Pediatric Burn Scar and Contracture Management

Overview

Scar and contracture care in the burned child is governed by one fact that adult practice does not face: the scar grows with the child, and a longitudinal scar band that crosses a joint cannot keep pace with a lengthening limb. The result is recurrent deformity. A guideline panel framing this problem noted that children are a distinct population for scar prevention and treatment because of the physiological structure of their skin and the demands of psychosomatic growth, and that approaches borrowed from adult consensus statements fail to account for the special needs of growth and development ^[1]. Post-burn hypertrophic scars in children can limit growth, interfere with function, and cause psychological problems ^[9].

The clinical task spans a continuum. At the front end, scar prevention is largely wound-healing management, because the single most consistent predictor of hypertrophic scarring is how long the wound takes to close ^[4]. Once a scar forms, conservative measures (pressure, silicone, rehabilitation) and procedural adjuncts (laser, intralesional agents) aim to soften, flatten, and improve it, though the evidence supporting them in children is thin and heterogeneous [2, 15, 16]. When a contracture becomes fixed and functionally limiting, surgical release with local flaps, Z-plasty, grafts, or tissue expansion restores motion [40, 43, 47]. Contractures continue to develop despite early positioning and splinting, and the long-term course of pediatric scar contractures remains incompletely characterized, with explicit calls for longer-term longitudinal study [55, 56].

Epidemiology

Contracture and hypertrophic scar are common sequelae of pediatric burns, and their reported frequency varies widely with timing and definition. A systematic review of contracture prevalence found a prevalence at discharge of 38 to 54%, with lower prevalence at longer follow-up, and reported that contractures were more likely in more severe burns, flame burns, children, females, the cervical spine, and the upper extremity ^[2]. Across studies the prevalence of burn scar contractures varies considerably ^[2]. A Burn Model System database analysis observed that contractures develop despite early therapeutic interventions such as positioning and splinting ^[55]. A preliminary longitudinal study in children and adolescents tracked the course of function-limiting scar contractures over time and called for longer-term data to understand their evolution ^[56].

The burden falls heaviest where access to early burn care is limited. A systematic review of pediatric burn contractures in low- and lower-middle-income countries reported that children with deep burns often fail to receive specialized burn care until months or years after injury, with the time from injury to consultation ranging from a few months to 17 years among 991 children with long-term sequelae; factors associated with late complications included total body surface area burned, burn depth, low socioeconomic status, limited infrastructure, and the interval between injury and reconstructive surgery ^[3]. Friction injuries are a distinct pediatric mechanism: a systematic review of pediatric upper-limb friction injuries (predominantly treadmill-related) reported that problematic scarring affected 20.5% of patients, of whom 38.3% underwent further scar revision surgery ^[62].

Pathophysiology

Hypertrophic scarring is a dermal fibroproliferative disorder of poor-quality wound healing that prolongs rehabilitation and increases morbidity after deep dermal injury ^[6]. In thermally injured patients with hypertrophic scars, serum transforming growth factor-beta was significantly higher than in controls, and biopsies of hypertrophic scar showed increased mast-cell numbers compared with normal skin from the same patients ^[6]. These mediator and cellular signatures distinguish the maturing hypertrophic scar from normal wound repair.

The dominant clinical determinant of hypertrophic scar is healing time. In a pediatric scald cohort, hypertrophic scar rates rose steeply with time to healing: 0% for wounds healing in under 10 days, 8% at 10 to 14 days, 20% at 15 to 21 days, 40% at 22 to 25 days, 68% at 26 to 30 days, and 92% beyond 30 days ^[4]. A separate pediatric scar-outcome study found that days to re-epithelialization significantly predicted skin and scar quality at three and six months, and that burn depth correlated with skin thickness ^[14]. This dose-response between delayed closure and scar severity is the mechanistic basis for treating rapid wound closure as the primary scar-prevention lever.

Host and injury factors modify the risk independent of healing time. A study of genetic and clinical risk factors in a predominantly adult burn cohort (median age 39 years) found that hypertrophic scar formation was associated with American Indian/Alaskan Native race (odds ratio 12.2), facial burns (odds ratio 9.4), and burn size of 20% total body surface area or more (odds ratio 1.99) ^[5]. The pediatric-specific dimension is anatomic and developmental: available skin for replacement is small, donor areas are limited, and the hypertrophic scar and contracture enlarge along with the child's physical growth ^[7].

Classification and Assessment

Scar is characterized along the dimensions captured by standard scar scales (pigmentation, vascularity, pliability, and height), and assessment in children draws on clinician-reported scales, patient- and parent-reported measures, and instrumental devices. A systematic review of scar-quality outcome instruments in pediatric burns identified 585 measurement instruments across 328 studies; the most frequently used were the modified Vancouver Scar Scale, ultrasound, and the Patient and Observer Scar Assessment Scale (POSAS) patient scale, with thickness and itch the most commonly assessed characteristics ^[10]. The review noted that patient-reported outcome measures have grown in use, particularly since 2016 ^[10].

