The effect of moisturisers on scars: a systematic review. Submitted by Tanja Klotz, BAppSc(OT), BSc Thesis submitted in fulfilment of the requirements for the degree of Master of Clinical Science Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide 2018 i Contents Contents ...................................................................................................................................... ii List of figures and tables ............................................................................................................ iv Thesis declaration ....................................................................................................................... v Acknowledgements .................................................................................................................... vi Abstract ..................................................................................................................................... vii 1. Introduction ........................................................................................................................... 10 1.1 Context of the review .......................................................................................................... 10 1.2 The need for this systematic review .................................................................................... 11 1.3 Skin and scar formation ...................................................................................................... 11 1.3.1 Skin .............................................................................................................................. 11 1.3.2 Wound healing and scar formation .............................................................................. 12 1.3.3 Trans-epidermal water loss, hydration and occlusion: its relationship to scar formation ............................................................................................................................................... 12 1.4 Types of scars...................................................................................................................... 13 1.4.1 Linear scars .................................................................................................................. 13 1.4.2 Hypertrophic scars ....................................................................................................... 14 1.4.3 Keloid scars .................................................................................................................. 15 1.4.4 Atrophic scars .............................................................................................................. 15 1.5 Scar management ................................................................................................................ 16 1.6 Moisturisers ......................................................................................................................... 16 1.6.1 Characterising moisturisers by type and availability ................................................... 17 1.7 The science of evidence synthesis ...................................................................................... 25 2. Methodology and method ..................................................................................................... 27 2.1 Review question ............................................................................................................. 27 2.2 Criteria for considering studies for inclusion in this review .......................................... 27 2.2.1 Types of studies ...................................................................................................... 27 2.2.2 Types of participants ............................................................................................... 27 2.2.3 Types of interventions ............................................................................................. 28 2.2.4 Comparators ............................................................................................................ 28 2.2.5 Types of outcome measures .................................................................................... 29 2.3 Review methods ............................................................................................................. 29 2.3.1 Search strategy ........................................................................................................ 29 2.3.2 Study selection and inclusion .................................................................................. 32 2.3.3 Assessment of methodological quality – critical appraisal ..................................... 32 ii 2.3.4 Data extraction ........................................................................................................ 33 2.3.5 Data synthesis .......................................................................................................... 33 3. Results of searching, selection and assessment of methodological quality .......................... 35 3.1 Results of searches.......................................................................................................... 35 3.1.1 Other searches ......................................................................................................... 35 3.2 Screening of studies ........................................................................................................ 36 3.3 Excluded studies ............................................................................................................. 37 3.4 Included studies .............................................................................................................. 37 3.4.1 Included studies: moisturiser group ........................................................................ 37 3.4.2 Included studies: imiquimod group ......................................................................... 39 3.5 Critical appraisal ............................................................................................................. 55 3.5.1 Methodological quality of included studies – moisturiser group ............................ 55 3.5.2 Methodological quality of included studies – imiquimod group ............................ 61 4. Review findings ..................................................................................................................... 63 Narrative synthesis of the effect of moisturisers on scars ......................................................... 63 4.1 Cosmesis of the scar ....................................................................................................... 63 4.2 Scar parameters ............................................................................................................... 66 4.3 Itch and pain ................................................................................................................... 72 4.4 Trans-epidermal water loss and hydration...................................................................... 76 4.5 In vitro outcomes ............................................................................................................ 76 4.6 Recurrence of excised keloids treated with 5% imiquimod – a meta-analysis .............. 79 4.6.1 Meta-analysis of all included studies in imiquimod group ..................................... 79 4.6.2 Meta-analysis – surgical technique ......................................................................... 80 4.6.3 Meta-analysis – location of keloid .......................................................................... 83 4.7 Adverse events ................................................................................................................ 85 5. Discussion and conclusions ................................................................................................... 87 5.1 Effect of moisturisers on outcomes ................................................................................ 87 5.2 Assumptions, limitations and delimitations ........................................................................ 98 5.3 Implications for research .................................................................................................... 99 5.4 Conclusions ....................................................................................................................... 101 References ................................................................................................................................... 102 Appendices .................................................................................................................................. 109 Appendix 1: Logic grids for database searching ..................................................................... 109 Appendix 2: Critical appraisal tools ........................................................................................ 113 Appendix 3: Excluded studies and reasons for their exclusion ............................................... 117 iii List of figures and tables Table 1-1: Australian availability to consumers of products examined in this systematic review18 Table 1-2: Cost and usual available sizes of prescription only creams ........................................ 19 Table 1-3 Cost and usual available size of high cost over the counter creams. Prices obtained by basic internet searching in January 2018. ....................................................................................