Pressure garment and silicone conservative scar management

Overview

Hypertrophic scarring is the dominant long-term morbidity of deep burns, developing in up to roughly 70% of burn patients ^[20][21]. These scars are not a cosmetic afterthought: they cause pruritus, pain, contracture across joints, and measurable loss of function and quality of life ^[22][23]. Conservative, nonsurgical management aims to influence the immature scar during the window when it is still actively remodeling, before mature contracture forces an operative answer.

Two modalities anchor that conservative approach. Pressure garment therapy is a traditional treatment for hypertrophic burn scars ^[1], and silicone gel sheeting entered burn-scar practice around 1981 ^[8]. The original rationale, articulated in the early rehabilitation literature, was that most ongoing rehabilitation difficulty stems from the continual wound contraction of immature burn scars, which pressure was thought to counter ^[1]. Pressure garments delivering approximately 15-25 mmHg are used to prevent and treat hypertrophic scar formation in burns ^[4], and silicone is applied over the scar ^[10]. Both are inexpensive relative to surgery, both can be self-administered at home, and both are embedded in burn-center protocols worldwide.

The tension that runs through this entire topic is the gap between near-universal use and the strength of the supporting evidence. A 2024 systematic review noted that pressure garment therapy is considered standard care globally yet carries continued uncertainty about its effectiveness ^[6]. The literature is large but heterogeneous, dominated by small studies with unvalidated scar scales and short follow-up, so the honest characterization is a thin and contested evidence base supporting widely accepted practice ^[42].

Mechanism

The biology of how pressure changes a scar is incompletely defined, and that uncertainty is openly acknowledged in the primary literature. Elastocompression is described as the best available means of preventing and controlling hypertrophic burn scars through a mechanism that has not been fully clarified ^[2]. Several converging strands give a partial picture. Mechanical compression induces release of prostaglandin E2, which in turn increases the expression of collagenases ^[2]. In one mechanistic study, PGE2 basal levels were significantly lower in hypertrophic scars than in normal skin, and compression produced a several-fold increase in PGE2 release in scars in both remission and active stages ^[2]. Pressure therapy has also been reported to induce local hypoxia and to reduce expression of transforming growth factor beta 1, limiting fibroblast activity ^[15]. Histologically, pressure-treated scars show reduced cell density, suppression of the myofibroblast population, and a measured decrease in total collagen ^[16][17]. One study quantified a 51.9% decrease in total collagen after pressure initiation ^[17].

Silicone works through a different and better-characterized pathway centered on the stratum corneum. Silicone acts as an occlusion that decreases transepidermal water loss and restores the normal hydration state of keratinocytes, which in turn signals dermal fibroblasts to downregulate extracellular matrix production ^[13][14]. The mechanism is not fully determined but is thought to involve occlusion and hydration with subsequent cytokine-mediated signaling from keratinocytes to dermal fibroblasts ^[14]. This shared occlusion-and-hydration logic explains why silicone and pressure are often used together and why neither is understood at the level of a single molecular target.

Assessment

Conservative scar management depends on two kinds of measurement: tracking the scar itself and verifying that the garment delivers therapeutic pressure. Scar tracking in the burn literature relies heavily on the Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale, which capture pigmentation, vascularity, pliability, and height ^[38]. These scales are workhorses but are also a source of the field's evidence weakness, since many studies used unvalidated assessment tools, lacked double-blinding, and reported short follow-up ^[42].

The second measurement problem is delivered pressure, and it is a real one. A garment is only therapeutic if it actually exerts the intended force, yet measured interface pressures vary widely. One study using a wearable sensor found that pressures exerted by standard garments ranged from 15 to 54 mmHg, with the highest readings on the wrists ^[39]. In another cohort, only 32% of stationary and 25% of dynamic measurements fell within the 15-25 mmHg window at first garment fitting ^[40]. Because garments also lose compression over time, delivered dose cannot be assumed from prescription alone ^[5].

Management

The conservative scar-management sequence follows wound healing. Compression for edema reduction is initiated 48-72 hours post-injury and continued for wounds that take longer than 21 days to heal, until scar maturation ^[10]. Custom-fabricated pressure garments are applied once edema stabilizes and adequate healing has occurred ^[10]. The target dose described in recent practice guidance is a maintained pressure above 15 mmHg with wear time exceeding 16 hours per day, with inserts added when needed to sustain pressure over contoured areas ^[10]. The original clinical observation that pressure of at least 15 mmHg tends to accelerate scar maturation comes from controlled garment work showing that "normal" compression-class garments scored significantly better for thickness than low-compression garments, with the difference most evident at one month ^[5].

Silicone is layered onto this framework. Silicone products in sheet or fluid form are widely regarded as a first-line option in the prevention and treatment of hypertrophic scars and keloids ^[7]. Topical silicone gel and silicone gel sheeting are comparably effective in pooled analysis, which matters clinically because gel is easier to apply over irregular surfaces than sheeting ^[18]. Pressure and silicone are frequently combined. A 2023 meta-analysis found that pressure plus silicone was superior to pressure alone for scar height and pliability, although Vancouver Scar Scale, vascularity, pigmentation, and adverse effects were similar between the two strategies ^[19].

Newer work has pushed on the dosing question. A 2026 study using adjustable low-fatigue garments reported that pressures as low as 10 mmHg reduced post-burn scar contraction and thickness if that pressure was reliably maintained throughout garment use, although the greatest improvement was at 30 mmHg ^[12]. Separately, pressure-monitoring technology that confirms delivered dose has been shown to enhance the effectiveness of pressure garments in a scar model ^[35]. Where conservative measures are insufficient, the cited literature positions intralesional triamcinolone and laser as more effective comparators for established hypertrophic and keloid scars ^[11].