Validated patient-reported instruments now extend scar assessment beyond the clinician's eye. The SCAR-Q, psychometrically tested in patients aged 8 to 88 with surgical (n=354), burn (n=184), and traumatic (n=199) scars, demonstrated high reliability and was developed as an internationally applicable measure for research, clinical care, and quality improvement ^[11]. The Brisbane Burn Scar Impact Profile (BBSIP) and POSAS quantify health-related quality of life in burn scar, and an equivalence study supported electronic delivery of both proxy and child-report forms, supporting their use in outpatient, telehealth, and remote-monitoring settings ^[13]. Risk-stratification work using the SCAR-Q identified a bothersome scar and the patient's perception of scarring badly as independent risk factors for worse scores and for self-reporting the need for future scar revision surgery ^[12].

Prevention and conservative management

Wound closure as the primary lever

Because hypertrophic scar risk tracks healing time, the most consequential scar-prevention decision is achieving rapid, durable wound closure. The clinical corollary drawn from the healing-time data is that scalds likely to take more than about three weeks to heal are the ones in which early surgical closure prevents the highest-risk scarring ^[4]. The mediator and cohort evidence converges on the same point: the longer the wound stays open, the worse the scar [4, 6, 14]. Acute wound-management choices that shorten healing time (covered in the acute pediatric burn pages) are therefore the foundation of scar prevention, and the conservative scar measures below operate on the scar that forms once closure is achieved.

Pressure garment therapy

Pressure garment therapy is a standard component of pediatric burn scar management, but the evidence supporting it is weak. A meta-analysis of pressure garment therapy was unable to demonstrate a difference between global assessments of treated and control scars (weighted mean difference -0.46); it found a small statistically significant reduction in scar height of questionable clinical importance, and concluded that the beneficial effects remain unproven while the morbidity and cost are not insignificant ^[15]. A 2024 Cochrane review found the evidence very uncertain on whether pressure garment therapy improves scars on the Vancouver Scar Scale compared with no treatment, and concluded there is insufficient evidence to recommend either pressure garments or an alternative for preventing hypertrophic scarring ^[16]. A feasibility randomized trial in adults and children reported that pressure garment therapy is a standard part of burn scar management but that there is little evidence of its clinical effectiveness or cost-effectiveness ^[17]. A 12-year within-wound study found that the clinical benefit of pressure garment therapy was restricted to patients with moderate or severe scarring ^[18].

Silicone and the silicone-versus-pressure question

Silicone gel and sheeting are the other mainstay of conservative scar care. A randomized, double-blind, placebo-controlled trial reported that silicone gel is an effective treatment for hypertrophic burn scars ^[22]. A comparative trial found that silicone products, in gel or sheet form, were superior to an onion-extract preparation for hypertrophic scar ^[23]. The most directly relevant pediatric evidence comes from a randomized trial of topical silicone gel, pressure garment therapy, and their combination in children: no difference was identified between silicone and pressure interventions alone, and the combined intervention offered no statistically or clinically significant benefit over either alone at 6 and 12 months [19, 20]. A trial-based economic evaluation of the same three models found topical silicone gel was the cheapest intervention, with a 70% probability that it dominated pressure garment therapy (cheaper and more effective) ^[21].

Rehabilitation, splinting, and exercise

Therapy is integral to contracture prevention, though its evidence base is also limited. A systematic review and expert-consensus exercise on orthoses in burn rehabilitation found that the low level of evidence supported only one practice guideline, which states that orthotic use is considered to improve range of motion or reduce contracture in adults after burn injury ^[24]. Exercise programs show a measurable surgical-burden benefit in children: a supervised exercise and physiotherapy program reduced the number of patients needing burn-scar-contracture release at 12, 18, and 24 months postburn compared with a home program, leading the authors to recommend incorporating supervised exercise into outpatient rehabilitation ^[25]. A randomized trial combining a physical therapy program with music therapy in children with lower-limb burns reported significant improvement in pain, range of motion, and gait parameters in both arms, with greater improvement in the combined-therapy group ^[26].

Procedural adjuncts: laser

Laser has become a prominent adjunct for established hypertrophic burn scar, with the strongest signal for fractional ablative and pulsed dye modalities. A meta-analysis of fractional CO2 laser for post-burn hypertrophic scars in children reported significant post-treatment reductions in Vancouver Scar Scale score (weighted mean difference -3.56) and in pigmentation, pliability, vascularity, and height ^[27]. A systematic review of combined 595-nm pulsed dye laser and 10,600-nm ablative fractional CO2 laser found that the combination significantly improved Vancouver Scar Scale and POSAS scores and reported it superior to single-modality laser, while also noting significant disorganization among studies and the need for higher-level evidence ^[28]. An analysis of CO2 and pulsed dye lasers found that both improved hypertrophic burn scars but reported no clinically meaningful benefit of combination over individual treatment ^[29]. A randomized split-scar study of low-energy fractional CO2 laser found a significantly lower POSAS score in the treated site at six months, and the low-energy approach was framed as more appropriate for children given procedural pain ^[30]. The Early Laser for Burn Scars randomized trial of early pulsed dye laser reported a statistically significant improvement in patient-rated scar quality at six months, but found no significant difference in quality of life, observer-rated scar quality, or color, and reported it was not cost-effective at six-month follow-up [31, 50]. A randomized dosimetry study of fractional CO2 laser in pediatric hypertrophic scar found that increasing treatment density produced earlier effect than increasing energy, with the best parameter combination at 17.5 mJ and 10% density ^[32]. A systematic review of procedural treatments concluded that light-based therapies and lasers may be safe, effective, and tolerable options in this age group, often eliminating the need for general anesthesia ^[33].

