b u r n s 3 4 ( 2 0 0 8 ) 4 9 8 – 5 0 4

avai lable at www.sc iencedi rec t .com

journal homepage: www.e lsevier .com/ locate /burns

Spray on skin improves psychosocial functioning in pediatricburns patients: A randomized controlled trial

Graham Martin a, Sarah Swannell a,*, Julie Mill c, Jonathan Mott c, Jackie Evans c,Nadine Frederiksen c, Melanie Hilder c, Roy Kimble b

aDepartment of Psychiatry, The University of Queensland, AustraliabDepartment of Pediatrics & Child Health, The University of Queensland, AustraliacStuart Pegg Pediatric Burns Centre, Royal Children’s Hospital, Australia

a r t i c l e i n f o

Article history:

Accepted 13 August 2007

Keywords:

Mental health

Pediatrics

MicroskinTM

Mature burn scars

a b s t r a c t

Purpose: MicroskinTM is a sprayed on, computer color-matched, skin camouflage which can

last for up to 5 days after application. It binds to the epidermis and the patient can sweat and

swim with it on. The purpose of the current study was to determine whether MicroskinTM

produces psychosocial benefit in pediatric burns patients.

Procedure: Twenty children with mature burn scars took part in the study and used Micro-

skinTM for 5 weeks. Initially, 10 children were randomized to a treatment group while the

remaining 10 became a wait-list group for 7 weeks. The wait-list group subsequently

received MicroskinTM for 5 weeks. Before and after using MicroskinTM, children completed

three psychosocial measures; the Strengths and Difficulties Questionnaire (SDQ), the Family

Assessment Device—General Functioning scale (FAD-GF), and the MicroskinTM Question-

naire (MQ—a questionnaire about their experience using MicroskinTM developed specifically

for this study). All children were followed up with the same measures 6 months after their

completed use of MicroskinTM.

Results: After the 5-week MicroskinTM trial there was improvement on all scales of

the SDQ for the 10 children in the first treatment group but not for the wait-list

group. After the wait-list group used MicroskinTM for 5 weeks they too improved

on all scales. Combining the results for all 20 children from before to after using

MicroskinTM there was a statistically significant improvement in the SDQ Emotional

Symptoms and Total Difficulties. There was also improved perception of family func-

tioning after using MicroskinTM. Six-month follow-up data showed continued psycho-

social improvement. Overall, children felt more confident, happier, and enjoyed social

outings more when they had MicroskinTM on, with 95% intending to continue to use

MicroskinTM.

Conclusions: MicroskinTM improves psychosocial functioning in pediatric burn patients and

is well-tolerated and acceptable. The small sample size precludes sophisticated statistical

analyses and generalization of results. There is a need for a full scale randomized controlled

study of MicroskinTM with a larger sample size.

# 2007 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: K Floor, Mental Health Centre, Royal Brisbane Hospital, Herston, Qld 4029, Australia.E-mail address: s.swannell@uq.edu.au (S. Swannell).

0305-4179/$34.00 # 2007 Elsevier Ltd and ISBI. All rights reserved.doi:10.1016/j.burns.2007.08.004

b u r n s 3 4 ( 2 0 0 8 ) 4 9 8 – 5 0 4 499

In the specialist field of burns, recent advances in medicine

have shifted the focus from saving lives to improving the

physical, social, and mental functional outcomes of burn

survivors [1]. Among adult burns survivors, the most

researched functional outcome dimension is education/work

status, while among child burns survivors, the most

researched dimension is mental health [1].

Many studies [2–7] reported on the psychosocial impact of

burn scars, yet few found differences in mental functioning

between child burns survivors and healthy controls. Two

exceptions include Meyer et al. [8] and Blakeney et al. [9] who

found approximately 25–40% of children with massive burns

(�80% TBSA) exhibited problems with behaviour and compe-

tence as measured by the Child Behaviour Check List (CBCL).

Research suggests poorer social functioning in burned

children [10], but other studies found no differences in social

functioning between child burns survivors and healthy

controls [11–13]. Pre-morbid family functioning appears to

have a large influence on psychosocial functioning after burn

in children [11].

