Patterns and predictors of burn scar outcome in the first 12 months after burn: The patient's perspective

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1

_Highlights

Burnsxxx(2019)xxx–xxx

Patterns

and

predictors

of

burn

scar

outcome

in

the

first

12 months

post-burn:

The

patient’s

perspective

Z.M.Rashaan*,K.A.A. Kwa,M.B.A.vanderWal,W.E.Tuinebreijer,P.P.M.vanZuijlen, R.S.Breederveld

ThePOSASpatienttotalandindividualitemscoresshowedastatisticallysignificantimprovementofthescarqualityinthefirst 12monthspost-burn,exceptforrelief.

Q6

Sex,age,depthofthewound,percentageofTBSAandflameburnswerepredictorsofvariousPOSASpatientitemsat3,6and 12monthspost-burn.

TheeffectofthepredictorswasnotthesameontheindividualPOSASpatientitems.

burns xxx (2019) xxx–xxx

Available

online

at

www.sciencedirect.com

ScienceDirect

(3)

1Q3

Patterns

and

predictors

of

burn

scar

outcome

in

the

2

first

12 months

post-burn:

The

patient

’s

perspective

3Q4Q5

_Z.M.

_Rashaan

a,b,

_*

_,

_K.A.A.

_Kwa

a,b

_,

_M.B.A.

_van

_der

_Wal

e

_,

4

_W.E.

_Tuinebreijer

b

_,

_P.P.M.

_van

_Zuijlen

c,d

_,

_R.S.

_Breederveld

a,b

5 a_Department_of_Surgery,_Leiden_University_Medical_Centre,_Albinusdreef_2,₂₃₃₃_ZA_Leiden,_Leiden,_T_he_Netherlands

6 b

BurnCentreandDepartmentofSurgery,RedCrossHospital,Vondellaan13,1942LE,Beverwijk,TheNetherlands

7 c_Burn_Centre_and_Department_of_Plastic_and_{Reconstructive}_Surgery,_Red_Cross_Hospital,_Vondellaan_13,₁₉₄₂_LE,

8 _Beverwijk,_T_he_Netherlands

9 d_Department_of_Plastic_and_{Reconstructive}_Surgery_and_MOVE_Research_Institute,_VU_University_of_Amsterdam,_Van

10 _der_{Boechorststraat}_7,₁₀₈₁_BT,_Amsterdam,_T_he_Netherlands

11 e

AssociationofDutchBurnCentres,Zeestraat27-29,1941AJ,Beverwijk,TheNetherlands

a

b

s

t

r

a

c

t

Objective:Thisstudyaimedtoprovideinsightintothepatternsandfactorsthatpredictburn scaroutcomesat3,6and12monthspost-burn.

Methods:ThePatientandObserverScarAssessmentScale(POSAS)wasusedtoassessthescar formationofeachpatient.Structuralequationmodellingwasused.Thepredictorvariablesused inthisstudyweresex,threeagecategories,TBSA,depthofthewoundandcauseoftheburn. Results:ThePOSASpatienttotalandindividualitemscoresdemonstrateda statistically significantdecreaseinthefirst12monthspost-burn,exceptforthereliefitem.Malepatients hadalowertotalanditemsscores(betterscarquality)forpainandprurituscomparedwith femalepatients.Fullthicknessburnshadahigherscoresforpruritus,pliability,thickness andreliefcomparedtothepartial-thicknessburns.Agesyoungerthan5years,higherTBSA valuesandflameburnswerepredictorsofvariousPOSASitemsat3and6monthspost-burn. Conclusion:ThePOSASpatienttotalandindividualitemscoresdemonstratedastatistically significantimprovementinthescarqualityinthefirst12monthspost-burn,exceptforthe relief.Sex,age,depthofthewound,thepercentageofTBSAandflameburnswerepredictors ofvariousPOSASpatientitemsat3,6and12monthspost-burn.

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Accepted26March2019 Availableonlinexxx 12 _Keywords: 13 _Burn_wounds 14 _Burn_scars 15 _POSAS 16 _Scar_quality

17 _Pred_ictors_and_patterns

18

_1.

_Introduction

19 _Burn_scars_have_extensive_impacts_on_burn_patients_in_terms_of 20 _quality _of _life, _functional _impairment _and _{physiological}

21 problems[1–3].Thus,theoptimalmanagementofburnscars

22 requires more insight into the factors that influence the

23 severityofburnscars.

24 Todate,sex,age,skintype,location,bacterialcolonisation,

25 time to wound healing, type of graft, multiple surgical Abbreviations:CFI,comparativefitindex;POSAS,thePatientandObserverScarAssessmentScale;SEM,structuralequationmodelling; LGM,latentgrowthcurvemodel;RMSEA,therootmeansquareerrorofapproximation.

* Correspondingauthor.