Procedural adjuncts: intralesional and injectable agents

Intralesional and topical antifibrotic agents are used as adjuncts for thick or symptomatic scar, often combined with laser. A randomized trial of fractional CO2 laser with or without triamcinolone acetonide or 5-fluorouracil found significant improvements across groups, with the laser-plus-triamcinolone arm improving pliability, height, and pigmentation, and reported no statistically significant difference in efficacy between 5-fluorouracil and triamcinolone ^[34]. A separate randomized trial reported that 5-fluorouracil combined with ultra-pulsed fractional CO2 laser was significantly more effective than laser alone, and identified advanced age, longer disease duration, and higher pre-treatment scar scores as factors negatively correlated with effectiveness ^[35]. A controlled clinical trial of topical 8% pirfenidone gel in pediatric hypertrophic scar reported it more effective than standard pressure therapy ^[36]. An intra-patient randomized study of botulinum toxin type A in children with post-burn hypertrophic scars and keloid reported efficacy and safety ^[37]. In contrast, a randomized double-blind placebo-controlled pilot study found that single-treatment autologous fat grafting did not improve mature pediatric burn scars compared with saline injection ^[38].

Surgical management of contracture

When release is indicated

When a contracture becomes fixed and functionally limiting despite conservative care, surgical release restores motion. The general principle drawn from pediatric hand-burn experience is that early correct management optimizes function and minimizes long-term scarring, with the American Burn Association advocating referral of pediatric hand burns to a verified burn center ^[58]. Reconstruction in children requires early interdisciplinary cooperation between pediatric and plastic surgeons to plan and stage the work across growth ^[57].

Release techniques

Contracture release uses a graded reconstructive ladder from local tissue rearrangement to grafts, flaps, and tissue expansion. Two bloodless techniques for pediatric postburn flexion-contracture release of the digits have been described, with the proximal interphalangeal joint the most commonly operated; a tumescent technique was reported as a feasible alternative to tourniquet ^[39]. A randomized comparison of flexion-contracture release under tourniquet versus tumescent technique in children found significantly better graft take, lower pain scores, and lower analgesic consumption in the tumescent group ^[40]. For digital and first-web-space reconstruction, a principles paper reported a range of reconstructive procedures (groin flap, full-thickness skin graft, split-thickness skin graft, Z-plasty, and reverse radial forearm flap), reflecting the staged, individualized nature of pediatric hand reconstruction ^[49].

Graft choice in release

When a release defect requires resurfacing, graft selection shapes durability. A systematic review and meta-analysis of full-thickness versus split-thickness skin graft in pediatric hand burns found that full-thickness grafts produced a statistically significant decrease in post-graft contracture (odds ratio 0.35) and in later surgical releases (odds ratio 0.06), and outperformed split-thickness grafts in postoperative function; split-thickness grafts scored better on scar, aesthetic, and color assessment with less hair growth ^[41]. A separate systematic review of split- versus full-thickness graft for the volar pediatric hand found no high-quality evidence that full-thickness grafts were superior for functional outcomes, and emphasized the role of splinting and physiotherapy alongside graft choice ^[42].

Flaps and tissue expansion

Flaps and tissue expansion address larger or anatomically demanding contractures, particularly of the face and neck. The extended lower trapezius myocutaneous flap was reported as valuable for face and neck burn-scar reconstruction in children ^[43]. Aesthetic microsurgical reconstruction of anterior neck deformities reported recovery of neck movement without recurrence of neck contracture ^[44]. An expanded frontal-parietal pedicled flap series reconstructed cervical scar contracture deformity in children with correction and without recurrence ^[45]. Previously burned skin can be used as random local flaps in pediatric burn reconstruction, reported as safe ^[46]. Tissue expansion is a useful tool in post-burn scar reconstruction in both adult and pediatric populations and across anatomic sites, but with consistently high complication rates, especially in the pediatric population ^[47].

Complications

The complications of scar and contracture management cluster around recurrence, donor-site burden, and the side effects of the therapies themselves. Recurrence after release in growing children is addressed under Special Considerations. Among conservative measures, pressure garments carry a recognized though uncommon risk: two children developed severe obstructive sleep apnea after introduction of pressure garments for facial and upper-body hypertrophic scar, leading the authors to caution that this serious side effect warrants consideration before such garments are advised ^[59]. Tissue expansion, while useful, carries consistently high complication rates in the pediatric population ^[47]. Laser adjuncts are generally well tolerated in children, though procedural pain has historically limited their application, motivating lower-energy techniques [30, 33].

Special Considerations

The growth dimension and recurrence

The defining feature of pediatric scar and contracture care is that the scar does not keep pace with the growing child. Hypertrophic scar and contracture enlarge along with the child's physical growth, while available donor skin is limited ^[7]. Recurrence after release is therefore frequent and expected rather than a marker of technical failure. In children treated with Ilizarov fixation for burn-related foot deformities, the recurrence rate across all 29 ankles and feet was 69%, the recurrence rate for equinus contractures was 74%, and the average time to recurrence was 17.3 months ^[48]. In surgical management of burn flexion and extension contractures of the toes, overall contracture recurrence was 35% and only severe contractures received secondary operations ^[51]. A classification and treatment series for scar-contracture-induced Achilles tendon shortening in children reported recurrence in 11 cases at six-month follow-up, concentrated in moderate and serious deformities ^[52]. One reconstructive observation explicitly leverages growth: with a groin flap in children, the flap continues to grow, thus preventing contracture recurrence ^[53]. Because recurrence across growth is frequent rather than exceptional ^[48], post-burn reconstruction in children requires early interdisciplinary cooperation between pediatric and plastic surgeons to plan and perform the work ^[57].

