b u r n s 4 0 ( 2 0 1 4 ) 1 5 1 3 1 5 2 0The effect of burn rehabilitation massage therapyon hypertrophic scar after burn: A randomizedcontrolled trial

Yoon Soo Cho a, Jong Hyun Jeon a, Aram Hong b, Hyeong Tae Yang c,Haejun Yim c, Yong Suk Cho c, Do-Hern Kim c, Jun Hur c, Jong Hyun Kim c,Wook Chun b,c, Boung Chul Lee d, Cheong Hoon Seo a,b,*aDepartment of Rehabilitation Medicine, Burn Center, Hangang Sacred Heart Hospital, Hallym University Medical

Center, Seoul, Republic of KoreabHallym University Burn Institute, Seoul, Republic of KoreacDepartment of Burn Surgery, Hallym Burn Center, Seoul, Republic of KoreadDepartment of Psychiatry, Hallym Burn Center, Seoul, Republic of Korea

a r t i c l e i n f o

Article history:

Accepted 9 February 2014

Keywords:

Burn

Hypertrophic scars

Rehabilitation

Massage therapy

a b s t r a c t

Objective: To evaluate the effect of burn rehabilitation massage therapy on hypertrophic

scar after burn.

Method: One hundred and forty-six burn patients with hypertrophic scar(s) were randomly

divided into an experimental group and a control group. All patients received standard

rehabilitation therapy for hypertrophic scars and 76 patients (massage group) additionally

received burn scar rehabilitation massage therapy. Both before and after the treatment, we

determined the scores of visual analog scale (VAS) and itching scale and assessed the scar

characteristics of thickness, melanin, erythema, transepidermal water loss (TEWL), sebum,

and elasticity by using ultrasonography, Mexameter1, Tewameter1, Sebumeter1, and

Cutometer1, respectively.

Results: The scores of both VAS and itching scale decreased significantly in both groups,

indicating a significant intragroup difference. With regard to the scar characteristics, the

massage group showed a significant decrease after treatment in scar thickness, melanin,

erythema, TEWL and a significant intergroup difference. In terms of scar elasticity, a

significant intergroup difference was noted in immediate distension and gross skin elas-

ticity, while the massage group significant improvement in skin distensibility, immediate

distension, immediate retraction, and delayed distension.

Conclusion: Our results suggest that burn rehabilitation massage therapy is effective in

improving pain, pruritus, and scar characteristics in hypertrophic scars after burn.

# 2014 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: Department of Rehabilitation Medicine, Hangang Sacred Heart Hospital, Hallym University, 94-200 Yeong-deungpo-Dong Yeongdeungpo-Ku, Seoul 150-030, Republic of Korea. Tel.: +82 2 2639 5730; fax: +82 2 2635 7820.

E-mail address: chseomd@gmail.com (C.H. Seo).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/burns

http://dx.doi.org/10.1016/j.burns.2014.02.0050305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

b u r n s 4 0 ( 2 0 1 4 ) 1 5 1 3 1 5 2 01514standard therapy and burn rehabilitation massage therapy,

and the control group, which received only standard therapy.

Tewameter is a common equipment used for evaluating skin

barrier function, and TEWL is measured in g/h/m2[26,30].1. Introduction

Hypertrophic scarring after surgical procedures and trauma,

especially, burns, is a great concern for patients and a

challenging problem for clinicians. Peacock defined hyper-

trophic scars as scars raised above the skin level but within the

confines of the original lesion [1]. Hypertrophic scars may

cause significant functional and cosmetic impairment, pain,

and pruritus, which compromise the patients quality of life

[24]. These scars are caused by a general failure in normal

wound-healing processes [5]. Post-burn hypertrophic scars

typically appear on the trunk and extremities.

Hypertrophic scars usually develop within 13 months of

injury, whereas keloid scars may appear up to 12 months after

the injury [6]. The nature of scarring appears to depend on

factors such as race, age, genetic predisposition, hormone

levels, atopy, and immunologic responses of the patient, type

of injury, wound size and depth, anatomic region affected, and

mechanical tension on the wound [7]. The presence of

complications, such as bacterial colonization and infection

of the wound, seems to promote hypertrophic scarring [611].

