Ultrapulsed fractional ablative carbon dioxide laser treatment of hypertrophic burn scars: evaluation of an in-patient controlled, standardized treatment approach

Evaluating the combination and comparison of ablative fractional lasers (CO2, Erbium-YAG) with pulsed dye laser (PDL) for treating hypertrophic scars: a systematic review

The aim of this study is to compare pulsed dye laser (PDL) and ablative fractional lasers (CO2, Erbium-YAG) in the treatment of hypertrophic scars in a systematic review. Databases including Web of Science, Science Direct, Google Scholar and PubMed were searched for clinical trials up to December 1, 2022; focusing on the role of ablative fractional lasers and pulsed dye lasers in treating hypertrophic scars, using comprehensive keywords and search syntaxes. Key data extracted included type of scars, the assessment indexes, treatment modalities, side effects and the final conclusion of each article. We found no significant difference between the PDL and the ablative fractional laser in the treatment of hypertrophic scars, and both showed significant improvement. The average number of treatment sessions in the group receiving ablative fractional laser was 3.43 sessions, in the group receiving PDL, 3.68 sessions, and in the group receiving the combination of the two lasers, 1.5 sessions. Ablative fractional laser was 57.5% effective in VSS scoring and 40.4% effective in POSAS scoring, while PDL laser was 49.4% effective in VSS scoring and 35.5% effective in POSAS scoring, also the combination of both methods may lead to better results and higher efficacy with no severe adverse reactions noted. More high-quality trials are needed to fully confirm the effectiveness of laser therapy. Ablative fractional laser and PDL are both effective in treating hypertrophic scars and there was no significant difference between them. However, studies investigating the combination of these two lasers have reported greater effectiveness than each method alone.

Impact of Fractional Ablative Laser Therapy on Function, Symptoms, and Quality of Life in the Management of Traumatic Scars: A Review

OBJECTIVES

A substantial and expanding body of literature addresses the safety and efficacy of fractional ablative laser therapy for traumatic scarring resulting from burns and other trauma. However, available scar research commonly employs standardized assessment scales that generally do not directly address the impact on function and overall quality of life. Unlike past reviews, this manuscript will explore available evidence with a focus explicitly on function and quality of life (QoL) outcomes and de-emphasize surrogate outcome measures that rely primarily on visual characteristics.

METHODS

Through literature review conducted up to January 2024, the authors examined relevant studies focusing on function and quality of life outcomes in traumatic and burn scar management with fractional ablative laser therapy. PubMed, EMBASE, MEDLINE, and Cochrane Library were utilized as primary databases. Reference lists were secondarily reviewed to supplement the literature review process. Studies that did not highlight functional or QoL endpoints or were not in the English language were excluded.

RESULTS

The reviewed studies demonstrated that fractional ablative therapy led to consistent significant and meaningful improvements in functional outcomes, relief from pruritus and pain, and overall enhancements in quality of life for patients with traumatic scarring. Adverse events associated with fractional ablative therapy were infrequent and generally of mild severity, indicating a favorable safety profile.

CONCLUSIONS

The findings from this literature review document ample existing evidence supporting the efficacy and safety of fractional ablative therapy to enhance function, mobility, reduce pruritus and pain, and improve overall QoL. Fractional ablative laser therapy should be integrated more widely into standard management protocols. Given the previous reliance on standardized scar assessment tools that heavily integrate visual characteristics, future studies should prioritize functional and QoL outcomes to further advance scar management protocols and optimize patient care.

Altering CO2 Laser Pulse Energy Settings Did Not Influence Differential Gene Transcription in Normal Skin in a Red Duroc Pig Model

OBJECTIVES

Fractional ablative CO2 lasers are used clinically to treat cutaneous burn scars with reported varying degrees of effectiveness. It was hypothesized that different laser pulse energy settings may lead to differential gene transcription in a porcine model.

METHODS

Uninjured skin from red Duroc pigs was treated with a fractional ablative CO2 laser set to 70, 100, or 120 mJ across the abdomen (n = 4 areas per treatment). Punch biopsies of both treated and untreated sites were taken before treatment (baseline), at 30 min, and at each hour for 6 h and stored in All-Protect tissue reagent. The biopsies were then used to isolate RNA, which was subsequently used in qRT-PCR for eight genes associated with wound healing and the extracellular matrix: CCL2, IL6, FGF2, TIMP1, TIMP3, COL1A2, MMP2, and DCN. RPL13a was used as a housekeeping gene to normalize the eight genes of interest. One-way ANOVA tests were used to assess for differences among laser pulse energies and two-way ANOVA tests were used to assess the differences between treated and untreated areas.

RESULTS

While six of the eight genes were upregulated after treatment (p < 0.05), there were no significant differences in gene expression between the different laser pulse energies for any of the eight genes.

CONCLUSION

While laser treatment is correlated with a positive and significant upregulation for six of the eight genes 4 h after intervention, the pulse energy settings of the laser did not lead to a statistically significant difference in gene transcription among the treatment areas. Different laser pulse energies may not be required to induce similar cellular responses in a clinical setting.

Prospective Evaluation of Fractional Carbon Dioxide Laser Treatment of Mature Burn Scars, Post-traumatic Scars, and Post-acne Scars

BACKGROUND

Annually, around 100 million patients worldwide acquire scars, some of which can cause significant problems. Various treatment interventions, such as topical scar creams, steroids, laser therapy, and surgery, have been developed to manage these scars. This study was conducted to evaluate the effectiveness of fractional CO2 laser treatment by assessing outcomes using the Patient Observer Scar Assessment Scale (POSAS) and clinical photographs.

MATERIALS AND METHODS

A total of 47 patients were included in the study, divided into three groups: a post-acne scar group with 14 patients, a post-burn scar group with 17 patients, and a post-traumatic scar group with 16 patients. Detailed histories were taken, and clinical examinations were performed and recorded on a prepared proforma. Aesthetic outcomes were evaluated based on clinical photographs, and total patient and observer scores were recorded using POSAS at baseline, and after one and three months. POSAS comprises two components: the observer scale (POSAS-O) and the patient scale (POSAS-P). Fractional CO2 laser treatments were performed in each group, with sessions repeated every four weeks for three consecutive sessions. Data were analyzed using the paired t-test for before-and-after comparisons in each study group. Welch's ANOVA test was used for comparisons among the three groups at a significance level of p=0.05, using MS Excel (Microsoft Corporation, Redmond, Washington) and IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York).

RESULTS

The mean age for men was 26.38 ± 8.19 years and for women 22.21 ± 6.38 years. The study comprised 34 female patients (72.34%) and 13 male patients (27.66%). The mean POSAS observer and patient scales were recorded and compared for all three types of scars from baseline to three months. The mean percentage change in POSAS-O and POSAS-P (total score) in relation to different scar sites was recorded. The most significant difference in mean percentage change, statistically significant (p-value < 0.05), was observed for facial scars, followed by scars on the neck, and was minimal for scars on the hand, in both observer and patient groups. Even a single session of fractional CO2 laser therapy had profound effects on the overall quality of scars.

CONCLUSION

Fractional carbon dioxide laser therapy improves the quality of scars and produces significant improvements in skin texture, with better effects on post-traumatic scars than on post-burn and post-acne scars. Future studies are needed to better understand the mechanism of action and to optimize the doses and timing of therapy.

Re-recognition of the role of roughness in keloid assessment

BACKGROUND

Under visual observation, keloids are more rough than normal skin. This roughness may be used to assess the activity and severity of keloids but lacks the support of objective and accurate evidence. The purpose of this study was to verify the role of roughness in the development of keloids and to clarify the advantage of roughness in the comprehensive assessment of keloids.