Anatomic regions of special concern

Certain regions demand particular attention because contracture there disrupts growth and development. Burns to the neck present a serious challenge to the pediatric burn team, and limiting neck mobility in children can disrupt the development of sensory and motor patterns essential to normal developmental progression ^[8]. The hand is a leading site of pediatric burn injury with significant potential for functional impairment, and the first web space and digits require staged, individualized reconstruction [49, 58]. Extracorporeal shockwave therapy and botulinum toxin-A injection have each been reported to treat postburn plantar-flexion contracture and optimize ankle kinematics during walking in children, without a preference established between them ^[60].

Psychosocial dimension

Scar in a developing child carries psychosocial weight that shapes management goals. Pediatric burn survivors and their caregivers report significantly higher emotional and behavioral problems and lower health-related quality of life than healthy counterparts ^[63]. A study of bullying found that 61% of burn-surviving children reported being bullied at school, and that those with visible scars reported bullying as a problem more often than those with hidden scars ^[54]. Parents may underperceive the stigmatization their children experience, a discrepancy clinicians should anticipate ^[61]. These findings frame scar management in children as a function-and-appearance problem with psychosocial stakes, not a purely cosmetic one ^[9].

Outcomes

Outcomes in pediatric scar and contracture care are measured along scar quality, function, and recurrence. Conservative and procedural measures produce measurable scar-scale improvements: fractional CO2 laser improved Vancouver Scar Scale, pigmentation, pliability, vascularity, and height in meta-analysis ^[27], and a systematic review of procedural treatments reported Vancouver Scar Scale reductions of 55 to 76% in laser-treated children with outcomes rated good to excellent ^[33]. Surgical release reliably restores motion, and graft choice modifies durability, with full-thickness grafting reducing re-contracture and reoperation in the hand ^[41].

Recurrence is the dominant long-term outcome signal in the growing patient, with reported recurrence after lower-extremity contracture release ranging from roughly one-third to three-quarters depending on site and severity [48, 51, 52]. The pediatric scar-management literature calls for longer-term longitudinal study to characterize how these contractures evolve ^[56] and emphasizes early interdisciplinary planning of reconstruction in children and adolescents ^[57]. National survey data reflect this uncertainty in practice: in a UK survey of pediatric post-burn scar management, silicones and pressure therapy were used by most services but the timing of initiation varied widely, and laser, ultrasound, and steroid therapy were used only sporadically ^[9].

Controversies and Evidence Gaps

The pediatric scar and contracture evidence base is thinner and more heterogeneous than the volume of literature suggests, and several core questions remain unsettled.

The mainstays of prevention rest on weak evidence. A 2024 Cochrane review found the evidence very uncertain on whether pressure garment therapy improves scars and concluded there is insufficient evidence to recommend either pressure garments or an alternative for preventing hypertrophic scarring; it added that, because pressure garment therapy is already common in practice and may benefit some patients, patient preference may reasonably guide therapy until more evidence emerges ^[16]. Earlier meta-analysis reached the same direction, finding the beneficial effects of pressure garment therapy unproven against non-trivial morbidity and cost ^[15]. The most directly relevant pediatric randomized trial found no difference between silicone and pressure alone and no benefit from combining them [19, 20].

No regimen, timing, or instrument is established as optimal in children. A national survey found marked variation in the timing and selection of commonly used scar-management modalities and called for a well-designed multicenter study to establish evidence-based best practice in children ^[9]. The systematic review of scar-quality instruments noted that patient-reported, clinician-reported, and device-based measures are often not specifically designed for or validated in pediatric burn patients ^[10]. The Vancouver Scar Scale itself has documented limitations of sensitivity and subjectivity.

Laser efficacy is real but the literature is disorganized. Reviews of laser for pediatric burn scar report consistent scar-scale improvement but flag significant heterogeneity, a paucity of controlled prospective studies with objective measures, and the absence of a clear winner among modalities or combinations [28, 29, 33]. The Early Laser for Burn Scars trial found a patient-rated scar-quality benefit from early pulsed dye laser but no quality-of-life benefit and no cost-effectiveness at six months ^[31].

Graft choice and release algorithms lack high-quality comparative evidence. A systematic review found no strong evidence that full-thickness grafting is superior to split-thickness grafting for functional outcomes of the volar pediatric hand, even as meta-analytic data favor full-thickness grafts for lower re-contracture [41, 42]. For complex regions, many corrective techniques and algorithmic approaches exist without consensus on optimal management.

Recurrence across growth is under-studied longitudinally. The course of function-limiting scar contractures over time in children has been described only preliminarily, with explicit calls for longer-term longitudinal studies to understand how these contractures evolve and to support improvements in burn care ^[56]. Contractures continue to develop despite early positioning and splinting, underscoring the need for more effective prevention strategies ^[55].