When compromised psychosocial functioning in burn

victims occurs, it results not only from the trauma associated

with the injury but also from burn scarring. Children with

visible burn scars report more body image difficulties than

children with non-visible burn scars [5,7] particularly when

scars are on exposed areas of skin such as the face and upper

limbs [7]. Studies also showed that up to 60% of adolescent

burn patients were annoyed by their scars, one third regularly

covered their scars with clothes or cosmetics, and 20%

experience difficulties in contact with the opposite gender

[7]. Children with visible burn scars (when compared to adults)

tend to have a higher rate of problems with peer socialization

because children are far more likely to express a negative

attitude towards disfigurement [4]. Self-esteem is an impor-

tant factor in long-term social adjustment and physical

appearance correlates highly with global self-esteem, espe-

cially in adolescents [4,6].

Cosmetic camouflage clinics were demonstrated to

improve psychosocial wellbeing in adults with burn scars

[14]. To date there are no comparable options for children with

burn scars. The aim of this study was to determine whether a

‘second skin formulation’, MicroskinTM, could confer the

psychosocial benefits of cosmetic camouflage seen in adults.

MicroskinTM is a unique simulated second skin formula-

tion. Digital photography and a color-matching program allow

the creation of a product exactly matched to a patient’s skin

tone which camouflages any visible skin blemishes (which

may be burns, birthmarks, vitiligo or other scarring). It can be

applied with the aid of a sponge or a spray gun for larger areas.

MicroskinTM is an alcohol and natural oil based substance

which bonds to the epidermis of the skin. It is waterproof,

affords sun protection but allows the passage of sweat and

also allows hair to grow through. It remains effective for up to

5 days at a time, and can be easily removed with alcohol and

oil based removal serum [15].

MicroskinTM International Pty Ltd. developed a 2-day

training course for potential users. This involves an initial

assessment, color matching, and production of the patient

specific formulation. Patients are also trained in the care and

application of the product. The course is conducted at

MicroskinTM International’s clinic in Brisbane. The cost of a

small (50 ml) bottle of MicroskinTM is AU$ 89.95 and with small

to medium applications (i.e. face), reapplying approximately

every 4 days, the bottle will last from 2 to 4 months, with an

average cost per application of 20–30 cents (Australian). The

cost increases as the area to be covered increases.

To date there have been no studies into the use of

MicroskinTM in children with burn scars. This study was a

prospective randomized controlled trial of MicroskinTM in

children with long-term burn scars. The aim was to determine

whether, by improving scar appearance, MicroskinTM would

have a beneficial effect on psychosocial wellbeing.

1. Method

1.1. Participants

Twenty children (13 females, 7 males) aged between 7 and 16

years with fully matured burn scars took part in this study.

Children were accompanied by a caregiver at all time points.

All children were outpatients from the Stuart Pegg Pediatric

Burns Centre, Royal Children’s Hospital, a major tertiary burns

referral centre in Brisbane, Australia. This Centre treated 549

new patients in 2006. The catchment of the Centre covers a

large geographic area of Australia and includes all of Queens-

land and northern New South Wales. In 2005 the population of

Queensland was over 4 million people and was the fastest

growing state in Australia. The population of Northern New

South Wales was 179,103 [16].

1.2. Measures

1.2.1. Demographic detailsSocio-economic information was not collected. Caregivers

completed a demographic section including the caregiver’s

relationship to child, gender of child, age of child, total body

surface area burned (TBSA), burn location, burn scar duration,

and length of hospitalization.

1.2.2. Vancouver Scar Scale (VSS)The Vancouver Scar Scale is a widely used and validated tool

to physically assess burn scars along four parameters:

pigmentation, vascularity, pliability, and height [17]. It

allows objective comparisons of the same burn scar by

different observers with a high degree of reliability [17,18].

The VSS was administered to each child at the initial

assessment.

1.2.3. Strengths and Difficulties Questionnaire (SDQ) [19]The SDQ is a 25-item behavioural screening and outcome

questionnaire for 3–16-year olds and consists of five sub-

scales—(1) Emotional Symptoms (five items), (2) Conduct

Problems (five items), (3) Hyperactivity (five items), (4) Peer

Problems (five items), and (5) Pro-social Behaviour (five items).

A Total Difficulties Score is obtained by summing the

Emotional Symptoms, Conduct Problems, Hyperactivity, and

Peer Problems scales. Modified versions are available for

children aged 3–10, children aged 11–17, caregivers of children

aged 3–10, and caregivers of children aged 11–17.

