Table 4.

Basic differences in capacity research approaches.

Marketing measures are aimed at achieving optimum use of infrastructure (more evenly burdened) by using pricing and other tools in the capacity allocation process, in particular:

The essence of organizational measures is the systematization and synchronization of driving times, where the aim is to achieve less heterogeneity of train paths and to bundle it with minimizing buffer times. There is a need for a change in the configuration of the railway infrastructure in the event of persistent problems with the insertion of train paths in the required sequence and the required timetable stays. In the operative operation, the fixed specification and order of the train paths will be followed. In the case of delay, the right to the train path will not be guaranteed.

Capacity management processes include the train path ordering processes, strategic dialog and advisory phases, conflict coordination and resolution, and capacity allocation. The aim is to create a comprehensive, effective, and motivating model, which will be composed of both technological procedures and pricing policies leading to the provision of efficient train paths.

A prerequisite for creating a capacity management concept is capacity planning for its further development and use. The essence of capacity management is based on a plan to create a basic timetable, which is usually 1 year and thus represents a medium-term plan. The output of the capacity management process is the allocation of train paths and the determination of the quantitative and qualitative indicators of the constructed timetable (as a result of the stability proof process), in particular the occupancy time, waiting time, standby time, and optimum traffic flow. Achieving optimum traffic flow over time requires infrastructure managers to Railway Infrastructure Capacity in the Open Access Condition: Case Studies on SŽDC… DOI: http://dx.doi.org/10.5772/intechopen.88929

use capacity management and marketing tools to allocate train paths to reflect traffic flow over time so as to get as close as possible to the defined optimal value. The first priority is the technical conditions for access to infrastructure and the second is the infrastructure access clearing system [2, 10, 16, 25, 28–31].

The aim is to create a comprehensive, effective, and motivating model consisting of both technological procedures and pricing policies, leading to the provision of efficient train paths:

Figure 5 shows the identified cycle of capacity allocation of the railway infrastructure using the proposed progressive methodological approaches. It is a set of methodological postulates in the following defined areas:

These methodological proposals are only a simplified procedure for timetable creators. If they are to be the basis for further processing, especially by means of IT techniques, it is necessary to create a mathematical model that will be revised to a computer model after appropriate verification. After validation, it is the basis for the creation of an applied computer program. The proposed methodologies can then be imported into software products supporting the construction of the order and capacity indicators.

In the liberalized railway market, further development of infrastructure capacity utilization in:

• searching for optimum traffic flow in order to achieve the desired quality of transport;

Marketing measures are aimed at achieving optimum use of infrastructure (more evenly burdened) by using pricing and other tools in the capacity allocation process,

Capacity related to infrastructure capacity Related to specific timetable

Methodology Analytical methods (SŽDC, ŽSR) Simulation methods (UIC)

Using quantities directly describing the quality of operation (delays)

Uneven track occupancy

Based on the degree of occupancy of individual

occupancy can be used for tracks used only by

Deterministic Based on even track occupancy; unequal track

freight transport

Basic differences in capacity research approaches.

• deviations from the time position, that is, penalty for delay caused by the carrier, as well as delay bonuses caused by the infrastructure manager (EPR system);

The essence of organizational measures is the systematization and synchronization of driving times, where the aim is to achieve less heterogeneity of train paths and to bundle it with minimizing buffer times. There is a need for a change in the configuration of the railway infrastructure in the event of persistent problems with the insertion of train paths in the required sequence and the required timetable stays. In the operative operation, the fixed specification and order of the train paths

Capacity management processes include the train path ordering processes, strategic dialog and advisory phases, conflict coordination and resolution, and capacity allocation. The aim is to create a comprehensive, effective, and motivating model, which will be composed of both technological procedures and pricing policies

A prerequisite for creating a capacity management concept is capacity planning for its further development and use. The essence of capacity management is based on a plan to create a basic timetable, which is usually 1 year and thus represents a medium-term plan. The output of the capacity management process is the allocation of train paths and the determination of the quantitative and qualitative indicators of the constructed timetable (as a result of the stability proof process), in particular the occupancy time, waiting time, standby time, and optimum traffic flow. Achieving optimum traffic flow over time requires infrastructure managers to

will be followed. In the case of delay, the right to the train path will not be

• allocation of train path depending on its time position;

• stricter conditions for "ad hoc" capacity allocation; and

• sanctions for nonuse of allocated capacity;

• the scope of use of ancillary services.

leading to the provision of efficient train paths.

• taking into account the acceptance of powerful train paths;

in particular:

Quality of operation

Capacity relationship

Source: [10].

Table 4.

devices

Transportation Systems Analysis and Assessment

guaranteed.

82

infrastructure, that is, the number of train paths that will be advantageous both for the infrastructure manager and operating and economical. The prerequisite for this is a clear definition of the capacity of railway infrastructure and train paths, determination of the basic principles of capacity detection by means of simulation tools, determination of optimum throughput, plus even ensuring the utilization of railway infrastructure capacity. The proposal outlined the process of determining the capacity of the railway infrastructure, including progressive capacity allocation approaches as key components of capacity management. The scientific and research contribution is proven in the focus, deepening the application of theoretical knowledge in the field of railway transport technology. The proposed procedures for determining the timetable stability and optimizing the process of inserting train paths into the timetable, with an emphasis on optimizing and systematizing them, can be applied as a manual for the needs of specific simulation procedures, as well as for the support software product developers. These benefits can be used in the practical tasks of allocating railway infrastructure capacity and identifying optimal traffic flow. At the same time, the proposed procedures for determining graphical stability can be applied as a manual for the needs of specific simulation procedures,

