Advances in the assessment of burn scars

Prof Roy Kimble1,2, Dr Megan Simons1,3, Dr Zephanie Tyack1

1Centre for Children’s Burns and Trauma Research, UQ Child Health Research Centre, Centre for Children’s Health Research, South Brisbane, Australia, 2Department of Paediatric Surgery, Urology, Neonatal Surgery, Burns and Trauma, Lady Cilento Children’s Hospital, South Brisbane, Australia, 3Department of Occupational Therapy, Lady Cilento Children’s Hospital, South Brisbane, Australia


Background:This paper aims to provide an overview of advances in the assessment of burn scars over the last 5-years.  This will include recent evidence regarding the content and psychometric properties of patient-reported outcome measures, risk factors for burn scarring, and objective measures that assess individual or multiple scar characteristics. Assessments of the dose of scar interventions delivered such as pressure beneath pressure garments will also be reviewed.

Method: Data will be reported from published systematic reviews and the authors’ own work from three longitudinal cohort studies. Work will be presented from the field of burns as well as from the broader fields of scar and chronic disease where evidence in burns is not available.

Results:Comprehensive burn scar assessment should go beyond the assessment of physical scar characteristics to include sensory, social and emotional outcomes as well as the burden of treatment and adherence. Assessments from multiple perspectives may be appropriate (i.e., families, patients, clinicians). Assessments that focus on predicting and evaluating scar outcomes over time have received little attention with further research required in these areas. As clinicians working in burn care have indicated they choose assessments based on the ease of use and speed of completion feasibility of translating scar assessments into practice is an important consideration.

Discussion: Advances in the future are likely to include assessments that are better targeted to the needs of patients and tailored to patients. Future directions in scar assessment from a methodological perspective will also be discussed.




Development of mechanism-based Lysyl oxidase inhibitors to reduce skin fibrosis and scarring

Ms Nutan  Chaudhari1, Dr.  Andrew Stevenson1, Ms. Priyanka Toshniwal1, Dr.  Wolfgang  Jarolimek2, Professor Fiona  Wood1, Dr. Mark Fear1

1Burn Injury Research Unit, University Of Western Australia, Crawley, Australia, 2Pharmaxis, 20 Rodborough Road, Frenchs Forest, Australia


Skin scars are disfiguring and debilitating and cause a large economic burden to society (De Roche et al., 1994). In addition to the loss of function and aesthetic issues, scars can also lead to psychological problems and pain (Loeser and Melzack, 1999). However, to date there are no approved treatments available and very few in development.

Scarring is a multi-factorial fibrotic process which ultimately results in excessive collagen accumulation with concomitant poor appearance and pliability (Penn et al., 2012). The lysyl oxidase (LOX) family of enzymes has a major role in the formation of cross-links in collagen and elastin. This cross-linking leads to decreased solubility and increased stability of collagen, exacerbating collagen accumulation (Hong et al., 1999). This makes LOX a potentially attractive target for anti-fibrotic drug development.

In this study, we have shown that fibroblasts isolated from patients with skin fibrotic disorders (Dupuytren’s disease and Keloid scarring) have increased expression of the LOX family members (LOX and LOXLL1) which results in highly cross-linked extracellular matrix. Novel small molecule mechanism-based LOX and LOXL1 inhibitors have been developed for topical applications. These inhibitors reduce cross-linking and normalise appearance of extracellular matrix in vitro. The inhibitors also improve scar appearance and repair in small animal and porcine injury models. The data suggests that these inhibitors may provide an effective therapeutic strategy for scarring and skin fibrosis.

De Roche R, Lüscher N, Debrunner H, et al. (1994) Epidemiological data and costs of burn injuries in workers in Switzerland: an argument for immediate treatment in burn centres. Burns 20: 58-60.
Hong H-H, Uzel MI, Duan C, et al. (1999) Regulation of lysyl oxidase, collagen, and connective tissue growth factor by TGF-beta1 and detection in human gingiva. Lab Invest 79: 1655-1667.
Loeser JD and Melzack R. (1999) Pain: an overview. The Lancet 353: 1607-1609.
Penn JW, Grobbelaar AO and Rolfe KJ. (2012) The role of the TGF-β family in wound healing, burns and scarring: a review. International journal of burns and trauma 2: 18.


Andrew Stevenson is a junior postdoc working at the Burn Injury Research Unit at the University of Western Australia. He was awarded his PhD in 2016 titled “Investigating the role of epigenetics in scar maintenance” from UWA, and has been lucky to continue on this and other research focused on the mechanisms and treatment of fibrosis at the Burn Injury Research Unit.

The Brisbane Burn Scar Impact Profile (caregiver version for children older than 8 years) is reliable and valid for measuring health-related quality of life in children with burn scars.

