Mental Health Outcomes and Psychosocial Impacts of Facial Burns: A Scoping Review

Abstract

Introduction:

Burn injuries have been proven to carry long-term psychological and social consequences.

Objective:

To identify the mental and psychosocial impacts of facial burns on patients’ quality-of-life outcomes.

Methods:

The methods were developed in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extensions for Scoping Review guidelines. A literature search utilizing the PubMed and Scopus databases was performed. Peer-reviewed, English-language studies examining psychological, social, or quality-of-life outcomes associated with facial burns were included.

Results:

Anxiety and depression were significantly worse in facial burn patients [Hospital Anxiety and Depression Scale (HADS) score: 2.5 ± 2.8, P < .002, HADS Score: 2.1 ± 2.7, P < .001, respectively]. Body image dissatisfaction was significantly higher in adolescent facial burn patients compared to those without facial burns, 1 year after the injury (P < .001). After undergoing augmented reality coupled rehabilitation, quality of life scores were improved compared to baseline (P < .001).

Conclusion:

This scoping review highlights the negative impacts of facial burns on mental health and psychosocial outcomes. Additional research is needed to further substantiate interventions, such as cognitive behavioral strategies and virtual reality-based rehabilitation, in the long-term management of individuals with facial burns.

Introduction

Burn injuries remain a prominent global health issue, killing over 180,000 people annually. ¹ Facial burns are a traumatic form of injury, not only due to their physical implications but also because of their profound impact on an individual’s psychological and social well-being. The scarring process for facial burn survivors marks a significant milestone in recovery, still facial burn survivors are likely to face a multitude of lifelong challenges. The visibility of facial burns poses unique challenges, such as social stigma, body image dissatisfaction, and significant mental health disorders. ² A change in someone’s physical appearance due to facial burns can impact how comfortable they feel interacting and socializing in public. ³ Severe facial burns can diminish a person’s self-esteem and lead to depression. ⁴ Given these unique challenges, the recovery process for facial burns needs to integrate both the psychological and physical aspects of healing.

It is necessary to address how cultural and social stigma can negatively impact facial burn survivors’ mental health. ⁵ Facial burn survivors frequently face significant challenges due to the visible scars and disfigurements that result from their injuries. ⁶ These physical marks can be profound and often do not align with the conventional beauty standards upheld in various cultures around the world. ⁶ Confronting and mitigating stigma is an important factor in improving the quality of life (QoL) for facial burn survivors.

This scoping review aims to consolidate and examine existing research on the mental health outcomes and psychosocial impacts associated with facial burns. By identifying patterns and gaps in the current literature, this review seeks to highlight the complexities of recovery and inform more targeted, effective interventions for this vulnerable population. Understanding these dynamics is crucial for developing comprehensive care strategies that address both the physical and emotional needs of those affected by facial burns. A holistic review is needed to help implement strategies to address the visible and invisible wounds, such as altered self-esteem, that a facial burn survivor may face. This scoping review can potentially help healthcare providers design interventions that are proactive in addressing the psychological impact of facial burns.

Materials and Methods

A scoping review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Scoping Review guidelines was performed in January 2025.

Search Strategy

Articles were searched in the PubMed database with the following thread of keywords:

[“Burns” (MeSH) OR “Facial Burns” OR “Facial burn injury” OR “Face burn” OR “Thermal injury” OR “Chemical burn” OR “Electrical burn”] AND [“Mental Health” (MeSH) OR “Psychosocial impact” OR “Psychological distress” OR “Depression” (MeSH) OR “Anxiety Disorders” (MeSH) OR “Post-Traumatic Stress Disorder” (MeSH) OR “PTSD” OR “Psychological resilience” OR “Coping mechanisms”]

Articles were also searched in Scopus with the following thread of keywords:

[TITLE-ABS-KEY (“burns” OR “facial burns” OR “facial burn injury” OR “face burn” OR “thermal injury” OR “chemical burn” OR “electrical burn”)] AND [TITLE-ABS-KEY (“mental health” OR “psychosocial impact” OR “psychological distress” OR “depression” OR “anxiety disorders” OR “post-traumatic stress disorder” OR “PTSD” OR “psychological resilience” OR “coping mechanisms”)]

Eligibility Criteria

Inclusion criteria were peer-reviewed publications investigating the psychological, social, or quality-of-life outcomes associated with facial burns. The search was restricted to human studies published in English. Excluded studies were non-English publications and studies not examining psychosocial outcomes with burn treatment.