Railway Infrastructure Capacity in the Open Access Condition: Case Studies on SŽDC…

The issue being solved by its impact on traffic and transport operations and on the railway market is so complex that a number of related aspects are subject to further research. When establishing capacity, focus should be on the required amount of buffer time and examining the waiting time in terms of overall capacity management and in the context of streamlining and shortening the entire process of allocating railway infrastructure capacity. These tasks have a significant impact on the main objective of European rail transport policy in order to strengthen its

The chapter is supported by the VEGA Agency by the Project 1/0509/19 "Optimizing the use of railway infrastructure with support of modal split forecasting,"

1 Faculty of Operation and Economics of Transport and Communications, University

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

which is solved at Faculty of Operations and Economics of Transport and

as well as for creators of supporting software products.

competitiveness in sustainable development.

DOI: http://dx.doi.org/10.5772/intechopen.88929

Communication, University of Žilina.

\* and Václav Cempírek2

\*Address all correspondence to<EMAIL_ADDRESS>
2 College of Logistics, Přerov, Czech Republic

provided the original work is properly cited.

Acknowledgements

Author details

Jozef Gašparík1

of Žilina, Slovakia

85

#### Figure 5.

Capacity allocation cycle using proposed progressive methodological approaches with regard to the railway infrastructure capacity.

### 5. Conclusion

Sizing the railway infrastructure, operational performance and quality of operation are interrelated. If two variables are known, the third can be derived. For example, on the Prague-Ostrava route, the current trend of shortening the length of long-distance passenger trains but increasing their frequency as a result of the liberalization of the rail market ("open access") significantly affects the capacity. From this situation, there is a clear need to plan a transport infrastructure for the future scope and concept of transport. Emergency events are a problematic point in the framework of the liberalization of rail transport, which is related to maintaining the number of traction units to the minimum possible. As a rule, RU does not have suitable tractive vehicles for diversion routes. The former unitary state railways had tractive vehicles for independent traction (multi-system locomotives), which could be used for such haulages (not only for freight).

In order to create harmonized conditions for access to infrastructure, it is important to correctly determine the optimum capacity of the railway

Railway Infrastructure Capacity in the Open Access Condition: Case Studies on SŽDC… DOI: http://dx.doi.org/10.5772/intechopen.88929

infrastructure, that is, the number of train paths that will be advantageous both for the infrastructure manager and operating and economical. The prerequisite for this is a clear definition of the capacity of railway infrastructure and train paths, determination of the basic principles of capacity detection by means of simulation tools, determination of optimum throughput, plus even ensuring the utilization of railway infrastructure capacity. The proposal outlined the process of determining the capacity of the railway infrastructure, including progressive capacity allocation approaches as key components of capacity management. The scientific and research contribution is proven in the focus, deepening the application of theoretical knowledge in the field of railway transport technology. The proposed procedures for determining the timetable stability and optimizing the process of inserting train paths into the timetable, with an emphasis on optimizing and systematizing them, can be applied as a manual for the needs of specific simulation procedures, as well as for the support software product developers. These benefits can be used in the practical tasks of allocating railway infrastructure capacity and identifying optimal traffic flow. At the same time, the proposed procedures for determining graphical stability can be applied as a manual for the needs of specific simulation procedures, as well as for creators of supporting software products.

The issue being solved by its impact on traffic and transport operations and on the railway market is so complex that a number of related aspects are subject to further research. When establishing capacity, focus should be on the required amount of buffer time and examining the waiting time in terms of overall capacity management and in the context of streamlining and shortening the entire process of allocating railway infrastructure capacity. These tasks have a significant impact on the main objective of European rail transport policy in order to strengthen its competitiveness in sustainable development.


**2. Conservative treatments**

the Black population was found as high as 16%. Keloid develops equally in both men and women. Although reported in all ages, it is rare in young children and elderly people. It is thought that there is a familial predisposition for hypertrophic scarring and keloid development. Although previous reports have implied an autosomal recessive inheritance pattern, an autosomal dominant transition with incomplete clinical penetrance and variable expression was considered in a recent review. Two rare syndromes involving spontaneous keloid devel-

The pathogenesis of hypertrophic scarring and keloid formation is unknown. In patients with hypertrophic scars and keloids, wound healing process shifts in a different direction than normal, and spontaneous involution does not generally occur. Its cause is unknown, but events such as infections, extreme wound tightness, and foreign bodies that are known to trigger for

Melanocytes may play a role in the development of hypertrophic scar, because keloids have not been reported in patients with oculocutaneous albinism and keloids are more common in dark-skinned individuals. Mast cells are found intensely in hypertrophic scars and keloids. Mast cell mediators regulate collagen synthesis and are known to contribute to excessive

Transforming growth factor-B (TGF-B) appears to be another molecule that causes scarring and keloid formation, because both transforming growth factor-B (TGF-B)-1 and TGF-B-2 are

Hypertrophic scars and keloids have many common features. Both are rough, often painful, itchy, pink-purple lesions. The epidermis is typically flat and the dermal part of the lesion is felt hard with palpation. Hypertrophic scars and keloids are malformed and may prevent normal movement of the surrounding tissues. Hypertrophic scars and keloids may appear anywhere of body, but especially ear lobe, upper part of body, and deltoid region are more risky areas. On the other hand, keloids are rare in the middle of the face, eyelids, and genital area. Although hypertrophic scars and keloids usually appear after a trauma, they can also develop spontaneously. Before the onset of hypertrophic scars and keloids, various skin injuries such as acne, infection, burns, and piercing can be found. Clinical findings of lesions distinguish hypertrophic scars from keloids. Although hypertrophic scars remain in the area of original damage and tend to regress progressively over time, keloids tend to slowly heal in the middle

Both hypertrophic scars and keloids have increased cellularity, vascularity, and connective tissue compared to normal skin and normal scar. Hypertrophic scars include myofibroblasts,

produced more from fibroblasts in keloid tissue than in normal fibroblasts [1–5].

opment are Rubinstein-Taybi and Goeminne syndromes [2, 3].

inflammation have been emphasized in the keloid development.

parts, but tend to invade the surrounding tissues [1, 2].

