ORIGINAL ARTICLE
Pediatric Scalp Burns: Hair Today, Gone Tomorrow? Seema Menon, MB, BCh, BAO,*† Madeleine Jacques, RN,† John G. Harvey, FRCS, FRACS,*† Andrew J. A. Holland, PhD, FRACS, FACS*†
Scalp burns in the pediatric population appear relatively uncommon, with most reported cases occurring in adults secondary to electrical burns. We reviewed our experience with the management of these injuries in children. A retrospective review was conducted at our institution from March 2004 to July 2011. Scalp burns were defined as any burn crossing over the hairline into the scalp region. During the 7-year 4-month study, there were 107 scalp burns, representing 1.8% of the 6074 burns treated at our institution during that time. The cause was scald in 97, contact in 4, flame in 3, friction in 2, and chemical in 1. The majority (n = 93, 87%) appeared superficial to mid-dermal, with an average time to complete healing of 10.3 days. The remaining 14 cases (13%) were mid-dermal to full thickness, with an average time to complete healing of 50.8 days. Grafting was required in 12 cases (11%). The mean time to grafting was 4 weeks (range, 2 weeks to 2.5 months). The main complication of scalp burns was alopecia, which occurred in all grafted sites as well as in 4 patients treated conservatively. There were no other complications after grafting and no cases of graft loss. In our pediatric series, scalp burns were most commonly caused by scald injuries and were superficial to mid-dermal in depth. These generally healed rapidly but occasionally resulted in alopecia. The management of deep dermal and full-thickness scalp burns remains challenging in children, with the decision to graft often delayed. (J Burn Care Res 2015;36:e18–e22)
Scalp burns, especially those isolated to the scalp, generally appear uncommon. In adults, flame, electrical, and chemical burns have all been reported and can be deep dermal to full thickness.1–4 Alopecia remains a known complication of partial and full-thickness burns and can present a considerable management challenge.5,6 The resultant cosmetic disfigurement often results in psychological and emotional difficulties, with patients subsequently requiring reconstructive surgery.6,7 Scalp burns in children have only been infrequently reported in the literature, although the classical pediatric scald burn from tipping over a hot cup From the *Children’s Hospital at Westmead Burns Research Institute and the †Burns Unit, Douglas Cohen Department of Paediatric Surgery, Sydney Medical School, The University of Sydney, New South Wales, Australia. Presented at the meeting of the Australian and New Zealand Burn Association, Brisbane, Australia, October 2011. Address correspondence to Andrew J. A. Holland, PhD, FRACS, FACS, Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, The University of Sydney, Locked bag 4001, Westmead, NSW 2145, Australia. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000071
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of coffee or tea may extend into the scalp. The cause of scalp burns in children seems to be likely different than that reported in adults, with a predominance of scald burns.1–4,8 Historically, at our institution, scalp burns have been managed conservatively. This has been based on the premise that the thickness of the scalp and presence of densely packed hair follicles and sebaceous glands lined with keratinocytes will migrate to reepithelize the burnt surface more effectively than in non–hair-bearing areas.9 Early studies have noted that hair-bearing areas tend to heal more rapidly than non–hair-bearing areas, and recent studies have confirmed that hair follicle bulge cells, as well as nonbulge follicular keratinocytes from the isthmus and infundibulum, contribute to reepithelialization of the epidermis.9,10 Following experience with several cases associated with prolonged healing and subsequent alopecia, at our institution we sought to review the experience with the management of scalp burns with the aim of creating an algorithm that could be used as a guide in the treatment of these uncommon but complicated burns.
Journal of Burn Care & Research Volume 36, Number 2
METHODS Study Design and Setting A retrospective case-note review was performed of all patients who sustained scalp burns at our institution between March 2004 and July 2011. The Burns Unit (BU) at The Children’s Hospital at Westmead is the only pediatric burns referral center in New South Wales and the Australian Capital Territory, serving a combined population of approximately 7.6 million. Our BU represents the pediatric arm of the New South Wales Statewide Burn Injury Service and accepts patients up to 16 years of age. The study was approved by the ethics committee of our institution.