Dr Megan Simons1,2, Professor Roy Kimble2,3, Dr Zephanie Tyack2,4

1Lady Cilento Children’s Hospital, Brisbane, South Brisbane, Australia, 2Centre for Children’s Burns and Trauma Research, Child Health Research Centre , South Brisbane, Australia, 3Department of Paediatric Surgery, Urology, Neonatal Surgery, Burns and Trauma, Lady Cilento Children’s Hospital, South Brisbane, Australia, 4Centre for Functioning and Health Research, Metro South Health, Buranda, Australia


This presentation reports the psychometric properties of a caregiver version of the Brisbane Burn Scar Impact Profile (BBSIP). The BBSIP is a burn-specific health-related quality of life (HRQoL), patient-report outcome measure consisting of 10 dimensions: overall impact; sensory symptoms; mobility; daily activities; friendships and social interaction; appearance; emotional reactions; physical symptoms; parent worries and parent concerns.

Data was collected between 2013 and 2016. A 1 to 2-week interval was used to test reliability and validity and a 1-month interval for longitudinal validity. Test-retest reliability was tested using intra-class correlation coefficients and concurrent validity using Spearman’s rho to test pre-specified hypotheses and correlations between change scores.

Sixty-three caregivers of children aged 8 years to 14 years, 11 months participated (median TBSA 1% [IQR = 2%, range <1%-26%]). Reliability was supported for dimensions expected to be stable (ICC = 0.75-0.86). Correlations with similar constructs from the POSAS (patient report) and PedsQL were small to large at baseline (ρ = 0.23 to 0.6; ρ = -0.31 to -0.73) and 1-month later (ρ = 0.18 to 0.54; ρ = -0.16 to -0.59) supporting validity.

The use of a reliable and valid burn-specific HRQoL measure to identify young children and adolescents at risk of health problems will be discussed. Scoring algorithms will be described. The BBSIP can aid in determining the burden of burn scarring on patients and families as well as reliably measuring the effectiveness of interventions on burn scarring over time in a paediatric population.


Dr Simons has completed research alongside the clinical, management and research capacity building position she currently holds. Dr Simon’s main area of research is paediatric burns, particularly understanding patient perspectives of burn scarring, with a focus on health-related quality of life and patient-reported outcome measures.

Validity and Reliability of Shear-wave Elastography to Evaluate Burn Scar Stiffness

Ms Helen Dejong1,2,3, Mr Steven Abbott5, Ms Marilyn Zelesco5, Dr Brendan Kennedy3,4, Dr Lisa Martin6, Prof  Melanie Ziman2, Prof Fiona Wood6,7

1Perth Scar And Pain Clinic , Mt Pleasant, Australia, 2Edith Cowan University, Joondalup, Australia, 3BRITElab, Harry Perkins Institute of Medical Research, Nedlands, Australia, 4Department of Electrical, Electronic & Computer Engineering, School of Engineering,The University of Western Australia, Crawley, Australia, 5Department of Medical Imaging, Fiona Stanley Hospital, Murdoch, Australia, 6Fiona Wood Foundation, Murdoch, Australia, 7State Burn Service of Western Australia, Murdoch, Australia


Shear-wave elastography (SWE) is an emerging imaging technology that provides quantitative assessment of tissue stiffness in-vivo. Based on ultrasound, SWE has been used to quantify stiffness associated with disease in the liver, breast, prostate and thyroid. This research aims to evaluate the validity and reliability of using SWE to objectively evaluate the stiffness of skin, burn scars and the associated non-injured subcutaneous tissues.

This prospective, cross sectional study evaluated adult burn patients with a healed partial thickness burn, at least 6 weeks post injury. Each participant had up to three scar sites of varying stiffness, and three matched, contralateral non-injured skin sites assessed with SWE, B-mode ultrasound and the POSAS.

Preliminary results (n=31 scars) indicate that SWE can quantify both the degree and extent of scar stiffness. Scar tissue demonstrated a higher average shear wave speed compared to non-injured skin. A novel trend was found indicating that increasing scar stiffness is also associated with a greater depth of stiffness. This stiffness extends into the non-injured subcutaneous adipose tissue, and in some cases to the peri-muscular fascia. Tests of validity and reliability were also performed.

Our results show that SWE provides a novel method with which to quantify both the degree and extent of increased tissue stiffness associated with a burn scar. Imaging both the scar and the surrounding non-injured subcutaneous tissues provides novel information regarding changes in mechanical properties of tissues associated with a burn.


Helen has been a clinical occupational therapist for over 20 years, working in Burns, upper limb trauma, neurology and chronic pain. She is currently doing her PhD titled the Mechanobiology of Scarring, and runs a private practice called the Perth Scar and Pain Clinic.

