Yu-Li Sung, Director, Medical Device Center,
Sunshine Foundation
Therapists often ask us what they can do or what they can say to convince patients to adhere to wearing pressure garments. Let’s face it, wearing pressure garments is challenging: they’re uncomfortable, they make you look very conspicuous and in summer or tropical climates, they can be suffocating and hot.
Eventually, the scars of our patients will mature and they will no longer need to wear garments. But sometimes, after succeeding in achieving compliance, therapists are confronted to a different problem: patients refuse to take them off although they no longer need them.
In this post, we will discuss how the therapist can help prepare the patient’s transition towards his new pressure garment-free life and how to deal with concerns, anxiety and fear that may arise when patients have difficulty letting go of their garments.
Why are some patients reluctant to discontinue the use of pressure garments?
For some patients, hearing their therapist say that they can discontinue the use of pressure garments can be very liberating, like they have finally graduated from rehabilitation. But for some patients, saying goodbye and letting go of their garments can be emotionally charged, symbolically opening up another chapter in their life that is full of new challenges and uncertainties.
Although the therapist has assessed that scars have reached maturity and there is no longer a risk of hypertrophic growth, some patients may still worry that without pressure garments, their scars will continue to grow. Some may get a feeling of protection and security from the garments. The garments not only protect the skin from the outside environment, but they also cover the scars and hide them from view. Removing garments implies revealing one’s scars, which can be emotionally challenging. Also, after wearing garments for many months, even years, they’ve become like a second skin for the patients and are part of their daily routine.
First, determine that pressure garment use can be safely discontinued
Pressure garment use can begin to be safely discontinued when scars are mature or almost mature, which can take one, two years or even more. Although time since injury can be used as a reference, because every patient’s scar maturation speed is different, the therapist can assess scars based on the following criteria:
Vascularity: Is the color closer to normal pinkish skin color?
Height: Does the scar look flatter?
Pliability: Is the scar suppler? Can it be pinched and raised more easily?
Another thing that both the therapist and patient can observe is whether the scar remains flat even when the garment is removed. If the scar is still active, it will tend to “rebound” and rise again after the garments have been removed. If the scar is more mature, the scar’s height will remain the same even after garments have been removed. The therapist can encourage the patient to observe how his scars behave after taking off garments for showering. Does the scar stay flat or does it tend to rise up again?
Second, help the patient prepare through progressive reduction of use
The patient created a daily routine of wearing and caring for his pressure garments, but now he must create a new routine of “unwearing the garments.” If the therapist’s assessment finds that the scars are close to maturity, the patient can progressively ease out of his garments by reducing the number of hours of wear in half, to about 12 hours. The therapist can discuss with the patient when is the best time to remove the garments, based on daily routine. For example, if the patient usually works outside and the garments feel hot, he can remove them during the day and wear them at home during the evening and at night. Or in the case of a child, if parents worry that the child is too rambunctious and can hurt his skin, they can let the child wear the garments during the day and remove them during the evening and at night.
You can also consider starting with reduction of use for one specific area or a specific garment and then progressively include other areas/garments.
It’s important to remind the patient to observe closely how scars react to reduction of pressure garment wear time and also schedule follow up with the patient to monitor scar status and adjust the strategy accordingly. For example, you can discuss another reduction of wear time if it seems that the scars remain stable and don’t show any signs of continued hypertrophy.
Third, understand the patient’s source of anxiety
Garment is part of patient’s life for many months, even many years. It has become like a second skin, a protective layer or even like an “armor.” If the patient seems worried or anxious about discontinuing pressure garment use, the therapist can discuss with the patient what is the source of his anxiety and together, identify possible strategies to facilitate the transition.
For example, if the patient fears that scars will continue to grow once he stops wearing garments, the therapist can explain the scar maturation process and show the patient’s progress with photos of scars and scar evaluation results over time. Tangible proofs (ex: showing the patient how his Vancouver Scar Scale scores become lower over time as a sign of scar maturation) can help the patient visualize his progress and lessen his fears of hypertrophic scar growth.
If the patient is not ready to show his scars and fears that once the garments are removed, everyone will notice them, he can wear long sleeves or long-legged pants in the meantime. The patient can then try to progressively get used to showing is scars by wearing short-sleeve shirt at home for a short while, then for a longer period, followed by short periods outside, and so on. The patient can also prepare short answers to potential questions from curious strangers or imagine what he would do under different types of scenarios. For example, the patient can say: “This is a burn scar. I was in an accident.” The most important thing is to practice progressively.
However, if scars cause body image issues that risk affecting the patient’s emotional well-being or even is return to a normal life, it may be a good idea to encourage the patient to talk to a psychological professional.
To summarize…
Make sure that scars are mature or close to maturity before discontinuing pressure garment use, by looking for specific signs like vascularity/color, height, pliability and “scar rebound.”
Discontinue use progressively, both in terms of increments of time, and in terms of body area/garment.
Reduction of use should be accompanied by close follow-up to determine how the pressure garment plan should be adjusted (ex: Continue reducing use? Or postpone?).
Explain reduction of pressure garment use with the patient and discuss any possible worries.
If the patient feels anxious, discuss the source of his anxiety and together, identify possible strategies.