Medical Record Review and Data Collection The study included all patients who had sustained a burn involving the scalp, defined as any burn crossing over the hairline into the scalp region. Data collected included patient details, mechanism, percentage TBSA, depth, management, complications, and length of follow-up. Burn depth was assessed by the treating burn clinician, supplemented in selected cases with the results of laser Doppler imaging. Use of laser Doppler imaging was limited in this study by the strict requirement of our institution’s Laser Safety Committee to ensure that the patient’s eyes were protected with laser safety goggles while scanning the head and neck region.11 Scalp burns were generally shaved at the time of initial presentation but not subsequently unless there were signs of infection or at the time of surgery when the area was deemed to require grafting. All wounds were routinely cultured on admission and subsequently during all dressing changes or at the time of any operative intervention. Minor areas of granulation tissue were treated with topical silver nitrate at the time of dressing changes.
Menon et al e19
location of the scalp burn was not clinically associated with differences in subsequent healing. Of the 107 scalp burns in the series, 12 (11%) patients ultimately required surgical intervention (11 split skin grafts and one primary excision). Three patients were grafted before 3 weeks, with a mean grafting time of 16.3 days and a mean healing time of 29.6 days. The remaining nine patients failed initial conservative treatment and were grafted late (all greater than 3 weeks): the mean grafting time was 48.1 days, with a prolonged mean healing duration of 84.6 days. In these nine patients, three patients were complicated by granulation tissue formation (Figure 1A) and the other six patients had areas of recurrent crusting and breakdown (Figure 1B), which ultimately led to delayed grafting. After skin graft, only one patient required regrafting for graft loss Overall, 93 (87%) burns were superficial to mid-dermal, with an average time to complete healing of 10.3 days. Three underwent early grafting and 90 of these were treated conservatively, with four developing alopecia at the burn site and two patients
RESULTS During the 7-year 4-month study period, there were 6074 children with burns referred to our BU. Of these, 107 (1.8%) were identified with burns involving the scalp, of which 11 were isolated scalp injuries. The average age of patients was 2.6 years (range, 4 months to 16 years), with the majority (n = 81, 76%) from metropolitan areas. Scald burns predominated, accounting for 97 (91%), with 4 contact, 3 flame, 2 friction, and 1 chemical. The average TBSA was 2.6% (range, 0.5–9%), and the mean time to complete healing was 16.2 days (range, 3–129 days). The frontal region was involved in 71 (66%) cases, parietal in 39 (36%), temporal in 54 (50%), and occipital in 8 (7%). The
Figure 1. Scalp granulation tissue (A) and crusting (B).
e20 Menon et al
complicated by crusting and infection with Staphylococcus aureus. In the 95 patients who were conservatively treated, 89 healed within 3 weeks, of which one patient was complicated by alopecia and three patients had pigmentation changes. The remaining six (three of which were mid-dermal to full thickness) took greater than 3 weeks to heal. Of these patients, three had alopecia, two had wound infections/breakdown (with S. aureus), and one patient and their family refused grafting. The mean time to complete healing in all of these patients was 37 days. Fourteen (13%) patients had mid-dermal to full-thickness scalp burns, with an average time to complete healing of 50.8 days. One of these underwent a primary closure; eight required split skin grafts and five were treated conservatively (of these, three took greater than 21 days to heal). Of those patients requiring grafting, all had alopecia: five subsequently required tissue expanders for the management of their hair loss. Hypertrophic scarring of the scalp was not documented in any of our patients nor were there clinically obvious cases of folliculitis. The average length of stay was 6.2 days (range, 0–102 days). The 41 patients with scalp burns that healed within 2 weeks did not require subsequent clinical review. Follow-up was required in 66 cases, with an average length of follow-up of 8.2 months (range, 1 month to 5 years).