**1.2. Pathogenesis**

62 Hot Topics in Burn Injuries

accumulation.

**1.3. Clinical features**

**1.4. Pathology**

#### **2.1. Pressure therapy**

Formation of hypertrophic scar (HS) is a common undesirable consequence of trauma directing to the skin [6]. A classical scar is in red-pink or purple color, rigid, and raised and usually together with pain and/or itchiness. Hypertrophic scar that significantly disrupts normal skin functions may lead to further restriction of daily activities [6, 7] and psychosocial troubles among the patients [8–14].

Pressure therapy also improves the hardness of hypertrophic scar and increases pliability, but data on this topic are quite limited [13, 24]. And finally, pressure therapy (only high pressure)

The Therapeutic Effects of Conservative Treatments on Burn Scars

http://dx.doi.org/10.5772/intechopen.70833

65

The most important problems with the use of pressure therapy are the long duration of treatment and need to wear pressure garment during 14–23 h/day, which reduce the patient's

An important point to be aware of during pressure therapy is that pressure loss of the garments over time. Pressure garments lose their elasticity over the wearing period. The reason is probably that pressure garments are usually made of spandex and nylon fabric and these materials decrease their elasticity upon prolonged wear. Pressure loss of the garments can

Hypertrophic scar emerges as a consequence of an excessive response of the skin to trauma. Hypertrophic scar can cause pain and itching as well as cause cosmetic problems and may

There is very limited evidence to show the effectiveness of treatments to reduce or prevent scar formation. Most of the available information and recommendations are based on experience of practitioners and small scale studies. Also, there are very limited scientific data on the long-term effects of these treatments. Nevertheless, treatments such as the use of intralesional corticosteroid injections, silicone sheets, occlusive dressings, and custom-made pressure gar-

The earliest known silicone gel sheet was developed by Perkins et al. for use at 6–8 weeks after the initial injury, when the scars started to develop. Since its first use in the early 1980s, silicone gels have a wide use in burn scar treatment. Although the mechanism of how to heal burn scars is not yet fully understood, the noninvasive character of silicone gels makes them easily acceptable for patients in treatment and prophylaxis of hypertrophic scars [26–28].

Studies demonstrated the effectiveness of silicone gels in the treatment of scars, but the mechanism of how to heal scars and physiological effects of silicone gel are not yet fully understood. It is believed that silicone gels affect the stratum corneum by decreasing evaporation and providing a better hemostasis in the scar tissue. Stratum corneum on the hypertrophic scar and keloid tissue causes more evaporation of water from the underlying tissue than in normal skin. Silicone gels reduce evaporation and thus provide an optimal hydration in the stratum corneum. The silicone gels may influence the stratum corneum by inhibiting mast cell activity and reducing edema, vasodilatation, and excessive extracellular matrix synthesis, but perhaps the main mechanism of action of gels may depend on their simpler effects such as changes in temperature, oxygen, pressure, hydration, and tension produced by wound coverage. Another hypothesis is that static electricity on silicone gels may cause the re- alignment of collagen deposition [26, 27, 29–31].

In studies, different types of silicone were used, such as silicone sheets (not specified), cicacare silicone gel sheets, silastic gel sheets, Sil-K silicone, and Epiderm silicone sheets or

lead to treatment failure, so the physician should be careful in this regard [6, 25].

causes a significant improvement in pigmentation of scar tissue [6].

compliance with treatment [24].

**2.2. Silicone gel**

restrict range of motion [26].

ments have a general acceptance [27].

Pressure therapy is considered as the first-line treatment option in improving the appearance of hypertrophic scar and reducing the rate of maturation. The general application way of pressure therapy is pressure garments [11–13]. Pressure therapy, dating back to Ambroise Pare in the sixteenth century, is a treatment that has been used for a long time by different methods. But, the popularity of pressure therapy for hypertrophic burn scars has been increased after successful results with this therapy reported from the Shriners Galveston Burn Hospital. In 1971, burn hospital team from Galveston declared a decrease in hypertrophic scar formation rate after thermal injury with pressure therapy application [13–17].

So far, the mechanism of action of pressure therapy has remained theoretical, and the efficacy and benefits of pressure garments are still a mystery. The optimal pressure level is also still a controversial topic. Theoretically, the minimum pressure to be applied during pressure therapy should be greater than the capillary pressure, meaning that the pressure should be at least 24 mmHg or more. But, there are studies in which 5–15 mmHg pressure was applied and successful clinical results such as less itching, better appearance of the scar, and so on were observed [18]. On the other hand, it was reported that paresthesia and maceration may occur shortly after application of high levels of pressure (over 40 mmHg) [19].

