblast proliferation (TGFb1, TGFb2, PDGF) and also thus decrease collagen production. Thus explained, it seems an interesting preventive strategy to protect against a pathological scar in a superficial burn. However, once to start? and also how lengthy to keep it? these are complicated questions come answer, essentially because scar hypertrophy can occur months after ~ the burn. In fact, the authors of the article with i m sorry I started this post,1 suggest the use of subject corticosteroids ~ epithelialization to limit possible persistent inflammation in the dermis, which would be responsible because that excess fibroblasts and also collagen bring about hypertrophy.
The few studies that have been released on topical corticosteroids in first and second degree superficial burns execute not assist us come answer this questions, as they emphasis on its analgesic and also early anti-inflammatory effect. Some authors suggest the benefit of that is early and also time-limited application (a few days) to to decrease inflammation and pain without affecting subsequent epithelialization. However, two clinical trials with healthy volunteers (15 and also 20 volunteers included) uncovered no innovation with respect come placebo when using medium or high potency corticosteroids in the first 24 hours2 or everyday for the an initial 3 days after the burn3.
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And what carry out the accuse say about topical corticosteroids in superficial burns?
The guidelines developed by the Japanese skiership Association,4 published in 2016, make recommendations on the usage of object corticosteroids in first- and second-degree superficial burns. That is stressed the its usage in this indication is based upon its anti-inflammatory task and that, regardless of the lack of easily accessible evidence, that is a widely provided treatment in clinical practice and also recommended through experts.
What is her experience? execute you recommend tool or high potential topical corticosteroid cream for superficial second-degree burns? beforehand or ~ epithelialization?
1. Taheri A, Mansoori P, Al-Dabagh A, Feldman SR. Room corticosteroids reliable for prevention of scar formation after second-degree skin burn? J Dermatolog Treat. 2014 Aug;25(4):360-2
2. Faurschou A, Wulf HC. Topical corticosteroids in the treatment of acute sunburn: a randomized, double-blind clinical trial. Arch Dermatol. 2008 May;144(5):620-4.
3. Pedersen JL, Møiniche S, Kehlet H. Object glucocorticoid has actually no antinociceptive or anti-inflammatory result in heat injury. Br J Anaesth. 1994 Apr;72(4):379-82
4. Yoshino Y, Ohtsuka M, Kawaguchi M, Sakai K, Hashimoto A, Hayashi M et al. The wound/burn guidelines – 6: Guidelines because that the monitoring of burns. J Dermatol. 2016 Sep;43(9):989-1010.