Selection of Sources of Evidence

Two reviewers (R.J.H. and J.K.) independently screened all abstracts to identify studies that fulfilled the eligibility criteria. Any disagreement between the reviewers was resolved by a third reviewer (J.E.L.). Qualitative data from each included study were extracted using standardization, including the study’s title, country of origin, study design and methods, population, patient sample size, and mental health outcome explored (Figure 1 and Table 1).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram.

Table 1.

Studies Included in Our Scoping Review.

Study	Country origin	Study design and methods	Population	Patient sample size	Mental health outcome explored	Mental health outcome significance
The impact of facial burns on short-term and long-term quality of life and psychological distress – a prospective matched cohort study 7	Germany	Prospective observational and matched cohort study design. SF-36 and HADS were completed by patients twice, control group completed them once	85% male with a median age of 37 in a German level 1 burn center. Thermal injuries: 85% fire, 7% electrical burn, 6% scald burn, and 2% contact burn. Median TBSA burned was 11%, with average involvement of 50% of the face. Most FBs healed without visible scarring at 1 y post-burn	110; 55 FB patients and 55 age- and sex-matched candidates for the control group. Also, comparable smoking status	HRQoL, as well as depression and anxiety levels	Depressive symptoms and self-esteem were not impacted by the severity of the individual’s scars; however, early depressive symptoms were associated with a worse self-scar rating, suggesting psychological testing be done routinely to prevent the formation of such perceptions in the individual’s mind
A fear avoidance model in facial burn body image disturbance 15	Greece	Literature review that included a cognitive behavioral approach in coping with facial disfigurement	N/A	N/A	Effect of facial disfigurement on body image and social integration	Cognitive behavioral therapy is an effective method for burn patients to cope and adjust to their new appearance, and can be beneficial in helping them reintegrate into social and interpersonal settings, establish confidence, and deal with adverse reactions from others
Psychological morbidity in patients with facial and neck burns 16	China	Not stated, but data were collected from surveys. Follow-up was done on 20 patients	Ages 6-72 y old, 74 males, 41 females. Seventy-four flame, 26 boiling water, 7 electric arc, 1 nitric acid, 5 sulfuric acid, and 2 electric contact burns. TBSA ranges from 1.2% to 26.5%. Sixty-five patients had deep partial thickness, 32 superficial partial thickness, and 18 full thickness. Post-wound healing, skin discoloration in 35, scar formation with visible deformity in 25 (7 received postage stamp skin grafting), and 18 excisions of burn wounds followed by autologous sheet grafting	115	QoL	Women, young adults, and individuals more heavily involved in social and cultural settings are more likely to suffer psychological distress as a result of sustaining burns. Individuals can utilize different psychological, surgical, and therapeutic treatment methods to cope with the burns and any accompanying injuries
Stigma and self-esteem in facial burn patients: a correlation study 4	China	Cross-sectional surveys in the form of questionnaires, which include sociodemographic and disease-related information questionnaires as well as the Chinese version of the Social Impact Scale, and the Self-Esteem Scale	Four burn units in China over the age of 18. Male 77.7%, average age of 36 y old; 83.8% had thermal burns, 8.1% electric burns, and 8.1% chemical burns	148	Stigma and self-esteem	Stigma and self-esteem are decreased in patients with FBs. Because there is a positive correlation between self-esteem and stigma, increasing the patient’s self-esteem can be an effective way to combat the stigma they perceive from other individuals
Impact of facial burns: relationship between depressive symptoms, self-esteem and scar severity 7	Netherlands	Prospective multicenter cohort study with 6 mo follow-up. Used Patient and Observer Scar Assessment Scale, Rosenberg Self-Esteem Scale, and HADS	Three Dutch burn centers included patients over 18 y old; 83% of participants were male with an average age of 40. Burns were mild to moderate, and the mean facial TBSA was 3.3%	132	Self-esteem and depressive symptoms	Same as the first study
The patient-body relationship and the “lived experience” of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment 17	Australia	Phenomenological study up to 4 mo of injury. Patients underwent the Burns Modified Adult Attachment Interview. Participants’ “lived experience” was the focus of the study	Two females and 4 males, average age of 43 y, with superficial to deep FBs from the severe burn injury unit in Australia. TBSA ranged from 0.8% to 55%	6	Relationships to self/other, coping, and more	Trauma-informed care is an important practice paradigm that must be implemented into the clinical setting to provide the best care possible for burn patients. The study showed that although patients experienced post-burn trauma, they used strategies like altruism and optimism to combat the negative aspects of the “lived experience” as a burns patient