METHODS

Patients with keloids who attended Peking Union Medical College Hospital were recruited. Keloids were classified into progressive, stable, and atrophic stages based on the change in size over the past year and blood perfusion. The keloids were evaluated using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). The roughnesses of the keloid and normal skin were measured using the Phaseshift Rapid In vivo Measurement Of the Skin (PRIMOS), and blood perfusion was measured using laser speckle contrast imaging (LSCI).

RESULTS

Thirty-three patients with a total of 81 keloids were included. The surface roughness values Sa, Sq, and Sz of the keloid region were 243.70 (143.85-328.05), 316.20 (179.85-475.20), and 1708.20 (1098.30-4087.20), respectively, which were 4.87, 4.80, and 3.08 times higher than those of normal skin. There were significant differences in roughness among the different keloid stages. A significantly strong correlation between roughness and other assessed indices was found.

CONCLUSIONS

Roughness as a morphological characteristic is of great value in the evaluation of keloids. It is recommended as an important examination for keloids.

Efficacy and safety of ablative CO2 fractional laser and narrowband intense pulsed light for the treatment of hypertrophic scars: a prospective, randomized controlled trial

BACKGROUND AND OBJECTIVES

Hypertrophic scarring is a complex process, and numerous methods have been introduced to treat scars. This study aims to evaluate the effect of combined CO2 fractional laser and narrowband intense pulsed light (IPL) compared to IPL alone in the treatment of hypertrophic scars.

MATERIALS AND METHODS

This was a prospective, randomized controlled study enrolled 138 patients with hypertrophic scars. The participants were randomly divided into two groups: CO2-IPL and IPL group, and received three sessions at 10-14-week intervals for 3-month follow-up. Two independent plastic surgeons evaluated the treatments using the Patient and Observer Scar Assessment Scales (POSAS). Overall satisfaction was evaluated using the Patient Satisfaction Scale (PSS).

RESULTS

101 subjects completed the study. Compared to single IPL, the combination CO2-IPL group showed a significant improvement in itching, color, stiffness, thickness, and irregularity, except for pain, and an enhancement in vascularization, pigmentation, thickness, relief, and pliability of the scar, assessed by POSAS (p < .01). 100% patients in the combination group were satisfied compared to 84% in IPL alone.

CONCLUSION

The combination of CO2 fractional laser and narrowband IPL efficiently improved the appearance and profile of hypertrophic scars, offering a comprehensive and reliable approach for scar therapy.

Scars

Wound healing occurs as a response to disruption of the epidermis and dermis. It is an intricate and well-orchestrated response with the goal to restore skin integrity and function. However, in hundreds of millions of patients, skin wound healing results in abnormal scarring, including keloid lesions or hypertrophic scarring. Although the underlying mechanisms of hypertrophic scars and keloid lesions are not well defined, evidence suggests that the changes in the extracellular matrix are perpetuated by ongoing inflammation in susceptible individuals, resulting in a fibrotic phenotype. The lesions then become established, with ongoing deposition of excess disordered collagen. Not only can abnormal scarring be debilitating and painful, it can also cause functional impairment and profound changes in appearance, thereby substantially affecting patients' lives. Despite the vast demand on patient health and the medical society, very little progress has been made in the care of patients with abnormal scarring. To improve the outcome of pathological scarring, standardized and innovative approaches are required.

A bibliometric and visualized research on global trends of scar, 2011-2021

OBJECTIVE

Pathological scars are the results of abnormal wound healing, which not only affect the appearance, but may also be accompanied by significant psychosocial burdens. In this study, we aimed to conduct a bibliometric and visualized analysis on pathological scars and provide directions for future research.

METHODS

The articles on scar research from 2011 to 2021 in the Web of Science Core Collection database were collected. The bibliometrics records were retrieved and analyzed with Excel, CiteSpace V and VOSviewer.

RESULTS

A total of 944 scar research records published between 2011 and 2021 were collected. Publication output has shown an upward trend as a whole. China ranked first in terms of country contributions (418 publications, 5176 citations), while Germany, with only 22 studies published, had the highest average citation rate (57.18). Shanghai Jiaotong University was the institution with the largest number of related articles published, followed by the fourth military medical university, the University of Alberta and the Second military medical university. Wound repair and regeneration, Burns, Journal of Burn Care & Research, Journal of Cosmetic Dermatology published the most research in this field. Dahai Hu was the most prolific author, while Rei Ogawa was the most cited. The cluster analysis of the reference contributions and keywords indicated that current research hotspots mainly include pathogenesis, treatment strategies, and the safety evaluation of new scar treatment options.

CONCLUSION

This study provides a comprehensive summary and analysis of the current status and research trends of pathological scars. International research interest in pathological scars is on the rise, and high-quality studies related to the field have also increased in the last decade. The pathogenesis of pathological scars, treatment strategies, such as fractional ablative CO2 laser and molecular targeted therapy, and the safety evaluation of new treatment options will be the focus of future research.

Laser, Intense Pulsed Light, and Radiofrequency for the Treatment of Burn Scarring: A Systematic Review and Meta-Analysis

Burns and scarring are considered some of the greatest problems in public health because of their frequent occurrence. Today, photo-electric technology shows promising results in the treatment of burn scars. Over the years, more clinical trials and more technologies for scarring have emerged. The aim of this study was to determine better timing and methods of photo-electric therapy for burn scars. This study was registered in PROSPERO (CRD42023397244), following the PRISMA statement, and was carried out in concordance with the PRISMA checklist. In October 2022, we searched PubMed.gov, Embase, and the Cochrane library (1980-present) for published studies related to the photo-electric treatment of burn scars. Two review authors independently selected the studies, extracted the data, assessed the risk of bias among the studies included, and carried out NIH assessments to assess the certainty of the evidence. A third review author arbitrated any disagreements. Our research included 39 studies. We found evidence suggesting that photo-electric therapy between six months and one year offers significantly better outcomes than treatment of scarring after one year. The evidence also suggests the use of IPL for the treatment of early burn scarring. However, it is important to emphasize that the scientific evidence remains insufficient. We need more clinical trials of higher quality and with less heterogeneity to confirm our results.

Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies

Hypertrophic scars and keloids can have significant detrimental effects on patients both psychosocially and functionally. A careful identification of patient risk factors and a comprehensive management plan are necessary to optimize outcomes. Patients with a history of dystrophic scarring should avoid unnecessary procedures and enhance the wound-healing process using various preventive strategies. As there is no single, fully efficacious treatment modality, prevention remains the best approach in reducing aberrant scar formation. When prevention therapies fail, keloids have been shown to be respond to a variety of therapies including topical and injectable corticosteroids, 5-fluorouracil, radiotherapy, lasers, and surgical excision, all with varying efficacies. As such, management should be tailored to the individual patient's risk factors with the use of combination therapies to reduce recurrence rates. Still, keloid and hypertrophic scar therapies are widely diverse with novel treatment modalities providing alternatives for recurring lesions. Laser-assisted drug delivery, skin priming, and novel topical therapies may provide alternative options for the management of hypertrophic scars and keloids.

