Daniele Bollero

Epidemiology and Risk Factors for Pathologic Scarring After Burn Wounds

OBJECTIVE To describe the clinical characteristics of postburn scars and determine the independent risk factors specific to these patients. While burns may generate widespread and disfiguring scars and have a dramatic influence on patient quality of life, the prevalence of postburn pathologic scarring is not well documented, and the impact of certain risk factors is poorly understood. METHODS A retrospective analysis was conducted of the clinical records of 703 patients (2440 anatomic burn sites) treated at the Turin Burn Outpatient Clinic between January 1994 and May 15, 2006. Prevalence and evolution time of postburn pathologic scarring were analyzed with univariate and multivariate risk factor analysis by sex, age, burn surface and full-thickness area, cause of the burn, wound healing time, type of burn treatment, number of surgical procedures, type of surgery, type of skin graft, and excision and graft timing. RESULTS Pathologic scarring was diagnosed in 540 patients (77%): 310 had hypertrophic scars (44%); 34, contractures (5%); and 196, hypertrophic-contracted scars (28%). The hypertrophic induction was assessed at a median of 23 days after reepithelialization and lasted 15 months (median). A nomogram, based on the multivariate regression model, showed that female sex, young age, burn sites on the neck and/or upper limbs, multiple surgical procedures, and meshed skin grafts were independent risk factors for postburn pathologic scarring (Dxy 0.30). CONCLUSION The identification of the principal risk factors for postburn pathologic scarring not only would be a valuable aid in early risk stratification but also might help in assessing outcomes adjusted for patient risk.

Toxic Epidermal Necrolysis Treated with Intravenous High-Dose Immunoglobulins: Our Experience

Background: Toxic epidermal necrolysis (TEN) is a rare severe acute exfoliative drug-induced skin disorder which has recently been ascribed to alterations in the control of keratinocyte apoptosis, mediated by an interaction between the cell surface death receptor Fas and its respective ligand. A therapeutic approach with intravenous immunoglobulins (IVIG) associated with pulse methylprednisolone, based on the inhibition of Fas-mediated keratinocyte death by naturally occurring Fas-blocking antibodies included in human immunoglobulin preparations, has produced good preliminary results. Objective: To analyse the efficacy of IVIG in the treatment of TEN. Patients: Nine patients with erythematous body surface area ranging from 38 to 85% and dermo-epidermal detachment from 4 to 37% were treated. Results: Eight patients were healed and 1 died of septic shock and multiple organ failure. Interruption of further epidermal detachment occurred after an average of 4.8 days from the onset of IVIG therapy. Complete wound healing occurred after an average of 12 days. Concerning complications, 3 out of 8 surviving patients had acute respiratory failure requiring mechanical ventilation and 1 acute renal failure was treated with dialysis. Late sequelae were limited to dyschromia and nail dystrophies. No hypertrophic scars were observed. Conclusion: IVIG therapy represents a safe and valid approach for TEN.

Acute complex traumas of the lower limbs : a modern reconstructive approach with negative pressure therapy

Acute traumas of the lower limbs cause complex functional damage for the association of skin loss with exposed tendons, bones, and/or vessels, requiring a multidisciplinary approach. Once bone fixation and vascular repair have been carried out, the surgical treatment for skin damage is usually based on early coverage with conventional or microsurgical flaps. Negative pressure therapy can play a primary role in the management of the elderly or intensive care patients, where wounds are secondary to life‐threatening problems. A total of 35 patients with 37 acute traumatic wounds of the lower limbs were treated with vacuum‐assisted closure (VAC®) therapy for an average of 22 days (range 3–46 days). The sponge was applied the day after bone fixation, vascular repair, and surgical debridement of nonviable tissues, so as to obtain a better control of bleeding. After VAC® treatment, all patients quickly developed healthy granulation tissue and a significant reduction in both extent and depth of wounds. Split‐thickness skin grafts were used to cover granulation tissue in most of the cases (66%—24 cases), and then local flaps (13%—five cases) or direct sutures (8%—three cases). The wounds healed spontaneously without surgical management in four patients. One patient died during the treatment period for concomitant diseases. No relevant complications directly related to VAC® therapy were observed other than one case of severe pain in an amputated stump. The average follow‐up duration was 265 days (range 33–874 days). No further tegumentary reconstruction was required. VAC® therapy may represent a valid alternative to immediate reconstruction in selected cases of acute complex traumas of the lower limb and allows for a stable functional result, using a minimally invasive approach.

Fig leaf tanning lotion and sun-related burns: case reports.

A sun tan is considered a symbol of well-being in our society, but incorrect methods of sun exposure can create serious problems. We present two cases of severe sun-related burns caused by fig leaf decoction used as home-made tanning lotion. Twenty four-thirty six hours after application and sun exposure, patients developed a phytophotodermatitis characterised by erythema, and blister formation involving all the photoexposed areas (45-70% BSA). Their general conditions became rapidly critical and they were admitted to our Burn Centre. The patients were discharged after 11 and 26 days, respectively. Haemolytic anaemia and retinal haemorrhages presented as systemic complications due to the furocoumarins present in the fig leaf decoction.

Negative pressure surgical management after pathological scar surgical excision: a first report

Wound dehiscence is a surgical complication caused by the application of opposing and distracting forces tending to pull apart the suture line. In recent years, a novel negative pressure surgical management system has been developed to prevent surgical wound complications. This system creates a closed environment that removes exudates and other potentially infectious material, protects the surgical site from external contamination, provides support in holding the edges of the incision together and promotes wound healing. In this study, we describe our first experience with Prevena™, a closed incision negative pressure management system used on suture line following wide pathological scars excision for the prevention of postoperative wound dehiscence. Eight patients with wide and mature pathological skin scars were treated with Prevena™. The device was positioned directly after surgical correction for 8 days with a continuous application of −125 mmHg negative pressure. All treated patients had no postoperative surgical wound dehiscence. In one case, a limit of the device was represented by its poor adherence on hairy surface, hampering the maintenance of an appropriate local negative pressure. In another case, suture line was longer than Prevena™ foam and it was covered partially. Prevena™ system appears to be safe, easy to use and may represent a support technique to wide pathological skin scars surgical correction.

Long-term follow-up of negative pressure wound therapy with instillation: a limb salvage procedure?

Negative pressure wound therapy (NPWT) is a treatment to reduce oedema, stimulate granulation tissue formation, remove wound exudate and diminish wound area, thus preparing it for secondary healing, skin grafting or coverage with flaps. The association of instillation to NPWT (NPWTi) is a new method for treating severe wounds, in particular, limb lesions at high risk for amputation. This therapy helps to deliver instillation fluid automatically into the contaminated wound, before application of negative pressure. These steps, repeated cyclically, help to remove infectious material, leading to a better moist environment, a necessary condition for wound healing. We report our experience of treating three patients with complex wounds and associated noble structure exposition conservatively with NPWTi and flap coverage. In a long‐term follow‐up (5 years), we were able to achieve a stable surgery reconstruction on preserved limbs, without evidence of chronic infection and other sequelae or complications. Despite the fact that our experience is limited , as it is based on only a few cases, it suggests how NPWTi could be considered useful in a conservative approach to the treatment of acute complex wounds of the lower extremities. In these patients with high risk of amputation, a long‐term follow‐up becomes fundamental in order to evaluate wound bed status after NPTWi.