Facial burns in Pakistani Cohort	Pakistan	Cross-sectional study: randomly selected patients were invited and recruited to undergo extra and intra-oral examinations and complete self-administered assessments. Deformity severity was assessed using the observer-rated disfigurement scale, with a greater rating indicating more severity. Caries were measured using the DMFT index, periodontal disease and oral hygiene status were measured using OHI-S and CPI. The composition score was determined using all 3 of these measures. OHRQoL was assessed using OHIP-14, which is a comprehensive instrument that assesses the impact of oral issues on several psychological and physical domains	Patients with FBs who attended the Burn Care Center in Islamabad, Pakistan. Patients were recruited if they were 15 y of age or older, with a burn injury that affected more than 10% of TBSA, including the H&N, and were able to feed with mouth	n = 271; 68.6% females, 78.9% under the age of 35, 65.7% with low income (<$140 USD); 48% with third degree burns, 88.9% with moderate to severe facial disfigurement	OHRQoL	OHRQoL is influenced by a plethora of factors, including dental caries, severity of the burns, oral hygiene practices, and time since the FB. Physicians who manage the care of burn patients, and the patients themselves, must be aware of these factors as they navigate the healing and subsequent maintenance process
Facial burns in children 5-18 18	USA	Longitudinal study. Parents of children aged from 5 to 18 y with burn injury completed the American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire at 6 mo intervals during the first 2 y, and then annually for up to 4 y after the child was discharged from acute care	Pediatric burn patients from ages 0 to 18, admitted for care into any 1 of the 4 Shriner’s Burns Hospitals across the country. Inclusion criteria were if the child was admitted within 30 d of sustaining injuries, at least 1 parent who was either English or Spanish speaking, and not subject to Child Protective Service guardianship. Parents were recruited either during acute care admission or at the first clinic visit after discharge	n = 678; 385 patients with an FB (56.8% of the sample) and 293 without an FB. Overall average age for the cohort was 9.1, average age for the FBs group was 9.3, and it was 8.7 for the non-FBs category. %TBSA burned was 34.5% for the overall group, 43.9% for the FBs group, and 22.1% for non-FBs. Overall, 72.1% male, 73.3% males in the FB category, and 70.7% males in the non-FB category	HRQoL with focus on physical, psychological, and social domains	FBs are much more likely to cause psychosocial distress in a cohort of young children, as compared to burns that do not involve the face
Looking in the mirror for the first time after facial burns: a retrospective mixed methods study 11	UK	Retrospective study with mixed methods. A study conducted qualitative and quantitative analyses through a questionnaire that collected patient data from April to July 2013. The questionnaire was developed by the authors and employed multiple-choice, anchored, Likert-scaled items, and open-ended questioning, along with patient interviewing	Patients treated for FBs at the Nottingham Burns Service in the UK were recruited for the study, using the iBID. Inclusion criteria were patients over the age of 18 y, fluent in English, with no known cognitive impairments. Patients who sustained burns due to self-injury or suicide attempts were excluded	n = 35, 20 patients were female (57%), the mean age was 46 (ranging from 19 to 94 y old). Thirty-one patients were White British, 1 patient was Black (African, Caribbean, or any other background), 1 was Asian (Indian, Pakistani, Bangladeshi, Chinese, or any other background), 1 was of “other ethnicity,” and 1 did not disclose. The study population was representative of iBID statistics on age, but not gender, as more males tend to have burn injuries nationally. Twenty-four patients (74%) had superficial or partial thickness burns, and 3 (12%) had full-thickness or deep dermal burns. The area of face affected was on average 1.2%. Average length of time since burn was 12 mo, ranging from 1 to 24 mo	Impact of FB on patients’ reaction and factors leading to distress when looking at themselves in the mirror for the first time after sustaining burns. Five domains were assessed: cognitive/affective/behavioral features before looking in the mirror, distress while looking at self, distress-related factors, comparisons vs expectations, and satisfaction	When looking in the mirror for the first time, on average, patients were moderately distressed, although the level of distress was less than compared to their expected. Distress was mainly related to preconceived negative images, preparation, and worry that were due to the burns. Adequately preparing the patients for viewing themselves for the first time is a crucial component of the recovery process that must be emphasized while starting the healing process
