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Diabetes mellitus (DM) is a disease with an increasing incidence worldwide including the US. It is expected to reach 15/1000 in the United States by the year 2050. Most burns in patients with diabetes are due to contact with hot objects or scalds. Patients with diabetes especially if uncontrolled are usually associated with poorer prognosis with more complicated and longer hospital stay compared to healthy people and need special attention as they will form a large percent of burn center and hospital admission in the future.

Diabetes mellitus is a chronic disease that has many complications, among which is the effect of diabetes on the blood vessels leading to damage, narrowing and/or blockage of the blood vessels, leading to peripheral vascular disease (PVD) that results in the alteration of blood perfusion and subsequent reduction in the oxygen and nutritional delivery to the tissues which will affect wound healing.

Diabetes can also affect the nerves leading to nerve damage (diabetic peripheral neuropathy); nerves affected by the disease are usually responsible for temperature, pressure, texture and pain sensation. The nerves of the lower legs and feet when affected can lead to insensitivity to temperature and pain in the legs and feet and patients may experience numbness and tingling sensation in these areas.

Diabetic patients with neuropathy have an increased risk of burn injuries. These burns may happen from soaking the feet in hot water, heating pads, walking on hot surface, and contact with a warming device such as heaters. Because of the impaired sensation of the feet in these patients, they may sustain a burn injury without being aware of it. These patients have poor wound healing due to the effect of diabetes on the nerves and blood vessels and the increased risk of wound infection in diabetic patients.

Burns in diabetic patients even when they are minor may lead to ulceration of the wound, serious infection and even amputation of the limb. Therefore preventing and early recognition of burns in diabetic patients is very important.


  1. Maintain a proper glucose level.
  2. Test water temperature before going into the bath with a sensitive body part such as the elbow.
  3. Avoid using a contact warming device such as a heater.
  4. Inspect your feet and toes every day for infection, burns, bruises and ulcer.
  5. Avoid walking barefoot even inside the house.
  6. Avoid using heating pads.
  7. Don’t wear tight or loose shoes; wear a well fit shoe with a soft, thick socks.
  8. Contact your doctor if there is an infection, an ulcer or a burn which is not healing well.
  9. Make sure your feet are examined during each doctor’s visit.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Bedsores or bed ulcers are areas of ulcerated or damaged skin that happens when the skin and underlying tissue over a bony prominence is compressed between that bony prominence and an external surface for a prolonged period of time, the unrelieved pressure on the skin and underlying tissue will lead to compression of the blood supply to that area. As a result of the decreased blood supply and oxygen the skin begins to die forming an ulcer. Friction of the skin created by the body sliding over a bed sheet, etc contributes also to the skin injury and the formation of ulcer, too much moister such as sweat and urine may also contribute to the formation of an ulcer. Although pressure ulcers can happen anywhere in the body, the hips, heals and buttocks are common sites.

Risk factors:

  • Persons at a high risk of developing pressure ulcers are those who are immobile due to an injury or an illness such as third  degree burns. Any injury or illness that leads to immobility or causes the patient to be bedridden for a long time will increase the risk of pressure ulcers.
  • Persons who have decreased or absence sensation due an injury or illness are also at risk.
  • Older persons have a higher risk because of their increased incidence of debilitating diseases and the thinning and fragility of their skin.

Clinical features:

Bedsores are classified into four stages depending on the severity

Stage 1: The skin is intact with pink or red coloration that doesn’t blanch with pressure; skin may be itchy, painful and may feel worm to the touch.

Stage 2: Partial thickness skin loss. There will be blistering or an open sore (ulcer), the area is red, painful and swollen, dead tissue may be present.

Stage 3: Full thickness skin loss, crater like ulcers are present that extends to the subcutaneous tissue.

Stage 4: Full thickness skin loss with the involvement of muscle, tendon, bone or joint.