References

[1] Chinese Burn Association. "[Clinical practice guideline for pediatric scar prevention and treatment]." Zhonghua shao shang yu chuang mian xiu fu za zhi 2025. PMID: 41326028. https://pubmed.ncbi.nlm.nih.gov/41326028/

[2] Oosterwijk AM, Mouton LJ, Schouten H, Disseldorp LM, van der Schans CP, Nieuwenhuis MK. "Prevalence of scar contractures after burn: A systematic review." Burns : journal of the International Society for Burn Injuries 2017. PMID: 27639820. https://pubmed.ncbi.nlm.nih.gov/27639820/

[3] Meng F, Zuo KJ, Amar-Zifkin A, Baird R, Cugno S, Poenaru D. "Pediatric burn contractures in low- and lower middle-income countries: A systematic review of causes and factors affecting outcome." Burns : journal of the International Society for Burn Injuries 2020. PMID: 31813620. https://pubmed.ncbi.nlm.nih.gov/31813620/

[4] Cubison TC, Pape SA, Parkhouse N. "Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury." Burns : journal of the International Society for Burn Injuries 2006. PMID: 16901651. https://pubmed.ncbi.nlm.nih.gov/16901651/

[5] Thompson CM, Hocking AM, Honari S, Muffley LA, Ga M, Gibran NS. "Genetic risk factors for hypertrophic scar development." Journal of burn care & research : official publication of the American Burn Association 2013. PMID: 23966119. https://pubmed.ncbi.nlm.nih.gov/23966119/

[6] Tredget EE, Shankowsky HA, Pannu R, Nedelec B, Iwashina T, Ghahary A et al. "Transforming growth factor-beta in thermally injured patients with hypertrophic scars: effects of interferon alpha-2b." Plastic and reconstructive surgery 1998. PMID: 9773986. https://pubmed.ncbi.nlm.nih.gov/9773986/

[7] Yanaga H, Udoh Y, Yamauchi T, Yamamoto M, Kiyokawa K, Inoue Y et al. "Cryopreserved cultured epidermal allografts achieved early closure of wounds and reduced scar formation in deep partial-thickness burn wounds (DDB) and split-thickness skin donor sites of pediatric patients." Burns : journal of the International Society for Burn Injuries 2001. PMID: 11600248. https://pubmed.ncbi.nlm.nih.gov/11600248/

[8] Hurlin Foley K, Doyle B, Paradise P, Parry I, Palmieri T, Greenhalgh DG. "Use of an improved Watusi collar to manage pediatric neck burn contractures." The Journal of burn care & rehabilitation 2002. PMID: 12032375. https://pubmed.ncbi.nlm.nih.gov/12032375/

[9] Liuzzi F, Chadwick S, Shah M. "Paediatric post-burn scar management in the UK: a national survey." Burns : journal of the International Society for Burn Injuries 2015. PMID: 25468478. https://pubmed.ncbi.nlm.nih.gov/25468478/

[10] Kemme FM, Mieras A, Ket JCF, Meij-de Vries A, van Zuijlen PPM, Pijpe A. "How to Assess Scar Quality in Pediatric Burn Patients: A Systematic Review on the Type and Content of Outcome Measurement Instruments." Journal of burn care & research : official publication of the American Burn Association 2025. PMID: 40317225. https://pubmed.ncbi.nlm.nih.gov/40317225/

[11] Ziolkowski NI, Pusic AL, Fish JS, Mundy LR, Wong She R, Forrest CR et al. "Psychometric Findings for the SCAR-Q Patient-Reported Outcome Measure Based on 731 Children and Adults with Surgical, Traumatic, and Burn Scars from Four Countries." Plastic and reconstructive surgery 2020. PMID: 32842115. https://pubmed.ncbi.nlm.nih.gov/32842115/

[12] Ziolkowski NI, Behman R, Klassen AF, Fish JS, Mundy LR, She RW et al. "Determining the Independent Risk Factors for Worse SCAR-Q Scores and Future Scar Revision Surgery." Plastic and reconstructive surgery 2021. PMID: 34076625. https://pubmed.ncbi.nlm.nih.gov/34076625/

[13] Meikle B, Simons M, Meirte J, Miller K, Kimble R, Tyack Z. "Electronic and paper delivery of parent proxy and children's report of two scar-specific patient-reported outcome measures (Brisbane Burn Scar Impact Profile and Patient and Observer Scar Assessment Scale): An equivalence study." Burns : journal of the International Society for Burn Injuries 2025. PMID: 39731969. https://pubmed.ncbi.nlm.nih.gov/39731969/

[14] Gee Kee EL, Kimble RM, Cuttle L, Stockton KA. "Scar outcome of children with partial thickness burns: A 3 and 6 month follow up." Burns : journal of the International Society for Burn Injuries 2016. PMID: 26546385. https://pubmed.ncbi.nlm.nih.gov/26546385/

[15] Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. "The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis." Journal of plastic, reconstructive & aesthetic surgery : JPRAS 2009. PMID: 18249046. https://pubmed.ncbi.nlm.nih.gov/18249046/