Burn morbidity: a follow-up study of physical and psychological disability 19	USA	Retrospective study. Burns patients’ records from 1970 to 1974 at the University of Utah Medical Center were retrospectively analyzed. Fifty-one patients and/or an immediate family member were personally interviewed or filled out a mailed questionnaire. The questionnaire included 4 basic sections: information pertaining to injury itself, psychological, physical, and social characteristics of the individual’s pre-burn life, post-burn status with aforementioned characteristics, and comparison of the individual’s activities before and after burns. The average duration of follow-up was 25.6 mo post-burn		n = 51, 37 males and 14 females, age range from 1 to 88. Average % BSB was 31.2%, with 22 patients (43%) having a facial/hand or just FB; 57% patients had a mixed third- and second-degree burn, 28% had only second-degree, and 15% had only third-degree	The study analyzed the effects of burn injuries on the patients’ ability to re-enter pre-burn physical and social activities, for example, in school and work environments. The impact of injuries on psychological domains was also assessed	Proper counseling for re-integration into societal activities and interactions is a crucial component of the post-recovery phase for patients. Although 79% of patients were able to return to work or school, proper coping strategies are necessary for a successful return
Rates, trends, and severity of depression after burn injuries 20	USA	Longitudinal study. Patient interviewing and chart review pertaining to emotional, rehabilitation, and physical status were conducted during inpatient hospitalization. Patients filled out further questionnaires upon discharge, and outpatient visits at 1 mo, 1, and 2 y intervals, or by mail if no appointment was made. Depressive symptoms were assessed using the BDI. Three groups of patients were identified: (1) those who provided depression scores once (n = 149), (2) twice (n = 76), and (3) 3 times (n = 33). There was no difference across all 3 groups for baseline depression, TBSA, age, or length of hospitalization	Patients at a regional burn center were recruited to be a part of a federally funded model rehabilitation system, from which longitudinal data were collected	n = 258 (197 males, 61 females); average age was 41 (range 18-81), on average spent 24 d in hospital (range 1-126). Mean %TBSA was 15.67% (range from 0.5% to 70%)	Rate and severity of depression in burn patients over time	Women had a higher prevalence of depression scores at each checkpoint, and there was an interaction between gender and depressive symptoms at the 1 mo and 1 y post-injury checkpoints. Routine depression screenings are recommended to ensure patients are properly healing
Risk factors for peri-traumatic distress and appearance concerns in burn-injured inpatients identified by a screening tool 21	England	Patients admitted to a burns unit were screened soon after admission using a psychosocial screen designed by the service. The questionnaire included items on pre-existing social support, coping, emotional, and psychological difficulties, as well as current trauma symptoms and current level of concern about changed appearance following the burn	Patients admitted to the Chelsea and Westminster Burns Service; 274 men, 187 women; age range = 16-96 y; mean age = 49.76; SD = 20.6. In terms of ethnicity, 45.8% of the sample identified as White British, 17% as White Other, followed by 3.7% as Black or Black British-African, 2.6% as Asian or Asian British-Indian, and 2.4% as Black or Black British-Caribbean. For 6.9% of the sample, ethnicity was recorded as “unable to choose”	461	Determine how frequently appearance and trauma concerns arise in a group of patients hospitalized for burn injuries. Also, determine which people are most likely to report these problems	Patients reported low levels of appearance concerns and trauma symptoms in the initial days following a burn injury. In those who did report concerns, there were some significant associations with demographic and other variables. Patients who experienced flashbacks were younger and had a larger TBSA burn. Higher levels of appearance concern were associated with younger women, larger TBSA, and FBs. However, the relationships found were weak and frequently confounded by other factors
Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: a Burn Model System National Database study 9	USA	Data were obtained from the Burn Model System National Database regarding characteristics of adult burn survivors with and without H&N burns. The data at 6, 12, and 24 mo after injury were compared for the following patient-reported outcome measures: SWL, CIQ, SWAP, SF-12 PCS, and SF-12 MCS	373 subjects had H&N burns while 324 had burns elsewhere. The 2 groups were similar in age (H&N burns, 44.6 ± 15.0 y; non-H&N burns, 44.8 ± 15.9 y) and gender (H&N burns, 73.7% male; non-H&N burns, 71.6% male). However, the subjects with H&N burns had larger burn sizes (26.0 ± 17.4 vs 13.3 ± 13.9; P < .001), were more likely to have a fire/flame injury (76.7% vs 42.6%; P < .001) and had longer lengths of stay in the hospital (37.5 ± 30.9 vs 24.0 ± 19.4; P < .001)	697	Investigate the differences in long-term patient-reported outcomes between those with and without H&N burns	Adult burn survivors with H&N burns show similar community integration, SWL, and physical outcomes to those with non-H&N burns. However, survivors with H&N burns exhibit worse satisfaction with their appearance compared to those without H&N burns
Facial disfigurement: Problems and management of social interaction and implications for mental health 3	USA	Longitudinal study where data were collected over an extended period through different studies and then synthesized to develop conclusions	N/A	N/A	Determine the impact of facial disfigurement on social interaction during brief encounters and the establishment of social relationships	Those with facial disfigurement have numerous methods they use to deal with the negative reactions in the social, such as developing a heightened level of awareness of others’ discomfort, acceptance of one’s disfigurement, or through the use of self-deprecating humor