Vascular and Collagen Target: A Rational Approach to Hypertrophic Scar Management

Significance: Hypertrophic scarring is a challenging issue for patients and clinicians. The prevalence of hypertrophic scarring can be up to 70% after burns, and patients suffer from pain, itching, and loss of joint mobility. To date, the exact mechanisms underlying hypertrophic scar formation are unclear, and clinical options remain limited. Recent Advances: Several studies have demonstrated that pathological scars are a type of hyperactive vascular response to wounding. Scar regression has been found to be accompanied by microvessel occlusion, which causes severe hypoxia, malnutrition, and endothelial dysfunction, suggesting the essential roles of microvessels in scar regression. Therefore, interventions that target the vasculature, such as intense pulsed light, pulsed dye lasers, vascular endothelial growth factor antibodies, and Endostar, represent potential treatments. In addition, the mass of scar-associated collagen is usually not considered by current treatments. However, collagen-targeted therapies such as fractional CO₂ laser and collagenase have shown promising outcomes in scar treatment. Critical Issues: Traditional modalities used in current clinical practice only partially target scar-associated microvessels or collagen. As a result, the effectiveness of current treatments is limited and is too often accompanied by undesirable side effects. The formation of scars in the early stage is mainly affected by microvessels, whereas the scars in later stages are mostly composed of residual collagen. Traditional therapies do not utilize specific targets for scars at different stages. Therefore, more precise treatment strategies are needed. Future Directions: Scars should be classified as either "vascular-dominant" or "collagen-dominant" before selecting a treatment. In this way, strategies that are vascular-targeted, collagen-targeted, or a combination thereof could be recommended to treat scars at different stages.

A Single-Institution Experience About 10 Years With Children Undergoing Fractional Ablative Carbon Dioxide Laser Treatment After Burns: Measurement of Air Pressure-Induced Skin Elevation and Retraction Time (Dermalab) Including Standardized Subjective and Objective Scar Evaluation

Laser treatment has gained more and more importance in the therapy of scars during the last years. Scientific work, especially in children, is scarce on this topic and mostly with an insufficient number of cases or only subjective descriptions. Our study included 77 children from 2012 to 2022 with scars after thermal injury. These were treated at least three times or more by CO2 laser or in combination with pulsed dyed laser (PDL). Beforehand, scar texture and elasticity were determined by a skin elasticity analysis system. Regarding the subjective evaluation, a questionnaire was given to the patients or their parents. Further criteria were the Patient and Observer Scar Assessment Scale (POSAS) and Vancouver Scar Scale (VSS). A statistically significant improvement in elasticity was demonstrated in all scars of any age after each laser treatment. In addition, a significant correlation was found between the number of laser treatments and an increase in elasticity. The assessments of scars after one or more laser sessions by the observer as well as the patient showed a decreasing score in all categories with an increase in the number of laser therapies. The VSS score also improved significantly after each laser session. The mean score before treatment was about 7, after the first laser session, the mean score was already below 6 with a statistical significance. Ninety-six percent of the patients or their parents were satisfied with the laser therapy, and 90% wished to repeat the procedure. This work confirms, by means of the objectification by the scar measurement, the previous scientific works concerning a scar therapy by laser and emphasizes particularly that this can also be used without problems with children with symptomatic scars, contractures, or with cosmetically relevant scars.

Evaluation of Scar Quality after Treatment of Superficial Burns with Dressilk® and Suprathel®-In an Intraindividual Clinical Setting

Background: Various synthetic and biological wound dressings are available for the treatment of superficial burns, and standard care differs among hospitals. Nevertheless, the search for an ideal wound dressing offering a safe healing environment as well as optimal scar quality while being economically attractive is a continuing process. In recent years, Dressilk^®, which consists of pure silk, has become the standard of care for the treatment of superficial burns in our hospital. However, no long-term scar-evaluation studies have been performed to compare Dressilk^® with the often-used and more expensive Suprathel^® in the treatment of superficial burns. Methods: Subjective and objective scar evaluations were performed three, six, and twelve months after treatment in patients who received simultaneous treatment of 20 superficial burn wounds with both Suprathel^® and Dressilk^®. The evaluations were performed using the Vancouver Scar Scale, the Cutometer^®, Mexameter^®, Tewameter^®, and the O2C^®. Results: Both dressings showed mostly equivalent results in subjective scar evaluations. In the objective scar evaluations, the wounds treated with Dressilk^® showed a faster return to the qualities of non-injured skin. Wound areas treated with the two dressings showed no significant differences in elasticity and transepidermal water loss after 12 months. Only oxygen saturation was significantly lower in wound areas treated with Suprathel^® (p = 0.008). Subjectively, wound areas treated with Dressilk^® showed significantly higher pigmentation after six months, which was not apparent after 12 months. Conclusion: Both wound dressings led to esthetically satisfying scar recovery without significant differences from normal uninjured skin after 12 months. Therefore, Dressilk^® remains an economically and clinically interesting alternative to Suprathel^® for the treatment of superficial burns.

Effectiveness of artesunate combined with fractional CO2 laser in a hypertrophic scar model with underlying mechanism

BACKGROUND AND OBJECTIVES

Both artesunate and fractional CO2 laser have been proved effective in the treatment of hypertrophic scars, yet little data are available for the efficacy of artesunate combined with fractional CO2 laser. In order to assess the pre-clinical significance and the underlying mechanism of this combined treatment profile, we attempted to observe the effectiveness of this therapy in rabbit models through determining the expression of BMP-7 and Fas.

MATERIALS AND METHODS

Twenty-Four New Zealand white rabbits with established hypertrophic scar samples were randomly divided into control group and three treatment groups. Artesunate (20 μl/cm2) was injected into the rat's scar of artesunate and combination groups, while fractional CO2 laser (Combo mode, deep energy:10 mJ, super energy: 50 mJ) was applied to rats in fractional CO2 laser and combination groups at week 4 after model establishment. All rabbits underwent a total of 3 sessions of treatment once every 2 weeks. Histological and immunohistochemistry study, Western blot assay, cell viability, ELISA and RT-QPCR were performed at week 10 to observe the aspects of hypertrophic scar sample changes and expression of BMP-7 and Fas in the scar tissues.

RESULTS

Compared with control group, hypertrophic scars and the collagen fibers were significantly inhibited after treatment, and higher inhibition was seen in the samples in combination group compared to that in artesunate and fractional CO2 laser groups (P < 0.01). Meanwhile, BMP-7 and Fas expressions were both notably increased in all treatment groups, and upregulation of the two proteins was dominant in combination group (P < 0.01).

CONCLUSIONS

Artesunate combined with fractional CO2 laser is effective in hypertrophic scarring in this rabbit model. Our findings can serve as a potential alternative strategy to treatment of hypertrophic scar in clinical practice.

Molecular Features of Hypertrophic Scars After Thermal Injury: Is There a Biologic Basis for Laser Therapy?

Significance: Hypertrophic scars (HTS) and keloids are common after thermal injuries and other trauma to deep regions of dermis of the skin. These abnormal scars can cause contractures and the thick masses of scar tissue that result in functional and cosmetic impairment. Management of these dermal fibrotic conditions includes a wide range of medical and surgical treatments, which can be time consuming, only partially effective, and often uncomfortable for patients. Recent Advances: The molecular pathophysiology of HTS has become more understood over the past two decades, where thermal injury to the reticular dermis results in an inflammatory response, fibrogenic growth factor release, and the formation of a dermal scar with increased collagen and proteoglycan composition in an abnormal morphology. Lasers are becoming a widely used form of treatment for these types of scars; however, the evidence for the beneficial effects of laser treatments and the understanding of their mechanism of action are still evolving. Critical Issues: Paradoxically, laser delivery of thermal energy to the skin is suggested to improve scar remodeling and wound healing, yet HTS is a well-recognized complication of excessive thermal energy delivered by laser treatments. This review aims to examine the current evidence for the use of lasers for HTS, and to investigate the molecular mechanisms where re-injury of a burn scar from laser treatment could result in overall improvements in scar quality. Future Directions: Improved design of clinical trials for the treatment of scarring in the future will evolve from new methodology and models of HTS in animals and humans.