E-mailaddresses:z.rashaan@vumc.nl(Z.M. Rashaan),kkwa@rkz.nl(K.A.A. Kwa),mbavdwal@hotmail.com(M.B.A. vanderWal),

wetuineb@knmg.nl(W.E. Tuinebreijer),pvanzuijlen@rkz.nl(P.P.M. vanZuijlen),rbreederveld@rkz.nl(R.S. Breederveld).

https://doi.org/10.1016/j.burns.2019.03.025

JBUR58071–8

Pleasecitethisarticleinpressas:Z.M.Rashaan,K.A.A.Kwa,M.B.A.vanderWaletal.Patternsandpredictorsofburnscaroutcomein thefirst12monthspost-burn:Thepatient’sperspective.Burns(2019),https://doi.org/10.1016/j.burns.2019.03.025

Available

online

at

www.sciencedirect.com

ScienceDirect

(4)

26 _procedures, _burn _severity _and _the _skin _being _subjected _to 27 _stretching_have_been_found_to_be_risk_factors_for_hypertrophic 28 _scarring_[₄_–8_]._The_impacts_of_burn_scars_not_only_entail_the 29 _appearance_of_the_scar_but_also_involve_of_its_accompanying 30 _symptoms. _Up _to _47% _of _patients _experience _pain _that _is 31 _associated_with_their_burn_scars_[₉_]._In_addition,_pruritus_was 32 _found_to_still_be_present_in_67%_of_the_burn_patients_at_two_years 33 _post-burn _[10]. _It _s_hould _be _noted _that _different _burn_scar 34 _assessment_strategies_were_used_in_these_studies,_and_these 35 _studies_were_often_limited_by_the_lack_of_an_appropriate_tool_for 36 _evaluating_scar_outcomes.

37 _Currently,_the_Patient_and_Observer_Scar_Assessment_Scale 38 _(POSAS)_is_widely_used_to_assess_scar_quality_[₁₁_]._The_POSAS 39 _consists_of_observer_and_patient_components_and_has_been 40 _found_to_be_a_reliable_and_valid_instrument_for_the_assessment 41 _of_burn_scars_[₁₂_,₁₃_]._The_POSAS_patient_scale_by_Draaijers_et_al. 42 _(version_1.0)_incorporates_scores_for_the_following_six_items_by 43 _using _a _10-point _rating _scale: _pain, _itch, _color, _pliability, 44 _thickness_and_relief_[₁₂_,₁₄_]._A_high_score_indicates_a_worse_scar 45 _quality. _There _is _a _paucity _of _research _{investigating} _the 46 _changes_in_the_POSAS _scores_after_burns_[₁₅_]._Van _der_Wal 47 _et _al. _described _that _full _thickness _wounds _and _a _higher 48 _percentage_of_TBSA _were _significant_predictors_of_a_higher 49 _POSAS_score,_whereas_the_aetiology_and_age_of_the_patient_had 50 _no _influence _on _the _scar _quality _[₁₆_]. _In _addition, _POSAS 51 _assessment_a_three_months_post-burn_found_to_be_predictive_of 52 _final_scar_quality_at_twelve_months_post-burn_[₁₇_].

53 _The _purpose _of _the _present _study _was _to _describe _the 54 _influence_of_predictors_on_changes_in_POSAS_patient_scores_at 55 _3,₆_and₁₂_months_post-burn.

56

_2.

_Materials

_and

_m

_ethods

57 _2.1. _Recruitment_and_study_population

58 _This_{retrospective}_study_was _performed_at_the_burn_centre 59 _outpatient_clinic_at_the_Red_Cross_Hospital,_Beverwijk_in_the 60 _Netherlands _between _June ₂₀₀₄ _and _December _2009. _This 61 _study_was_conducted_in_accordance_with_the_ethical_standards 62 _of_the_{institutional}_and/or_national_research_committee_and 63 _with_the₁₉₆₄_Helsinki_declaration_and_its_later_amendments_or 64 _comparable_ethical_standards._The_POSAS_{questionnaire}_is_a 65 _standard_part_of_each_routine_follow-up_visit_of_each_of_the_burn 66 _patients_in_the_outpatient_clinic_at_3,₆_and₁₂_months_at_our 67 _specialized_burn_centre._The_data_of_the _patients_who _were 68 _admitted_to_the_burn_centre_and_who_were_subsequently_seen 69 _at_the_outpatient_clinic_at_3,₆_and₁₂_months_post-burn_were 70 _included _in _the _analysis. _In _this _consecutive _sample, _the 71 _patients_who_participated_in_clinical_trials_for_wound_or_scar 72 _treatments _were _excluded _from _the _study. _The _parents_or 73 _caregivers_were_asked_to_fill_in_the_POSAS_patient_component 74 _for _patients _who _were _under _the _age _of₅ _years. _Baseline 75 _{characteristics} _such _as _sex, _age _at _the _time _of _burn, _the 76 _percentage _of _total _body _surface _area _(TBSA), _burn _depth 77 _(partial_or_full_thickness)_and_the _cause_of_the_burn_wound 78 _(flame_or_scald)_were_collected._At_our_institution,_patients_with 79 _{full-thickness} _burns _were _operated _(skin _grafting). _Mixed 80 _burns_(partial_and_{full-thickness)}_were_{conservatively}_treated 81 _for_{approximately}₁₀_–14 _days._Burn _wounds_of_>3_cm2_that

82 were not yet healed, were considered for skin grafting

83 procedures.Partial-thicknessburnsweretreatedwithtopical

84 antisepticsorhydrofibredressings.Thistreatmentalgorithm

85 waschosenbecausewoundhealingthattakesmorethanthree

86 weeks to complete, is considered to be a risk factor for

87 hypertrophic scarformation[18].Patients werecategorized

88 intothefollowingthreeage-groups:<5years,5–18yearsand

89 >18years.Thecut-offvalueof5yearswaschosenbecauseof

90 tworeasons.First,theepidemiologyofburnwoundstendsto

91 bedifferentbetweenchildren<5yearsandolderchildren.In

92 general,scaldburnsweremorecommoninchildrenwhowere

93 youngerthan 5yearscomparedwitholderchildren[19,20].