Psychological consequences of burn injury 14	Great Britain	Postal questionnaires were completed by selected patients. The Hospital Anxiety Depression Scale, a self-assessment scale designed to detect mood disorders in non-psychiatric populations, and The Impact of Event Scale, designed to measure current subjective distress related to a specific event (post-traumatic stress disorder). This is a self-report scale based on items comprising the commonly reported experiences of intrusion and avoidance. In addition, information concerning mobility, functional impairment, visibility of burn, pain, etc., was gathered in a further series of questions	The patient sample comprised an unselected consecutive series of adult burn patients. All patients were included regardless of severity of burn, comorbidity, or demographic characteristics. All had been inpatients in the Burn Unit of Bangour General Hospital and were discharged between September 1988 and June 1989. Patients were contacted as near as possible to 1 y after first discharge from the unit	23	The major psychological conditions experienced by patients 1 y after burn injury were investigated	Over one-third of the patients were found to have premorbid characteristics that could predispose them to injury. Over one-third were still experiencing significant psychological problems. Anxiety was most common, followed by posttraumatic stress symptoms and depression. The visibility of the burn was found to be a useful factor in the prediction of psychological outcome. No additional variables were found to increase the significance of the prediction. Patients indicated that practical advice in the form of staff-led discussions, before or immediately after discharge, would be the most valuable help
Health-related quality of life after burns: a prospective multicenter cohort study with 18 mo follow-up 22	Netherlands	EQ-5D questionnaires were given to patients to assess QoL after burns. Eligible patients were invited to participate in the study during hospitalization, usually between 4 and 14 d. The first questionnaires were administered during the patients’ stay in the hospital, or patients took the questionnaires home if they were discharged from the hospital at an earlier time. Once patients left the burn center, a researcher/staff member of the burn center continued the follow-ups by sending mail with the follow-up questionnaires	Consecutive adult patients with acute burns admitted to 1 of 6 burn centers in the Netherlands and Belgium requiring hospitalization for at least 72 h were enrolled in the study between March 2003 and April 2005. Patients with poor Dutch proficiency and those with chronic psychiatric disorders (eg, psychotic disorders, suicide attempts) and cognitive disorders were excluded. Other reasons for exclusion of patients included being homeless or having physical handicaps, such as blindness, that make participation difficult or impossible	260	Quantify the health loss in patients with burns and then assess the contribution of injury extent, age, gender, and psychological factors to HRQoL and speed of recovery	Patients suffered from substantial health losses in the short term, but after 18 mo the majority reached a HRQOL comparable with the norm population, except for patients requiring 2 or more surgeries. The best predictor of long-term HRQOL and the speed of recovery was the number of surgeries, followed by psychological problems. Screening for traumatic stress is recommended
Adolescents with and without head and neck burns: comparison of long-term outcomes in the Burn Model System National Database 10	USA	Comparisons were made between 2 groups based on the presence of a H&N burn using the following patient-reported outcome measures: SWAP Scale, SWL Scale, CIQ, and SF-12 Health Survey at 6, 12, and 24 mo after injury. Regression analyses were used to assess the association between outcome measures and H&N group at 12 mo	Data collected for burn survivors between 14 and 17.9 y of age from the Burn Model System National Database	392	Examine the differences in long-term outcomes with and without H&N burns in adolescents	The H&N group had more extensive burns, had longer hospital stays, were more likely to be burned by fire/flame, and were more likely to be Hispanic compared to the non-H&N group. Regression analysis found that H&N burn status was associated with worse SWAP scores. No significant associations were found between H&N burn status and other outcome measures. Future research should examine interventions to help improve body image and coping for adolescent burn survivors with H&N burns