Efficacy and safety of a dual-scan protocol for carbon dioxide laser in the treatment of split-thickness skin graft contraction in a red Duroc pig model

BACKGROUND

Fractional CO₂ laser plays an important role in scar management post split-thickness skin graft by loosening the graft contracture and restoring the smoothness of the surface. However, the optimal treatment protocol remains unknown. This study applied a dual-scan protocol to achieve both releasing and ablation of contracted skin graft. We comprehensively describe this treatment method and compare the efficacy and safety between this dual-scan method and the conventional mono-scan mode.

METHODS

A hypercontracted scar model after split-thickness skin grafting in red Duroc pigs was established. All scars meeting the inclusion criteria were randomly divided into four groups: high fluence-low density (HF-LD), low fluence-high density (LF-HD), combined group and control group. The energy per unit area was similar in the HF-LD and LF-HD groups. Two laser interventions were performed at a 6-week interval. The efficacy of the treatment was evaluated by objective measures of scar area, release rate, elasticity, thickness and flatness, while the safety was evaluated based on adverse reactions and melanin index. Collagen structure was observed histologically. The animals were followed up for a maximum of 126 days after modeling.

RESULTS

A total of 28 contracted scars were included, 7 in each group. At 18 weeks postoperatively, the HF-LD and the combined groups showed significantly increased scar release rate (p = 0.000) and elasticity (p = 0.036) and decreased type I/III collagen ratio (p = 0.002) compared with the control and LF-HD groups. In terms of flatness, the combined group was significantly better than the HF-LD group for elevations <1 mm (p = 0.019). No significant skin side effects, pigmentation or scar thickness changes were observed at 18 weeks.

CONCLUSIONS

Dual-scan protocol could achieve superficial ablation and deep release of contracted split-thickness skin graft in a single treatment, with similar contraction release and texture improvement compared to a single deep scan. Its main advantage is to restore a smoother scar appearance. Adequate laser penetration was necessary for the release of contracted scars.

595-nm pulsed dye laser combined with fractional CO2 laser reduces hypertrophic scar through down-regulating TGFβ1 and PCNA

595-nm pulsed dye laser and fractional CO2 laser have been demonstrated effective to treat hypertrophic scar. The underlying mechanism may involve transforming growth factor-beta1 (TGFβ1) and proliferating cell nuclear antigen (PCNA), but remains to be clarified. Our study was performed to investigate how 595-nm pulsed dye laser combined with fractional CO2 laser treats hypertrophic scars in a rabbit model through regulating the expression of TGFβ1 and PCNA. Twenty-four New Zealand white rabbits were randomly divided into control group, pulsed dye laser group, fractional CO2 laser group, and pulsed dye laser + fractional CO2 laser (combination) group. Surgical wounds were made and allowed to grow into hypertrophic scars at day 28. Next, 595-nm pulsed dye laser (fluence: 15 J/cm2; square: 7 mm; pulse duration: 10 ms) was used in pulsed dye laser and combination group, while fractional CO2 laser (combo mode, deep energy: 12.5 mJ; super energy: 90 mJ) in fractional CO2 laser and combination groups, once every 4 weeks for 3 times. The appearance and thickness of hypertrophic scar samples were measured with hematoxylin-eosin and Van Gieson's straining. The expressions of TGFβ1 and PCNA were evaluated by immunohistochemical and western blot analysis. A significant improvement was noted in the thickness, size, hardness, and histopathology of hypertrophic scar samples after laser treatment, especially in combination group. Scar Elevation Index (SEI), fiber density (NA), and collagen fiber content (AA) decreased most significantly in combination group (2.10 ± 0.14; 2506 ± 383.00; 22.98 ± 2.80%) compared to 595-nm pulsed dye laser group (3.35 ± 0.28; 4857 ± 209.40; 42.83 ± 1.71%) and fractional CO2 laser group (2.60 ± 0.25; 3995 ± 224.20; 38.33 ± 3.01%) (P < 0.001). Furthermore, TGFβ1 and PCNA expressions were more suppressed in combination group (8.78 ± 1.03; 7.81 ± 1.51) than in 595-nm pulsed dye laser (14.91 ± 1.68; 15.73 ± 2.53) and fractional CO2 laser alone group (15.96 ± 1.56; 16.13 ± 1.72) (P < 0.001). The combination of 595-nm pulsed dye laser with fractional CO2 laser can improve the morphology and histology of hypertrophic scars in a rabbit model through inhibiting the expression of TGFβ1 and PCNA protein. Our findings can pave the way for new clinical treatment strategies for hypertrophic scars.

The efficacy and safety of fractional CO2 laser therapy in the treatment of burn scars: A meta-analysis

Although we have numerous publications about the effect of fractional CO₂ laser therapy for burn scars, quantitative data about its efficacy and safety are sparse. The purpose of this meta-analysis was to assess the efficacy and safety of fractional CO₂ laser therapy for the treatment of burn scars. Pertinent studies were identified by a search of PubMed, Embase and Web of Science up to 20 September 2020. Weighted mean difference (WMD) was conducted to combine the results, and a random-effect model was used to pool the results. Publication bias was estimated using Begg and Egger's regression asymmetry test. Twenty articles were included. Our pooled results suggested that fractional CO₂ laser therapy significantly improved the Vancouver Scar Scale (VSS) score (WMD = -3.24, 95%CI: -4.30, -2.18; P < 0.001). Moreover, the Patient and Observer Scar Assessment Scale (POSAS)-patient (WMD = -14.05, 95%CI: -22.44, -5.65; P = 0.001) and Observer (WMD = -6.31, 95%CI: -8.48, -4.15; P < 0.001) also showed significant improvements with the treatment of fractional CO₂ laser therapy. Fractional CO₂ laser significantly reduced scar thickness measured with ultrasonography (WMD = -0.54, 95%CI: -0.97, -0.10; P < 0.001). For other outcomes, including pigmentation, vascularity, pliability, and height of scar, vascularity and relief, laser therapy was associated with significant improvements. However, only the cutometer measure R2 (scar elasticity) (WMD = -0.06, 95%CI: -0.10, -0.01; P = 0.023) was significantly improved with the laser therapy, but cutometer measures R0 (scar firmness) (WMD = 0.03, 95%CI: -0.04, 0.09; P = 0.482) was not. Side effects and complications induced by fractional CO₂ laser were mild and tolerable. Fractional CO₂ laser therapy significantly improved both the signs and symptoms of burn scars. Considering potential limitations, more large-scale, well-designed RCTs are needed to verify our findings.

Subjective Tools for Burn Scar Assessment: An Integrative Review

OBJECTIVE

To review the clinical and scientific literature on the subjective ways of assessing burn scars and describe their main characteristics.

DATA SOURCES

The Latin American, Caribbean Health Sciences Literature, Nursing Database, PubMed, CINAHL, and Scopus and Web of Science databases were used to search for studies published between 2014 and 2018 using descriptors in Portuguese, Spanish, and English.

STUDY SELECTION

After establishing the research question and the location and definition of the studies, as well as accounting for differences among databases and application of filters based on inclusion and exclusion criteria, 886 references remained.

DATA EXTRACTION

Investigators reviewed the titles and abstracts of the sample and selected 188 relevant studies for full review.

DATA SYNTHESIS

Twenty-six subjective forms of assessment were found; most research concerned the Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale.

CONCLUSIONS

The Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale are the most common scales for assessing burn scars and have similar evaluation points such as vascularization, pliability, pigmentation, and height, which are the main parameters that contribute to the general assessment and severity of a scar. There is a need to improve instructions for application of the scales to facilitate better understanding and improve agreement among evaluators.