It was showed in studies that application of pressure significantly decreases the thickness of hypertrophic scar and the number of surgical procedures needed for correction. It is still unclear how the pressure has reduced the scar thickness. It is claimed that the pressure provides the rearrangement of collagen fibers, decreases the development of whorled typed collagen nodules, and thus, provokes the softening of scar tissue and the reduction of its thickness [6, 11, 13]. Despite the general acceptance that pressure therapy is effective, there is no clear consensus about the minimum effective amount of pressure. Although partially good results with low pressure values (5–15 mmHg) were reported in previous studies, it is thought that the higher amount of pressure provides more reduction in scar thickness [6, 11, 19]. In their study, Candy et al. observed that high pressure (>20 to 25 mmHg) garment demonstrated its superior effects on reducing scar thickness after 5 months treatment, leading to an overall reduction of 40.05% in thickness and the most prominent improvement was observed after the first month of intervention. Although scars with low pressure treatment also showed significant improvement, for this group overall thickness reduction was 19.79% [6].

The presence of erythema has always been considered as a major marker of hypertrophic scarring after burns. It has been shown that redness is increased in scar tissues which have higher vascularity, determined using Laser Doppler from previous studies [6, 20, 21]. Parallel to this, a reduction in redness/erythema may imply a decrease of vascular flow to the scar tissues [21, 22]; meaning that, the nutrient and oxygen supply for cellular activities was reduced. Hypoxic milieu due to pressure therapy may trigger fibroblasts apoptosis process [20–23]. Although it was reported that higher pressure (>20 to 25 mmHg) values lead to reductions in erythema, the pressure must be at least 24 mmHg or higher to provide a significant reduction [6, 11].

Pressure therapy also improves the hardness of hypertrophic scar and increases pliability, but data on this topic are quite limited [13, 24]. And finally, pressure therapy (only high pressure) causes a significant improvement in pigmentation of scar tissue [6].

The most important problems with the use of pressure therapy are the long duration of treatment and need to wear pressure garment during 14–23 h/day, which reduce the patient's compliance with treatment [24].

An important point to be aware of during pressure therapy is that pressure loss of the garments over time. Pressure garments lose their elasticity over the wearing period. The reason is probably that pressure garments are usually made of spandex and nylon fabric and these materials decrease their elasticity upon prolonged wear. Pressure loss of the garments can lead to treatment failure, so the physician should be careful in this regard [6, 25].

#### **2.2. Silicone gel**

together with pain and/or itchiness. Hypertrophic scar that significantly disrupts normal skin functions may lead to further restriction of daily activities [6, 7] and psychosocial troubles

Pressure therapy is considered as the first-line treatment option in improving the appearance of hypertrophic scar and reducing the rate of maturation. The general application way of pressure therapy is pressure garments [11–13]. Pressure therapy, dating back to Ambroise Pare in the sixteenth century, is a treatment that has been used for a long time by different methods. But, the popularity of pressure therapy for hypertrophic burn scars has been increased after successful results with this therapy reported from the Shriners Galveston Burn Hospital. In 1971, burn hospital team from Galveston declared a decrease in hypertrophic scar formation

So far, the mechanism of action of pressure therapy has remained theoretical, and the efficacy and benefits of pressure garments are still a mystery. The optimal pressure level is also still a controversial topic. Theoretically, the minimum pressure to be applied during pressure therapy should be greater than the capillary pressure, meaning that the pressure should be at least 24 mmHg or more. But, there are studies in which 5–15 mmHg pressure was applied and successful clinical results such as less itching, better appearance of the scar, and so on were observed [18]. On the other hand, it was reported that paresthesia and maceration may occur

It was showed in studies that application of pressure significantly decreases the thickness of hypertrophic scar and the number of surgical procedures needed for correction. It is still unclear how the pressure has reduced the scar thickness. It is claimed that the pressure provides the rearrangement of collagen fibers, decreases the development of whorled typed collagen nodules, and thus, provokes the softening of scar tissue and the reduction of its thickness [6, 11, 13]. Despite the general acceptance that pressure therapy is effective, there is no clear consensus about the minimum effective amount of pressure. Although partially good results with low pressure values (5–15 mmHg) were reported in previous studies, it is thought that the higher amount of pressure provides more reduction in scar thickness [6, 11, 19]. In their study, Candy et al. observed that high pressure (>20 to 25 mmHg) garment demonstrated its superior effects on reducing scar thickness after 5 months treatment, leading to an overall reduction of 40.05% in thickness and the most prominent improvement was observed after the first month of intervention. Although scars with low pressure treatment also showed

significant improvement, for this group overall thickness reduction was 19.79% [6].

The presence of erythema has always been considered as a major marker of hypertrophic scarring after burns. It has been shown that redness is increased in scar tissues which have higher vascularity, determined using Laser Doppler from previous studies [6, 20, 21]. Parallel to this, a reduction in redness/erythema may imply a decrease of vascular flow to the scar tissues [21, 22]; meaning that, the nutrient and oxygen supply for cellular activities was reduced. Hypoxic milieu due to pressure therapy may trigger fibroblasts apoptosis process [20–23]. Although it was reported that higher pressure (>20 to 25 mmHg) values lead to reductions in erythema, the pressure must be at least 24 mmHg or higher to provide a

rate after thermal injury with pressure therapy application [13–17].

shortly after application of high levels of pressure (over 40 mmHg) [19].

among the patients [8–14].

64 Hot Topics in Burn Injuries

significant reduction [6, 11].

Hypertrophic scar emerges as a consequence of an excessive response of the skin to trauma. Hypertrophic scar can cause pain and itching as well as cause cosmetic problems and may restrict range of motion [26].