The development of hypertrophic scars in burn wounds is

mainly influenced by the time to heal and the depth and size of

the wound [12,13]. Unfortunately, most of the reports

published on post-burn scarring do not accurately define

these factors [14,15], and only a few authors have used

validated criteria or classification systems to define hyper-

trophic scarring [12,1618].

Hypertrophic scars are currently managed by application of

silicone gel, pressure therapy, intralesional corticosteroid

injection, laser therapy, cryotherapy, radiation, surgery, etc.

According to Roh et al., massage therapy for post-burn

hypertrophic scar improved pruritus, Vancouver scar scale

(VSS), and depression [19].

Various tools are currently available for the assessment of

hypertrophic scars. The VSS is a validated subjective scale [20

22], as is the patient and observer assessment scale (POSAS),

which encompasses both patient and observer evaluations

[23,24]. Tools for the objective assessment of hypertrophic

scars are scarce. Nevertheless, reports have been published on

the use of negative impressions of the scar, ultrasound

images, laser doppler flow, color measurements, and three-

dimensional systems for the analysis of hypertrophic scars

[20,25,26].

This study sought to determine the effects of burn

rehabilitation massage therapy for hypertrophic scar manage-

ment after burn by using objective evaluation tools.

2. Materials and methods

We enrolled patients who were admitted to our hospital for

the rehabilitation hypertrophic scars developing after the

acute management of burns, including skin grafts. The study

was designed as a prospective randomized experimental and

control group study; the subjects were randomized into 2

groups, namely, the massage group, which received bothMedical staff not involved in the study randomly assigned

patients to the 2 groups using a computer-generated allocation

random number table and prepared the procedure for each

patient. All participants were reviewed and approved by the

Institutional Review Board. The standard therapy comprised

range of motion (ROM) exercise for the prevention of burn scar

contracture, silicone gel application, pressure therapy, intra-

lesional corticosteroid injection, and application of whitening

cream, anti-redness cream, and moisturizing oil for hyper-

trophic scar management. Patients were administered burn

rehabilitation massage 3 times a week, at 30 min per session

for each area by specialized burn rehabilitation massage

therapists. Effleurage, friction, and petrissage massage were

performed after the application of Rosakalm1 cream (Plante

system, France), moisturizing Emu oil (Emu spirit, Australia)

oil and Physiogel1 lotion (Stiefel, United States). The effects of

the treatment were evaluated on the basis of the visual analog

scale (VAS; score, 010) and itching scale (score of 04) for

pruritis. Additionally, 5 of the following parameters were

applied to objectively investigate and measure burn scar

characteristics: (1) scar thickness, (2) scar melanin and

erythema, (3) scar transepidermal water loss (TEWL), (4) scar

sebum, and (5) scar elasticity. Patients were assessed both

before treatment and after treatment, before discharge from

the hospital, by rehabilitation doctor. And assessors blinded to

whether the patient had received standard care or burn

rehabilitation massage therapy.

A total of 160 subjects were divided into a massage group

(n = 80) and a control group (n = 80), but 4 subjects in the

massage group withdrew from the study and 10 from the

control group were excluded since they were lost to follow up.

The final analysis included 76 subjects in the massage group

and 70 in the control group, i.e., 146 subjects in all (Fig. 1).

2.1. Methods of measurement

2.1.1. Measurement of scar thicknessThe thickness of the scar was measured by a high-resolution

ultrasonic wave equipment (128 BW1 Medison, Korea) by

using a 7.5-MHz probe. The ultrasound image enabled the

differentiation of the subcutaneous fat layer and the muscle

layer from the scar. The measurements enabled the assess-

ment of the thickness of the scar in a unit centimeter (cm) [27

29].

2.1.2. Measurement of level of scar melanin and erythemaThe mexameter1 (MX18 Courage-Khazaka Electronics GmbH,

Germany), which uses the principle of photo-spectrum

analysis, was used to measure the melanin and severity of

erythema in the skin, in a relative unit of A.U., ranging from 0 to

999. A higher value indicates a higher level of melanin deposition

and erythema. The measurement is obtained immediately after

the skin comes in contact with the sensor [26,30].