Handling traumatic experiences in facially disfigured female burn survivors 23	Pakistan	Cross-sectional study design. PSQ, SCQ, State-Trait Resilience Scale, Coping with Burns Questionnaire, and WHOQOL Brief Questionnaire were used for assessment	Female burn survivors with facial disfigurement	N = 100	QoL	The analyses showed a significant positive relationship among resilience, coping with burns, and social comfort. A significant negative relationship was found between perceived stigmatization and coping with burns, resilience, and social comfort. All these variables were tested for differentiation based on survivor’s age (less vs more than 30 y), occupation (housewife vs gainfully employed), education (less vs more than matriculation), social status (low vs middle class), family system (nuclear vs joint), siblings (yes vs no), residence (living in home vs shelter home), and psychological help received or not after the burn injury. Results indicate a mixed type of phenomenon among the variables’ differentiation. Path analysis through Analysis of Moment Structures (AMOS) resulted in a model showing no direct relationship of QoL with coping with burns, perceived stigmatization, and resilience; however, social comfort mediates the relationship between QoL and coping with burns, perceived stigmatization, and resilience
The effect of self-care nursing intervention model on self-esteem and quality of life among burn patients 24	Egypt	A quasi-experimental research design was utilized. A pretest and posttest were used to assess patients with second-degree burns after being exposed to a self-care nursing intervention model that included self-care requisites, stress management techniques, and strategies for improving self-esteem, in addition to routine hospital care. Three tools were used to assess: the Burn Assessment Tool, the Rosenberg Self-Esteem Scale, and the WHOQOL Scale	Thirty-four patients at the burn unit of the emergency hospital, Menoufia University at Menoufia governorate, Egypt	34 Patients	Self-esteem and QoL	There was a statistically significant improvement in self-care knowledge related to burn management after implementation of the self-care model. There was a statistically significant improvement in self-esteem and QoL among burn patients post-intervention compared to pre-intervention
The correlation between quality of life and acceptability of disability in patients with facial burn scars 25	China	Cross-Sectional Survey. The study collected demographic information, QoL, disability acceptance, and related factors of patients with FB scars after discharge. The questionnaires used included demographic data and investigations using the burn scars table, BSHS-B, and ADS	Patients with FB scars were investigated in an outpatient clinic of tertiary hospitals in Guangzhou, China	121 Valid questionnaires	QoL and disability acceptance	The overall QoL of patients with FB scars was divided into 77-160 points with an average score of 137.0 ± 17.05 points, indicating that the QoL of patients with FB scars is at a moderate or low level. The results of this study show that the total score of disability acceptance of FB scar patients is 185.68 ± 23.74, which is close to the score of other subjects (181.46 ± 39.45) and higher than the score range of the low level of acceptance. This finding indicates that the disability acceptance of burn scar patients is at a medium level and still needs to be improved. The QoL of FB scar patients will improve with the improvement of disability acceptance level
Assessment of psychological status and quality of life in patients with facial burn scars 26	India	Questionnaire-based study. Patients had sustained burns at least 6 mo from the time of interview up to a maximum of 5 y prior. Patients then completed Beck’s Depression Inventory, and WHOQOL Questionnaire – Brief (Hindi version) to assess their psychological profile and overall QoL	Group 1: patients with FBs without deformity of the faceGroup 2: patients with FBs with deformity of the face	20 Patients	Level of depression and QoL	The study showed an equivocal presence of depression in all the burn scar patients, irrespective of their gender. Men were found to have a lower degree of depression as compared with women. Subjects showed marked differences in QoL categories of psychological well-being and social relationships
Rehabilitation of burn victims: improving quality of life in victims with face and neck burn through an augmented reality coupled pamphlet 13	Iran	Intervention group: patients were asked to use the AR software during their stay in the burn center (2 wk) up to 4 wk after discharge (a total 6 wk). The patients had to execute their physical rehabilitation program based on the content of the AR-coupled pamphlet every day, considering their personal endurance and capacity. The patients were asked to perform the exercises at least 4 to 5 times a day, simultaneously with the AR coupled pamphlet, and to complete the exercise checklist daily. Every day, all patients were contacted by the researcher to remind the exercises and to ensure the correct use of the AR softwareControl group: in this group, after the completion of the BSHS-FN, the method of performing the physical rehabilitation exercises during the hospital stay until 4 wk after discharge was explained to the patients by their bedside through oral training for about 30 to 45 min. Then, a simple educational pamphlet with content similar to the oral training was given to them as well.Both groups completed the Burn Specific Health Scale for Face and Neck (BSHS-FN) 2 and 6 wk after starting the exercises	Patients with face/neck burns	60 Patients	QoL	The results of this study showed that a rehabilitation program for patients with face and neck burns using AR after discharge helps improve their QoL and can be considered as a practical method for burn patients to perform physical rehabilitation exercises