94 Second,thePOSASpatientscoresofthisagecategorywere

95 completed by the caregivers, which may influence the

96 outcomescomparedwitholderchildrenwhocompletedthe

97 POSASpatientscoresontheirown.Thestudylocationatthree

98 monthspost-burnwasdefinedasthemostapparentpartof

99 the scar according to the patient. Standard treatment

100 consisted ofsilicones or pressure garments depending on

101 the location and scar activity. If there was a significant

102 functional impairment during ADL, then there was an

103 indicationofreconstructionsurgeryduringthefirst12months

104 post-burn. After 12 months post-burn, an operation was

105 indicated for both functional impairment and esthetical

106 reasons.

107

2.2. ThePOSAS

108 Tothebestofourknowledge,thereisconflictingdatainthe

109 literatureconcerningtheanalysisofthePOSASpatientscores.

110 VanderWaletal.foundthatthePOSASpatientquestionnaire

111 wasunidimensional.Therefore,theindividualandsumofthe

112 itemsofthePOSASpatientscorescouldbeusedforstatistical

113 analysis[21].Conversely,deJongetal.foundthatthePOSAS

114 patientquestionnairewasmultidimensional.Therefore,the

115 only individual POSAS patients scores could be used for

116 statistical analysis [13]. In this study, we used both the

117 individualandsumofthePOSASpatientscoresforstatistical

118 analysis. Ifthepatientwasunabletoanswerthe

question-119 naire,e.g.inthecaseofchildren<5yearsorinthecaseof

120 mentallyimpairedpatients,thenthecaretakerwasaskedto

121 scoretheitems.

122

2.3. Studymodelandstatisticalanalyses

123 Structuralequationmodelling(SEM)wasperformedusingthe

124 IBMSPSS statisticalpackage AMOSTL₂₄ _[₂₂_]._We _applied_a

125 latent growth curve model (LGM), which was a special

126 applicationoftheSEMwithseveraladvantages.Latentgrowth

127 curvemodellinginAMOSwasabletoaccommodateirregularly

128 spaced measurements at the three time points (3, 6 and

129 12monthspost-burn)inourdata[23].Inaddition,theuseof

130 LGMmadeitpossibletoassessthefitofthemodeltothedata

131 andtoeffectivelycomputethemaximumlikelihoodestimates

132 inourdataset,whichwasnotcompletedatallthreeofthetime

133 points(AppendixB).TheInter-individualdifferencesinthe

134 changesovertimewereassessed,andgroup-levelstatistics

135 such asthe mean change rates and mean interceptswere

136 provided. TheLGM accountsfortheofchange(slopecurve

137 analysis)attheindividuallevel(patient)andatthegrouplevel

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138 _(for_instance,_the_depth_of_the_burn_wound,_sex,_etc.)._The_fit_of 139 _the_LGM_was_tested._The_absolute_and_comparative_fit_indices 140 _were_calculated.

141 _The _following _predictor _variables _were _entered _into _the 142 _models:_sex,_age_<5_years,_age₅_–18_years_and_age_>18_year_s,_the 143 _percentage_of_TBSA,_depth_of_the_wound_and_cause_of_the_burn. 144 _Our_model_was_based_on_our_earlier_study_that_used_the_POSAS 145 _patient_scale_to_study_the_influence_of_{time-invariant}_predictors 146 _(such_as_sex,_the_percentage_of_TBSA,_wound_depth_and_age 147 _categories)_on_the_POSAS_scale_in_the_same_group_of_patients 148 _[₁₆_]._The_three_different_intercept_estimates_represented_the 149 _patients_’_total_scores_at_3,₆_or₁₂_months._The_time_moment_of 150 _the_{intercept was}_dependent_{on how the}_{time values were coded} 151 _(0,_1,_3; _1,_0,₂_or _3, _2,_0)._The_slope_estimates_represented_the 152 _patients_’_rates_of_change_between_3,₆_and₁₂_months_post-burn. 153 _Positive_intercepts_indicated_higher_POSAS_scores_at_3,₆_and 154 ₁₂_months_post-burn,_which_thus_indicated_a_worse_scar_quality 155 _compared_to_that_of_the_reference_group._Significant_negative 156 _slopes_in_the_POSAS_scores_indicated_a_slower_rate_of_change_in 157 _the _presented _predictor _category _compared _to _that _in _the 158 _reference_category_(for_example,_flame_burns_compared_to_the 159 _reference_category_scald_burns).

