Management of Postburn Alopecia

Introduction

The importance of burn involvement of the scalp is due to its very visible location on the body. Deformities of the scalp may not always be easy to hide or camouflage, causing great distress to the individual. In large surface area burns, the scalp may be involved in 25–45% of cases. Superficial burns of the scalp heal rapidly owing to the abundance of dermal epithelial structures. However in cases of deep dermal or full-thickness burns, the loss of dermal adnexa manifests as alopecia once healing is complete. As with anywhere else in the body, burns of the scalp that take more than 2 weeks to heal spontaneously are at a risk of developing increased scarring with accompanying cicatricial alopecia.

Repeated split skin graft (SSG) harvesting from the scalp may also result in scalp alopecia. Although scalp, because of its thickness and high density of hair follicles, lends itself to reharvesting of SSG, Brou et al. reported a 61% incidence of alopecia if scalp was used to harvest skin grafts and had also sustained burns. This is in contrast to only a 2.2% incidence of alopecia in patients without scalp burns who underwent harvesting of SSG from scalp.

Spectrum of Postburn Alopecia

Burns of the scalp may purely involve the soft tissue or may also involve the underlying calvarium. While deeper partial-thickness burns may cause alopecia, full-thickness burns will inevitably lead to alopecia. A different dimension is added to the clinical problem if the calvarium also sustains burns, as is likely in an electrical injury. Optimal management of such an extensive injury has been a topic of discussion for a long time, with an evolving consensus for optimal management.

Classification of Scalp Burns

Harrison offered a classification to guide the treatment based on the depth of the injury:

Type I : Total skin loss with intact pericranium
Type II : Total skin loss with involvement of pericranium
Type III : Total skin loss with involvement of outer table
Type IV : Total skin loss with involvement of both plates of the skull.

Patients with type I injuries typically require SSG for wound coverage in the acute stage, and later they present for alopecia reconstruction. Type II/III injuries require débridement until a vascular surface is reached, followed by immediate application of SSG; this may involve chiseling until reaching the underlying diploë. Alternatively, after soft tissue débridement multiple holes may be drilled in the outer cortex until reaching bleeding diploë. The wound is dressed for a few weeks until it is fully covered by healthy granulations and then split-skin grafted. Alopecia reconstruction is undertaken at 6–9 months after skin grafting. Immediate coverage with local flaps to obviate temporary alopecia is not warranted except in small wounds with normal surrounding scalp. In type IV injuries, because there is loss of calvarium, the exposed dura requires coverage with local flaps (for small defects) or a free flap. Historically SSG has been applied directly to dura to cover defects in a strategy that is risky but may be the only option in a resource-constrained setting. The goal is to obtain an early wound closure and restore aesthetics as a secondary procedure. These patients may have more complex reconstructive needs other than simple alopecia reconstruction. It is not unusual in developing countries to see patients requesting coverage of exposed calvarium several months after the injury.

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