2.1.3. Measurement of scar TEWLTEWL was measured by a Tewameter1 (Courage-Khazaka

Electronic GmbH, Germany). The probe was positioned on the

affected area for 30 s, and an average value was obtained. The1

d (

ion litat 16

b u r n s 4 0 ( 2 0 1 4 ) 1 5 1 3 1 5 2 0 1515Contro l Gro up (n = 80 )

Rang e of motion exer cise

Standard ther apy : sili cone gel, pres sure therapy, corticos teroid in jection, moisturizing crea m

Randomize

Admissrehabi

(n = 2.1.4. Measurement of the level of sebum in the scarSebum in the scars was measured by Sebumeter1 (Courage-

Khazaka Electronic GmbH, Germany). The measurement is

based on the principle of grease-spot photometry. The

measuring head of the cassette with its special tape is placed

on the skin. It is then inserted into a slot in the device, where

the transparency is measured by a light source passing

through the tape. A photocell measures the transparency. A

microprocessor calculates the result, which is shown on the

display in mg sebum/cm2 of the skin [31].

2.1.5. Measurement of scar elasticitySkin elasticity was measured using Cutometer SEM 5801

(Courage-Khazaka Electronic GmbH, Colongne, Germany).

This device pulls skin using negative pressure on an 8-mm

diameter probe and indicates the skins maximum level of

distortion by a numerical value. Two seconds of negative

pressure of 450 m bar is followed by 2 s of recess, and this

consists of a complete cycle. Three successions of cycles

were carried out, and the average value was obtained

[26,30].

Lost to f ollow-up (n = 10)

Follow-up as sessment (n = 70)

Pain (VAS) , Pruri tus (itching scale ) Scar chara cteristic s (thick nes s, melan in, erythema, TEW L, sebum , elasti city)

Fig. 1 Diagram for subject enrollment, allocation, and follow-u

loss.Initial ass essm ent (n = 160)

Pain( VAS ), Pruri tus(itching scale ) Scar chara cteri stics (thic kness, melani n, erythema, TEWL, se bum, elas ticity)

Massage Grou p (n = 80 )

Rang e of motion exer cis e

Stan dar d therapy : sili cone ge l, pr essure the rapy, co rtico steroid injection, moisturizing cream Burn rehabil itat ion massage thera py

n = 160 )

for ion 0)3. Statistical analysis

Collected data were analyzed by using SPSS 21.0 program

(SPSS Inc., Chicago, USA). Fishers exact test and independent

samples t-test were used for homogeneity test. Independent

samples t-test was used to ensure homogeneity between the 2

groups at the initial assessment. Paired t-test was used to

compare the pre- and post-treatment status, and the analysis

of covariance (ANCOVA) was used. p Value below 0.05 was

considered statistically significant.

4. Results

4.1. Demographic and clinical characteristics of thepatients

A total of 146 patients comprised 111 men and 35 women. Of the

76 subjects in the massage group, 61 were men and 15 were

women, while the control group comprised 50 men and

Lost to follow up (n = 4)

Follow-up as sessment (n = 76)

Pain (VAS ), P ruritus (itching scale ) Scar chara cteristic s (thick nes s, melani n, erythema, TE WL, sebum, elasticity)

p. VAS, visual analog scale; TEWL, transepidermal water

Table 1 Demographic and clinical characteristics of patients

Co

Gender (M:F) 50

Age (years) 47

TBSA (%) 35

Interval between burn injury and rehabilitation therapy (days) 15

Period of rehabilitation therapy (days) 35

Times of burn rehabilitation massage therapy (times)

* Fishers exact test.y Independent samples t-test, values are represented as mean (standardTBSA, total body surface area.

b u r n s 4 0 ( 2 0 1 4 ) 1 5 1 3 1 5 2 01516Table 2 Pre-homogeneity test of initial assessment.

Control group (n = 70)

Pain(VAS) 5.65 (1.48)

Pruritus (itching scale) 2.78 (0.86)

Thickness (cm) 0.26 (0.15)

Melanin 177.78 (137.91)

Erythema 519.71 (106.31)

TEWL (g/h/m2) 33.74 (12.04)

Sebum (mg sebum/cm2) 40.32 (24.67)

Skin distensibility 0.1656 (0.1313)

Immediate distension 0.0942 (0.1168)

Biologic skin elasticity 0.4922 (0.0647)

Gross skin elasticity 0.6708 (0.1144)

Immediate retraction 0.0972 (0.0662) 20 women. The mean age was 46.06 (standard deviation 8.63)

years in the massage group. The mean total body surface area

(TBSA) was 37.25% (18.6) in the massage group. The mean interval

between burn and rehabilitation therapy was 148.77 (56.85) days

in the massage group. This study group is about the rehabilitation

patients who underwent skin grafts after burns. We had to start

the massage therapy started after the total burn wounds healed.