Treatment of cutaneous basal cell carcinoma with combined laser extirpation and methyl aminolevulinic acid: five-year success rates

INTRODUCTION

Basal cell carcinoma is the most common cancer. Excisional surgery is associated with a high clearance rate, at the expense of significant functional and aesthetic morbidity, especially within the T-zone or for extensive lesions. We report five-year follow-up outcomes for carbon dioxide laser extirpation of cutaneous basal cell carcinoma, assisted by immediate methyl aminolevulinate photodynamic therapy and cost-benefit considerations.

MATERIALS AND METHODS

Retrospective cohort database analysis of adult patients with biopsy-proven primary cutaneous basal cell carcinoma, completing five years of follow-up. Direct per-lesion cost was compared with conventional wide local excision. Patients with morphoeic basal cell carcinoma were excluded.

RESULTS

Treated lesions were up to 1% total body surface area and up to 3.8mm (1.38 ± 0.695cm, mean ± standard deviation) in biopsy-proven depth. At the five-year follow-up mark, 93.6% of treated areas remained free of recurrence. Nodular basal cell carcinoma was the most common subtype (41.5%). A mean tumour depth greater than 2 ± 0.872mm was significantly associated with recurrence (Mann-Whitney, p = 0.0487). For a service delivered through the NHS at 2015 prices, we report a 43% saving, equating to a saving of £235 per basal cell carcinoma or a national annualised saving of £70 million by 2025 for the NHS.

CONCLUSION

Our results suggest that CO2-assisted photodynamic therapy is non-inferior to excision but may offer better functional and cosmetic preservation at a fraction of the direct like for like cost of operative surgery. Investigation of this method by randomised controlled methodology is warranted.

The Thermal Damage of Canine Vocal Fold by CO2 Laser Under Different Laser Emission Mode

OBJECTIVE

The purpose of this study is to review the differences between continuous wave (CW) and UltraPulse (UP) on thermal damage of the laser with different power.

METHODS

Four adult beagle dogs underwent transoral laser microsurgery (TLM) using CO₂ laser. The laser emission mode and power was CW (3 W, 5 W, and 8 W) and UP (3 W and 5 W), respectively. The tissue from 4 animals was evaluated histologically on postoperative days 1 and 3. The thermal damage of the laser was measured using slide scan system via SlideViewer version 1.5.5.2 software.

RESULTS

All dogs underwent TLM uneventfully. Under microscope examined, the laser damage area was composed of 2 parts: the vaporized zone (VPZ) and thermal damage area. The thermal damage area can be divided into thermal coagulative necrosis area (TCN) and hydropic degeneration area. The width of VPZ and TCN in UP mode was less than that in CW mode (P < .01). The data indicate that lower laser power created less thermal damage (P < .01). In addition, the width of VPZ on postoperative day 3 was less than that on postoperative day 1 (P < .01).

CONCLUSION

CO₂ laser with UP and lower power could decrease the laser thermal damage and may offer more prompt wound healing.

Effect of Artesunate Combined With Fractional CO2 Laser on the Hypertrophic Scar in a Rabbit Model

BACKGROUND AND OBJECTIVES

Hypertrophic scar (HS), a common complication in wound healing, is characterized by the disarrangement of collagen, fibers, and extracellular matrix. Artesunate (ART) can inhibit the abnormal formation of fibroblasts and collagens. Fractional CO2 laser (FCO2 L) can facilitate tissue remodeling and the absorption of drugs into ablative microthermal columns in HS. So far, no research has investigated the efficacy of ART combined with an FCO2 L in treating HS. To investigate the theoretical basis and clinical significance of this combination, we established a rabbit model of HS to observe the change in the expression of transforming growth factor β1 (TGF-β1) and proliferating cell nuclear antigen (PCNA).

STUDY DESIGN/MATERIALS AND METHODS

Forty New Zealand white rabbits were randomly divided into four groups: control group, ART group, FCO2 L group, and ART + FCO2 L (combination) group. Four wounds were surgically established in the ear of each rabbit and allowed to develop into HS. ART (20 μL/cm2 ) was injected in ART and combination groups, and FCO2 L (combo mode, deep energy:10m J, super energy: 50 mJ) in FCO2 L and combination groups on the 28th day after HS occurred. Three rounds of treatment were applied (once every 14 days). HS samples were measured by hematoxylin and eosin staining, Van Gieson staining, immunohistochemistry, and Western blot analysis on the 70th day.

RESULTS

The morphological and histopathological changes in HS were significant. HSs were smoother and smaller and the collagen fibers were thinner and less disordered in the combination group than those in ART and FCO2 L groups. Meanwhile, the hypertrophic index (HI), fiber density (NA), and collagen fiber content (AA) were lower in the combination group (1.54 ± 0.15, 3.30 ± 0.22, 30.37 ± 1.41%) than in the ART group (2.51 ± 0.22, 4.69 ± 0.16, 44.68 ± 2.30%) and FCO2 L group (1.99 ± 0.14, 4.13 ± 0.12, 37.74 ± 1.38%) (P < 0.01). Additionally, the expressions of TGF-β1 and PCNA protein were suppressed in the ART group (0.30 ± 0.03, 0.25 ± 0.03) and FCO2 L group (0.35 ± 0.03, 0.32 ± 0.05), and the suppression was more significant in the combination group(0.07 ± 0.02, 0.07 ± 0.02) (P < 0.01).

CONCLUSIONS

The combination of ART and FCO2 L can effectively reduce HS in the rabbit model. This is the first report about this combination in the treatment of HS. A novel treatment is expected to be based on our findings. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Fractional ablative carbon dioxide laser treatment of facial scars: Improvement of patients' quality of life, scar quality, and cosmesis

BACKGROUND

Disfiguring facial scars can be a massive burden on patients' psychosocial health and severely impact patients' self-esteem.

AIMS

The aim of this study was to analyze whether ablative fractional carbon dioxide laser (CO2-AFL) treatment can positively influence facial scarring and quality of life (QoL) while improving the aesthetic appearance.

PATIENTES/METHODS

Patients with facial scars who had received CO2-AFL treatment between May 2019 and May 2020 were included in a retrospective study. The post-interventional course and patient and/or observer reported outcomes were inquired before and three months after treatment. Primary outcomes were changes in the Patient and Observer Scar Scale (POSAS) and QoL (Short Form (SF) 36). In addition, two independent examiners evaluated the aesthetic outcome by comparing initial scarring with the post-intervention results using photographs.

RESULTS

A total of 16 patients with facial scars were included. Most of the scars were caused by burns (43.8%) or trauma (31.3%). The post-interventional course was uneventful. Overall POSAS scores improved decisively for both observers (n=2) and patients (n=16) (p<0.001 and p<0.001). Also, there was an improvement in QoL with an increase in emotional well-being (p=0.043) and social functioning (p=0.01). Furthermore, the aesthetic outcome was significantly enhanced (p=0.001) after treatment.

CONCLUSION

The CO2-AFL offers a safe and effective treatment for disfiguring facial scars. We have shown that improvement of scar appearance and scar quality was meaningful to the patient, with a significant impact on a patient's life quality. Based on these findings we suggest including the CO2-AFL in the facial scar treatment concept.