160 _The_correlations_between_the_intercepts_and_slopes_were 161 _calculated._A_positive_value_indicated_a_high_initial_score_at 162 ₃_months_post-burn_with_a_greater_rate_of_change,_whereas_a 163 _negative_correlation_indicated_a_high_initial_score_at₃_months 164 _post-burn_with_a_lower_rate_of_change.

165 _The_LGM_was_investigated_in_a_model_for_the_total_score_and 166 _was_individually_investigated_in_a_model_for_the_six_items_that 167 _were_incorporated_in _the_POSAS_patient_scale,_both_with_and 168 _without_predictors._The_intercept_estimate_can_be_interpreted_as 169 _the_influence_of_the_predictors_on_the_POSAS_patient_scores_at_3, 170 ₆_and ₁₂ _months _post-burn. _The _positive_intercepts _implied 171 _higher_POSAS_scores_compared_to_the_reference_category._The 172 _slope _estimate _can _be _interpreted _as _the _influence _of _the 173 _predictors_on_the_changes_in_the_POSAS_scores_over_time._Positive 174 _slopes_indicate_higher_degree_of_change_over_time_compared_to 175 _the_reference _category. _An _detailed_description _of _the _study 176 _model_and_statistical_analyses_can_be_found_in_Appendix_D.

177

_3.

_Results

178 _3.1. _Baseline_{characteristics}

179 _A_total_of₂₈₄_children_and₁₉₀_adult_patients_were_included_in_this 180 _study._The_patients_’_{characteristics}_are_shown_in_Table₁_._There 181 _were_no _{statistically}_significant_differences _in _the _total_TBSA 182 _(p₌_0.99,_independent_t-test),_{full-thickness}_burns_(p₌_0.30, inde-183 _pendent_t-test),_or_surgeries_on_the_evaluated_scars_(p₌_0.53, chi-184 _square_test)_that_were_observed_between_the_groups_of_patients 185 _who_completed_all_three_evaluations_(n₌₁₅₇₎_and_the_patients 186 _who_completed_one_or_two_of_the_evaluations_moments_(n₌_317).

187 _3.2. _The_fit_indices_for_the_different_models

188 _The _fit _indices _for _the _different _models _are _presented _in 189 _Appendix_B_._The_fit_indices_for_the_model_with_the_total_score 190 _and _the _six_predictors ₍_A_ppendix _A₎_revealed _the _following 191 _results: _The _minimum _discrepancy _(CMIN) _was _6.751 _with

192 7degrees of freedom (df)and ap-valueof 0.455. Thecomparative

193 fit index (CFI) was 1.00. The root mean square error of

194 approximation(RMSEA)was0.0001withaconfidenceinterval

195 of0.0001–0.055.Thesevaluesofthefitindicesagreewitha

good-196 to-perfect fitwiththetotal scoreandthe sixpredictors.Allofthe

197 modelsthatevaluatedthesixindividualitemshadaperfectfit.

198 Themodelwiththetotalscorewithoutthesixpredictorshada

199 moderatefit,andthemodelswiththeitemsofthicknessor

200 reliefandwithoutthesixpredictorshadapoorfit.

201

3.3. PatternsofchangeinthePOSASpatientscores

202 Theparameterestimatesfortheinterceptandslopesofthe

203 modelthatevaluatedtheseparatetotalPOSASpatientscale

204 scoresandtheseparate6itemswithoutthe6predictorsare

205 showninTable2.TheparameterestimatesforthetotalPOSAS

206 scoresobtainedfromthepredictormodelsarepresentedin

207

Table2andAppendixA.Painhadthelowestseparateintercept 208 score,whichimpliedthatpainhadthelowestitemscoreoutof

209 thesixitemsinthePOSASat3monthspost-burn.Thetotal

210 score and all of the items (except relief) had significant

211 negativeslopes,whichimpliedthattheratesofchangeinthe

212 scoresshowedadecreasingtrend.Thecovariancesbetween

213 thepredictorvariablesofthetotalPOSASpatientscalescors

214 areshowninAppendixC.

215

3.4. Sex

216 MalepatientshadlowertotalPOSASpatientscoresat3,6and

217 12monthspost-burn,withnosignificantdifferenceintherate

Table1–Patientcharacteristics. _Q1 Characteristic <18years 18years

Numberofpatients(%) 284(60) 190(40)

Sex,n(%)

-Male 186(64.5) 103(54.2)

-Female 98(34.5) 87(45.8)

Ageatburn,medianinyears(range) 2.5(0.7–17.8) 43.2(18.6–85.6)

TBSA,median(range)

-Total 7(0.5–76) 7.3(0.5–85) -Fullthickness 1(0.5–75) 3(0.5–60) Causeoftheburn(%)

-Scald 172(60.6) 26(13.7) -(Flash)flame 70(24.6) 115(60.5) -Contact 19(6.7) 15(7.9) -Oil/ fat 20(7.0) 27(14.2) -Chemical 0(0) 6(3.2) -Electricity 3(1.1) 0(0) -Other 0(0) 1(0.5)

Treatmentofevaluatedscar

-Conservativetreatment,n(%) 86(30.3) 31(16.3)

-Surgery(skingrafting),n(%) 198(69.7) 159(83.7)

Evaluated,n(%)

-At3monthspostburn 224(78.9) 135(71.1)

Totalevaluations,n(%)

-Oneevaluationcompleted 76(26.8) 81(42.6)

-Twoevaluationscompleted 101(35.6) 71(37.4)

-Threeevaluationscompleted 97(34.2) 38(20.0)

TBSA:totalbodysurfacearea.