The mean period of rehabilitation therapy was 34.69 (22.53) days

in the massage group. In the massage group, the mean number of

times of burn rehabilitation massage therapy administration was

12.46 (7.17). There is no significant intergroup difference

( p > 0.05) (Table 1). No significant intergroup difference was

noted at the initial assessment ( p > 0.05) (Table 2).

Skin viscoelasticity 0.7752 (0.4732)

Delayed distension 0.0962 (0.0996)

Independent samples t-test, values are represented as mean (standard d

VAS, visual analog scale; TEWL, transepidermal water loss.

Table 3 The Change in scar pain (VAS) and pruritus(itching scale).

Initial Follow up Adjusted difference(95% confidence

interval)

p value

Pain (VAS)

CG 5.65 (1.48) 4.47 (1.34)

MG 5.63 (1.47) 3.02 (0.81) 1.36 (0.692.02)

Fig. 2 Comparison of scar thickness. yp < 0.05.

b u r n s 4 0 ( 2 0 1 4 ) 1 5 1 3 1 5 2 0 15174.6. The change in scar sebum

The scar sebum increased in the massage group. No significant

difference was noted (CI, 1.27.1; p = 0.51) (Fig. 6).

4.7. The change in scar elasticity

The skin distensibility increased in the massage group. The

difference between initial and follow-up skin distensibility

Fig. 3 Comparison of scar melanin. *p < 0.05.

Fig. 4 Comparison of scar erythema. *p < 0.05.Fig. 5 Comparison of scar TEWL. *p < 0.05.showed no significant difference (CI, 0.0030.368; p = 0.17). The

immediate distension increased in the massage group. The

difference between initial and follow-up immediate disten-

sion showed a significant difference (CI, 0.1110.310; p = 0.01).

The biologic skin elasticity increased in the massage group.

The difference between the initial and follow-up biologic skin

elasticity showed no significant difference (CI, 0.0840.206;

p = 0.13). The gross skin elasticity in the massage group. The

difference between the initial and follow-up gross skin

elasticity showed significant difference ( p = 0.01) (CI, 0.137

0.539). The immediate retraction increased in the massage

group. The difference between initial and follow-up immedi-

ate retraction showed no significant difference (CI, 0.076 to0.172; p > 0.69). The skin viscoelasticity increased in the

massage group. The difference between initial and follow-

up skin viscoelasticity showed no significant difference (CI,

0.307 to 0.245; p = 0.21). The delayed distension increased inthe massage group. The difference between initial and follow-

up delayed distension showed no significant intergroup

difference (CI, 0.111 to 0.083; p = 0.76) (Table 4).

5. Discussion

Hypertrophic scarring, a particularly difficult burn manage-

ment problem, has been extensively described in the literature.

Hypertrophic scars are morphologically characterized by an

Fig. 6 Comparison of scar sebum level.

dju

.183

.211

.061

.282

.048

.031

.014

rou

b u r n s 4 0 ( 2 0 1 4 ) 1 5 1 3 1 5 2 01518abnormal collagen pattern, with decreased numbers of elastin

fibers; persistent cellularity; alterations in the abundance and

composition of proteoglycans; and a prolonged, chronic

inflammatory reaction, which includes increased vascularity

and deposition of ground matrix [32].

Although the management of hypertrophic scars has

advanced in the past years, the lesions remain difficult to

prevent and treat. Hypertrophic scarring after burns requires a

specific therapeutic approach since the scars are often non-

linear and widespread [18]. Recurrences are common patient

Table 4 The change in scar elasticity.