  1. Treatment of bedsore starts by identifying and managing the underlying cause.
  2. Relieving pressure by changing position and using pressure relieving mattresses or cushion is important for healing.
  3. The treatment of a bedsore depends on the stage of the ulcer. When the skin is intact, removing the pressure will allow the pressure ulcer to heal.
  4. Pain medication may be used when the bedsore is painful.
  5. When the skin is broken, the protective barrier is no longer present leading to an increased risk of infection; antibiotics may be used when there are signs of infection.
  6. When dead tissue is present, it should be removed by debridement as dead tissue increases the risk of infection and interferes with healing.
  7. Cleansing the wound and dressing changes are important in decreasing infection.
  8. Special dressings can be used to promote healing of bedsores.
  9. Deep ulcers especially those beyond stage 2 may be difficult to treat and if they are deep, they may require surgical repair.
  10. Transplanting healthy skin to the affect area may be needed in some cases (Skin graft)
  11. Topical negative pressure therapy (suction) may be used in some cases.
  12. Your health care provider will decide what the best treatment options for you are and will assess the healing progress.
  13. Healing time varies from days to months and some may not heal especially when there is an associated illness.


  1. Frequent changes in the patient’s position, turning them every 2 hours in bed and every 30 to 60 minutes in a chair.
  2. Checking the skin every day for redness, bruises and blisters and documenting the findings.
  3. Keep the skin clean and avoiding dryness by using moisturizers.
  4. Adequate fluids, protein, vitamins and minerals should be encouraged and correction of malnutrition when present.
  5. Using foam cushions or pads or other supporting devices on the beds and chairs, ask your healthcare provider about the one that is suitable for you. Donut shaped cushions are not recommended as they may interfere with the flow of blood.


  1. Septicemia which is spread of infection from an infected ulcer to the blood.
  2. Bone infection (osteomyelitis) from an infected ulcer.
  3. Limb amputation in severe cases.
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Compartment Syndrome:

A compartment is defined as a closed space of nerves, muscle tissue and blood vessels. This space is surrounded by fascia (thick layer of tissue) that doesn’t stretch. When the pressure inside the compartment increases from any cause and if the pressure increases substantially, this may lead to the compression of the nerves, blood vessels and muscles inside the compartment. The result may be impaired blood flow and reduced oxygenation that may result in muscle and nerve damage. Compartment syndrome most commonly involves the forearm and lower leg although it can occur in other places.

In third degree burns the pressure increases due to fluid retention and edema (swelling) causing compression of muscles, nerves and blood vessels which will lead to ischemia (reduction in blood flow) and necrosis (death) of tissue if not managed quickly.

Clinical features include:

  1. Pain: it is usually severe pain and out of proportion with the injury. The pain doesn’t respond to pain medication and is increased by stretching the muscle group within the compartment.
  2. Alteration or decrease sensation of the skin.
  3. Paleness of the skin.
  4. Weakness and in later stages paralysis of the limb may occur if not treated.
  5. Capillary refill time (the rate at which blood refills empty capillaries) of the digits is prolonged.
  6. Congestion of the digits.

Compartment syndrome is considered a medical emergency that requires immediate surgical treatment. The surgical procedure is called a fasciotomy which is simply done by making a long incision in the fascia to release the pressure building inside.


Seizures can happen following third degree burns specially in the first few days following the injury. Seizures may happen due to electrolyte imbalance, low oxygen level in the blood (hyp0xemia) or low level of oxygen in the tissues (hypoxia), infections leading to septicemia and septic shock, the toxic effect of certain medications administrated in burned patients or the accumulation of toxins in the body as a result of poor or malfunction of the kidneys.