[16] Harris IM, Lee KC, Deeks JJ, Moore DJ, Moiemen NS, Dretzke J. "Pressure-garment therapy for preventing hypertrophic scarring after burn injury." The Cochrane database of systematic reviews 2024. PMID: 38189494. https://pubmed.ncbi.nlm.nih.gov/38189494/

[17] Moiemen N, Mathers J, Jones L, Bishop J, Kinghorn P, Monahan M et al. "Pressure garment to prevent abnormal scarring after burn injury in adults and children: the PEGASUS feasibility RCT and mixed-methods study." Health technology assessment (Winchester, England) 2018. PMID: 29947328. https://pubmed.ncbi.nlm.nih.gov/29947328/

[18] Engrav LH, Heimbach DM, Rivara FP, Moore ML, Wang J, Carrougher GJ et al. "12-Year within-wound study of the effectiveness of custom pressure garment therapy." Burns : journal of the International Society for Burn Injuries 2010. PMID: 20537469. https://pubmed.ncbi.nlm.nih.gov/20537469/

[19] Wiseman J, Ware RS, Simons M, McPhail S, Kimble R, Dotta A et al. "Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children: a randomized controlled trial." Clinical rehabilitation 2020. PMID: 31565952. https://pubmed.ncbi.nlm.nih.gov/31565952/

[20] Wiseman J, Simons M, Kimble R, Ware RS, McPhail SM, Tyack Z. "Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children 12-months postburn: A parallel group randomised controlled trial." Clinical rehabilitation 2021. PMID: 34107792. https://pubmed.ncbi.nlm.nih.gov/34107792/

[21] McPhail SM, Wiseman J, Simons M, Kimble R, Tyack Z. "Cost-effectiveness of scar management post-burn: a trial-based economic evaluation of three intervention models." Scientific reports 2022. PMID: 36329128. https://pubmed.ncbi.nlm.nih.gov/36329128/

[22] Momeni M, Hafezi F, Rahbar H, Karimi H. "Effects of silicone gel on burn scars." Burns : journal of the International Society for Burn Injuries 2009. PMID: 18672332. https://pubmed.ncbi.nlm.nih.gov/18672332/

[23] Karagoz H, Yuksel F, Ulkur E, Evinc R. "Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars." Burns : journal of the International Society for Burn Injuries 2009. PMID: 19766399. https://pubmed.ncbi.nlm.nih.gov/19766399/

[24] Parry IS, Schneider JC, Yelvington M, Sharp P, Serghiou M, Ryan CM et al. "Systematic Review and Expert Consensus on the Use of Orthoses (Splints and Casts) with Adults and Children after Burn Injury to Determine Practice Guidelines." Journal of burn care & research : official publication of the American Burn Association 2020. PMID: 31504622. https://pubmed.ncbi.nlm.nih.gov/31504622/

[25] Celis MM, Suman OE, Huang TT, Yen P, Herndon DN. "Effect of a supervised exercise and physiotherapy program on surgical interventions in children with thermal injury." The Journal of burn care & rehabilitation 2003. PMID: 12543995. https://pubmed.ncbi.nlm.nih.gov/12543995/

[26] Eid MM, Abdelbasset WK, Abdelaty FM, Ali ZA. "Effect of physical therapy rehabilitation program combined with music on children with lower limb burns: A twelve-week randomized controlled study." Burns : journal of the International Society for Burn Injuries 2021. PMID: 33288333. https://pubmed.ncbi.nlm.nih.gov/33288333/

[27] Chen Y, Wei W, Li X. "Clinical efficacy of CO2 fractional laser in treating post-burn hypertrophic scars in children: A meta-analysis." Skin research and technology : official journal of International Society for Bioengineering and the Skin (ISBS) [and] International Society for Digital Imaging of Skin (ISDIS) [and] International Society for Skin Imaging (ISSI) 2024. PMID: 38332516. https://pubmed.ncbi.nlm.nih.gov/38332516/

[28] Yin Z, Zhang XH, He YY, Cai D, Zhou X, Li YT et al. "Combination therapy of pulsed dye laser and ablative fractional carbon dioxide laser for the treatment of pediatric postburn scar: a systematic review." Lasers in medical science 2025. PMID: 39918788. https://pubmed.ncbi.nlm.nih.gov/39918788/

[29] Cooper LE, Nuutila K, Kemp Bohan PM, Diaz V, Batchinsky M, Carlsson AH et al. "Analysis of the Utility of CO2 and Pulse-Dye Lasers Together and Separately in the Treatment of Hypertrophic Burn Scars." Annals of plastic surgery 2022. PMID: 35943226. https://pubmed.ncbi.nlm.nih.gov/35943226/

[30] Won T, Ma Q, Chen Z, Gao Z, Wu X, Zhang R. "The efficacy and safety of low-energy carbon dioxide fractional laser use in the treatment of early-stage pediatric hypertrophic scars: A prospective, randomized, split-scar study." Lasers in surgery and medicine 2022. PMID: 34487566. https://pubmed.ncbi.nlm.nih.gov/34487566/

[31] Brewin MP, Docherty S, Heaslip V, Rhodes S, Ukoumunne OC, Burnett-Fry NC et al. "Early Laser for Burn Scars (ELABS) - Randomised controlled trial of pulsed dye laser treatment and standard care versus standard care alone for the treatment of hypertrophic burn scars." Burns : journal of the International Society for Burn Injuries 2025. PMID: 40319828. https://pubmed.ncbi.nlm.nih.gov/40319828/

