The effectiveness of moisturizers for the management of burn scars following severe burn injury: a systematic review protocol
Authors: Klotz Tanja , Kurmis Rochelle , Munn Zachary , Heath Kathryn , Greenwood John 
Published: December 2014

Review question/objective
The objective of this review is to identify and synthesize the best available evidence on the effectiveness of moisturizer use for the management of burn scars following severe burn injury.
More specifically, the review will focus on the following question(s): What are the recommended types of moisturizers used on scar formation in patients who have sustained a burn injury?
What is the effectiveness of moisturizer use on scar outcomes, including formation, breakdown, patient acceptance and water loss, following severe burn injury?

Background
The common mantra that patients often leave a burns unit with is "moisturize and massage". The modality of scar massage is well-recognized as an important part of burn scar management.1 Following the maturation of scar tissue after a burn injury, massage is commenced as part of the standard care offered to victims of burn injury. The premise behind massage is that it maintains joint mobility, aids softening and remodelling of scar tissue and improves scar elasticity through loosening adhering fibrous tissue, whilst also assisting with pruritus, a common side effect of healing following burn injury.1 When healing skin has gained sufficient strength to tolerate massage with the use of friction, scar massage is routinely performed with the use of lubricants,1 which commonly consist of skin moisturizers. Although existing literature provides guidance on the use of products that are fragrance free and free from other skin irritants,1 little is known in regards to recommendations on the ideal composition of moisturizers for optimal scar management. Products used should not have a negative effect on skin/scar integrity, such as breakdown of the skin. Various products have been reported for use in practice as well as in literature on scar management, include aqueous cream BP, bees wax and herbal oil creams,2 silicone based creams and paraffin/petroleum based products.
Aqueous cream BP is a readily available and relatively cheap emollient that is fragrance and color free. Its formulation consists of purified water, white soft paraffin, cetearyl alcohol and sodium lauryl sulfate (SLS), liquid paraffin, and phenoxyethanol. Previously reported as the "standard treatment" for moisturization and massage in some burns units,2 aqueous Cream BP contains SLS, which has been documented as a known skin irritant.3-6 The application of aqueous cream BP in subjects with healthy skin, following the removal of increasing amounts of their stratum corneum, has also been shown to increase transepidermal water loss (TEWL) and disrupt the normal skin maturation process.7 Chronic application of aqueous cream BP was also shown in this study to increase the rate of skin turnover as well as contribute to thinning of the stratum corneum.7

This is of particular concern in burn injury as scar tissue has been shown to have increased TEWL when compared with healthy skin,8. In contrast, a comparison study between aqueous cream BP and bees wax and herbal oil cream indicated that newly healed skin in the bees wax and herbal oil group "appeared supple and moist" when compared to the aqueous BP group. Healing skin in the latter group was reported as appearing dry in contrast.2 Although the study had a small sample size, it did demonstrate that bees wax and herbal oil cream provided a greater reduction in the symptom of itch following burn injury along with a decreased use of antipruritic medications when compared to aqueous cream BP.2 The aim of this study was to compare the effectiveness of both preparations in the management of post burn itch.
Anecdotal reports of alternate formulations, including silicone and petroleum based products (such as Vaseline), being used by burns units around the world are often reported at burns symposiums and forums, with their selection appearing to be based on historical practice, clinician preference, patient tolerance or beliefs in herbal medicine. Pressure garment manufacturers often also recommend the avoidance of petroleum based emollients where pressure garments are worn as they may reduce the elasticity of the pressure garment, in turn reducing its effectiveness and the life of the garment. No review on the optimal lubricant for burn scar management has been identified to date via searches of the Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports and PubMed database, so this review aims to elucidate the best available evidence on the choice of moisturizer in the management of burn scars.