Abbreviations: ADS, Acceptance Disability Scale; AR, augmented reality; BDI, Beck Depression Inventory; BSB, body surface burn; BSHS-B, Burn-Specific Health Scale – Brief; CIQ, Community Integration Questionnaire; CPI, Community Periodontal Index; FB, facial burn; H&N, head and neck; HADS, Hospital Anxiety and Depression Scale; iBID, International Burn Injury Database; MCS, mental component score; OHIP-14, Oral Health Impact Profile-14; OHI-S, Oral Hygiene Index – Simplified; OHRQoL, oral health-related quality of life; PCS, physical component score; PSQ, Perceived Stigmatization Questionnaire; QoL, quality of life; SCQ, Social Comfort Questionnaire; SD, standard deviation; SF-36, 36-Item Short Form; SWAP, satisfaction with appearance; SWL, satisfaction with life; TBSA, total body surface area; WHOQOL, World Health Organization Quality of Life.

Results

Psychological Burden and Mental Health Outcomes

Facial burns impose an unparalleled psychological burden, with anxiety, depression, and post-traumatic stress disorder (PTSD) emerging as dominant outcomes. The visibility of facial burns amplifies emotional distress by continuously exposing survivors to altered self-perception and stigmatizing social interactions. Studies consistently show that individuals with facial burns experience significantly elevated levels of psychological distress compared to those without visible injuries. For instance, Hospital Anxiety and Depression Scale scores revealed heightened anxiety (4.8 ± 3.2) and depression (3.9 ± 3.5) in facial burn patients compared to controls (anxiety: 2.5 ± 2.8, P < .002; depression: 2.1 ± 2.7, P = .01). ¹ These symptoms persisted even 1 year post-injury, underscoring the chronic nature of psychological distress.

The interplay between body image dissatisfaction and psychological outcomes is evident, with early depressive symptoms predicting worse self-esteem and higher scar severity 6 months post-burn. ⁷ Women and younger patients demonstrate greater vulnerability to PTSD and depression compared to their counterparts, as reflected in risk scores (P < .001). ⁸

Stigma, Body Image Dissatisfaction, and Their Interconnections

Medium-level stigma scores (58.01 ± 7.57) and low self-esteem scores (19.72 ± 2.43) were indicative of the challenges burns patients face, and the positive correlation between stigma and self-esteem (r = 0.286, P < .01) highlights the cyclical relationship between these factors. ⁴ In addition, socioeconomic factors such as income and education were shown to significantly predict stigma levels, accounting for 33.7% of its variation (F = 8.659, P < .01).

Body image dissatisfaction was a recurring theme across studies, with patients with facial burns frequently reporting lower satisfaction with appearance compared to those with non-facial burns. For example, SWAP scores were significantly worse among facial burn survivors (P < .01). ⁹ Adolescents with facial burns demonstrated persistent dissatisfaction with their appearance 1 year post-injury, further reinforcing the link between stigma, self-perception, and mental health. ¹⁰

Mirror exposure often serves as a pivotal moment in shaping survivors’ self-image and emotional response. Nearly half of the patients expressed apprehension before viewing their reflection, and 27% avoided mirrors altogether initially. ¹¹ For this reason, Shepherd et al found that preparing patients for this experience was of paramount importance, as it mitigated stress, fostered resilience, and was an integral part of the healing process.

QoL and Interventions

Facial burns adversely affect QoL across physical, psychological, and social domains. QoL scores were significantly lower among facial burn survivors, with scar severity negatively correlating with physical and psychological well-being. ¹² Rehabilitation strategies, such as augmented reality (AR)-based interventions, have shown promise in improving outcomes. A randomized clinical trial demonstrated significant gains in QoL scores after 6 weeks of AR-coupled rehabilitation compared to baseline (P < .001). ¹³

Discussion

This scoping review assessed the impact of facial burns on affected individuals and the psychological burden and challenges that these patients faced. By analyzing the included studies, we uncovered important connections between the psychological impacts that facial burns have on individuals as well as the detriment they serve to the QoL of these patients. These findings accentuate the negative implications associated with facial burns and provide a framework for improving the problem. Despite being a scoping review, this study offers significance by providing a comprehensive overview of the current psychological impacts of facial burns. It offers healthcare professionals, researchers, and policymakers a consolidated foundation on which to build more targeted and evidence-based interventions against this problem.