Table 1 – Burn location

Location N Percent of total Percent of cases

Arm/hand 18 29.5 90

Legs/feet 12 19.7 60

Face 9 14.8 45

Chest 7 11.5 35

Back 6 9.8 30

Head 5 8.2 25

Abdomen 2 3.3 10

Neck 1 1.6 5

Buttocks 1 1.6 5

Total 61a 100 305a

a Children had burns on more than one location.

b u r n s 3 4 ( 2 0 0 8 ) 4 9 8 – 5 0 4500

1.2.4. Family Assessment Device—General Functioning scale(FAD-GF) [20]The Family Assessment Device—General Functioning scale

screens for family difficulties and consists of 12 items (i.e.

‘Individuals are accepted for what they are’), each rated on a 4-

point Likert scale—‘strongly disagree’, ‘disagree’, ‘agree’,

‘strongly agree’). Reliability for the scale is 0.92 [20,21].

Children and caregiver pairs completed the FAD-GF before

and after a 5-week trial of the child using MicroskinTM.

1.2.5. MicroskinTM Questionnaire (MQ)This 15-item questionnaire was specifically developed for the

study to assess ease of use, cosmetic effect on burn scars,

effect on emotions and behaviour, intent to use in the future,

and side effects/problems associated with using MicroskinTM

from both the child’s and caregiver’s perspective. The

questionnaire contained 11 Likert-style questions, one yes/

no question, and three short answer questions.

1.3. Procedure

The study was approved by the Brisbane Royal Children’s

Hospital Human Research Ethics Committee prior to com-

mencement.

Patients and caregivers were provided with an information

booklet fully outlining the nature of the study and the research

protocol. Those interested attended an introductory informa-

tion session about MicroskinTM conducted by a clinical

investigator. It was made clear both through the information

booklet and the information session that participation was

completely voluntary and that the identity of the patient

would not be made known to any person not a clinical

investigator, a member of the Burns Research Group, or an

employee of MicroskinTM International. All caregivers were

invited to sign a consent form. A total of 20 patients and their

caregivers consented to participate.

All patients attended the Burns Outpatient Centre for initial

assessment and completed the Vancouver Scar Scale, the

Strengths and Difficulties Questionnaire, and Family Assess-

ment Device—General Functioning scale. Caregivers com-

pleted demographic information and the parent versions of

the SDQ and FAD-GF (results not reported here). All data were

recorded along with each patient’s hospital identification

number and kept within the Burns Centre at the Royal

Children’s Hospital.

Immediately after initial assessment, children were ran-

domized to either the treatment group or the wait-list group

(both groups contained 10 children and their caregivers). Two

weeks later, the treatment group attended a 2-day training

course at the MicroskinTM Clinic, where their unique Micro-

skinTM formulation was produced and the child and caregiver

were taught how to use the product. The treatment group then

used MicroskinTM for 5 weeks, while the wait-list group

received treatment as usual.

Children from both groups were assessed for a second time

after the treatment group had finished their 5-week trial of

MicroskinTM. Both groups completed the SDQ and FAD-GF and

the treatment group also completed the MQ. Two weeks after

this, the wait-list group attended the 2-day training course at

the MicroskinTM Clinic, and then commenced using Micro-

skinTM for 5 weeks. After 5 weeks, they completed the SDQ,

FAD-GF, and MQ.

Six months after the wait-list group had completed the 5-

week MicroskinTM trial, all 20 children and caregivers

completed the SDQ, FAD-GF, and the MQ.

2. Analyses

Non-parametric tests were used as data was non-normally

distributed and the sample size was small.

3. Results

3.1. Demographics

The mean age of children was 11.95 years (S.D. = 2.74; range 8–

16) and the mean total body surface area burned was 20.5%

(range 20–60%). The body part most frequently scarred was the

arm/hand (30%), followed by the legs/feet (20%) and face (15%)

(Table 1).The mean timeelapsedsince the burnwas over5 years

(range 6 months to over 5 years). There were no burns within the

previous 6 months, consistent with the selection criteria of

having fully matured scars. The mean time previously spent in

hospital as a result of theburns was between 1 and 6 months (no

child spent more than 6 months in hospital).

The treatment group had a higher mean age than the wait-

list group, but the difference was not significant. No other

differences between the groups were evident. Demographic

details are shown in Table 2.

