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Three factors to consider in regards to the “23 hours” general rule for pressure garment wear time

Yu-Li SUNG, Physiotherapist and Director, Medical Device Center,

Sunshine Social Welfare Foundation

 
Do patients really need to wear pressure garments all day, every day?

Burn patients are usually instructed to wear pressure garments 23 hours each day for better scar control results. As a general rule, pressure garments are worn all day, and are usually removed when the patient needs to shower or bathe, do wound care for small wounds, or sometimes when eating to avoid getting the pressure garment mask dirty.


But garments can be uncomfortable and patients may be reluctant to comply. Also, applying this “23 hours general rule” to the letter may not be feasible or even recommend for a variety of reasons. How should the therapist plan the patient’s pressure garment wear schedule? In this article, we’ll outline three important factors to consider:


Factor 1: Phase of scar maturation

Continuous wear is recommended because hypertrophic scars will begin to form 6 weeks to 3 months after the wound is healed. Initially, collagen production speed (synthesis) outpaces its breakdown speed (lysis). In the active growth phase, collagen is deposited at a higher rate than normal, in thick bands, in a whorl-like pattern with no overall orientation. This process goes on 24 hours, 7 days a week non-stop. This accumulation of collagen in nodules is what gives the scar its raised and rigid appearance.


Although in the later stage of the maturation phase, collagen production speed will eventually slow down naturally, the purpose of early and continuous pressure therapy is to apply vertical pressure to the scar, which will encourage the collagen in scar tissues to realign in a paralleled direction, which will result in softer, smoother scars. It will also speed up the process of scar maturation, which can take at least a year and can last up to two years or even longer.

Effect of pressure on burn scar
Effect of pressure on burn scar

If the scar is in its active growth stage, continuously wearing pressure garments for 23 hours is recommended to counteract hypertrophic growth. But as the scar becomes more and more mature, wear time can be progressively decreased until the use of pressure garments is eventually discontinued.


Factor 2: Status of the skin

Another important factor to consider is the status of the skin. The surface of recently healed scars will be more unstable and fragile, wounds and blisters will tend to form more easily. Therefore, although the scar may have entered its active growth phase and require continuous pressure therapy to control hypertrophic growth, its surface might not be stable enough to sustain friction from the fabric of pressure garments over the skin. If that is the case, other pressure therapy tools like elastic bandages or self-adherent elastic bandages (like Coban) can be used as a temporary pressure therapy measure, until the surface of the scar is less fragile and the patient can start wearing garments. Elastic bandages or self-adherent elastic bandages can provide pressure without producing shearing force over fragile scar surface.


Factor 3: Age of the patient

The “23 hours” general rule applies if the surface of the scar is stable enough and the scar is currently in its active hypertrophic growth phase with one caveat…


Young children.


Because young children are still developing, there is a possibility that excessive or prolonged application of pressure can affect growing tissues and structures like bones. Indeed, some papers have reported skeletal and dental deformity in some children after use of pressure garments [1, 2].


Therefore, pauses are recommended throughout the day, during which the child can remove garments for a short while. These pauses can be scheduled according to the child’s daily routine. For example, if the child takes a nap after lunch, garments can be removed before the child has his lunch and put back on after his nap. This can avoid the inconvenience of having to take off and put back on the garments numerous times.


However, it’s still important to consider the status of hypertrophic scar growth of the child. If scar hypertrophy is serious, it is not suitable to excessively reduce the wearing time of pressure garments, and the following methods can be used to achieve a balance.

  1. To avoid complications, pressure garments should not provide excessive pressure. Pressure should be just enough that the garment leaves a slight indentation on the scar. If garments are too tight, they should be adjusted as soon as possible.

  2. Frequent follow up (once a month) is recommended, not only to make sure that the pressure garments still fit, but also to verify that scars are under control and that the child’s development is not affected. Special attention should be given to the face, torso, limbs and in the case of girls, the development of breasts.

  3. Garments should be replaced in a timely manner. Usually, a new set of pressure garments should be made every six months. For fast-growing children, pressure garments may need to be replaced 4 to 5 months in advance to avoid adverse effects of inappropriate pressure garments on children.

Remember! The “23 hours” general rule is the guiding principle, but it may need to be adjusted to the patient’s situation in terms of scar phase, skin status and age.


References:

1. K.S. Leung, J.C.Y. Cheng, G.F.Y. Ma, J.A. Clark, P.C. Leung, Complications of pressure therapy for post-burn hypertrophic scars, Burns, August 1984, Volume 10, Issue 6, Pages 434–438


2. Fricke, Nanette B. BS, PT; Omnell, M. Lena DDS, MSD; Dutcher, Kristi A. BS, PT; Hollender, Lars G. DDS; Odon, T.; Engrav, Loren H. MD, Skeletal and Dental Disturbances in Children After Facial Burns and Pressure Garment Use, Journal of Burn Care and Research, 1999;20:239-49

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