Anxiety, depression, and PTSD were greatly increased in this population, underscoring the importance of integrating mental healthcare into burn treatment.^8,14 The heightened vulnerability of women and younger patients indicates that targeted psychological interventions toward those populations may be beneficial in diminishing long-term distress. ⁸ Importantly, the integration of trauma-informed care, psychological screening, and reconstructive surgery into routine burn management can enhance recovery. Early identification of high-risk individuals, particularly women and adolescents, is critical. Studies underscore the necessity of holistic approaches that address the psychological, social, and physical dimensions of recovery. These findings highlight the need for a multidisciplinary approach to provide comprehensive mental health support. One of the most striking findings within the literature is the impact of facial burns on body image and self-esteem. Body image dissatisfaction and stigma contribute to a persistent state of psychological distress. Social stigma remains a detriment to the recovery process within patients, as the perception that society has on physical appearance significantly affects self-worth and body image.^4,15 The positive relationship between body image and self-esteem suggests that addressing societal attitudes and providing psychosocial support can be crucial in treating facial burn patients, leading to more favorable outcomes psychologically. In addition to this, mirror exposure also presents as a potential aid in the recovery process as it unveils the psychological challenges that patients face while confronting their distorted appearance. Many patients experienced apprehension or avoidance when seeing their reflections post-burn, leading to the integration of structured mirror exposure therapy to ease the transition. ¹¹ Another therapy that proved to be particularly effective for facial burn patients was cognitive-behavioral therapy (CBT). The use of the Newell CBT model targeted the fears of these patients by encouraging gradual confrontation of the social anxieties that these individuals suffer, leading to the development of adaptive coping strategies. ¹⁵ Psychological preparation and support during these critical moments aid in alleviating distress and promoting acceptance of one’s new appearance.

While this scoping review provides valuable insight into the psychosocial impacts of facial burns, several limitations must be addressed. The librarian at our institution suggested to data from Scopus and PubMed. This provided the study with valuable insights, but a more comprehensive review incorporating additional databases such as MEDLINE and Embase would be beneficial for capturing a more diverse range of literature on facial burns and mental health. The inclusion of only peer-reviewed, English-language studies may have been impacted by selection bias, leading to the potential omission of relevant research papers from non-English sources. Furthermore, variability in study designs, patient populations, and measurement tools across the included studies may have affected the standardization of the reported outcomes. Many studies relied on self-reported psychological measures, which may introduce a level of response bias. In addition, many of these studies were conducted in high-income countries, limiting the broadness of findings to low- and middle-income countries where access to facial burn care may differ drastically.

Further research should aim to validate and expand upon the findings presented in this paper. Future studies should utilize longitudinal designs to assess the long-term psychological effects of facial burns, as most current literature lacks follow-up beyond 1 year post-injury. In addition, the design of randomized controlled trials to evaluate the efficacy of structured mirror exposure therapy in reducing body image distress and self-esteem to improve QoL. The role of social support networks and peer mentorship programs should also be explored to determine the efficacy in treating the psychological issues within facial burn survivors.

Conclusion

This study aimed to assess the impact of Mental Health Outcomes and The Psychosocial Consequences of Facial Burns. The results indicate a significant association between facial disfigurement and increased risk of obstacles surrounding self-esteem and QoL. Facial burns present a multifaceted challenge, profoundly affecting not only physical health but also mental and psychosocial well-being. This scoping review underscores the significant psychological burden associated with facial burn injuries, including heightened anxiety, depression, PTSD, and body image dissatisfaction. The cyclical relationship between stigma, self-esteem, and QoL highlights the need for comprehensive, patient-centered care. While emerging interventions such as cognitive behavioral strategies and AR-based rehabilitation show promise, further high-quality longitudinal studies are necessary to validate their efficacy. Integrating psychological screening, trauma-informed care, and tailored interventions into routine burn management can promote holistic recovery. Prioritizing mental health support alongside rehabilitation is essential in improving outcomes and enhancing the overall QoL for facial burn survivors.