Fractional CO2 laser treatment for burn scar improvement: A systematic review and meta-analysis

Burn injury can cause abnormal healing and pathologic scar formation that significantly impairs patients' ability to return to baseline levels of functioning. Quality of life can be significantly diminished due to pain, stiffness, contracture, and the psychological burden of disfigurement. Traditional scar therapies such as silicone sheeting and compression garments are highly reliant on patient compliance, and have not demonstrated satisfactory efficacy. Even more invasive therapies such as intralesional medication delivery or surgical contracture release have high recurrence rates. Recently, fractional CO₂ laser therapy has emerged as a promising treatment modality for burn scars, but there is a lack of recent studies that aggregates extant data to demonstrate outcomes after laser therapy. To address this, we conducted a systematic review and meta-analysis to determine the efficacy of fractional CO₂ lasers in treating burn scars, and found that laser therapy alone yielded statistically significant improvements in scar profiles. There were very few reports of adverse effects, most treatments were provided as outpatient, and both patient and burn practitioners reported high satisfaction. By sharing our findings, we hope that more burn practitioners will consider adopting laser therapy as a safe and cost-effective first-line therapy for burn scar management.

Combination treatment utilizing fractional ablative and continuous wave CO2 lasers for hypertrophic burn scars

BACKGROUND

Hypertrophic scars are devastating outcomes of severe burn injuries, producing physical and mental burdens. Adequate treatment is of benefit to relieve these burdens. Laser therapy has shown scar reducing effects. In this study, we compared outcomes after combination of two different lasers or single laser treatment to treat severe hypertrophic burn scars.

METHODS

Forty patients with hypertrophic burn scars were included in one of two therapeutic groups: continuous wave CO₂ laser and fractional ablative CO₂ laser group (group 1, n = 20) or fractional ablative CO₂ laser alone group (group 2, n = 20). Hypertrophic scars were evaluated by the observer-rated Vancouver Scar Scale (VSS) before and after treatment and by patient-completed questionnaires after treatment. Comparative analyses were performed before and after treatment, and time-dependent improvement was also analyzed.

RESULTS

Forty patients (54 hypertrophic scars) completed the laser treatment protocols. Group 1 exhibited significantly more improvement in VSS vascularity, pliability, and height indices than group 2 (p < 0.05). Time-dependent analysis of total VSS scores suggested that group 1 experienced more improvement during a shorter treatment period (p < 0.05). For patient-reported outcomes, group 1 noted better grades than group 2 in four indices, namely scar appearance, scar thickness, pain, and pruritus (p < 0.05).

CONCLUSION

Effective scar reduction was achieved using combination laser treatment, with significant improvement in multiple observer- and patient-reported outcomes. The shorter treatment period of the combination method can be a merit, as prolonged hypertrophic scars may increase morbidity. Nonetheless, cautious treatment protocols are necessary to avoid undesirable sequelae related to laser application.

Laser treatment of specific scar characteristics in hypertrophic scars and keloid: A systematic review

BACKGROUND

Hypertrophic scarring and keloid can cause significant emotional and physical discomfort. Cosmetic appearance, functional limitations, pain and pruritus form a degree of impairment. While the etiology is not fully known, there is a wide array of treatment options, which include excision, radiation, cryotherapy, silicone gel sheeting, and intralesional injections. A relatively new modality is laser therapy. While results are promising, the number of different laser systems is substantial. This review evaluates the available evidence regarding outcomes on specific objective characteristics (i.e., erythema, pigmentation, height, and pliability) of the different laser systems.

METHODS

A systematic literature review was performed using MEDLINE, Cochrane Library, and EMBASE. Data on scar characteristics were extracted from scar scales Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS), and from objective measurement tools.

RESULTS

Heterogeneity was seen in a lot of aspects: maturity of scar, origin of scar, follow-up, and number of treatments. The fractional ablative lasers CO₂ 10,600 nm and Er:YAG 2940 nm were found to produce the best results regarding erythema, height, and pliability, while the flash lamp-pumped pulsed dye laser (PDL) 585 nm scored slightly below that.

CONCLUSIONS

Laser systems, and specifically the fractional ablative lasers CO₂ and Er:YAG, improved various characteristics of excessive scarring. An overview of preferred laser modality per scar characteristic is presented. Accounting for the methodological quality and the level of evidence of the data, future research in the form of randomized trials with comparable standardized scar scales is needed to confirm these results.

Ablative fractional laser treatment of hypertrophic burn and traumatic scars: a systematic review of the literature

Hypertrophic scars (HTS) following burns and other trauma and are associated with significant functional and psychosocial impairment. Ablative fractional lasers (AFLs) are increasingly being applied in the treatment of HTS supported by a rapidly expanding multidisciplinary base of literature. The multidisciplinary authors sought to evaluate existing literature, provide context and identify gaps, and make recommendations for a path forward. A systematic review was conducted to identify literature pertinent literature through September 2019. Retrospective cohort, randomized controlled trials, quasi-randomized controlled trials, observational prospective cohort, or case series with five or more subjects with hypertrophic scars incurred from burns and related trauma were considered. Twenty-two of the 23 evaluated studies documented statistically significant and/or meaningful qualitative improvements in nearly all outcome measures. Adverse events were generally infrequent and minor. Significant heterogeneity was observed among the studies included in this systematic review, precluding metaanalysis of pooled data. There is abundant existing literature on the use of AFLs in the management of HTS but study heterogeneity limits generalizability. Future studies should prioritize standardized protocols including assessments of function and quality of life.

Improvement of Burn Scars Treated With Fractional Ablative CO2 Lasers—A Systematic Review and Meta-analysis Using the Vancouver Scar Scale

Fractional ablative CO2 laser is being used increasingly to treat burn scars; however, objective measures of outcome success vary widely. This systematic review and meta-analysis extracts and pools available data to assess the outcomes of patients with burn scars treated with fractional ablative CO2 laser. A search of MEDLINE, EMBASE, and the gray literature was performed. The review included studies that reported patients with a confirmed diagnosis of scarring as a result of a burn injury, who were treated with fractional ablative CO2 laser and whose progress was recorded using the Vancouver Scar Scale (VSS). Eight studies were included in the systematic review and meta-analysis. Treatment regimens varied amongst studies, as did patient outcomes. Pooled data revealed an average VSS improvement of 29% across 282 patients following fractional CO2 ablative laser treatment. Although the heterogeneity of treatment regimens across studies limits this systematic review’s ability to provide specific treatment recommendations, the overall trend towards improvement of burns scars treated with fractional CO2 laser based on the VSS encourages further exploration of this modality as a therapeutic tool.

3D Mesh Releasing Method: A Retrospective Analysis of Fractional CO2 Treatment on Contracture Scars

BACKGROUND AND OBJECTIVES

There has been reports on fractional CO₂ laser successfully improving contracture scars that impair the function of a joint. It seems that certain contracture problems could be solved by laser instead of surgery. However, the clinical application could be difficult when the efficacy of the method remains unknown. The purpose of this study is to report the releasing capacity of the fractional CO₂ laser on contracture scars based on a defined treatment method.

STUDY DESIGN/MATERIALS AND METHODS

We conducted a retrospective study in patients with limited function in joints caused by contracture scars. Fractional CO₂ laser and our "3D mesh releasing" protocol were applied. The primary outcome was the improvement measured in range of motion (ROM) of the relevant joint before all intervention and 6 months after the last treatment.

RESULT

From November 2016 to January 2018, 11 joints of 10 cases were treated by the fractional CO₂ laser. Patients went through 2.27 (standard deviation [SD] 1.42, 1-5) sessions. The average progress of ROM before and 6 months after all treatments was 19.13° (SD 10.25, P < 0.02). In six cases, we recorded that there was an 8.53° (SD 5.81, P < 0.02) of increase in ROM immediately after the laser session, and the average improvement reached up to 13.58° (SD 8.15, P < 0.02) after 2-3 months during the next follow-up.