[32] Zhang ZB, Zhou ZL, Xing FX, Li Y, Sun XC, Zhao YT et al. "Analysis of Energy and Density in Treating Hypertrophic Scar After Burn in Children with CO2 Dot Matrix Laser." The international journal of lower extremity wounds 2025. PMID: 36536604. https://pubmed.ncbi.nlm.nih.gov/36536604/

[33] Roohaninasab M, Najar Nobari N, Ghassemi M, Behrangi E, Jafarzadeh A, Sadeghzadeh-Bazargan A et al. "A systematic review of procedural treatments for burn scars in children: Evaluating efficacy, safety, standard protocols, average sessions and tolerability based on clinical studies." International wound journal 2024. PMID: 39379072. https://pubmed.ncbi.nlm.nih.gov/39379072/

[34] Younes B, Mandour E, Soliman Hashish M, Gamal Shoukr T. "The efficacy of fractional CO2 laser with or without triamcinolone acetonide or 5-fluorouracil in the treatment of early postburn hypertrophic scars." Lasers in medical science 2025. PMID: 39847194. https://pubmed.ncbi.nlm.nih.gov/39847194/

[35] Jiang Y, Dai Q, Shi W, Zhang Y, Xie S, Xu Q. "Therapeutic efficacy and influencing factors of 5-fluorouracil combined with ultra-pulsed fractional carbon dioxide laser treatment for hypertrophic scars in burn patients." Cutaneous and ocular toxicology 2025. PMID: 40576104. https://pubmed.ncbi.nlm.nih.gov/40576104/

[36] Armendariz-Borunda J, Lyra-Gonzalez I, Medina-Preciado D, Gonzalez-García I, Martinez-Fong D, Miranda RA et al. "A controlled clinical trial with pirfenidone in the treatment of pathological skin scarring caused by burns in pediatric patients." Annals of plastic surgery 2012. PMID: 21659848. https://pubmed.ncbi.nlm.nih.gov/21659848/

[37] Tawfik AA, Ali RA. "Evaluation of botulinum toxin type A for treating post burn hypertrophic scars and keloid in children: An intra-patient randomized controlled study." Journal of cosmetic dermatology 2023. PMID: 36718819. https://pubmed.ncbi.nlm.nih.gov/36718819/

[38] Gal S, Ramirez JI, Maguina P. "Autologous fat grafting does not improve burn scar appearance: A prospective, randomized, double-blinded, placebo-controlled, pilot study." Burns : journal of the International Society for Burn Injuries 2017. PMID: 28041747. https://pubmed.ncbi.nlm.nih.gov/28041747/

[39] Abass O, Michael AI, Abubakar ML, Adebayo WO, Kabir MA, Ibrahim A. "Pediatric Postburn Flexion Contracture Release: Early Outcomes Using 2 Bloodless Techniques." Journal of burn care & research : official publication of the American Burn Association 2024. PMID: 38442297. https://pubmed.ncbi.nlm.nih.gov/38442297/

[40] Bashir MM, Sohail M, Wahab A, Iqbal U, Qayyum R, Jan SN. "Outcomes of post burn flexion contracture release under tourniquet versus tumescent technique in children." Burns : journal of the International Society for Burn Injuries 2018. PMID: 29454711. https://pubmed.ncbi.nlm.nih.gov/29454711/

[41] Alsaif A, Karam M, Hayre A, Abul A, Aldubaikhi A, Kahlar N. "Full thickness skin graft versus split thickness skin graft in paediatric patients with hand burns: Systematic review and meta-analysis." Burns : journal of the International Society for Burn Injuries 2023. PMID: 36280545. https://pubmed.ncbi.nlm.nih.gov/36280545/

[42] Prasetyono TO, Sadikin PM, Saputra DK. "The use of split-thickness versus full-thickness skin graft to resurface volar aspect of pediatric burned hands: A systematic review." Burns : journal of the International Society for Burn Injuries 2015. PMID: 25720658. https://pubmed.ncbi.nlm.nih.gov/25720658/

[43] Zheng XY, Guo X, Wang TL, Wang JQ. "Extended lower trapezius myocutaneous flap in burn scar reconstruction of the face and neck of children." Pediatric surgery international 2011. PMID: 21822656. https://pubmed.ncbi.nlm.nih.gov/21822656/

[44] Angrigiani C. "Aesthetic microsurgical reconstruction of anterior neck burn deformities." Plastic and reconstructive surgery 1994. PMID: 8115505. https://pubmed.ncbi.nlm.nih.gov/8115505/

[45] Xia CD, Xue JD, Xing PP, Guo HN, Cao DY, Xie JF et al. "[Effects of expanded frontal-parietal pedicled flap in reconstructing cervical scar contracture deformity in children after burns]." Zhonghua shao shang yu chuang mian xiu fu za zhi 2022. PMID: 35599421. https://pubmed.ncbi.nlm.nih.gov/35599421/

[46] Barret JP, Herndon DN, McCauley RL. "Use of previously burned skin as random cutaneous local flaps in pediatric burn reconstruction." Burns : journal of the International Society for Burn Injuries 2002. PMID: 12163293. https://pubmed.ncbi.nlm.nih.gov/12163293/