Psychological complications:

Burn injuries can be devastating and can affect the patient both physically and emotionally. Children with severe burn injuries may suffer for psychological trauma for a long time such as post traumatic stress disorder (PTSD); they may also suffer bed wetting, nightmares and sleep disturbance. Anxiety, attacks of agitation, panic disorder and depression are also common. Patients may suffer personality issues such as low self esteem and disturbed self image as a result of the scarring and disfigurement caused by the burn injury; this often result in social withdrawn, feeling of worthlessness and loneliness. Psychological therapy play an important role in the healing of patients following burn injuries.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Third degree burns are burns that causes injury to all  layers of the skin (epidermis, dermis and subcutaneous tissue), it may also damage the muscles and bones. These burns are serious and may result in extensive scarring as well as other injuries and limitations. Third degree burns are vulnerable for  many complications, some of which are due to  the burn injury itself while others are due to the reaction of the body during treatment and healing process.

Complications may include:

Burn Infection:

The skin act as the main barrier against infection and when this is lost, the body becomes susceptible for infection by variable pathogens. Infection is one of the most common complications of burn injuries and the risk is more with third degree burns due to the depth of the burn and the wide area involved. When infection is severe, septicemia and septic shock may result due to the spread of infection to the blood stream which is a serious condition that may lead to multi-organ failure and death therefore, urgent treatment is needed.

Fluid loss and hypovolemia:

Hypovolemia is defined as a decrease in the volume of blood or fluids in the body. When the blood vessels are damaged as a result of a burn injury, their permeability to fluid increase leading to excessive fluid loss leading to a decrease in the blood volume of the patient. In addition, one of the functions of skin is to act as an insulation barrier to regulate the insensible fluid loss from the body, when this is lost in burn injury, the rate fluid loss and evaporation increases leading to hypovolemia. Hypovolemic shock and electrolyte imbalance may also happen due to excessive fluid loss, therefore fluid and electrolyte replacement are one of the main steps of burn management.

Deep vein thrombosis (DVT) and pulmonary embolism:

Patients who sustain third degree burns may need to stay bedridden for a long period of time. Lower limb muscle contraction during movement and walking act as a pump pushing the blood from the lower extremities back to the heart against gravity. Extended periods of bed rest increases the risk of developing blood clots as immobility can interfere with circulation of blood making it slower and causing the blood to collect in the veins forming blood clots. When these clots lodge in the veins of the limbs, it can cause DVT which is a serious condition that need to be treated as it may lead to pulmonary embolism and death if left untreated. It is important to start ambulating as soon as possible as the longer the patient is bedridden, the higher the risk of developing blood clots and DVT.  Using blood thinners and pneumatic compression devices (directed by the treating team) can reduce the risk of developing blood clots.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.


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During the recovery process, burned patient begins to heal both physically and emotionally. Some patients and depending on the severity of the burn injury (second and third degree burns) will go through painful procedures and treatments and start to be aware of the impact of the injury and how their injuries have changed their lives as some may lose loved ones and some may lose everything they have worked for.

Patients in this stage may experience sleep disturbance due to many factors including being in a hospital environmental with the lights and the staff awakening them for medication and vital signs checking. Anxiety and depression as a result of the burn also play a role in sleep disturbance so as nightmares, agitation and pain for the burn injuries. Psychological issues (pre-burn) such as depression may have an adverse effect on the outcome of the patient. These patients may stay in the hospital for a longer time and may have more severe psychological consequences after the injury.

Anxiety and depression counseling may be helpful to reassure the patient that after a trauma like this, it’s not uncommon to experience these symptoms and these symptoms may disappear on their own with time. Sometimes medication may be needed in addition to counseling.

Drugs, in the form of Opiates, may be used to treat the pain. They can be either long acting or short acting. Long acting opiates are used for pain caused by the burn injury while short acting opiates are used for pain due to procedures performed such as wound care.

Non drug methods include hypnosis and cognitive behavioral therapy. A new technique called virtual reality can be helpful in burn patients, these patients often experience excruciating sensations of pain, and this will distract the attention of the patient from the painful procedures as a person can only focus on one stimulus at a time.