3.2. Vancouver Scar Scale

The average score on the VSS was 2.12 � 0.94 points (range 0.5–

4.5 points).

3.3. Strengths and Difficulties Questionnaire

The Strengths and Difficulties Questionnaire (SDQ) results are

taken from children’s self-report. Results of the SDQ at initial

testing, before and after the MicroskinTM trial, and again at

follow-up are outlined in Table 3. For the initial treatment group

all scales on the SDQ improved after completing the 5-week

Table 2 – Demographic details

Treatment group Wait-list group

Relationship of caregiver to child 8 mothers 6 mothers

1 father 3 fathers

1 foster mother 1 grandmother

Gender of child 4 males 3 males

6 females 7 females

Mean age of children 12.30 (S.D. = 2.87) 11.60 (S.D. = 2.63)

TBSAa 4 with 1–20% 7 with 1–20%

5 with 21–40% 3 with 21–40%

1 with 41–60% –

Recency of burn – Less than 12 months (N = 1)

Less than 5 years (N = 1) Less than 5 years (N = 3)

More than 5 years (N = 9) More than 5 years (N = 6)

Time spent in hospital Less than 1 month (N = 3) Less than 1 month (N = 5)

1–6 months (N = 7) 1–6 months (N = 5)

a TBSA: total body surface area burned.

b u r n s 3 4 ( 2 0 0 8 ) 4 9 8 – 5 0 4 501

MicroskinTM trial, although none of these improvements

reached statistical significance. In contrast, for the wait-list

group following 5 weeks of treatment as usual (and prior to

their own trial of MicroskinTM) there was no change on two

scales, slight deterioration on one scale and slight improve-

ment on three scales. Again no changes were statistically

significant.

After the wait-list group completed their 5-week Micro-

skinTM trial there was improvement from before to after the

trial on all subscales of the SDQ as measured by the Wilcoxin

rank sums test. For these 10 children, improvement reached

statistical significance on Emotional Symptoms (Z = �1.992,

p = 0.046), Conduct Problems (Z = �1.976, p = 0.048), and Total

Difficulties (Z = �2.354, p = 0.019).

We combined data from the initial treatment group and the

wait-list/second treatment group to improve statistical power

(N = 20). Overall, there were statistically significant improve-

ments from before to after using MicroskinTM on Emotional

Symptoms (Z = �2.254, p = 0.024) and Total Difficulties

(Z = �2.199, p = 0.028), with the improvement on Conduct

Table 3 – Mean scores on the Strengths and Difficulties Quest

Scale Before Microskmean (S.D.

Initial treatment group

Total Difficulties 15.70 (3.23)

Emotional Symptoms 5.10 (2.03)

Conduct Problems 3.10 (1.97)

Hyperactivity 5.30 (2.54)

Peer Problems 2.20 (1.93)

Pro-social Behaviour 8.80 (1.03)

Wait-list/second treatment group

Total Difficulties 17.30 (8.67) 17.00 (8.21)

Emotional Symptoms 4.90 (2.08) 4.90 (2.23)

Conduct Problems 3.70 (3.09) 3.90 (2.38)

Hyperactivity 5.50 (3.24) 5.50 (3.03)

Peer Problems 3.20 (3.08) 2.70 (3.06)

Pro-social Behaviour 7.63 (2.05) 7.65 (1.42)

Problems (Z = �1.952, p = 0.051) nearing statistical signifi-

cance.

To determine whether the benefits of MicroskinTM had a

lasting effect on psychosocial functioning, children were

followed up 6 months after their completion of the 5-week

trial. Three children did not complete the SDQ follow-up (two

from the initial treatment group did not return, and one

declined). For the group as a whole (N = 17), there was

continued improvement from completion of the trial to 6

months follow-up on all scales except for Peer Problems and

Pro-social Behaviour. None of the changes were statistically

significant, although the improvement on Emotional Symp-

toms approached significance (p = 0.052).

Over three time points (before MicroskinTM, after Micro-

skinTM and 6-month follow-up), for both groups combined

(N = 17), there was a statistically significant decrease in

Emotional Symptoms (from 4.88 to 3.71 to 2.65, x2 = 11.627,

p = 0.003) and Total Difficulties (x2 = 6.118, p = 0.047) (Fried-

man’s related samples test). The Conduct Problems and

Hyperactivity subscales showed similar trends in mean scores

ionnaire over time (children self-report)

inTM,)

After MicroskinTM,mean (S.D.)

