Burn-injured skin heals in one to three years if scar tissue develops. Pressure garments and plastic orthoses may shorten the healing time. If thick scars do not form, healing is complete when the pink color fades (6–12 months). Burns, graft sites and donor sites that are done healing are called mature wounds.
Burns produce two types of pain. The first type is background pain, which is present, tolerable and described at a level of about two to three on a scale of ten. The second type of pain is the excruciating and intolerable pain that may occur during wound cleansing, dressing changes or rehabilitation therapy. Because patients experience two distinct kinds of pain, the Burn Center uses two different kinds of pain medication. Methadone is used to control background pain while morphine IV is the drug of choice for the acute pain. In addition, relaxation techniques in conjunction with medications often help relieve pain. No magic remedy is available for pain management and the amount of medication that would eliminate all pain would also suppress the respiratory system to a dangerous level. Despite our best efforts, the fact remains that some pain will be associated with recovery from a burn injury.
The itch sensation for burn survivors may be a tingling feeling caused by nerves regrowing or from dry skin caused by the lack of natural oil production because oil glands may have been damaged or destroyed by the burn.
Here are some things that can help:
When a burn site first heals, the healed outer skin layer (epidermis) is not tightly attached to the deeper layers of the skin. Newly healed skin is very fragile—open areas, tears and blisters are a common problem. It is also common to lose small areas of a skin graft because of the build up of fluid under the graft that occurs right after surgery. Grafted areas aren’t as thick as normal skin, and as a result can open easily.
Several topical applications including Xerform, Unna zinc oxide impregnated bandage, silver sulfadiazine (Silvadene® or SSD) and Bacitracin might be used alone or in some combination on your open areas. If one topical does not work, another is used. Often dressings are used on a trial basis to see if they will help close the wound. What works best for each patient is discovered by trial and error and physician preference.
Donor skin causes damage to the normal layers of the skin, similar to how a burn injures the skin. Therefore, although the layer of skin taken as a donor is very thin, it also has the potential to scar. Skin pigment change is the most common and noticeable scar in donor sites.
The cells in the superficial or upper layers of skin, known as the epidermis, are constantly replacing themselves. This process of renewal is basically exfoliation (shedding) of the epidermis. But the deeper layers of skin, called the dermis, do not go through this cellular turnover and so do not replace themselves. Thus, scars and foreign bodies (such as tattoo dyes) implanted in the dermis will remain.
If the burn extends over a joint, maintaining a range of motion will be a challenge. Skin tightness that limits range of motion can be permanent if the “tight” area is not stretched during the skin maturation phase of healing. If skin tightness is present, anti-contracture positioning is recommended 24 hours a day. As skin matures, it softens and feels less tight. A surgical release might also be necessary to add skin to a contracted area. The area most likely to be released is in the armpit (axilla).
Encouraging blood flow and circulation helps wounds heal faster. Exercise helps prevent complications such as contractures and blood clots in legs. Walking and exercise is important for total recovery, especially to the areas affected by the burn.
Skin products that do not use alcohol or perfumes are generally less irritating. It is best to try a sample of the product on a small patch of skin to check for irritation. If no problems develop, application on a larger area should be fine.
When neglected, chronic ulceration (a wound that is open for a very long time) results in a rare, but highly malignant condition known as a Marjolin’s Ulcer. This condition generally only occurs in areas with neglected scars with chronic or recurrent ulcerations.
Silver sulfadiazene cream (Silvadene®) does indeed turn black as the silver ion oxidizes. However, the black pigments are not incorporated into the healing skin. Permanent skin discoloration is not from using silver sulfadizene on burn wounds. As healing skin matures, melanocytes, the cells that produce pigment return. People with little pigment in their skin (e.g., Asian and Mediterranean) tend to have more melanocytes and more pigment than unburned skin, often leaving permanent dark discoloration. Also, some people who expose their recently-healed burns to the sun experience a permanent dark discoloration. We recommend no sun (UV) exposure until the injured skin is mature, 12–18 months after the injury.
A mature burn wound is one in which the bright pink color has faded to a more normal color and the skin feels soft and supple again. This process often takes longer than 12 months.
Steroids are thought to soften tissue because of their effects on collagen (the strong fibers that connect skin cells to each other). Steroid injections are painful for one to two hours after they are administered and work 40–60 percent of the time.