There is very limited evidence to show the effectiveness of treatments to reduce or prevent scar formation. Most of the available information and recommendations are based on experience of practitioners and small scale studies. Also, there are very limited scientific data on the long-term effects of these treatments. Nevertheless, treatments such as the use of intralesional corticosteroid injections, silicone sheets, occlusive dressings, and custom-made pressure garments have a general acceptance [27].

The earliest known silicone gel sheet was developed by Perkins et al. for use at 6–8 weeks after the initial injury, when the scars started to develop. Since its first use in the early 1980s, silicone gels have a wide use in burn scar treatment. Although the mechanism of how to heal burn scars is not yet fully understood, the noninvasive character of silicone gels makes them easily acceptable for patients in treatment and prophylaxis of hypertrophic scars [26–28].

Studies demonstrated the effectiveness of silicone gels in the treatment of scars, but the mechanism of how to heal scars and physiological effects of silicone gel are not yet fully understood. It is believed that silicone gels affect the stratum corneum by decreasing evaporation and providing a better hemostasis in the scar tissue. Stratum corneum on the hypertrophic scar and keloid tissue causes more evaporation of water from the underlying tissue than in normal skin. Silicone gels reduce evaporation and thus provide an optimal hydration in the stratum corneum. The silicone gels may influence the stratum corneum by inhibiting mast cell activity and reducing edema, vasodilatation, and excessive extracellular matrix synthesis, but perhaps the main mechanism of action of gels may depend on their simpler effects such as changes in temperature, oxygen, pressure, hydration, and tension produced by wound coverage. Another hypothesis is that static electricity on silicone gels may cause the re- alignment of collagen deposition [26, 27, 29–31].

In studies, different types of silicone were used, such as silicone sheets (not specified), cicacare silicone gel sheets, silastic gel sheets, Sil-K silicone, and Epiderm silicone sheets or Dermatix topical silicone gel in diverse patient populations. Therefore, it is not easy to assess which kind of silicone gels is more effective and optimal [24].

Different formulations, including silicone- and petroleum-based products (such as vaseline), are applied by burns units around the world with their selection appearing to be based on historical practice, clinical experience, and because patients have confidence in such treat-

The Therapeutic Effects of Conservative Treatments on Burn Scars

http://dx.doi.org/10.5772/intechopen.70833

67

Although the need for scar tissue hydration is supported by almost all researches because of the enhanced transepidermal water loss rates compared to healthy skin, information and literature on the ideal composition of moisturizers for burn scar treatment are quite limited [24].

Tissues with high collagen content such as scar tissue show a high attenuation for ultrasound energy. It has been reported that topical therapeutic ultrasound application to scar tissue causes a temperature rise in scar tissue, which provides an increase in the elasticity of collagen and thus enlarges the range of motion. It is also declared that application of topical

But, in their randomized placebo controlled double blind study, with a low overall bias rating score, Ward et al. found no significant intergroup results on range of motion and pain [37].

Cuignet et al. designed a study to observe the effects of a combination of manual (MA) and electro-acupuncture (EA) on the pain scores and on the sensory thresholds of the nociceptive pathways in patients presenting with pathological burn scars (PPBS). And, at the end of the study, they demonstrated that EA combined to MA reduces the pain scores of patients suffering from pain associated with burn scar. Using quantitative sensory testing (QST), they confirmed that the pain of PPBS comes from a peripheral hyperalgesia eliminated by E/MA. And,

It was reported that, in a study with 120 Asian patients, onion extract decreased the rate of scar formation in dark-skinned patients receiving laser treatment of tattoos, and the enhancement in width of scar after thoracic surgery was less for onion extract-treated fresh scars than in untreated scars after 1 year of treatment. On the other hand, in a side-by-side, randomized, double-blinded, split-scar study, scar cosmesis or symptomatology did not show any improvements with application of onion extract gel, when compared with standard therapy in the management of postoperative wounds [41, 42]. It is thought that the effect of onion extract therapy on decrease in scar height may increase when used with occlusive silicone dressing [43]. In a randomized controlled trial with 60 patients of median sternotomy, the combination of onion extract and silicone products was seen effective in the prevention of hypertrophic scar formation. Onion extract is also effective in burn scars. It was observed that combination of onion extract and silicone gel provided good results in 45 patients with

ultrasound improves the pain seen in scars [24, 37–39].

they also observed a significant relief of pruritus after E/MA [40].

ments [36].

**2.4. Ultrasound**

**2.5. Electroacupuncture**

**2.6. Onion extract**

postburn hypertrophic scar [44, 45].

In a prospective randomized clinical trial, the authors applied silicone gel sheeting (SGS) 24 hour per day for 6 months. In this study, subjects with 6-month silicone gel intervention showed a reduction of scar thickness measured by tissue ultrasound palpation system. The scar in the group used silicone gel was softer and more pliable as measured by The Vancouver Scar Scale and there was reduction on pain and itchiness from patients. Although the vascularity and pigmentation did not show any statistical significant difference, individuals in the SGS groups stated that the scar became less reddish, paler, and more resembled normal skin. When compared to the control group, patients in the SGS group also had faster rate of recovery from pain and itchiness, but the results at the 6-month assessment were not different between the two groups [32].

The topical silicone gel was applied twice a day and was typically worn 12–24 h a day, excluding bathing time. The duration of application varies between 12 and 28 weeks [24].

