Pressure garments and wounds. To use or not to use?

Vita TU, Project Manager and Occupational Therapist

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Pressure garments are considered part of the standard care for post-burn scar management. By applying pressure over scars, the garments contribute to controlling hypertrophic scar growth and promoting scar maturation. But therapists are often confronted to the problem of wounds. Wounds may be already present on the surface of the skin and the therapist will hesitate to use pressure garments. Or the friction caused by the use of pressure garments may cause new wounds and the therapists will hesitate to continue the use of pressure garments. In this post, we’ll explain why it’s important to consider wounds when deciding whether pressure garments are an appropriate pressure therapy intervention, as well as what to evaluate in order to make our decision.

Why do wounds matter when considering whether to wear pressure garments?

Wounds matter because we cannot interfere with their healing process. Longer wound healing time will affect scarring and can increase the risk of complications, like infections. Wounds on joints can worsen and cause damage to underlying tissues and structures, like tendons. Small wounds can cause great discomfort to patients by making every movement painful. This will not only affect patients’ daily living activities, but can also greatly reduce their motivation to do rehabilitation and their compliance with the rehabilitation program.

Recently re-epithelized wounds have a light pink color. At this point, the epidermis and dermis have not yet formed a tightly connected mesh structure. As a result, transversal friction and shear between the epidermis and dermis means that skin will break and blister more easily, causing new wounds [1]. This unstable skin condition may last for several months. Because wearing pressure garments can cause friction on the skin, it’s important to evaluate the stability of the skin and the status of wounds before choosing to use this particular pressure therapy intervention.

How to evaluate if pressure garments can be used when wounds are present?

To determine skin stability, the therapist can observe the skin, but also ask the burn patient and the caregivers whether skin tends to break easily due to friction caused by wearing clothes, using gauze, bandages and pressure garments, or by scratching oneself to relieve itch [2]. If wounds are already visible, the therapist can observe the location, size, depth, color and exudate of the wounds.

Generally speaking, pressure garments can be used if there are small, scattered wounds or blisters. A protective layer of gauze can be used over the skin to reduce friction from the garments. However, use of pressure garments should be postponed or discontinued under the following circumstances:

1. The scar is still “fresh” and the skin is still highly unstable. Using pressure garments would easily create wounds (picture 1).

2. The patient has wounds bigger than 2.5cm in diameter [3].

3. The patient has smaller wounds but their depth or their location risk causing damage to underlying tissues. For example, a wound on the dorsal side of the finger joint can cause damage to the tendons.

Picture 1: The skin is in its unstable phase, using pressure garments will cause more wounds.

Picture 2: Should the use of pressure garment need to be postponed or discontinued, self-adhesive bandages or elastic bandages can be used as pressure therapy interventions.

In these aforementioned cases, it is better to apply pressure on scars by using elastic bandages or self-adhesive elastic bandages like Coban (Picture 2). Once the skin is more stable and wounds have started healing, pressure garments can be used.

Be creative by adapting, modifying or combining pressure therapy interventions

By remembering the aforementioned circumstances during your evaluation, you will be able to determine whether the use of pressure garments is the best choice at that specific moment. But it’s possible that for some specific areas, pressure from pressure garments is still not recommended. Instead of further postponing the use of garments, modifications to the garments can be made or garments can be used in combination with other pressure therapy tools to reduce pressure over specific areas at a higher risk of developing wounds (Picture 3).

Picture 3: Once the skin is more stable, use of pressure garments can begin or resume. In this picture, there is still a wound present on the dorsal side of the PIP joint of the right hand’s little finger. To relieve pressure over the joint, the seam of the pressure garment glove has been cut over the little finger, and self-adhesive bandage is being used temporarily instead. Later, after the wound has healed, the seam can be stitched back together and the glove can be used normally over the little finger.

Four tips to better evaluate if pressure garments are the right intervention when wounds are present

• Controlling scar growth through pressure therapy is important, but interventions shouldn’t interfere with the process of wound healing and they shouldn’t result in additional or more severe wounds.

• Postpone or discontinue use of pressure garments if:

  • The scar is still “fresh” and the skin is still highly unstable.

  • The patient has wounds bigger than 2.5cm in diameter.

  • The patient has smaller wounds but their depth or their location risk causing damage to underlying tissues.

• Be creative with pressure therapy tools. Garments can be modified or garments can be used in combination with different pressure therapy tools to reduce pressure over areas at a higher risk of developing wounds.

• Follow-up frequently to track changes, quickly identify problems and adjust the intervention when necessary.

References:

[1] Ira D. Papel, Principles of Facial Plastic and Reconstructive Surgery. In: Facial Plastic and Reconstructive Surgery. Thieme, 2011.

[2] Wound Care & Scar Management after Burn Injury. Produced by Model Systems Knowledge Translation Center. 2011.

[3] Richard, R.L. & Staley, M.J. Scar Management. In: Burn Care of Rehabilitation: Principle and Practice. Philadelphia (1994): F.A. Davis Company.