3

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218 _of_change _when_compared_to_female _patients.(_Table₃₎_The 219 _male_patients_had_lower_pain_scores_at₃_and₆_months post-220 _burn,_with_an_equal_rate_of_change_compared_to_females._Men 221 _tended_to_have_lower_itch_scores_at₃_and₆_months_post-burn. 222 _{Nevertheless,} _the _changes _in _the _scores _over _time _were 223 _comparable.(_Table_4A₎_Male_patients_had_higher_POSAS_scores 224 _for_relief_at₃_and₆_months_post-burn,_with_lower_pliability 225 _scores_at₆_and₁₂_months_post-burn._However,_the_changes_in 226 _the _scores _were _comparable _to _those _observed _in _female 227 _patients_(Table_4B).

228 _3.5_. _Wound_depth

229 _Patients_with_full_thickness_burns_had_higher_POSAS_patient 230 _total_scores_at₃_months_post-burn_and_a_lower_rate_of_change 231 _during_the_first₁₂_months_post-burn_compared_to_patients_with 232 _partial _thickness _burns. _The _total _POSAS _scores _for _full 233 _thickness_and _partial_thickness_burns_showed_no_difference 234 _at₁₂_months_post-burn_(Table_3)._Prur_itus_scores_at₃_months 235 _were_{significantly}_higher_in_patients_with_full_thickness_burns 236 _than_those_in_patients_with_partial_thickness_burns._The_rate_of 237 _change_in_the_pruritus_scores_was_{significantly}_lower_in_patients 238 _with_full_thickness_burns_(Table_4A)._Fina_lly,_patients_with_full 239 _thickness _burns _had _{significantly} _higher _POSAS _scores _for 240 _pliability,_thickness_and _relief_at₃_and ₆_months_post-burn 241 _compared_with_patients_with_partial_thickness_burns_(Table_4B).

242 ₃_.6. _Age

243 _There_was_no_significant_difference_in_the_total_POSAS_scores 244 _between_younger_patients _or_patients _who _were_older_than

245 5years.However,patientswhowereyoungerthan5yearshad

246 significantlylowerpruritusscoresat12monthspost-burnand

247 lowerratesofchangecomparedtoolderpatients.(Table4A)

248 Patientsagedbelow5yearshadhigherscarcolor,pliabilityand

249 thicknessscoresat3and6monthspost-burn,whilepatients

250 olderthan18yearshadahigherscarcolorscoresat12months

251 post-burn anda greaterchangeinscoresthanthe younger

252 patients(Table4B).Patientsolderthan18yearshadhigherpain

253 scoresat3,6and12monthspost-burnthanyoungerpatients,

254 butgroupsofpatientshadequalratesofchange.(Table4A)

255

3.7. AetiologyandpercentageofTBSA

256 The covariancesbetweenthe predictor variablesof thetotal Q7

257 POSASpatientscoreareshowninAppendixAandAppendixC.

258 NoeffectsofthepercentageofTBSAorcauseofburnwerefound

259 onthetotalPOSASpatientscale.(Table3)Patientswithflame

260 burnsgenerallyhadsignificantlyhighercolorscoresat3and

261 6monthspost-burn.(Table4A)Patientswithahigherpercentage

262 ofTBSAhadhigherPOSASscoreforreliefat3and6months

post-263 burn.(Table 4B) Pruritus scores at 6 and 12 months post-burn were

264 higherinpatientswithahigherpercentageofTBSAvalues.

265

4. Discussion

266 Thechange inthe POSASpatient scalescores wasstudied

267 between 3 and 6 months post-burn and between 6 and

268 12monthspost-burn.ThePOSASpatienttotalscoreandallof

269 the itemscoresshowedastatisticallysignificantdeclinein

270 thesetwotimeperiods,exceptforthereliefitem.Thegreatest Table2–Estimatesoftheintercepts,slopesandcovariancesbetweeninterceptsandslopesofthetotalscoresanditemspain, pruritus,color,pliability,thicknessandreliefwithoutpredictors.