[47] Margulis A, Billig A, Elia J, Shachar Y, Adler N. "Complications of Post-Burn Tissue Expansion Reconstruction: 9 Years Experience with 42 Pediatric and 26 Adult Patients." The Israel Medical Association journal : IMAJ 2017. PMID: 28457060. https://pubmed.ncbi.nlm.nih.gov/28457060/

[48] Carmichael KD, Maxwell SC, Calhoun JH. "Recurrence rates of burn contracture ankle equinus and other foot deformities in children treated with Ilizarov fixation." Journal of pediatric orthopedics 2005. PMID: 15958908. https://pubmed.ncbi.nlm.nih.gov/15958908/

[49] Greyson MA, Wilkens SC, Sood RF, Winograd JM, Eberlin KR, Donelan MB. "Five Essential Principles for First Web Space Reconstruction in the Burned Hand." Plastic and reconstructive surgery 2020. PMID: 33141534. https://pubmed.ncbi.nlm.nih.gov/33141534/

[50] Heaslip V, Docherty S, Rhodes S, Obioha U, Breheny K, Attrill K et al. "Patients' experiences of treatment and the scar management pathway during the Early Laser for Burn Scars (ELABS) trial: An embedded qualitative study." Burns : journal of the International Society for Burn Injuries 2026. PMID: 41297231. https://pubmed.ncbi.nlm.nih.gov/41297231/

[51] Chang JB, Kung TA, Levi B, Irwin T, Kadakia A, Cederna PS. "Surgical management of burn flexion and extension contractures of the toes." Journal of burn care & research : official publication of the American Burn Association 2014. PMID: 24390110. https://pubmed.ncbi.nlm.nih.gov/24390110/

[52] Chen B, Xu M, Song H, Gao Q, Chai J, Wang F et al. "Classification of Achilles tendon shortening induced by scar contracture and corresponding treatment strategies for pediatric patients - A single unit experience." Burns : journal of the International Society for Burn Injuries 2021. PMID: 33549395. https://pubmed.ncbi.nlm.nih.gov/33549395/

[53] Grishkevich VM. "Postburn perineal obliteration: elimination of perineal, inguinal, and perianal contractures with the groin flap." Journal of burn care & research : official publication of the American Burn Association 2010. PMID: 20647936. https://pubmed.ncbi.nlm.nih.gov/20647936/

[54] Rimmer RB, Foster KN, Bay CR, Floros J, Rutter C, Bosch J et al. "The reported effects of bullying on burn-surviving children." Journal of burn care & research : official publication of the American Burn Association 2007. PMID: 17438488. https://pubmed.ncbi.nlm.nih.gov/17438488/

[55] Goverman J, Mathews K, Goldstein R, Holavanahalli R, Kowalske K, Esselman P et al. "Pediatric Contractures in Burn Injury: A Burn Model System National Database Study." Journal of burn care & research : official publication of the American Burn Association 2017. PMID: 27355656. https://pubmed.ncbi.nlm.nih.gov/27355656/

[56] Oosterwijk AM, Mouton LJ, Akkerman M, Stoop MM, van Baar ME, Scholten-Jaegers SMH et al. "Course of prevalence of scar contractures limiting function: A preliminary study in children and adolescents after burns." Burns : journal of the International Society for Burn Injuries 2019. PMID: 31676251. https://pubmed.ncbi.nlm.nih.gov/31676251/

[57] Germann G, Cedidi C, Hartmann B. "Post-burn reconstruction during growth and development." Pediatric surgery international 1997. PMID: 9244090. https://pubmed.ncbi.nlm.nih.gov/9244090/

[58] Palmieri TL. "Initial management of acute pediatric hand burns." Hand clinics 2009. PMID: 19801120. https://pubmed.ncbi.nlm.nih.gov/19801120/

[59] Hubbard M, Masters IB, Williams GR, Chang AB. "Severe obstructive sleep apnoea secondary to pressure garments used in the treatment of hypertrophic burn scars." The European respiratory journal 2000. PMID: 11292128. https://pubmed.ncbi.nlm.nih.gov/11292128/

[60] Elnaggar RK, Samhan AF, Elshafey MA. "Differential Effects of Extracorporeal Shockwave Therapy and Botulinum Toxin-A Injection on Postburn Contractures and Gait Kinematics in Burn Children." Journal of burn care & research : official publication of the American Burn Association 2020. PMID: 31867608. https://pubmed.ncbi.nlm.nih.gov/31867608/

[61] Lawrence JW, Rosenberg L, Mason S, Fauerbach JA. "Comparing parent and child perceptions of stigmatizing behavior experienced by children with burn scars." Body image 2011. PMID: 21074503. https://pubmed.ncbi.nlm.nih.gov/21074503/

[62] Baldwin AJ, Mavromatidou G, Coleman C, Murray A. "Epidemiology, management and outcomes of paediatric upper limb friction injuries: A systematic review." Injury 2025. PMID: 40561811. https://pubmed.ncbi.nlm.nih.gov/40561811/

[63] Maskell J, Newcombe P, Martin G, Kimble R. "Psychosocial functioning differences in pediatric burn survivors compared with healthy norms." Journal of burn care & research : official publication of the American Burn Association 2013. PMID: 23702857. https://pubmed.ncbi.nlm.nih.gov/23702857/