Overview
Definition:
Pressure garment therapy (PGT) involves the application of custom-fitted elasticated garments to exert continuous pressure over a healing or mature scar
Its primary aim is to modulate scar maturation, reduce scar hypertrophy, improve scar pliability, and prevent or release scar contractures
Scar modulation refers to the process of altering the natural progression of scar formation to achieve a more functional and aesthetically acceptable outcome.
Epidemiology:
Hypertrophic scarring and keloid formation are common complications following thermal injuries, surgical incisions, and trauma, affecting an estimated 30-50% of patients with significant burns
Scar contractures can occur in up to 80% of patients with deep burns
PGT is a widely used intervention in burn centers and reconstructive surgery units globally, with varying protocols and reported efficacy.
Clinical Significance:
Improper scar management can lead to significant functional impairment, pain, itching, psychological distress, and cosmetic disfigurement
Effective scar modulation, including PGT, is crucial for restoring joint mobility, preventing disfigurement, and improving the patient's quality of life post-injury or surgery
Understanding PGT principles is vital for surgeons involved in wound healing and reconstructive procedures.
Indications For Pgt
Established Scars:
Hypertrophic scars and keloids, typically 4-6 weeks post-healing or post-surgery, when the scar is mature enough to withstand pressure without compromising vascularity.
Contracture Prevention:
Early application in at-risk areas (e.g., over joints, flexural surfaces) to prevent scar contracture development and maintain range of motion.
Post Operative Management:
Following skin grafting, flap reconstruction, scar revision surgery, or excision of keloids to optimize scar outcomes.
Specific Conditions:
Burn scars, surgical scars, traumatic scars, acne scars, post-acne erythema and pigmentation, and scars from other dermatological procedures where abnormal scarring is a risk.
Mechanism Of Action
Mechanical Pressure:
Constant pressure (typically 20-30 mmHg, or higher based on scar assessment) compresses dermal fibroblasts and collagen fibers, disrupting the abnormal orientation and excessive deposition seen in hypertrophic scars.
Vascular Compression:
Reduces blood flow to the scar tissue, potentially decreasing the supply of nutrients and growth factors necessary for fibroblast proliferation and collagen synthesis, thereby reducing erythema and hypertrophy.
Collagen Remodeling:
Encourages more organized collagen deposition and cross-linking, leading to a softer, flatter, and more pliable scar.
Alteration Of Extracellular Matrix:
May influence the production and degradation of hyaluronic acid and glycosaminoglycans within the scar tissue, contributing to improved hydration and flexibility.
Application And Management
Initial Assessment:
Thorough evaluation of scar characteristics (color, thickness, pliability, presence of contractures, symptoms like itching or pain), patient's skin condition, and affected anatomical areas.
Garment Design:
Custom-fitted garments are preferred, especially for complex anatomical areas or significant scarring
Off-the-shelf garments can be used for simpler or smaller scars
Material choice (e.g., silicone, elasticated fabric) and closure methods are considered.
Fitting Protocol:
Garments should fit snugly without causing constriction, pressure sores, or ischemia
Gradual introduction may be necessary for sensitive patients
Ensure even pressure distribution and proper coverage of the scar.
Wear Schedule:
Typically worn 23 hours per day
Continuous wear is crucial for efficacy
Patients should remove garments for hygiene, skin inspection, and potential exercise.
Duration Of Therapy:
Variable, often ranging from 3 months to over 1 year, depending on scar maturity, response to therapy, and patient adherence
Therapy may continue until scar maturation is complete and functional goals are met.
Potential Complications And Precautions
Skin Irritation:
Redness, itching, rash due to friction, trapped moisture, or sensitivity to garment material
Proper skin hygiene and breathable materials can help.
Pressure Sores:
Can occur over bony prominences or areas with compromised circulation
Requires careful fitting and regular skin checks.
Decreased Mobility:
If garments are too tight or improperly fitted, they can restrict movement.
Heat Intolerance:
Garments can increase body temperature
advise patients to avoid overheating.
Discomfort And Non Adherence:
Psychological impact of continuous wear can lead to poor compliance
Patient education and support are essential.
Adjunctive Therapies
Silicone Sheeting:
Often used in conjunction with PGT to provide continuous hydration and pressure, particularly beneficial for superficial hypertrophic scars.
Massage:
Scar massage, performed by the patient or therapist, can further improve scar pliability and reduce adhesions, complementing PGT.
Pharmacological Agents:
Topical or intralesional corticosteroids (e.g., triamcinolone acetonide) may be used for particularly refractory hypertrophic scars or keloids, often in combination with PGT.
Other Modalities:
Laser therapy (e.g., pulsed dye laser for erythema), radiotherapy (for recalcitrant keloids), and surgical scar revision may be considered as adjuncts or alternatives when PGT alone is insufficient.
Key Points
Exam Focus:
Understand the indications, mechanism of action, application protocol, and potential complications of PGT
Be prepared to discuss its role in managing hypertrophic scars and contractures post-burn or surgery.
Clinical Pearls:
Emphasize patient education and adherence
it is the cornerstone of successful PGT
Regular follow-up with a multidisciplinary team (surgeon, therapist, nurse) is essential for optimal outcomes.
Common Mistakes:
Incorrect garment sizing leading to ineffective pressure or skin damage
Insufficient duration of therapy
Lack of adjunctive measures for stubborn scars
Underestimating the psychological burden on patients.