POSASpatientscale Intercept Slope Covariances

Estimate SE CR P Estimate SE CR p Estimate SE CR p

Totalscore 3months 29.18 0.55 53.25 <0.001 2.02 0.25 8.25 <0.001 2.86 4.56 0.63 0.531

6months 27.16 0.47 57.75 <0.001 1.13 2.94 0.38 0.701 12months 23.12 0.65 35.60 <0.001 2.34 8.83 0.26 0.791 Items: Pain 3months 2.38 0.10 22.45 <0.001 0.17 0.04 4.26 <0.001 0.07 0.14 0.47 0.637 6months 2.21 0.09 25.01 <0.001 0.01 0.09 0.07 0.942 12months 1.87 0.11 16.75 <0.001 0.15 0.27 0.55 0.581 Pruritus 3months 4.54 0.13 33.81 <0.001 0.49 0.06 8.09 <0.001 0.67 0.26 2.55 0.011 6months 4.05 0.11 36.05 <0.001 0.10 0.18 0.54 0.592 12months 3.07 0.15 19.92 <0.001 1.05 0.51 2.06 0.039 Color 3months 6.94 0.11 64.43 <0.001 0.54 0.06 9.56 <0.001 0.52 0.21 2.52 0.012 6months 6.40 0.09 74.02 <0.001 0.17 0.14 1.27 0.204 12months 5.32 0.14 39.26 <0.001 0.52 0.39 1.32 0.187 Pliability 3months 5.79 0.13 44.66 <0.001 0.47 0.07 7.07 <0.001 0.40 0.30 1.37 0.172 6months 5.33 0.11 50.73 <0.001 0.10 0.19 0.52 0.600 12months 4.40 0.16 27.59 <0.001 0.50 0.58 0.87 0.383 Thickness 3months 5.26 0.13 39.84 <0.001 0.31 0.06 5.06 <0.001 0.08 0.28 0.29 0.770 6months 4.96 0.11 43.61 <0.001 0.10 0.18 0.52 0.601 12months 4.34 0.16 26.80 <0.001 0.12 0.57 0.21 0.832 Relief 3months 5.08 0.13 39.10 <0.001 0.09 0.06 1.34 0.179 0.35 0.29 1.19 0.236 6months 5.00 0.11 47.33 <0.001 0.07 0.19 0.37 0.715 12months 4.82 0.16 30.83 <0.001 0.48 0.57 0.85 0.397

SE,standarderror;CR,criticalratio.

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271 _decline_was_observed_during_the_longer_time_period_between 272 ₆_and₁₂_months_post-burn._The_pain_item_scale_presented_the 273 _lowest_decline_score,_and_the_color_item_exhibited_the_highest 274 _decline_score. _Therefore,_the _pain_and _color _items_had _the 275 _lowest _and _highest _influences _on _the _total _POSAS _score, 276 _{respectively.} _The _low _pain _scores _could _be _the _result _of 277 _effective_medication_for_pain_and/or_the_result_of_real_low_pain 278 _values_in_patients_after₃_months_post-burn._The_high_color 279 _values _represent _the _importance _of _color _for _the _patient 280 _assessment_of_his_or_her_scars._Patients_with_the_highest_total 281 _and_item_scores_presented_the_lowest_changes_during_the₃_and 282 ₆_months_post-burn,_thus_leading_to_the_lowest_decline_in_the 283 _total_score.

284 _In_our_study,_a_strong_effect_of_sex_was_observed_on_the_total 285 _POSAS_patient_score._Male_patients_had_a_better_scar_quality, 286 _which_was_caused_by_lower_score_of_pruritus_and_pain,_as_well 287 _as_a_better_score_for_pliability_and_relief_compared_to_the_scar 288 _quality_in_female_patients._Various_studies_have_demonstrated 289 _higher_pain-related_symptoms_in_women_compared_with_men 290 _[₂₆_–28_]._Sex_role_beliefs,_pain_coping_strategies,_pain-related 291 _expectations_and_even_hormonal_factors_may_possibly_explain 292 _the_difference_in_pain_experience_between_males_and_females 293 _[₂₉_]._In_line_with_our_study,_two_studies_observed_higher_itch 294 _intensity_scores_in_women_compared_to_men,_although_this 295 _phenomenon_is_not_well_understood_[₁₀_,₃₀_]._Higher_pliability

296 and relief scores in the female group in our study could

297 possibly be explained by the differences in body images

298 betweenmalesandfemales.Ingeneral,womenhaveamore

299 negative body imagecompared to men[31–33].Dyer et al.

300 observedthatwomenwithscarsthatresultedfromaccidents

301 orsurgeriesreportedamorenegativebodyimage[33].

302 PatientswithfullthicknessburnshadhighertotalPOSAS

303 scores,whichwerecausedbyhigherscoresforthepruritus,

304 pliability,thicknessandreliefitems.Otherstudieshavealso

305 described higheritchingscoresforfullthicknessburnsand

306 graftedwounds[10,30,34].Anincreaseinbothmediatorsand

307 neuronal damage are thought to contribute to pruritus

308 symptomsinfullthicknessburns[35].Inourstudy,pruritus

309 diminishedafter3monthspost-burn;afindingthathasbeen

310 previously describedinother studies[10,16]. HigherPOSAS

311 scoresforpliability,thicknessandreliefareexplainedbythe

312 lossofepidermalanddermalstructures.

313 Previousstudieshavefoundthattheageofthepatientdoes

314 notinfluencescarbehavior[6,16,36].Ourresultsareconsistent

315 withthesereportswhenconsideringthetotalPOSASscore.

316 However, thisisnotthecasewhenlookingattheseparate

317 items.Patientswhowereagedbelow5yearshadsignificantly

318 higher scores for color, pliability and thickness at 3 and

319 6monthspost-burn,andthesepatientsalsohadsignificantly

320 lesspruritusat12monthspost-burn.Thefactthatcaretakers Table3–Regressionweightsandp-valuesofthePOSASpatientscoresandthepredictorsTBSA,burndepth,agecategory, Q2 sexandcauseofburn.