In severe burn injury or when there is inhalational injuries, patients may need to be admitted to the intensive care unit of the hospital. In this scary environment with all the tubes and instruments attached to the patient, the painful procedures that the patient is going through, separation from friends and family, limited outside communication, struggling for survival and other factors such as the high doses of medications used in the treatment, infections, metabolic conditions and others may contribute to the patient’s symptoms; the patient may experience psychological issues such as extreme drowsiness, confusion, disorientation and delirium and the patient may start to misinterpret his/her surrounding when there is an altered state of consciousness, like misidentifying friends, hear things that are not really there, etc.

Members of the burn team taking care of the patient will work with the patient’s family to do whatever they can to enhance recovery. The patient is encouraged to deal with this unusual situation in the intensive care unit with whatever means possible such as denial. Family members play an important role in the recovery, although it is hard and distressing for them to see a loved one in this condition and going through all of this, they should always be calm and give hope to the patient as this will help in the recovery.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Nutritional support is considered as a critical component in the treatment and wound healing of patients suffering from burn injuries (second and third degree burns). The aim of the nutritional support is to provide enough nutrients and supplements either enteral (feeding using the gastrointestinal tract such as oral or feeding tube) and/or parenteral (intravenous infusion) to meet the body demands in response to the metabolic changes that happen in moderate to severe burns. It have been shown that the early introduction of enteral feeding in the burned patients is vital for survival (Rodriguez et al, 2011).

When a burn happens and depending on the severity of the burn, the body react to the injury by increasing the production and secretion of certain hormones which in turn cause an increase in the metabolic demand (hypermetabolic response) that will result in the need of more nutritional support which may sometimes be accompanied by alteration in the carbohydrate, protein and fat breakdown.

The nutritional needs of the patient can be assessed in many ways taking into consideration many factors including the age of the patient, body weight, the percentage of the body surface area burned among other factors. The Curreri formula is used for adults and children. The Harris-Benedict formula is used for adults and the Galvaston formula used for children. Dietitians and treating doctors will assess, monitor, and adjust the nutritional needs frequently as the patient’s condition improves or deteriorates.

There are different ways of delivering these nutrients to the patients, depending on the burn severity and the condition of the patient. The patient may be fed by mouth, through the veins, through a tube in the intestinal tract or a combination of more than one method.

1- Carbohydrates:

It is important to provide enough amount of carbohydrates to supply the energy needed and to spare proteins from being broken down and used as a source of energy. Carbohydrates make up the bulk of the nutrition and provide the majority of calorie intake. These carbohydrates will be turned by the body into glucose that will be used by the burn wounds as a source of energy. Carbohydrates will provide the energy for healing allowing protein eaten to be used to rebuild muscles rather than being used as a source of fuel.

2- Proteins:

The provision of adequate amount of proteins is essential to replenish the depleted protein stores because of the loss of proteins through the burn wound. Proteins are also important to rebuild the muscles as the muscle tissue is broken down during the healing process to produce the extra energy needed for healing.

3- Fat:

Fat is also needed to provide essential amino acids (essential amino acids are amino acids that the body can’t synthesize and has to be supplied) and extra calories, it is recommended that no more than 30% of calories come from fat; too much fat can result in significant stress on the liver as well as weaken the immune system.

4- Vitamins and minerals:

After a burn injury, it has been found that patients have reduced levels of iron, zinc, copper and selenium as well as vitamins A, C, E and D. These vitamins and minerals play a role in wound healing, immune response and preventing free radicals from causing damage to the tissues. Decrease of the level of these elements may lead to reduced immune function and poor wound healing.

  • Burned infants and children represent more complex diet therapy challenges because in addition to the increased nutritional needs imposed by the burn, growth and developmental requirements must be considered. The patient will be assessed and nutritional needs will be calculated as soon as possible after hospital admission.
  • Parents have an important role in the healing process and in encouraging their child to eat, parents after consulting with child’s physician and dietitian can bring the child’s favorite food and have to praise the child even when small amount of food eaten.
  • It is important to follow the instructions given to you at the time of discharge as some patients may be discharged home with special instructions regarding nutritional requirements.