DISCUSSION This study found that scalp burns remain uncommon in children, accounting for less than 2% of all children referred to our BU. Although uncommon, this would appear more frequent than scalp burns in adults, in whom deep electrical burns predominate, whether related to occupation or misadventure, with a reported incidence of 0.95%.3 Scalds accounted for the great majority (88%) of burns in our patients, of which 89% healed without operative intervention. In our series, the mid-dermal to full-thickness burns that were conservatively managed resulted in prolonged treatment times, multiple admissions, and scalp infections with granulation tissue. The initial management of all scalp burns should be appropriate resuscitation, noting that the scalp can compose up to 18% TBSA in a child
Pediatric Scalp Burns: Hair Today, Gone Tomorrow? Seema Menon, MB, BCh, BAO,*† Madeleine Jacques, RN,† John G. Harvey, FRCS, FRACS,*† Andrew J. A. Holland, PhD, FRACS, FACS*†
Scalp burns in the pediatric population appear relatively uncommon, with most reported cases occurring in adults secondary to electrical burns. We reviewed our experience with the management of these injuries in children. A retrospective review was conducted at our institution from March 2004 to July 2011. Scalp burns were defined as any burn crossing over the hairline into the scalp region. During the 7-year 4-month study, there were 107 scalp burns, representing 1.8% of the 6074 burns treated at our institution during that time. The cause was scald in 97, contact in 4, flame in 3, friction in 2, and chemical in 1. The majority (n = 93, 87%) appeared superficial to mid-dermal, with an average time to complete healing of 10.3 days. The remaining 14 cases (13%) were mid-dermal to full thickness, with an average time to complete healing of 50.8 days. Grafting was required in 12 cases (11%). The mean time to grafting was 4 weeks (range, 2 weeks to 2.5 months). The main complication of scalp burns was alopecia, which occurred in all grafted sites as well as in 4 patients treated conservatively. There were no other complications after grafting and no cases of graft loss. In our pediatric series, scalp burns were most commonly caused by scald injuries and were superficial to mid-dermal in depth. These generally healed rapidly but occasionally resulted in alopecia. The management of deep dermal and full-thickness scalp burns remains challenging in children, with the decision to graft often delayed. (J Burn Care Res 2015;36:e18–e22)
Scalp burns, especially those isolated to the scalp, generally appear uncommon. In adults, flame, electrical, and chemical burns have all been reported and can be deep dermal to full thickness.1–4 Alopecia remains a known complication of partial and full-thickness burns and can present a considerable management challenge.5,6 The resultant cosmetic disfigurement often results in psychological and emotional difficulties, with patients subsequently requiring reconstructive surgery.6,7 Scalp burns in children have only been infrequently reported in the literature, although the classical pediatric scald burn from tipping over a hot cup From the *Children’s Hospital at Westmead Burns Research Institute and the †Burns Unit, Douglas Cohen Department of Paediatric Surgery, Sydney Medical School, The University of Sydney, New South Wales, Australia. Presented at the meeting of the Australian and New Zealand Burn Association, Brisbane, Australia, October 2011. Address correspondence to Andrew J. A. Holland, PhD, FRACS, FACS, Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, The University of Sydney, Locked bag 4001, Westmead, NSW 2145, Australia. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000071
e18
of coffee or tea may extend into the scalp. The cause of scalp burns in children seems to be likely different than that reported in adults, with a predominance of scald burns.1–4,8 Historically, at our institution, scalp burns have been managed conservatively. This has been based on the premise that the thickness of the scalp and presence of densely packed hair follicles and sebaceous glands lined with keratinocytes will migrate to reepithelize the burnt surface more effectively than in non–hair-bearing areas.9 Early studies have noted that hair-bearing areas tend to heal more rapidly than non–hair-bearing areas, and recent studies have confirmed that hair follicle bulge cells, as well as nonbulge follicular keratinocytes from the isthmus and infundibulum, contribute to reepithelialization of the epidermis.9,10 Following experience with several cases associated with prolonged healing and subsequent alopecia, at our institution we sought to review the experience with the management of scalp burns with the aim of creating an algorithm that could be used as a guide in the treatment of these uncommon but complicated burns.
Journal of Burn Care & Research Volume 36, Number 2
METHODS Study Design and Setting A retrospective case-note review was performed of all patients who sustained scalp burns at our institution between March 2004 and July 2011. The Burns Unit (BU) at The Children’s Hospital at Westmead is the only pediatric burns referral center in New South Wales and the Australian Capital Territory, serving a combined population of approximately 7.6 million. Our BU represents the pediatric arm of the New South Wales Statewide Burn Injury Service and accepts patients up to 16 years of age. The study was approved by the ethics committee of our institution.