Sensory Descriptors Used by People With Burn Scarring

Ms Naomi Davis1, Dr Laura Miller1, Dr Megan Simons2,3,4, Prof Roy Kimble3,4,5,6, Dr Zephanie Tyack2

1School of Allied Health, Australian Catholic University, Brisbane, Australia, 2Centre for Burns and Trauma Research, Child Health Research Centre, Centre for Children’s Health Research, South Brisbane, Australia, 3Department of Occupational Therapy, Lady Cilento Children’s Hospital, South Brisbane, Australia, 4School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia, 5Centre for Childrens Burns and Trauma Research, Queensland Childrens Medical Research Institute, The University of Queensland, Brisbane, Australia, 6Department of Paediatric Surgery, Urology, Neonatal Surgery, Burns and Trauma, Lady Cilento Children’s Hospital, Brisbane, Australia, 7School of Medicine, The University of Queensland, Brisbane, Australia


Background: There is little empirical evidence regarding diverse sensory experiences other than itch and pain. Sensory descriptors can provide valuable information to inform tailored scar management and assess the effectiveness of interventions. Distressing sensory experiences are associated with reduce wellbeing and quality-of-life outcomes for burns patients. This study aimed to identify sensory descriptors used by adults at the time of scar development.

Method: Participants were patients aged 18 years and older, attending an acute tertiary hospital for post-acute burn scar interventions with burn wounds at least 85% re-epithelialised. Participants completed the adult version of the Brisbane Burns Scar Impact Profile (BBSIP) at baseline (85% re-epithelisation). Responses to the open ended sensory item were analysed using content analysis.

Results: The open-ended question was completed by 112 participants, aged 18 to 85 years. Sensory descriptors were reported as single words (73%) or in phrases (52%). Fourteen categories emerged with neuropathic descriptors used by 40 participants (33%) including sub-categories of pins and needles (14%), burning (8%) and mechanical allodynia (21%). Tightness was the most commonly reported sensory descriptor (43%) by participants followed by itch (38%).

Conclusion: The findings provide unique insights into the diversity of sensory experiences patients report in relation to their burn scars, which extend beyond itch and pain. Reporting of neuropathic burn descriptors should be included in patient reported outcome measures (PROMs) to facilitate comprehensive assessment and enable development of novel, and individualised interventions.


Naomi Davis has over 12 years working within the health sector in public, not for profit and private sectors. She has recently completed studies in Occupational Therapy and undertaken an honours research project in collaboration with the Brisbane Burns Research Centre, the University of Queensland and the Australian Catholic University.

Construct Validity of Dermoscopy in Measuring Vascularity of Hypertrophic Scars (HS)

Miss Huan Deng1, Professor Cecilia Li1

1The Hong Kong Polytechnic University, Hong Kong, Hong Kong


Background: The Vascularity of hypertrophic scars (HS) is an important indicator of scar maturation. A reliable and accurate measurement tool on documentation of the vascularity of hypertrophic scars (HS) will contribute to the identification of active scars in the early stage post injuries, such that early intervention on scar would prevent excessive proliferation of scar tissues. As one of morphological imaging devices, the Dermoscopy is preliminarily supported to measure the vascularity in scars.

Purpose: This study aimed to explore the construct validity of the application of Dermoscopy for measurement of vascularity in hypertrophic scars (HS).

Methods: An observational study was conducted and 20 subjects with hypertrophic scars at different stages of maturation would be recruited. Comprehensive scar assessment would include The Patient and Observer Scar Assessment Scale (POSAS), the Spectrocolorimeter for measurement of scar pigmentation and the Dermoscopy to measure the vasculartiy. Data measured by the Dermoscopy,  the POSAS and the Spectrocolorimeter would be calculated to find out the correlation among the three parameters. Results and findings of this study will be presented.


Miss Deng is a PhD student of the Hong Kong Polytechnic University.

Differentiating Elasticity from Pliability, and its Importance in Hypertrophic Scar Assessment

Ms Walei Zhang1, Prof  Cecilia  Li-Tsang1

1The Hong Kong Polytechnic University , Hung Hom, Kln, Hong Kong


Both pliability and elasticity are commonly used to describe the mechanical property of hypertrophic scar (HS) in reporting treatment efficacy. However, the differences between these two terms were seldom addressed. This study aimed to differentiate HS elasticity from pliability by (1) examining the concepts of these two terms; (2) illustrating their relationships with HS thickness; and (3) evaluating the suitability of these two parameters in describing HS progression and maturation.
41 subjects with post-burn HS were recruited. Post days of Injury (PDOI) were calculated prior to the assessment. HS thickness was measured using Midray Diagnostic Ultrasound System. Pliability was assessed using the DermaLab Elasticity Measurement. Elasticity was derived based on the pliability and thickness measured. The Pearson’s correlations were used to examine the relationship among pliability, elasticity, HS thickness and PDOI. Best fit models were explored to reveal the relationship between elasticity and PDOI.
Pliability is commonly measured by the deformation of tissue under a certain force, thus could be severely affected by the thickness. However, elasticity is a physical term that describes the nature of the tissue, thus independent from thickness. Significant correlation was identified between pliability and thickness (Pearson’s r= 0.420, p<0.01); and between elasticity and PDOI (Pearson’s r= -0.375, p<0.01). An inverse model was established between elasticity and PDOI (r2=0.333, F= 53.337, p<0.01).
The results confirmed pliability and elasticity are different concepts. The measurement of pliability could be significantly affected by HS thickness. HS elasticity could be a more suitable method in describing HS progression and maturation.


Ms Eve Walei Zhang is a PhD student from the Hong Kong Polytechnic University.


ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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