Six-month follow-up,mean (S.D.)

13.70 (5.54) 10.29 (5.74)

3.45 (2.58) 2.71 (2.43)

2.80 (1.32) 2.29 (0.95)

5.10 (3.14) 3.86 (2.12)

1.40 (1.58) 1.43 (1.81)

8.70 (0.95) 9.00 (0.82)

13.00 (7.09) 12.50 (6.80)

3.30 (1.89) 2.60 (1.27)

2.95 (2.61) 2.50 (2.32)

4.70 (2.87) 5.20 (2.70)

2.00 (2.50) 2.20 (2.20)

8.40 (1.51) 8.10 (1.66)

Table 4 – Mean scores on the Family Assessment Device—General Functioning scale over time (children self-report)

Before MicroskinTM,mean (S.D.)

After MicroskinTM,mean (S.D.)

Six-month follow-up,mean (S.D.)

Initial treatment group 1.98 (0.27) 1.81 (0.35) 1.85 (0.32)

Wait-list/second treatment group 1.80 (0.30) 1.89 (0.29) 1.52 (0.28) 1.62 (0.43)

b u r n s 3 4 ( 2 0 0 8 ) 4 9 8 – 5 0 4502

across time, but did not reach significance. The mean score for

Peer Problems increased non-significantly from post-treat-

ment (1.53 � 2.00) to follow-up (1.88 � 2.02), but was still short

of the pre-treatment score (2.41 � 2.67). The mean score on

Pro-social Behaviour remained exactly the same over the 6-

month follow-up at 8.47 � 1.42, but was still higher than pre-

treatment (8.26 � 1.42).

3.4. Family Assessment Device—General Functioning scale

For the initial treatment group (N = 10), children’s scores on

the FAD-GF improved after 5 weeks of MicroskinTM while after

5 weeks of treatment as usual, scores deteriorated for children

in the wait-list group (though neither change was statistically

significant; Table 4). Scores subsequently improved signifi-

cantly for the wait-list group (N = 10) after their completion of

the MicroskinTM trial (before MicroskinTM: m = 1.89 � 0.29;

after MicroskinTM: m = 1.52 � 0.28; Z = �2.371, p = 0.018; Wil-

coxin rank sums test).

Combining data from the treatment and wait-list groups

to improve power, overall results showed a statistically

significant improvement on the FAD-GF scale from before

(m = 1.94� 0.277) to after using MicroskinTM (m = 1.67� 0.340;

Z = �3.036, p = 0.002; Wilcoxin rank sums test).

To determine whether the benefits of MicroskinTM had a

lasting effect on the perception of family relationships, FAD-

GF scores were examined 6 months after the wait-list group

completed the trial. Two children from the initial treatment

group did not return for follow-up, and one child from the

original wait-list group declined to complete the FAD. For the

groups combined (N = 17), there was a slight (non-significant)

deterioration in perceived family functioning at follow-up.

The scores at follow-up, however, remained an improvement

from the initial assessment.

3.5. MicroskinTM Questionnaire

For this sample as a whole, MicroskinTM was applied on

average every 4–7 days. The majority of children found it easy

to learn how to apply MicroskinTM. Seventy percent found it

easy to apply (25% ‘very easy’, 45% ‘easy’), 15% found it ‘ok’,

15% found it ‘hard’, but nobody found it ‘very hard’. Caregivers

reported more difficulty in learning to apply MicroskinTM

compared to children. Forty-five percent of caregivers found it

easy (15% ‘very easy’, 30% ‘easy’), 40% found it ‘ok’, 15% found

it ‘hard’, and nobody found it ‘very hard’.

Actually applying the MicroskinTM also appeared relatively

easy, and reported ease in application was similar between

children and caregivers. Among children, 65% found it easy

(15% ‘very easy’, 50% ‘easy’), 20% found it ‘ok’, 15% found it

‘hard’, but none found it ‘very hard’ to apply. Among

caregivers, 60% found it easy (10% ‘very easy’, 50% ‘easy’),

25% found it ‘ok’, 5% found it ‘hard’, and 10% found it ‘very

hard’ to apply.