CONCLUSION

The fractional CO₂ laser could achieve functional improvement in contracture scars and it maintained its effect for at least 6 months. The "3D Mesh Releasing" protocol would help to standardize the treatment procedure. This modality has minimal-invasiveness and potentially could become a supplement to the current treatment choices for mild contracture scars. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Treatment of keloids using 5-fluorouracil in combination with crystalline triamcinolone acetonide suspension: evaluating therapeutic effects by using non-invasive objective measures

BACKGROUND

Intralesional 5-fluorouracil (5-FU) in combination with triamcinolone acetonide (TAC) has been recommended as a promising alternative for keloids not responding to silicone-based products, cryotherapy or intralesional corticosteroids alone. Although numerous studies support the efficacy of this regime, there is a lack of objective data.

OBJECTIVES

In this study, we evaluate the therapeutic effect of four courses of intralesional 5-FU in combination with TAC (3 : 1) utilizing 3D analysis (PRIMOS^®pico ), ultrasound and scar scales such as the Patient and Observer Scar Assessment Scales (POSAS) and the Dermatology Life Quality Index (DLQI).

METHODS

Twenty-five patients with keloids were treated using 5-FU and TAC every 4 weeks. Objective assessments were performed and the scar scales administered at baseline, as well as during consecutive visits at 1- and 12-month follow-up (FU). Routine laboratory tests were performed at baseline and at 1-month FU.

RESULTS

3D PRIMOS and ultrasound measurements revealed highly significant and stable reductions in height (baseline mean score: 4.0 ± 1.7 mm, 1-month FU mean score: 1.5 ± 0.8 mm, 12-month FU mean score: 1.8 ± 0.9 mm, P = <0.0001), volume (baseline mean score: 1,105 ± 911.5 mm³ , 1-month FU mean score: 416.1 ± 218.1 mm³ , 12-month FU mean sore: 431.2 ± 253.6 mm³ , P = <0.0001, respectively) and penetration depth of keloids (relative reduction between baseline and 12-month FU of 74.4%, P = <0.0001). The POSAS and DLQI scales confirmed significant objective and subjective improvements in scar appearance in all categories. The life quality associated with keloid appearance improved from a 'moderate effect' to a 'small effect' throughout the course of the study.

CONCLUSIONS

Results of this study confirm the efficacy and safety of the combination of 5-FU and TAC in keloids. Treatments were well tolerated and demonstrated stable results at 12-month FU.

Lasers for the prevention and treatment of hypertrophic scars: a review of the literature

Despite the increasing knowledge about wound healing mechanisms and the advancements made in laser technology, hypertrophic scars remain difficult to manage. This review intends to discuss the laser devices studied in the prevention and treatment of HS, arising from trauma, surgery, and burns, detail their mechanisms of action, and emphasize those devices with the most promising effects. Most of the suggested mechanisms and explanations for the use of lasers in treating hypertrophic scars are based on selective photothermolysis, in which the light energy emitted from a laser is absorbed by its intended target, thereby disrupting existing collagen and altering the cycle of neocollagenesis. Through our literature review, we have determined that combination therapies, utilizing more than one laser target demonstrate enhanced clinical efficacy. Further, early use of laser devices has been shown to enhance the cosmetic result of sutured wounds and may play a role in preventing the development of hypertrophic scars.

Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations

BACKGROUND AND OBJECTIVES

There is currently intense multidisciplinary interest and a maturing body of literature regarding laser treatments for traumatic scars, but international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the tremendous potential of laser techniques, offer recommendations for safe and efficacious treatment, and promote wider patient access guided by future high-quality research.

STUDY DESIGN/MATERIALS AND METHODS

An international panel of 26 dermatologists and plastic and reconstructive surgeons from 13 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the laser treatment of traumatic scars. A three-step modified Delphi method took place between March 2018 and March 2019 consisting of two rounds of emailed questionnaires and supplementary face-to-face meetings. The panel members approved the final manuscript via email correspondence, and the threshold for consensus was at least 80% concurrence among the panel members.

RESULTS

The manuscript includes extensive detailed discussion regarding a variety of laser platforms commonly used for traumatic scar management such as vascular lasers and ablative and non-ablative fractional lasers, special considerations such as coding and laser treatments in skin of color, and 25 summary consensus recommendations.

CONCLUSIONS

Lasers are a first-line therapy in the management of traumatic scars and contractures, and patients without access to these treatments may not be receiving the best available care after injury. Updated international treatment guidelines and reimbursement schemes, additional high-quality research, and patient access should reflect this status. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Fractional CO2 laser is as effective as pulsed dye laser for the treatment of hypertrophic scars

BACKGROUND

Both pulsed dye laser (PDL) and fractional CO₂ laser (FCO₂L) are used commonly for the treatment of hypertrophic scars.

OBJECTIVE

To compare the efficacy of PDL and FCO₂L on hypertrophic scars.

PATIENTS AND METHODS

One part of each scar, or one of the two similar scars in 35 patients was treated with PDL and the other parts, or scars were treated with FCO₂L. The parameters used for FCO₂L were: power = 30 W, pulse energy = 50 mJ, density = 200 spots/cm². The parameters used for 585 nm PDL were 9 J/cm² with 5 mm spot size. The FCO₂L side was treated for three passes to debulk the scar. The coagulated tissue was wiped out before the next pass. The PDL side was treated with two superimposed passes. The procedures were repeated every month for 4 months.

RESULTS

After four sessions of laser therapy, both sides showed remarkable improvement but no meaningful difference was detected between two areas that were treated with PDL and FCO₂Ls (p > .05). The mean Vancouver Scar Scale was 7.31 ± 1.93 in the beginning and 4.26 ± 1.48 for FCO₂L and 4.33 ± 1.70 for PDL one months after the final session.

CONCLUSIONS

Both PDL and FCO₂Ls were equally effective on hypertrophic scars.

Fractional CO2 laser ablation of porcine burn scars after grafting: Is deeper better?

INTRODUCTION

Fractional CO₂ lasers have been used in clinical settings to improve scarring following burn injury. Though used with increasing frequency, the appropriate laser settings are not well defined and overall efficacy of this therapy has not been definitively established. As it has been proposed that for thick hypertrophic scars proportionally greater fluence and thus deeper ablation into the scar tissue would be most effective, the goal of this study was to examine the role of ablation depth on scar outcomes in a highly-controlled porcine model for burn scars-after grafting.

METHODS

Properties of laser ablated wells were quantified on ex vivo pig skin as a function of laser energy (20, 70 or 150mJ). Full-thickness burn wounds were created on the dorsum of red Duroc pigs with the eschar excised and grafted with a split-thickness autograft meshed and expanded 1.5:1. After four weeks of healing, sites were treated with either 20, 70, or 150mJ pulse energy from a fractional CO₂ laser at 5% density or left untreated as a control. Sites were treated every four weeks with three total sessions. Scar area, pigmentation, erythema, roughness, histology, and biomechanics were evaluated prior to each laser treatment at day 28, 56, and 83, as well as four weeks after the final laser treatment, day 112. Additional biopsies were collected at day 112 for gene expression analysis.

RESULTS

The depth of the laser ablated wells increased with increasing pulse energy while the width of the wells was smaller in the 20mJ group and not significantly different in the 70 and 150mJ groups. Scar properties (area, color, biomechanics) were not significantly altered by laser therapy at any of the laser energies tested versus controls. Average scar roughness was improved by laser therapy in a dose dependent manner with scars treated with 150mJ of energy having the smoothest surface; however, these changes were not statistically significant. Assessment of matrix metalloproteinase 9 gene expression showed a slight upregulation in scars treated with 70 or 150mJ versus control scars and scars treated with 20mJ pulse energy.

