Understanding the Limitations of Pressure Garments in Burn Scar Management and How to Mitigate Them

Yu-Li Sung, Physical Therapist and Director, Medical Device Center

Sunshine Social Welfare Foundation

---

Pressure garments are a cornerstone of pressure therapy in managing hypertrophic scars. However, while indispensable, they are not without limitations. Indeed, no single pressure therapy tool is a panacea to deal with hypertrophic scars. This post explores what pressure garments can and cannot do, helping to set realistic expectations for both therapists and patients. We will also examine what are the strategies to manage or reduce the impact of the limitations of pressure garments in burn scar management.

Limitations of Pressure Garments in Burn Scar Management: Tips to Manage or Reduce their Impact

1. Uneven Pressure Distribution

Pressure garments work by applying pressure through the elastic material's circular coverage. The level of pressure will fluctuate depending on the body part's curvature, as well as the design of the garment:

• Convex areas: Areas with a small radius of curvature, slender or protruding areas like fingers or the chin receive the most pressure.

• Flat areas: Large, flat regions such as the stomach and thighs typically experience lower pressure due to the larger radius of curvature.

• Concave areas: Areas like the webspaces of fingers and toes, palms, or the wings of the nose often receive inadequate pressure or even no pressure at all.

• Openings in garments: Pressure around garment openings, like mask openings (e.g., around eyes, nose, mouth and ears), garment edges (e.g., collar of vest, cuffs of sleeves, tip of fingers on gloves), or pants openings (e.g., crotch), will be lower.

Tips and Strategies:

• Convex areas: Monitor these areas regularly for signs of excessive pressure to prevent complications like irritation or skin breakdown.

• Flat areas: If pressure seems to be insufficient, inserts can be used inside the garments. In addition, making te garment by using a double layer of pressure garment fabric can help increase pressure.

• Concave areas: Use inserts made of silicone, foam, or other padding materials like leather or jeans to fill in gaps and ensure pressure reaches these areas.

• Openings in garments: Combine garments with silicone gel sheets or other inserts for areas around eyes, ears, and garment openings.

2. Insufficient Pressure in Soft Tissue Areas

Regions with substantial soft tissue, such as the buttocks, thighs, and breasts, often lack the bone support needed for effective compression. Soft tissue areas are more pliable and compressible than areas with less soft tissue. The soft tissue can absorb some of the applied pressure, reducing the effectiveness of the garment in maintaining consistent pressure across the area. This results in less force being applied to the scar.

Tips and Strategies:

Add reinforcement layers or specialized padding to improve pressure application on soft tissues like the buttocks or breasts. Consider using adjunct pressure therapy devices, such as silicone sheets or Otoform inserts, for areas where garments alone cannot achieve adequate pressure.

3. Dependency on Customization

Custom-made garments aim to provide a snug fit. Well-fitting garments are not only more comfortable for the patient, but they ensure that all the areas that need pressure indeed receive it.

• Measurement timing is critical: Measurements taken when there is still edema or swelling can result in poorly fitting garments. That’s because between the time of measurement and the delivery of the garments to the patient, edema may have subsided, therefore the garment will no longer fit.

• Changes over time: Weight fluctuations, growth (especially in children), or scar progression may affect the garments’ fit, necessitating frequent adjustments.

Tips and Strategies:

• Regular reassessments: Conduct periodic evaluations of fit and effectiveness, especially in children or patients with significant weight changes.

• Flexible garment options: When possible, using separate pieces can reduce the impact of having to modify garments for fit. For example, instead of using a pressure garment vest with long sleeves, a short sleeve vest can be used with separate sleeves. If the vest needs to be adjusted, the patient can continue wearing the sleeves.

4. Fabric Limitations

The elastic materials used in pressure garments can stretch, lose elasticity, or become fragile with repeated use and washing. This compromises their ability to maintain consistent pressure over time.

Tips and Strategies:

• Two sets of garments: Patients should receive two sets of garments so that they can be worn and washed alternately.

• Proper care and maintenance: Educate patients on the importance of delicate washing, drying, and storing of garments to prolong elasticity and lifespan.

• Reinforce high-stress areas: Use double stitching or thicker material in regions prone to wear and tear.

• Frequent replacements: Replace garments every 4–6 months or as needed to ensure optimal performance.

5. Discomfort and Compliance Issues

Comfort plays a pivotal role in therapy adherence. Patients often find pressure garments uncomfortably hot, particularly in warm tropical climates or during summer. Also, garments can sometimes cause skin irritation, especially in high-friction areas like the back of the knees or armpits, or bony prominences like elbows. Physical discomfort, combined with the need for daily washing and upkeep, can sometimes lead to inconsistent use by the patients.

Tips and Strategies:

• Friction reduction: Add soft liners or fabric padding to high-friction areas, like behind knees or underarms, to help reduce friction.

• Gradual introduction: Patients are not used to wearing pressure garments and initially, the surface of their scar may still be unstable and fragile. For this reason, start with garments that have lower pressure. As patients adapt to the garments and their scars become more stable and able to tolerate pressure, gradually increase the level of pressure.

• Patient-centered adjustments: Regularly check with patients about fit and comfort, making modifications as necessary to encourage compliance.

6. Risk of Over-Pressure

To control scar growth, we want pressure garments to provide the “just right” pressure. Excessive pressure can cause complications, such as circulatory issues (e.g., edema, paresthesia), skin problems (e.g., maceration, blisters), or even developmental concerns in children, such as growth limitations and deformities.

Tips and Strategies:

• Educate patients: Train patients to recognize signs of excessive pressure (e.g., numbness, skin discoloration) and report them immediately.

• Frequent follow-ups: Schedule regular check-ups to assess pressure levels and adjust the garments if necessary.

• Gradual pressure increases: Begin with lower pressures in fragile or early-stage scars, increasing only as skin tolerance improves.

• Alternative pressure therapy devices: Use silicone gel sheets or other pressure therapy devices as substitutes to compensate for areas with insufficient pressure, as opposed to increasing pressure by tightening the garments.

Conclusion

Pressure garments are a powerful tool for managing hypertrophic scars, but they are not a standalone solution. By understanding their limitations, combining them with complementary therapies, and doing regular follow-ups, therapists can maximize outcomes for burn patients.