The amount of MicroskinTM used per child depended on the

size of the burn scar, which was between 20 and 60% of the

body, as well as the type of clothing worn with the

MicroskinTM. The children did not generally use MicroskinTM

on areas that were covered with clothing. Therefore, there

would have been considerable differences in the amount of

MicroskinTM applied per person and the amount would also

differ depending on the clothing worn.

Ninety-five percent of children thought MicroskinTM made

their scars look better (40% ‘much better’, 45% ‘better’, and 10%

‘a little better’), although one child (5%) thought the scars

looked ‘no different’. One hundred percent of caregivers

thought their child’s scars looked better (50% ‘much better’,

40% ‘better’, and 10% ‘a little better’). No child or caregiver

thought the scars looked worse with MicroskinTM applied.

Children were asked how aware they were of MicroskinTM

being on the skin once it was applied. Ninety percent of

children were mostly unaware of the product on their skin

(60% ‘not at all’, 30% ‘rarely’), 10% reported being aware of the

product ‘sometimes’, while no child reported being aware of

MicroskinTM ‘usually’ or ‘always’. Caregivers were more likely

to perceive their children as being aware of the product.

Seventy percent thought their children were mostly unaware

of the product (50% ‘not at all’, 20% ‘rarely’), 5% thought their

child was aware of it ‘sometimes’, 10% ‘usually’, and 15%

thought their children were ‘always’ aware of MicroskinTM

once it was applied.

One hundred percent of the children selected ‘not at all’

when asked if MicroskinTM limited their daily activities.

Caregiver responses were similar, with 95% reporting that

MicroskinTM limited their child’s activity ‘not at all’, and 5%

(one caregiver) reporting that MicroskinTM limited activity

‘sometimes’. When examined further, the limitation noted by

this particular caregiver was that MicroskinTM came off when

swimming.

Fifteen percent (6 of 40) of children and caregivers reported

side-effects from MicroskinTM. Side effects were itching,

decreased sensation in the areas where the MicroskinTM

was applied, drying to the face, and slight erythema.

When asked if they felt happier with MicroskinTM applied,

90% of the children in the study responded in the affirmative

(40% ‘very true’, 40% ‘mostly true’, and 10% ‘sometimes true’).

Ten percent responded ‘unchanged’. Results showed a similar

pattern when children were asked if they felt more confident

with MicroskinTM applied: 95% responding in the affirmative

(40% ‘very true’, 40% ‘mostly true’, and 15% ‘sometimes true’),

while 5% responded ‘unchanged’. ‘Fitting in’ did not appear to

be as strongly influenced by wearing MicroskinTM. When

asked to respond to the statement I feel like I fit in more when I

have the Microskin on, 80% responded in the affirmative (25%

b u r n s 3 4 ( 2 0 0 8 ) 4 9 8 – 5 0 4 503

‘very true’, 30% ‘mostly true’, 25% ‘sometimes true’) and 20%

responded ‘unchanged’.

Ninety percent of children enjoyed going out more (to

parties, friend’s houses, the movies) when they had Micro-

skinTM on. In response to this statement, 25% indicated ‘very

true’, 35% indicated ‘mostly true’, 30% indicated ‘sometimes

true’, and 10% indicated ‘unchanged’.

Ninety-five percent of children intended to continue to use

MicroskinTM in the future.

4. Discussion

Compromised psychosocial functioning in burned children

results from the trauma associated with the injury as well as

post-burn scarring. Children with visible burn scars report a

range of difficulties associated with their scarring [2–7].

Cosmetic camouflage clinics demonstrated improved

psychosocial wellbeing in adults with burn scars [14] but

there are no published comparable options for children with

burn scars. This study set out to determine the effect of

MicroskinTM, a simulated ‘second skin’ camouflage, on the

psychosocial functioning of children with long-term burn

scars, as well as determine its acceptability to children and

their parents.

The idea of the wait-list group grew out of our concerns that

once young people and their families discovered a possible

way of managing long-term burn scars, they might develop an

optimistic frame of mind, an expectancy, which could have its

own impact on our scales. This seems not to have been the

case, with only three subscales of the Strengths and

Difficulties Questionnaire showing an ‘improvement’ in the

wait-list group, one subscale staying the same and two

deteriorating over the 7 weeks of waiting time. None of these

results reached significance, but the result is at odds with the

improvement of the initial treatment group over 5 weeks

where each scale showed improvement even though these

changes also were not statistically significant. The lack of

psychosocial change in the young people we randomized to

the group who had to wait 7 weeks to begin the treatment is in

marked contrast also to the changes that occurred when they

did get MicroskinTM. As with the initial treatment group, there

was improvement in the means of all subscales on the SDQ,

with three subscales (Emotional Symptoms, Conduct Pro-

blems, and Total Difficulties) all reaching significance. This

was a strong result given the small numbers in the group

(N = 10).