CONCLUSION

The current study demonstrated that the properties of the ablative well (depth and width) are not linearly correlated with laser pulse energy, with only a small increase in well depth at energies between 70 and 150mJ. Overall, the study suggests that there is little difference in outcomes as a function of laser energy. Fractional CO₂ laser therapy did not result in any statistically significant benefit to scar properties assessed by quantitative, objective measures, thus highlighting the need for additional clinical investigation of laser therapy efficacy with non-treated controls and objective measures of outcome.

Beneath the Surface: A Review of Laser Remodeling of Hypertrophic Scars and Burns

Significance: Hypertrophic scars, keloids, and burn injuries of the skin have a significant impact on patients' lives and impact the health care system tremendously. Treating skin wounds and lesions can be challenging, with a variety of choices available for treatment. Scar and burn managements range from invasive, surgical options such as scar excision to less invasive, nonsurgical alternatives such as laser therapy or topical drug application. Recent Advances: Laser treatment has become increasingly popular, with a growing body of research supporting its use for scars and burns. Numerous methods are available for the treatment of these skin diseases, including different nonsurgical laser therapies. Critical Issues: To date, the optimal treatment method for scars, keloids, and burn injuries of the skin has not yet been established, although it is an area of increasing clinical concern. Future Directions: This review provides an updated summary of the treatment of scars and burn wounds of the skin using different laser treatments, including the most recent technologies. It addresses their indications, mechanisms of action, differences, efficacies, and complications.

Mid- to Long-term Outcomes After Split-thickness Skin Graft vs. Skin Extension by Multiple Incisions

BACKGROUND/AIM

Skin extension by multiple incisions (SEMI) may be superior to split-thickness skin graft (STSG) for closure of large soft tissue defects.

MATERIALS AND METHODS

Twenty-six patients who had undergone STSG were compared to 29 patients who had undergone SEMI on the extremities. Patient and Observer Scar Assessment Scale (POSAS), Dermatology Life Quality Index, Wound QoL (Quality of Life) and Short Form Health Survey 36 were used. Elasticity, thickness and skin sensation were compared between the treated and contralateral extremity. Range of motion in adjacent joints was measured. Complication rates were compared.

RESULTS

A total of 55 patients with a mean follow-up of 5.5 years (range=2-9 years) were examined. Patients with STSG had significantly worse scores in POSAS. The scar was thinner, less elastic and did not provide intact sensibility. Other scores, ROM and complication rates did not differ significantly.

CONCLUSION

SEMI was superior to STSG regarding patient satisfaction and scar quality.

Evaluation of a non-ablative, fractional 1565 nm laser for the improvement of striae distensae albae

BACKGROUND AND OBJECTIVE

Striae distensae (SD) represent therapeutically challenging forms of dermal atrophic scarring. In addition to topical ointments, medical needling and various energy-based devices, non-ablative fractional lasers have been suggested for their improvement. However, objective evaluations of their efficacy are widely missing. In this study, we aimed to assess the clinical improvement of SD albae after three treatments with a non-ablative fractional 1565 nm Er: glass laser by employing three-dimensional analysis and several questionnaires.

METHODS

A total of 16 Caucasians suffering from SD albae were included in this prospective study. Every patient received three treatments - one every 4 weeks - using a non-ablative, fractional 1565 nm laser (two passes: 300 μbeams/cm² , 40 mJ inside the SD; 150 μbeams/cm² , 50 mJ inside the SD and within the surrounding area). Questionnaires (DLQI, POSAS), digital photography and three-dimensional analysis employing PRIMOS^® software and VECTRA^® camera system were taken at baseline, 1 and 6 months after the last treatment.

RESULTS

Evaluation of objective measurements at 6-month follow-up (FU) showed a significant reduction in depth of atrophic lesions by 31.7% and less skin irregularities with S_max at baseline of 621.2 μm decreasing to 411.6 μm (P < 0.01, respectively). Improvement in objective measurements was supported by significant changes in patients' rating of skin appearance. POSAS patient total score declined from 33.5 points to 17.5 points throughout the study (P < 0.001). From baseline to 6-month FU, patients' life quality improved by 68.0% (DLQI score). Procedures showed no lasting negative side-effects and little to no down time.

CONCLUSION

The use of a fractional non-ablative 1565 nm laser represents a safe approach for the treatment of SD albae. Clinically observed improvements were supported by significant data from objective measurements. The results achieved at 1-month FU represented at 6-month FU, showing stable clinical improvements.

[The role of CO2-laser in scarring management]

AIM

To assess the role of CO2-laser in treatment of various scars and to determine the indications for its application.

PATIENTS AND METHODS

It has been carried out a prospective analysis of treatment of 218 patients with scars of different duration, locations and anatomic areas with the use of CO2-laser for the period 2011-2017. POSAS scale and sonography were used for analysis.

RESULTS

1. Laser therapy is not effective for scarring-related functional defects (contractures, ectropion, microstomia), when surgery is indicated. 2. The outcomes of treatment (both surgical and laser) depend on the time of existence of the scars rather their cause and anatomical region. 3. Laser therapy is not effective enough for formed scars existing over 12 months. 4. Laser therapy is effective for immature scars, especially indicated for cicatricial deformation when the aesthetics cannot be repaired with traditional surgery.

CONCLUSION

Application of CO2-laser in scars treatment with regard to its real efficiency determines the effectiveness of therapy.

[Therapy of scars with lasers]

Scar formation is the consequence of trauma to the skin that affects the deep parts of the dermis. Different scar types like immature, mature, atrophic, hypertrophic, or keloid scars can develop depending on factors like age, anatomic localization, cause of trauma, the course of the healing process, and individual predispositions. Keloids and hypertrophic scars are often associated with itching, pain, tautness of the skin, and functional impairments, thus, leading to significantly reduced quality of life in some patients. However, even seemingly physiologically healed scars can cause tremendous psychological strain as is the case with self-harm scars. Despite increased research efforts, the exact pathomechanisms of excessive scarring are still scarcely understood, and dependably effective treatment options are often lacking. However, through continually improving scientific progress, scar treatment paradigms for a variety of scar types, thus far often dominated by conventional treatment methods, are increasingly complemented by new laser technologies and wavelengths.

Objective evaluation of the efficacy of a non-ablative fractional 1565 nm laser for the treatment of deliberate self-harm scars

Scars resulting from deliberate self-harm (DSH) represent therapeutically challenging forms of scarring due to their highly variable patterns, with no official therapeutic guidelines available. In this pilot study, we aimed to evaluate the effectiveness and safety of a non-ablative fractional Er:glass 1565 nm laser, as a potential new, minimal-invasive approach for the improvement of DSH scars. Sixteen Caucasians suffering from mature DSH scars were included in this clinical study. Patients received a total of three treatments using a non-ablative fractional 1565 nm Er:glass laser every 4 weeks, employing two passes (300 μbeams/cm², 40 mJ, onto the scar; 150 μbeams/cm², 50 mJ, overall area). Measurements included questionnaires (DLQI, POSAS), digital photography, and objective three-dimensional analysis using PRIMOS and VECTRA software at baseline, 1 and 6 months after treatment. PRIMOS objective measurements showed highly significant changes in scar surface with a reduction of atrophic lesions by 27.5% at 6 months follow-up (FU), a decrease in scar height by 42.7% at 6 months FU, resulting in an overall diminished skin irregularity dropping from 678.3 μm at baseline to 441.6 μm throughout the course of the study (p = <0.001 respectively). Improvements in objective measurements were supported by clinical evaluation of scar parameters and showed a strong correlation with enhanced life quality of treated patients. Procedures were well-tolerated, with no lasting negative side effects and little to no downtime. The use of a fractional non-ablative 1565 nm Er:glass laser represents a promising and safe approach for the therapy of DSH scars. Although these scars will never fully resolve, their appearance can be significantly improved to a cosmetically and socially more acceptable appearance.