This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Treatment may not stop itching completely but help in decreasing the severity of itching. Some patients may need more than one treatment option depending on the intensity of itching and the quality of life affected. Your treating physician or care provider will determine the best treatment for you.

Treatment may include:

1- Oral medications:

  • Oral antihistamines: these medications act by blocking the histamine receptors which trigger the itching cycle. They are available over the counter in different forms including syrups for children and tablets for adults. An e.g is Benadryl. Please contact your treating physician before using any over the counter medications for advice including dose and frequency.
  • Sleeping medicine: they may be used after consulting with the treating physician if itching disturbs sleeping.


2- Topical medications:

  • Emollients: which are used to moisturize the skin and decrease skin dryness as dryness aggravates itching. They should be applied regularly and after bathing. It is advised to use fragrance- free moisturizers as those containing perfumes may irritate the skin.
  • Topical Antihistamines: these medications block the effect of histamine which is one of the mediators of itching. They can be found over the counter such as Diphenydramine.

3- Cool baths or cold compresses: they can provide temporary relief as heat may aggravate itching. Excessive bathing should be avoided as it causes more skin dryness. Moisturizers should be applied after bathing to keep the skin moist.

4- Compression garments: they should be used 23 hours/day and may help with itching.

5- Gentle massage of the skin: massaging the skin may produce some relief.

6- Itching in children is more difficult to deal with. It may interfere with school as it makes it harder to concentrate. Cutting the finger nails short can help in reducing scratching; using distraction methods and activities can break the itch-scratch cycle such is watching television and playing games.

7- Using sunscreens and protective clothing when exposed to the sun and trying to avoid sun exposure during peak hours as heat exposure aggravates itching.

8- Using fragrance free detergents and moisturizers as perfumes may irritate the skin.

9- Avoiding skin dryness and excessive heat.


This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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Itching is the feeling or sensation that leads to the desire to scratch. Itching is a normal part of the healing process and most patients recovering from burn injuries experience itching at some point during their recovery. The itching sensation happens due to the activation of sensory neurons that have their peripheral nerve endings situated on the surface of the skin (Stein, 1983).

There prevalence of itching to happen post burn is high; it initially affects more than 90% of burned patients (Carrougher et al, 2013). When the skin is burned, the oil glands (Pilosebaceous glands) location in the skin will be damaged. These gland are responsible for secreting an oily material (sebum) that lubricates the skin and keep it moist. As a result of the lack of these glands in the healing and scar tissue, the skin will be dry leading to the sensation of itching that can be problematic and distressing to the patient.

The severity of itching varies from one patient to another; the frequency of itching and its intensity may not be related to the severity and size of the burned area. Itching may be so severe that it may interfere sleeping, eating, working, moving and the quality of life of the patient. Anything that increases the temperature of the body may lead to an increase in the itching sensation (due to an increase in the histamine release which is one of the mediators of itching) such as physical activities including sports and exercise.

Itching is usually worse at night due to decreased movement and pain making falling asleep more difficult. Itching may increase in areas where a skin graft is used to treat the burned area as well as in the donor area where the graft is taken from. Scratching due to continuous itching may lead to beading and opening of the healing areas which are fragile making it more liable for infection. The onset of scratching to the point of bleeding is usually linked to pruritus (chronic or long lasting itchiness) and specific personality type (Gauffin et al, 2015). Patient with thick scars, at a young age and with dry skin are more liable for post burn itching (Carrougher et al, 2013). Itching usually improves as the healing process proceeds and becomes less over time.


This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.