Despite the effectiveness of silicon gels, there are some limitations to their use. Patient compliance can be low when silicone gels are used on scars on visible regions, the appearance can make them less popular for the patient to use, and scar located near to joints, due to their potential restriction of movements and because gels sometimes do not stay adherent on these regions.

In addition, hygiene of gels and involved skin must be considered, especially in hot climates, to avoid irritation or rash and infections [26, 27, 32–34].

#### **2.3. Hydration**

When the wound healing reaches enough strength to tolerate skin massage, it is a routine practice to perform a scar massage with a solution that usually contains a moisturizing product [33]. Because hydrating effect of silicone gels on the stratum corneum has been suggested as a mechanism underlying its therapeutic effectiveness, many authors have reported the efficacy of treatment with topical silicone gel sheet for keloids and hypertrophic scars. Additionally, it is recommended that hydration/moisturizing of scar tissue, since transepidermal water loss rates are higher when compared to healthy skin [24, 32, 33].

Various products, including aqueous cream BP, bees wax and herbal oil creams, siliconebased creams, and paraffin/petroleum-based products, have been reported for use in practice as well as in literature on scar management [35].

Aqueous cream BP, which is fragrance and color free, is a readily available and relatively not expensive emollient production. Purified water, white soft paraffin, cetearyl alcohol and sodium lauryl sulfate (SLS), liquid paraffin, and phenoxyethanol are carried in this formulation [35].

Bees wax and herbal oil cream are the other two agents providing a greater decrease in the symptom of itch following burn injury when compared to aqueous cream BP, especially along with the use of antipruritic medications [35, 36].

Different formulations, including silicone- and petroleum-based products (such as vaseline), are applied by burns units around the world with their selection appearing to be based on historical practice, clinical experience, and because patients have confidence in such treatments [36].

Although the need for scar tissue hydration is supported by almost all researches because of the enhanced transepidermal water loss rates compared to healthy skin, information and literature on the ideal composition of moisturizers for burn scar treatment are quite limited [24].

### **2.4. Ultrasound**

Dermatix topical silicone gel in diverse patient populations. Therefore, it is not easy to assess

In a prospective randomized clinical trial, the authors applied silicone gel sheeting (SGS) 24 hour per day for 6 months. In this study, subjects with 6-month silicone gel intervention showed a reduction of scar thickness measured by tissue ultrasound palpation system. The scar in the group used silicone gel was softer and more pliable as measured by The Vancouver Scar Scale and there was reduction on pain and itchiness from patients. Although the vascularity and pigmentation did not show any statistical significant difference, individuals in the SGS groups stated that the scar became less reddish, paler, and more resembled normal skin. When compared to the control group, patients in the SGS group also had faster rate of recovery from pain and itchiness, but the results at the 6-month assessment were not different

The topical silicone gel was applied twice a day and was typically worn 12–24 h a day, exclud-

Despite the effectiveness of silicon gels, there are some limitations to their use. Patient compliance can be low when silicone gels are used on scars on visible regions, the appearance can make them less popular for the patient to use, and scar located near to joints, due to their potential restriction

In addition, hygiene of gels and involved skin must be considered, especially in hot climates,

When the wound healing reaches enough strength to tolerate skin massage, it is a routine practice to perform a scar massage with a solution that usually contains a moisturizing product [33]. Because hydrating effect of silicone gels on the stratum corneum has been suggested as a mechanism underlying its therapeutic effectiveness, many authors have reported the efficacy of treatment with topical silicone gel sheet for keloids and hypertrophic scars. Additionally, it is recommended that hydration/moisturizing of scar tissue, since transepidermal water loss

Various products, including aqueous cream BP, bees wax and herbal oil creams, siliconebased creams, and paraffin/petroleum-based products, have been reported for use in practice

Aqueous cream BP, which is fragrance and color free, is a readily available and relatively not expensive emollient production. Purified water, white soft paraffin, cetearyl alcohol and sodium lauryl sulfate (SLS), liquid paraffin, and phenoxyethanol are carried in this formula-

Bees wax and herbal oil cream are the other two agents providing a greater decrease in the symptom of itch following burn injury when compared to aqueous cream BP, especially along

ing bathing time. The duration of application varies between 12 and 28 weeks [24].

of movements and because gels sometimes do not stay adherent on these regions.

to avoid irritation or rash and infections [26, 27, 32–34].

rates are higher when compared to healthy skin [24, 32, 33].

as well as in literature on scar management [35].

with the use of antipruritic medications [35, 36].

which kind of silicone gels is more effective and optimal [24].

between the two groups [32].

66 Hot Topics in Burn Injuries

**2.3. Hydration**

tion [35].

Tissues with high collagen content such as scar tissue show a high attenuation for ultrasound energy. It has been reported that topical therapeutic ultrasound application to scar tissue causes a temperature rise in scar tissue, which provides an increase in the elasticity of collagen and thus enlarges the range of motion. It is also declared that application of topical ultrasound improves the pain seen in scars [24, 37–39].

But, in their randomized placebo controlled double blind study, with a low overall bias rating score, Ward et al. found no significant intergroup results on range of motion and pain [37].

#### **2.5. Electroacupuncture**

Cuignet et al. designed a study to observe the effects of a combination of manual (MA) and electro-acupuncture (EA) on the pain scores and on the sensory thresholds of the nociceptive pathways in patients presenting with pathological burn scars (PPBS). And, at the end of the study, they demonstrated that EA combined to MA reduces the pain scores of patients suffering from pain associated with burn scar. Using quantitative sensory testing (QST), they confirmed that the pain of PPBS comes from a peripheral hyperalgesia eliminated by E/MA. And, they also observed a significant relief of pruritus after E/MA [40].