Initial Follow up A

Skin distensibility

CG 0.165 (0.131) 0.212 (0.221)

MG 0.252 (0.178) 0.395 (0.273) 0

Immediate distension

CG 0.094 (0.116) 0.044 (0.043)

MG 0.147 (0.104) 0.255 (0.183) 0

Biologic skin elasticity

CG 0.492 (0.064) 0.467 (0.203)

MG 0.440 (0.077) 0.528 (0.184) 0

Gross skin elasticity

CG 0.670 (0.114) 0.482 (0.332)

MG 0.723 (0.115) 0.821 (0.182) 0

Immediate retraction

CG 0.097 (0.066) 0.173 (0.178)

MG 0.124 (0.083) 0.221 (0.154) 0

Skin viscoelasticity

CG 0.775 (0.473) 0.584 (0.229)

MG 0.488 (0.474) 0.615 (0.468) 0

Delayed distension

CG 0.096 (0.099) 0.153 (0.153)

MG 0.095 (0.087) 0.139 (0.102) 0

Values are represented mean (SD), CG, control group; MG, massage gsatisfaction with the treatment is variable [18]. Extensive

research has increased the knowledge base regarding the

pathophysiologic processes of wound healing and scar

formation [5], but there is still no consensus regarding the

best treatment strategy for reducing and preventing hyper-

trophic scarring.

Physicians and therapists have used and reported a variety

of therapeutic modalities for the treatment of hypertrophic

scar. Techniques such as silicone gel application, pressure

therapy, intralesional corticosteroid injection, laser therapy,

cryotherapy, radiation, and others have been used but are yet

to demonstrate any objective, reproducible improvement in

the character of hypertrophic scars. One of the techniques

reported to soften restrictive fibrous bands and improve the

pliability of the scar tissue is massage therapy.

They are many types of massage, such as effleurage,

friction, and petrissage. Basically, the effects of massage are

reflex and mechanical. The reflex effects of massage therapy

are realized through the stimulation of the afferent peripheral

nerves to the central nervous system to produce muscle

relaxation, a decrease in painful sensations, and an overall

sense of well-being. The mechanical effects of massage are

related to an improvement in venous return and lymphatic

drainage. Further, massage therapy stimulates movement

between muscle fibers, which results in more fluid muscle

movement.In this study, the massage group received an average of

12.46 7.17 burn rehabilitation massage therapies during34.69 22.53 days in average. Each session of 30-min treat-ment included effleurage, friction, and petrissage massage

after applying whitening cream, anti-redness cream, and

moisturizing oil, and this massage treatment improved pain,

pruritus, and scar characteristics (thickness, melanin,

erythema, TEWL, elasticity) to a significantly greater degree

than only standard therapy.

A study by Morien at al. reported that 8 children who were

sted difference (95% confidence interval) p value

(0.003 to 0.368) 0.17

(0.111 to 0.310) 0.01

(0.084 to 0.206) 0.13

(0.137 to 0.539) 0.01

(0.076 to 0.172) 0.69

(0.307 to 0.245) 0.21

(0.111 to 0.083) 0.76p.treated with 2025 minute-long daily massage therapy for 35

days improved the ROM in the knees, neck, and shoulders [33].

Roh et al. compared 18 subjects who received massage therapy

and 17 who received standard therapy for 3 months and

reported that the massage-therapy group showed greater

improvements in pruritus, VSS score, and depression [19].

Filed at al. reported greater immediate and long-term

improvements in pruritus, pain, anxiety, and mood in the

10 subjects who received massage therapy for 5 weeks than

the 10 subjects who only received standard therapy [34].

Previous studies on the effects of massage therapy lacked

objectivity in scar condition measurements. However, Ultra-

sound, Mexameter1, Tewameter1, Sebumeter1, and Cut-

ometer1 were used in this study to objectively measure scar

conditions, and the measurement revealed that the scar

thickness, melanin, erythema, TEWL, and elasticity of the scar

improved to a significantly greater extent with massage

therapy than with the standard therapy alone.

However, evidence to support the use of scar massage is

inconclusive, although its efficacy appears to be greater in

postsurgical scars. There is much variability and inconsis-

tency with regard to when treatment should be initiated, the

appropriate treatment protocol and duration, and evaluation

and measurement of outcomes. Because these results are

difficult to interpret, evidence-based recommendations can-

not be made. Potential positive effects of scar massage include

b u r n s 4 0 ( 2 0 1 4 ) 1 5 1 3 1 5 2 0 1519involving patients in their treatment, hastening the release

and absorption of buried sutures, aiding the resolution of

swelling and induration, and economic value, especially

compared to silicone gel application. Possible negative aspects

of this therapy include wasting the patients time if massage is

not an efficacious treatment, irritation from friction, and

developing irritant or contact dermatitis from the lubricant

used for massage.