Medical Record Review and Data Collection The study included all patients who had sustained a burn involving the scalp, defined as any burn crossing over the hairline into the scalp region. Data collected included patient details, mechanism, percentage TBSA, depth, management, complications, and length of follow-up. Burn depth was assessed by the treating burn clinician, supplemented in selected cases with the results of laser Doppler imaging. Use of laser Doppler imaging was limited in this study by the strict requirement of our institution’s Laser Safety Committee to ensure that the patient’s eyes were protected with laser safety goggles while scanning the head and neck region.11 Scalp burns were generally shaved at the time of initial presentation but not subsequently unless there were signs of infection or at the time of surgery when the area was deemed to require grafting. All wounds were routinely cultured on admission and subsequently during all dressing changes or at the time of any operative intervention. Minor areas of granulation tissue were treated with topical silver nitrate at the time of dressing changes.
Menon et al e19
location of the scalp burn was not clinically associated with differences in subsequent healing. Of the 107 scalp burns in the series, 12 (11%) patients ultimately required surgical intervention (11 split skin grafts and one primary excision). Three patients were grafted before 3 weeks, with a mean grafting time of 16.3 days and a mean healing time of 29.6 days. The remaining nine patients failed initial conservative treatment and were grafted late (all greater than 3 weeks): the mean grafting time was 48.1 days, with a prolonged mean healing duration of 84.6 days. In these nine patients, three patients were complicated by granulation tissue formation (Figure 1A) and the other six patients had areas of recurrent crusting and breakdown (Figure 1B), which ultimately led to delayed grafting. After skin graft, only one patient required regrafting for graft loss Overall, 93 (87%) burns were superficial to mid-dermal, with an average time to complete healing of 10.3 days. Three underwent early grafting and 90 of these were treated conservatively, with four developing alopecia at the burn site and two patients
RESULTS During the 7-year 4-month study period, there were 6074 children with burns referred to our BU. Of these, 107 (1.8%) were identified with burns involving the scalp, of which 11 were isolated scalp injuries. The average age of patients was 2.6 years (range, 4 months to 16 years), with the majority (n = 81, 76%) from metropolitan areas. Scald burns predominated, accounting for 97 (91%), with 4 contact, 3 flame, 2 friction, and 1 chemical. The average TBSA was 2.6% (range, 0.5–9%), and the mean time to complete healing was 16.2 days (range, 3–129 days). The frontal region was involved in 71 (66%) cases, parietal in 39 (36%), temporal in 54 (50%), and occipital in 8 (7%). The
Figure 1. Scalp granulation tissue (A) and crusting (B).
e20 Menon et al
complicated by crusting and infection with Staphylococcus aureus. In the 95 patients who were conservatively treated, 89 healed within 3 weeks, of which one patient was complicated by alopecia and three patients had pigmentation changes. The remaining six (three of which were mid-dermal to full thickness) took greater than 3 weeks to heal. Of these patients, three had alopecia, two had wound infections/breakdown (with S. aureus), and one patient and their family refused grafting. The mean time to complete healing in all of these patients was 37 days. Fourteen (13%) patients had mid-dermal to full-thickness scalp burns, with an average time to complete healing of 50.8 days. One of these underwent a primary closure; eight required split skin grafts and five were treated conservatively (of these, three took greater than 21 days to heal). Of those patients requiring grafting, all had alopecia: five subsequently required tissue expanders for the management of their hair loss. Hypertrophic scarring of the scalp was not documented in any of our patients nor were there clinically obvious cases of folliculitis. The average length of stay was 6.2 days (range, 0–102 days). The 41 patients with scalp burns that healed within 2 weeks did not require subsequent clinical review. Follow-up was required in 66 cases, with an average length of follow-up of 8.2 months (range, 1 month to 5 years).
DISCUSSION This study found that scalp burns remain uncommon in children, accounting for less than 2% of all children referred to our BU. Although uncommon, this would appear more frequent than scalp burns in adults, in whom deep electrical burns predominate, whether related to occupation or misadventure, with a reported incidence of 0.95%.3 Scalds accounted for the great majority (88%) of burns in our patients, of which 89% healed without operative intervention. In our series, the mid-dermal to full-thickness burns that were conservatively managed resulted in prolonged treatment times, multiple admissions, and scalp infections with granulation tissue. The initial management of all scalp burns should be appropriate resuscitation, noting that the scalp can compose up to 18% TBSA in a child