Even with the low probability of the Total Difficulties result

being a chance event in the second group, it could still be

argued that our results for both groups of 10 children may have

been due to chance; these are after all rather small numbers.

To improve the confidence in our results we combined the

results for both treatment groups. The overall results (N = 20)

did show improvement on all subscales from before to

immediately after treatment, with significant results at

respectable probability on the SDQ Emotional Symptoms

and Total Difficulties.

The long-term follow-up results (from completion of

treatment to follow-up) are also impressive given that children

only had 5 weeks of treatment (a relatively small dose) and

then had no treatment for the next 6 months. On many

subscales the improvement in the mean score was sustained.

The level of reported Emotional Symptoms continued to wane,

as did the Total Difficulties Scores. Most impressive is the

result over the three time points from before to after treatment

and then to follow-up, where the results for these two scales

reach significance. We have to conclude that despite small

numbers, the use of MicroskinTM appears to have a powerful

impact on psychosocial problems in children with mature

burn scars.

MicroskinTM appears to also have some impact on the

perception of family functioning, which improved signifi-

cantly during the treatment phase in the eyes of the young

people. At the 6-month follow-up, family functioning

appeared to have deteriorated somewhat since the end of

the actual MicroskinTM trial, but still with maintained

improvement over the initial pre-treatment assessment.

The limitations of this study relate mainly to the small

overall numbers, which precluded a more sophisticated

analysis, and generalization of results. In addition, burns

are different in area covered, severity and the way healing

occurs, so to randomize a small group of 20 could mean that

we ended up with very different groups. Reflecting

on composition of the two groups we do not believe this

to have been so; both groups had a roughly equal gender

mix, an apparent equal spread of socio-economic back-

grounds (though this was a clinical impression from case

files and not formally measured), and a heterogeneous mix

of burn types. Another problem relates to monitoring.

MicroskinTM application was done at home, and while

clinic nurses are convinced that the product was used, we

have no guarantee that the children actually used it. Clearly

a much larger randomized study is necessary to confirm

our results.

MicroskinTM was well accepted as a cosmetic treatment

for visible burn scars in pediatric burns patients. It was

applied approximately every 4 days and was relatively easy

to learn to apply. Most children were unaware of the product

on their skin once they had applied it, and not one child

reported that MicroskinTM limited their normal daily

activities. Although half of the children reported side-effects

from MicroskinTM, on closer examination, many of the

reported ‘side-effects’ were actually difficulties applying the

product. The most common ‘real’ side-effect was occasional

itching of the skin.

Ninety-five percent of children reported an intention to

continue to use MicroskinTM in the future, which suggests that

MicroskinTM is an acceptable alternative for consumers. Most

children, when wearing MicroskinTM, felt happier and more

confident, and enjoyed social outings more.

5. Conclusion

This study was a randomized controlled trial with 20 patients

and their caregivers. Findings indicate that MicroskinTM is an

acceptable camouflage for mature burn scars, successfully

improves psychosocial functioning among children, and

improves perceived family interaction. Despite the excitement

that the treatment generated amongst staff and families,

b u r n s 3 4 ( 2 0 0 8 ) 4 9 8 – 5 0 4504

methodological drawbacks necessitate cautious interpreta-

tion of results. A randomized controlled trial with a much

larger sample is indicated.

Acknowledgements

The authors would like to thank all the patients and families

from the Stuart Pegg Pediatric Burns Centre for their

participation in this trial; Megan Simons for her invaluable

assistance with the research; Aung Win and Kathryn Ollson

for data entry; and MicroskinTM International Pty Ltd. for

supplying the MicroskinTM used in the study. This study was

not supported by any source of funding. MicroskinTM Inter-

national Pty Ltd. had no involvement in the study design,

collection, analysis and interpretation of data; writing of the

manuscript; or decision to submit the manuscript for pub-

lication.

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