The natural history of acute wound healing progresses

through distinct but interconnected stages: inflammation,

proliferation, and remodeling [35,36]. The remodeling phase

can last from months to years, during which time the scar

matures and improves in appearance and pliability. This

process occurs in the absence of any intervention. Although

the effect of massage on this phase of wound healing is

unknown, it may shorten the time needed to form a mature

scar.

Notwithstanding the lack of evidence, massage should

theoretically be effective. One hypothesis supporting its use is

that mechanical disruption of fibrotic tissue increases the

pliability of scars. Mechanical forces induce changes in the

expression of extracellular matrix proteins and proteases, and

massage may alter the structural and signaling milieu [37,38].

A study of cultured human skin fibroblasts by Kanazawa

and colleagues revealed a decrease in messenger ribonucleic

acid (mRNA) and protein levels of connective tissue growth

factor and collagen type 1 alpha 2 (Col1a2) after 24 h of uniaxial

cyclical stretching [39]. Because connective tissue growth

factor has been implicated in maintaining fibrosis induced by

transforming growth factor-beta [40], its downregulation may

prevent abnormal scarring. In another in vitro model, human

hypertrophic scar samples responded to mechanical loading

by inducing apoptosis and decreasing levels of tumor necrosis

factor-alpha [41], although another study showed that biaxial

mechanical strain upregulates matrix metalloproteinase-1

and collagen type 1 and 3 mRNA expression and down-

regulates the proapoptotic protein Bax [42]. These results

suggest that massage may be exert its beneficial effects

through its ability to affect matrix remodeling and fibroblast

apoptosis, although the exact mechanism remains to be

determined.

In addition to physical modifications of the scar, massage

may have other benefits. Massage therapy is an effective

adjunct therapy in managing lower back pain, depression,

addiction, atopic dermatitis, etc. [4345]. Connective tissue

massage produces a statistically significant elevation of beta-

endorphins levels in healthy volunteers [46], which suggests

that this therapy may have a beneficial effect on the pain relief

and the patients sense of well-being. Other studies have

shown reduction of urinary cortisol level and increase in

serotonin and dopamine levels after massage therapy [47,48],

which suggests that massage therapy may improve the

patients mood and decrease anxiety. In addition to the

release of endogenous opioid peptides and neurotransmitters,

the beneficial effect of massage therapy on pain be explained

by the gate theory of pain, described by Melzack and Wall in

1965 [49].

The limitations of this study are as follows. First, themassage therapy was performed for an average of

34.69 22.53 days, and therefore, its long-term effects werenot identified. Second, evolution of hypertrophic scar was not

considered. Typically, burn scars undergo hypertrophy

between 6 and 12 months and tend to regress between 18

and 24 months [30]. In addition, there may be a positive

correlation between pruritis and hypertrophy of the burn scar.

Thus, the effect of massage may differ depending on whether

the burn scar is in the early or late stages of maturation. Future

studies should focus on comparing the effect of massage on

new and old burn scars.

6. Conclusion

Burn rehabilitation massage therapy can be one of the

modality for controlling post-burn hypertrophic scar pain,

pruritus and the scar characteristics (thickness, melanin

deposition, erythema, TEWL, and elasticity). However, further

studies are needed to establish a standard protocol for burn

scar massage therapy on the basis of the long-term ther-

apeutic effects and evolution of hypertrophic scars.

Conflict of interest

None declared.

Acknowledgment

This study was supported by a grant of the Korean Health

Technology R&D Project, Ministry of Health & Welfare,

Republic of Korea (A120942).

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The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized controlled trialIntroductionMaterials and methodsMethods of measurementMeasurement of scar thicknessMeasurement of level of scar melanin and erythemaMeasurement of scar TEWLMeasurement of the level of sebum in the scarMeasurement of scar elasticity

Statistical analysisResultsDemographic and clinical characteristics of the patientsThe change in scar pain VAS and itching scale scoresThe change in scar thicknessThe change in scar melanin and erythemaThe change in scar TEWLThe change in scar sebumThe change in scar elasticity

DiscussionConclusionConflict of interestAcknowledgmentReferences