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Treatment of keloid scars may be challenging and some patients may need more than one treatment option; others may need to repeat the treatment more than once. The available treatment options may include:

  • Compression garments: the idea behind wearing compression garments is that these garments apply continuous pressure on the keloid scar which will help to flatten and improve the scar appearance. It is important to wear these garments in the early stages of scar formation as the scar will respond better when the compression garments are used since the beginning were the scar is still fresh and immature. Compression garments should not be loose and should be worn for 23 hours a day and taken only when bathing and during dressing change. Burned patients may be asked to wear the garments for years. Ask your treating physician for how long you should wear them.
  • Surgery: surgical removal of keloids was traditionally recommended however, there is a high incidence of recurrence of the keloid scar (50%-100%) if surgery is not combined with other modalities of treatment. The recurrent keloid may be larger and more severe than the original one that was present. Surgical removal is done by excising the keloid and suturing the area to help close the wound or using skin graft is the area is big combined with another method such as silicone gel.
  • Steroid injection into the scar: it is considered as a mainstay for both treatment and prevention of recurrence. The way steroid injection works is by promoting the breakdown of collagen fibers and decreasing the inflammation which will help flatten the scar and make it less tender. An example of steroid injection is Triamcinolone.
  • Applying steroid impregnated tape to the area of keloid for 12 hours a day. Avoid applying the tape on the normal skin as it may cause thinning of the normal skin.
  • Applying silicone gel sheeting or dressing to the keloid area: this method may be used as an alternative to the injection of steroid. This method should be used for several months however, there is limited evidence to suggest its effectiveness to treat or prevent keloid scars.
  • Laser therapy: this method is usually used in combination with steroid injections to get the best results possible. Using laser usually decreases the redness of the scar, make it more smooth or flat without affecting the size of the scar.
  • Cryotherapy: this is done by freezing the keloid using liquid nitrogen at an early stage to prevent it from growing and getting bigger.
  • Radiotherapy: this method uses low dose superficial radiotherapy, it is mainly used to prevent the recurrence of severe keloid scars.
  • Medication: such as 5- fluorouracil, interferon and bleomycin.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.

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After a burn injury, the body tries to repair and heal the damaged skin by forming new tissue as part of the natural healing process. Collagen which is an important structural protein plays an important role in the healing process (Di Lullo et al, 2002). Collagen accumulates around the damaged area and builds up to help the wound seal the area. Usually there is a balance between the production and the breakdown of collagen.

The healing process can cause a scar to appear which usually fades away over time by becoming smoother and less noticeable. When the scar continue to grow and invade the healthy surrounding skin, it will form what is called a keloid. Keloid scars are bigger than the original wound that was created by the burn injury. They are usually higher than the normal surrounding skin, hairless and shiny, and can feel rubbery to touch.

Keloids can affect anyone but, certain people are more predisposed to form keloids more than others such as African, African-Caribbean and south Indian communities (Dark skin people tend to get keloids easier than fair skin people). More than 50 percent of patients with keloid scarring have a positive family history of keloids (Bayat et al 2005). The bigger and the deeper the burn is (reaching the dermis), the more are the chances of forming a keloid scar. It is hard to tell how much the patient will scar after a burn injury; most second and third degree burns will cause some degree of scaring.

Certain areas of the body tend to form keloids more than others when exposed to burns or trauma such as the earlobes, the sternum area, the upper back, the back of the neck and the upper arms. People usually develop keloids between the ages of 10 and 30 years but it can happen at any age. Keloids are not contagious (not transmittable by direct or indirect contact), usually not painful and are benign (non-cancerous). Very rarely, keloids may become cancerous.

Keloids can happen even after a minor trauma like an insect bite. They can develop early as the wound is healing or may take them months or even years to form. If a patient had a keloid before than he/she is at an increased risk of developing a keloid in the future. Keloid may cause disfigurement or psychological distress in some patients depending on the site, size and appearance of the scar. Keloids may limit the range of motion or cause contractures if they are located on or near a joint.

Keloid treatment can be difficult and the response to treatment is not always successful and some patients may need more than one treatment type. Despite the presence of several treatment options, there is no option which is completely effective and there is no way of preventing keloids from happening but, there are some measures that can be done to minimize the effect of the scar.

This information is not intended nor implied to be a substitute for professional medical advice; it should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. Call 911 for all medical emergencies.