#### **2.6. Onion extract**

It was reported that, in a study with 120 Asian patients, onion extract decreased the rate of scar formation in dark-skinned patients receiving laser treatment of tattoos, and the enhancement in width of scar after thoracic surgery was less for onion extract-treated fresh scars than in untreated scars after 1 year of treatment. On the other hand, in a side-by-side, randomized, double-blinded, split-scar study, scar cosmesis or symptomatology did not show any improvements with application of onion extract gel, when compared with standard therapy in the management of postoperative wounds [41, 42]. It is thought that the effect of onion extract therapy on decrease in scar height may increase when used with occlusive silicone dressing [43]. In a randomized controlled trial with 60 patients of median sternotomy, the combination of onion extract and silicone products was seen effective in the prevention of hypertrophic scar formation. Onion extract is also effective in burn scars. It was observed that combination of onion extract and silicone gel provided good results in 45 patients with postburn hypertrophic scar [44, 45].

#### **2.7. Massage therapy**

Hypertrophic scar development is a common complication after burn injury and the incidence is up to 77%. The existence of hypertrophic scar after a burn trauma may lead to many physical and psychological impairments, including pruritus, increased pain levels, scar contracture and limited ROM, elevated anxiety levels, and decreased health-related quality of life [46].

**2.8. Combined therapy**

effective results [24].

scar tissue [26, 51].

**Author details**

Mehmet Unal

Konya, Turkey

non-combination groups [51, 52].

reduce the duration needed for treatment [51].

Address all correspondence to<EMAIL_ADDRESS>
and scar tissue becomes more pliable [18, 22, 24].

of scars.

Among the conservative therapies, the most common options used as a combination treatment for burn scars are pressure therapy and silicone gel therapy. Since the mechanisms of action of silicone gels and pressure therapy are complementary to each other, it appeared to be evident that the combined therapy of silicone and pressure would give mixed and more

The Therapeutic Effects of Conservative Treatments on Burn Scars

http://dx.doi.org/10.5772/intechopen.70833

69

Pressure therapy has been used since the early 1970s as a conservative method in hypertrophic scar prevention or treatment and usually applied in the forms of garment or dressing. It was reported that pressure therapy has potential to prevent hypertrophic scar formation or limited its maturation and consequently to provide a better appearance of scars. Pressure therapy can reduce itching and pain as well as improve the appearance

Although how pressure therapy prevents the formation or maturation of hypertrophic scar has not yet been fully elucidated, the pressure caused by the pressure garments which is thought to reduce blood flow, oxygen, and nutrient support to the scar tissue can diminish collagen synthesis. Because of the mechanical load effect of the pressure therapy on the scar zone also leads to the rearrangement of the collagen fibers, thickness of scar tends to reduce

Silicone gels have been used as a conservative method in the treatment of hypertrophic scar since 1980. It is thought that silicone gels diminish evaporation, provide a better homeostasis, reduce edema and vasodilatation, inhibit activity of mast cells, prevent excessive extracellular matrix formation, form a pressure on scar zone, and hydrate the

In some previous studies, it was showed that combination of pressure therapy and silicone gel therapy is more effective in reduction of scar thickness, pliability, pigmentation, pain, and pruritus than the use of these treatments alone. Furthermore, it was reported that combination therapy provided an earlier response to these scar parameters. On the other hand, in some other studies, no significant different results were found between combination and

The general view is that combined treatment with both pressure therapy and silicone gels should be implemented on hypertrophic scar to enhance the effectiveness of treatments and

Faculty of Medicine, Department of Dermatology and Venereology, Selcuk University,

Massage therapy is a non-surgical conservative method that is used to reduce the negative results of hypertrophic scar after burn injuries [47]. The aim of massage therapy is to produce relaxation, reduce the pain, or improve circulation with the manipulation of the skin and underlying tissues with varying degrees of hand pressure. Classical massage consists of movements such as petrissage (kneading), effleurage (stroking and gliding), and tapotement (percussion). But, in different burn rehabilitation centers, many kinds of massage techniques are applied [47, 48].

Scar massage has various positive clinical utilities in scar management including decreased scar thickness, decreased pruritus, decreased pain and skin sensitivity, increased scar pliability and range of movement, and decreased anxiety [46].

Severe itching/pruritus is a common complication after burn injuries, especially in patients who have wounds on leg and arm, and the incidence in adult patients is up to 87%. Itching is not just itching and usually associated with disruption of daily living activities, anxiety and sleep disturbance. Pain is another common complication after burn trauma. Pain and related conditions such as depression and anxiety may influence the wound healing process and consequently adversely affects the patient's functioning. In patients who have been exposed to burn trauma, alternative or complementary treatments may be beneficial in the decrease of itching or pain, and these applications are not widely used. The research has shown that massage therapy reduces various types of pain [49].

A possible mechanism of the pain relief effect of the touch may be through the gate theory. Gate theory expresses that pain can be relieved by pressure or cold application. Since receptor fibersrelated pressure and cold stimuli are larger and more myelinated, they reach the brain receptors more rapidly and close the gate before the smaller, less myelinated pain fibers reach the brain receptors. Massage therapy has been also showed to lessen anxiety and stress hormone levels in burn patients and provides an improvement in redness, pruritus, lichenification, scaling, and excoriation. Increased vagal activity, which may enhance more relaxation and decrease the peripheral vasoconstriction associated with sympathetic activity, provided by massage therapy may be the potential mechanism for reducing stress and improving other skin findings mentioned above [49].