POSASpatientscaletotalscore Estimate SE CR p

Predictors

Sex:male Interceptat3months 3.327 1.138 2.922 0.003

Interceptat6months 3.204 0.973 3.292 <0.001

Interceptat12months 2.959 1.332 2.222 0.026

Slope 0.122 0.504 0.243 0.808

Depth:fullthickness Interceptat3months 3.543 1.283 2.762 0.006

Slope 1.546 0.568 2.722 0.006

Age<5years Interceptat3months 3.130 1.664 1.881 0.060

Slope 1.458 0.735 1.984 0.047

Age>18years Interceptat3months 0.649 1.443 0.450 0.653

Slope 0.580 0.639 0.907 0.364

Cause:flameburns Interceptat3months 1.006 1.490 0.675 0.499

Slope 0.166 0.651 0.255 0.799

TBSA Interceptat3months 0.024 0.044 0.552 0.581

Slope 0.017 0.019 0.893 0.372

SE,standarderror;CR,criticalratio.Referencecategorieswerefemalesex,partialthicknessburns,age5–18years,scaldburns.TBSAwasa

continuousvariableinthemodel.

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321 _completed_the_{questionnaires}_for_the_patients_under₅_years 322 _old_may_have_contributed_to_the_differences_in_the_outcomes 323 _between _the_age _groups. _We _did _not_find_any _studies_that 324 _reported_the_influence_of_age_on_color_change_in_burn_scars. 325 _Furthermore,_it_should_be_noted_that_different_studies_have 326 _described_a_negative_association_between_age_and hypertro-327 _phic _scar _formation _[₃₇_]. _This _finding _is _supported _by _the 328 _decreased _{proliferation,} _{reepithelization} _and _inflammatory 329 _responses_that_are_observed_during_wound_healing,_as_well_as 330 _the_slower_epidermal_turnover_and_the_different_remodeling 331 _phase_that_are_observed_in_aged_individuals_[₇_,₃₇_,₃₈_]._However, 332 _the _present _study _did _not _investigate _hypertrophic _scar 333 _formation. _Finally, _patients _who _were _above ₁₈ _years _had 334 _higher_pain_scores_at_3,₆_and₁₂_months_post-burn_compared 335 _to_patients_who_were_below₁₈_years.

336 _The_percentage_of_TBSA_was_a_predictor_for_the_pruritus, 337 _thickness_and_relief_item_scores._The_effect_of_the_percentage 338 _of _TBSA _on _pruritus _has _been _well _described _in _various 339 _studies._However,_there_are_conflicting_data_on_the_effect_of 340 _the_percentage_of_TBSA_on_the_duration_of_pruritus._Van_Loey 341 _et_al._described_a_higher_TBSA_to_be_a_risk_factor_for_pruritus_at 342 ₃ _months _post-burn_[₁₀_]. _The _scar _tissue _modulation _and 343 _nerve _density_which_are_thought _to_be_highest_in _the_first 344 ₆_months_post-burn_could _explain_this_effect._However, _in 345 _line_with_other_studies,_we_found_the_effect_of_the_percentage

346 ofTBSAtobesignificantevenat12monthspost-burn[30,39].

347 Furthermore, the effect of full thickness burns and the

348 percentageofTBSAonitchingisdifferentthantheeffectof

349 fullthicknessburnsonpain.Painscoreswereobservedtobe

350 thelowestofallthescoreditemsonthePOSASpatientscale.

351 Thiscouldbecausedbyadifferentmechanismorbyabetter

352 treatmentforpain.

353 Scaldinjuriesaremoreoftenobservedinpatientswhoare

354 under5years,whereasfire/flameburnsareobservedmore

355 ofteninolderpatients.Additionally,moremalesthanfemales

356 areadmittedtoburncentres.Fullthicknessburnsandburns

357 withahigherpercentageofTBSAtendtooccurmoreoftenin

358 patientswhoareolderthan18years.Flameburnsaremore

359 oftendeepdermalorfull-thicknessburns.Overall,ourdataare

360 corroborated by the findings of various epidemiological

361 studies[19,40].

362 Our studyhad several limitations.First, the age-related

363 findings ofthepatients whowereunder5yearsshouldbe

364 interpretedwithcaution,giventhatthecaregiverscompleted

365 the questionnaires.Second,nosamplesizecalculationwas

366 performed,giventhelargenumberofincludedpatientsand

367 giventhatthedatawereretrospectivelycollected.However,a

368 samplesizecalculationcouldstillberelevant,basedonthe

369 amountofmissingdata.Third,theextentoftheinfluenceof

370 theexcludedpatientsontheresultsofthecurrentstudyis Table4A–Regressionweightsandp-valuesoftheitemspain,pruritusandcolorofthePOSASpatientscalefromthe predictorsTBSA,burndepth,agecategory,sexandcauseofburn.