Complications

The adverse-effect profile of conservative scar management is generally mild but clinically meaningful, and it is the main driver of treatment abandonment ^[43]. Silicone gel sheeting is associated with rash, skin breakdown, cessation of scar responsiveness, pruritus, contact dermatitis, and dry skin ^[26]. Prolonged uninterrupted sheeting can cause more serious local problems; one report described recurrent chest-wall abscesses after six years of round-the-clock silicone gel sheeting on a keloid, attributed to maceration of the soggy skin beneath the sheet ^[28].

Pressure therapy carries its own risks, principally from excessive or poorly distributed force. The most common complication is ulceration from excessive soft-tissue pressure, which delays and prolongs treatment ^[27], and there is specific caution about maceration or necrosis at pressures above 40 mmHg ^[25]. Beyond direct tissue injury, the dominant practical problem is non-adherence: up to 40% of adult burn patients are non-adherent with prescribed compression garment wear ^[30]. Adherence is shaped less by health beliefs than by the lived burden of treatment, including the practical labor of maintaining garments, hospital appointments, and the emotional labor of daily care ^[29]. These tolerability and adherence limits are why the choice between modalities often comes down to which one a given patient will actually use; one Cochrane review noted that silicone may result in fewer adverse events or better adherence than pressure garments, though on very low-certainty evidence ^[6].

Special Considerations

Children are the population where conservative scar management is both most needed and most fraught. Pressure garments applied to the growing face can cause harm: in children with facial burns, pressure garments may lead to skeletal and dental deformities, and children with total face burns have shown altered direction of mandibular growth ^[31][32]. This is a genuine trade-off rather than a contraindication, since pressure therapy remains an important rehabilitative strategy for pediatric facial scarring, typically delivered through headgear and transparent pressure facemasks ^[34]. Treatment duration in children is long; in pediatric scald injury, pressure garments need to be continued for a minimum of one year ^[37].

Silicone has a population-specific hazard of its own: silicone sheeting can be swallowed whole by infants, a safety concern that shapes its use in babies even where silicone gel is otherwise recommended for upper-lip scar management after cleft repair ^[33]. Anatomic site also constrains conservative therapy. Conventional facial compression garments distribute pressure poorly over curved areas such as the cheeks, around the mouth, and the slope of the nose, which is the specific gap that custom transparent facemasks and newer 3D-printed sensor-equipped masks are designed to close ^[4].

Outcomes

When the evidence is read by modality, a consistent pattern emerges: measurable improvement on some scar dimensions, with the magnitude and certainty heavily dependent on study quality. For pressure therapy, a 2019 meta-analysis found that the treated group had a significantly higher effective ratio and lower Vancouver Scar Scale score and scar vascularity, but no clear change in scar hardness, pigment, thickness, or color ^[36]. An earlier pooled analysis was blunter, concluding that pressure garment therapy did not appear to alter global scar scores and that the small improvement in scar height it produced was of questionable clinical importance ^[9].

Silicone shows a similar shape. A 2013 Cochrane review found that silicone gel sheeting produced a statistically significant reduction in scar thickness and improvement in scar color in treatment studies, but that these studies were highly susceptible to bias ^[8]. A 2020 meta-analysis found topical silicone gel significantly reduced pigmentation, height, and pliability scores postoperatively compared with placebo or no treatment ^[18]. For keloids specifically, a 2023 review concluded there is a lack of randomized controlled trial evidence about the clinical effectiveness of silicone gel sheeting ^[41]. A pressure-therapy review the same year reported sufficient evidence to support prophylactic and curative use and suggested pressure therapy can improve scar color, thickness, pain, and overall quality ^[15]. The 2024 Cochrane review of pressure garment therapy reached the opposite conclusion, finding the evidence very uncertain on whether pressure improves scars versus no treatment ^[6]. For silicone gel sheeting, the evidence was rated low or very low, often because of imprecision from few participants and low event rates ^[44].

Controversies and Evidence Gaps

The central controversy is the mismatch between ubiquity and proof. Despite the magnitude of hypertrophic scarring and the ubiquitous use of pressure garments, strong clinical evidence of the efficacy of pressure garment therapy is lacking ^[24]. The 2024 Cochrane review concluded there is insufficient evidence to recommend either pressure garment therapy or an alternative for preventing hypertrophic scarring after burn injury ^[6]. A 2025 comparative review went further, finding that triamcinolone is the most effective treatment for hypertrophic and keloid scars and that evidence supporting pressure garment therapy is inconsistent ^[11]. Even the most authoritative scar-management overview in the corpus frames the field as needing better delineation of indications, duration, and efficacy of established therapies ^[3].

Several specific gaps recur across the reviews. Delivered pressure is hard to standardize and frequently misses the 15-25 mmHg target, confounding any dose-response interpretation ^[39][40]. The optimal pressure threshold is itself unsettled: long-standing practice targets 15 mmHg or more, yet recent work suggests as little as 10 mmHg may suffice if reliably maintained ^[5][12]. Trials are small, often use unvalidated scar scales, and rarely follow patients to scar maturation ^[42]. Whether silicone and pressure are genuinely additive remains unresolved, with combination therapy showing benefit only for height and pliability in pooled data ^[19]. Finally, adherence is both an outcome and a confounder, since the treatments that work on paper are abandoned by a substantial fraction of patients in practice ^[30][29]. These gaps explain why a treatment family used for half a century still rests on low-certainty evidence.

References

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