Additionally, it is showed that massage therapy has some mechanical effects associated with an improvement in venous return and lymphatic drainage. Moreover, massage therapy stimulates movement between muscle fibers, which results in more fluid muscle movement. In their randomized controlled trial, Cho et al. reported that massage therapy affects the scar thickness, scar elasticity, scar melanin and erythema, and scar transepidermal water loss (TEWL) positively as well as reducing pain and itching [50].

In summary, findings from studies show that scar massage is effective in improving scar height, vascularity, pliability, pain, pruritus, and depression in patients with hypertrophic scarring as a result of burn injury [46–50].

#### **2.8. Combined therapy**

**2.7. Massage therapy**

68 Hot Topics in Burn Injuries

Hypertrophic scar development is a common complication after burn injury and the incidence is up to 77%. The existence of hypertrophic scar after a burn trauma may lead to many physical and psychological impairments, including pruritus, increased pain levels, scar contracture and limited ROM, elevated anxiety levels, and decreased health-related quality of life [46].

Massage therapy is a non-surgical conservative method that is used to reduce the negative results of hypertrophic scar after burn injuries [47]. The aim of massage therapy is to produce relaxation, reduce the pain, or improve circulation with the manipulation of the skin and underlying tissues with varying degrees of hand pressure. Classical massage consists of movements such as petrissage (kneading), effleurage (stroking and gliding), and tapotement (percussion). But, in different

Scar massage has various positive clinical utilities in scar management including decreased scar thickness, decreased pruritus, decreased pain and skin sensitivity, increased scar pliabil-

Severe itching/pruritus is a common complication after burn injuries, especially in patients who have wounds on leg and arm, and the incidence in adult patients is up to 87%. Itching is not just itching and usually associated with disruption of daily living activities, anxiety and sleep disturbance. Pain is another common complication after burn trauma. Pain and related conditions such as depression and anxiety may influence the wound healing process and consequently adversely affects the patient's functioning. In patients who have been exposed to burn trauma, alternative or complementary treatments may be beneficial in the decrease of itching or pain, and these applications are not widely used. The research has shown that

A possible mechanism of the pain relief effect of the touch may be through the gate theory. Gate theory expresses that pain can be relieved by pressure or cold application. Since receptor fibersrelated pressure and cold stimuli are larger and more myelinated, they reach the brain receptors more rapidly and close the gate before the smaller, less myelinated pain fibers reach the brain receptors. Massage therapy has been also showed to lessen anxiety and stress hormone levels in burn patients and provides an improvement in redness, pruritus, lichenification, scaling, and excoriation. Increased vagal activity, which may enhance more relaxation and decrease the peripheral vasoconstriction associated with sympathetic activity, provided by massage therapy may be the potential mechanism for reducing stress and improving other skin findings mentioned above [49]. Additionally, it is showed that massage therapy has some mechanical effects associated with an improvement in venous return and lymphatic drainage. Moreover, massage therapy stimulates movement between muscle fibers, which results in more fluid muscle movement. In their randomized controlled trial, Cho et al. reported that massage therapy affects the scar thickness, scar elasticity, scar melanin and erythema, and scar transepidermal water loss

In summary, findings from studies show that scar massage is effective in improving scar height, vascularity, pliability, pain, pruritus, and depression in patients with hypertrophic

burn rehabilitation centers, many kinds of massage techniques are applied [47, 48].

ity and range of movement, and decreased anxiety [46].

massage therapy reduces various types of pain [49].

(TEWL) positively as well as reducing pain and itching [50].

scarring as a result of burn injury [46–50].

Among the conservative therapies, the most common options used as a combination treatment for burn scars are pressure therapy and silicone gel therapy. Since the mechanisms of action of silicone gels and pressure therapy are complementary to each other, it appeared to be evident that the combined therapy of silicone and pressure would give mixed and more effective results [24].

Pressure therapy has been used since the early 1970s as a conservative method in hypertrophic scar prevention or treatment and usually applied in the forms of garment or dressing. It was reported that pressure therapy has potential to prevent hypertrophic scar formation or limited its maturation and consequently to provide a better appearance of scars. Pressure therapy can reduce itching and pain as well as improve the appearance of scars.

Although how pressure therapy prevents the formation or maturation of hypertrophic scar has not yet been fully elucidated, the pressure caused by the pressure garments which is thought to reduce blood flow, oxygen, and nutrient support to the scar tissue can diminish collagen synthesis. Because of the mechanical load effect of the pressure therapy on the scar zone also leads to the rearrangement of the collagen fibers, thickness of scar tends to reduce and scar tissue becomes more pliable [18, 22, 24].

Silicone gels have been used as a conservative method in the treatment of hypertrophic scar since 1980. It is thought that silicone gels diminish evaporation, provide a better homeostasis, reduce edema and vasodilatation, inhibit activity of mast cells, prevent excessive extracellular matrix formation, form a pressure on scar zone, and hydrate the scar tissue [26, 51].

In some previous studies, it was showed that combination of pressure therapy and silicone gel therapy is more effective in reduction of scar thickness, pliability, pigmentation, pain, and pruritus than the use of these treatments alone. Furthermore, it was reported that combination therapy provided an earlier response to these scar parameters. On the other hand, in some other studies, no significant different results were found between combination and non-combination groups [51, 52].

The general view is that combined treatment with both pressure therapy and silicone gels should be implemented on hypertrophic scar to enhance the effectiveness of treatments and reduce the duration needed for treatment [51].