ItemsPOSASpatientscale Pain Pruritus Color

Predictors Estimate p Estimate p Estimate p

Sex:male Intercept3months 0.730 <0.001 0.676 0.015 0.181 0.419

Intercept6months 0.598 <0.001 0.614 0.009 0.039 0.830

Intercept12months 0.335 0.124 0.489 0.118 0.246 0.375

Slope 0.132 0.117 0.062 0.611 0.143 0.217

Depth:fullthickness Intercept3months 0.125 0.572 0.756 0.016 0.249 0.324

Slope 0.035 0.708 0.383 0.005 0.150 0.250

Age<5years Intercept3months 0.070 0.807 0.069 0.866 1.031 0.002

Slope 0.000 0.997 0.384 0.031 0.371 0.027

Age>18years Intercept3months 1.282 <0.001 0.480 0.175 0.008 0.978

Slope 0.049 0.648 0.169 0.275 0.352 0.016

Cause:flameburns Intercept3months 0.303 0.240 0.065 0.858 0.951 0.001

Slope 0.010 0.926 0.038 0.810 0.424 0.004

TBSA Intercept3months 0.001 0.854 0.020 0.067 0.001 0.900

Slope 0.000 0.948 0.003 0.506 0.004 0.405

Referencecategorieswerefemalesex,partialthicknessburns,age5–18years,scaldburns.TBSAwasacontinuousvariableinthemodel.

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371 _unknown, _because _no _data _of_the _excluded _patients _were 372 _recorded._Fourth,_there_are_conflicting_data_on_whether_the 373 _POSAS_score_is_a_{unidimensional}_instrument._Therefore,_the 374 _scores_of_the_individual_items_could_be_summed_into_a_total 375 _score_[₁₃_,₂₁_]. _In_theory,_the _POSAS_patient_{questionnaire}_is 376 _based_on_a_formative_model_in_which_the_individual_items_of 377 _the _POSAS _patient _score _are _causal _indicators _of _the _scar 378 _quality._A_formative_{questionnaire}_could_consist_of_more_than 379 _one_dimension._Thus_the_individual_items_could_be_summed_to 380 _a_final_score,_for_example_as_is_done_for_the_Apgar_score._Finally, 381 _the_included_study_predictors_were_obtained_from_the_available 382 _literature,_whereas_no_systematic_search_was_performed._As_a 383 _result,_there_may_be_predictors_that_are_not_included_in_the 384 _current_study,_which_may_be_relevant_in_the_context_of_changes 385 _in_the_POSAS_scores_at_3,₆_and₁₂_months_post-burn.

386

_5.

_Conclusion

387 _This _{retrospective} _study, _the _POSAS _patient _total _and 388 _individual_item_scores_demonstrated_a_{statistically}_significant 389 _improvement_in_the_first₁₂_months_post-burn,_except_for_the 390 _relief _item. _Furthermore, _sex, _age, _depth _of _the _wound, 391 _percentage _of _TBSA _and _flame _burns _were _predictors _of

392 variousPOSASpatientitemsat3,6and12monthspost-burn.

393 However,theeffectofthesepredictorswasnotthesamefor

394 theindividualPOSASpatientitems.

395

Source

of

funding

396 Thisworkwasconductedwithoutexternalfinancialsupport.

397

Conflict

of

interest

398 Noneoftheauthorshaveanypotentialconflictsofinterestto

399 disclose. 400

Uncited

re

ferences

401 [24,25]. 402

Acknowledgements

403 None.

Table4B–Regressionweightsandp-valuesoftheitemspliability,thicknessandreliefofthePOSASpatientscalefromthe predictorsTBSA,burndepth,agecategory,sexandcauseofburn.

ItemsPOSASpatientscale Pliability Thickness Relief

Predictors Estimate p Estimate p Estimate p

Sex:male Intercept3months 0.393 0.138 0.136 0.617 0.520 0.051

Slope 0.151 0.262 0.134 0.294 0.085 0.528

Depth:fullthickness Intercept3months 1.151 <0.001 0.797 0.009 1.076 <0.001

Intercept6months 0.682 0.005 0.463 0.080 0.863 <0.001

Slope 0.468 0.002 0.334 0.020 0.213 0.162

Age<5years Intercept3months 1.333 <0.001 0.953 0.016 0.574 0.141

Slope 0.533 0.007 0.167 0.369 0.122 0.536

Age>18years Intercept3months 0.492 0.143 0.026 0.940 0.031 0.928

Slope 0.185 0.280 0.007 0.964 0.178 0.299

Cause:flameburns Intercept3months 0.277 0.425 0.514 0.147 0.025 0.942

Slope 0.041 0.813 0.212 0.196 0.127 0.465

TBSA Intercept3months 0.004 0.667 0.021 0.042 0.026 0.010

Slope 0.001 0.827 0.006 0.212 0.003 0.517

Referencecategorieswerefemalesex,partialthicknessburns,age5–18years,scaldburns.TBSAwasacontinuousvariableinthemodel.

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404

_Appendix

_A.

_{Supplementary}

_data

405 _{Supplementary} _material _related _to _this _article _can _be 406 _found,_in_the_online_version,_at_doi:_{https://doi.org/10.1016/j.} 407 _{burns.2019.03.025}_.

408

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