A Review of Laser Therapies for the Treatment of Scarring and Vascular Anomalies.

Significance: Laser use has become part of the gold standard of treatment as an effective adjuvant in multimodal therapy for pathologic scarring caused by burns, trauma, acne, and surgery, as well as vascular anomalies. Understanding indications and applications for laser therapy is essential for physicians to improve patient outcomes. Recent Advances: Since the 1980s, the medical use of lasers has continuously evolved with improvements in technology. Novel lasers and fractionated technologies are currently being studied in the hopes to improve treatment efficacy, while reducing complications. Recent advancements include acne treatment with novel picosecond lasers, new hypertrophic scar therapies with simultaneous laser and intense pulsed light use, and novel systems such as lasers with intralesional optical fiber delivery devices. In addition, optimizing the timing of laser therapy and its use in multimodal treatments continue to advance the field of photothermolysis. Critical Issues: Selecting the correct laser for a given indication is the fundamental decision when choosing a laser balancing effective treatment with minimal complications. This article covers the principles of laser therapy, the preferred lasers used for the treatment of scarring and vascular anomalies, and discusses the current evidence behind these laser choices. Future Directions: To optimize laser therapy, larger randomized control trials and split scar studies are needed. Continued advancement through better randomized controlled studies will help to improve patient outcomes on a broader scale.

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.

Efficacy of Combined Intense Pulsed Light (IPL) With Fractional CO2 -Laser Ablation in the Treatment of Large Hypertrophic Scars: A Prospective, Randomized Control Trial.

BACKGROUND AND OBJECTIVES: Scar rehabilitation is a complex process that incorporates medical, surgical, and physical therapeutic measures to best restore function and visual normalcy. Lasers have emerged as essential tools in the management of scars, with devices available to address scar size, dyschromia, and contour irregularities. As different lasers treat these different features, multi-laser, same session therapeutic approaches may offer a more comprehensive approach to scar revision. In this study, we aim to demonstrate the effect of a combinatorial, same session treatment with intense pulsed light (IPL) and fractional ablative CO2 as compared to single laser treatment with fractional ablative CO2 laser alone or control in the treatment of mature hypertrophic scars. MATERIALS AND METHODS: This institutional review board-approved, randomized controlled trial, enrolled 23 healthy adults with large (>100 cm2 ) hypertrophic scars who were randomized to one of three treatment arms: (i) IPL and CO2 ablative fractional laser (AFL), (ii) CO2 AFL alone, and (iii) control (no laser treatment). Subjects underwent a total of four treatment sessions at 6-8-week intervals with follow-up visits at 1, 3, and 6 months following the last treatment session. Primary endpoints included blinded scoring of before and after photographs via the Manchester Scar Scale (MSS). Secondary endpoints included the Patient-Observer Scar Assessment Scale (POSAS). RESULTS: As compared to control and CO2 AFL laser alone, the combination of CO2 AFL and IPL demonstrated statistically significant improvement across a greater number of scar domains, as assessed by the MSS. 100% of subjects in both treatment groups showed a statistically significant decrease in the POSAS scale after the series of four treatment sessions. No adverse events were reported. CONCLUSION: Treatment with combined IPL and CO2 AFL demonstrated higher average improvements across the majority of assessed scar domains, as compared to both control and CO2 laser alone. The difference was not statistically significant in overall MSS score as expected due to the role of CO2 as the main source of improvement. However, only the combination group had statistically significant improvement in both color and texture. These findings support the assertion that a multi-photo-thermolytic approach with combined IPL and CO2 AFL can have a positive impact on the treatment of hypertrophic scars by using multiple wavelengths to maximize laser-skin interactions in targeting the different chromophores expressed in scar tissue. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Treating Hypertrophic Burn Scar With 2940-nm Er:YAG Laser Fractional Ablation Improves Scar Characteristics as Measured by Noninvasive Technology.

Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.

Laser in the management of burn scars.

BACKGROUND AND OBJECTIVE: Burn scars are associated with significant morbidity ranging from contractures, pruritus, and disfigurement to psychosocial impairment. Traditional therapies include silicone gel, compression garments, corticosteroid injections, massage therapy, and surgical procedures, however, newer and advanced therapies for the treatment of burn scars have been developed. Lasers, specifically ablative fractional lasers, show potential for the treatment of burn scars. METHODS: Both MeSH and keyword searches of the PubMed, Medline and Embase databases were performed and relevant articles were read in full for the compilation of this review. RESULTS: Fifty-one relevant observational studies, clinical trials, and systematic reviews published in English from 2006 to 2016 were reviewed and summarized. CONCLUSION: Laser therapy is effective for the treatment of burn scar appearance, including measures such as pigmentation, vascularity, pliability, and thickness. Ablative fractional laser therapy, in particular, shows significant potential for the release of contractures allowing for improved range of motion of affected joints. Patients may benefit from the use of lasers in the treatment of burn scars, and the safety profile of lasers allows the benefits of treatment to outweigh the risks. Laser therapy should be included in burn scar treatment protocols as an adjuvant therapy to traditional interventions.

Anesthetic Practices for Laser Rehabilitation of Pediatric Hypertrophic Burn Scars.

The use of ablative fractional carbon dioxide laser therapy and pulsed dye laser therapy has led to significant improvements in the rehabilitation of hypertrophic burn scars. However, laser procedures are associated with appreciable pain among pediatric patients. Clinical consensus suggests using general anesthesia for pediatric laser procedures; however, guidelines for perioperative care are lacking. The objective of this quality improvement study is to determine whether a difference exists in postoperative pain outcomes in pediatric patients who receive intraoperative opioid regimens compared with patients who receive opioid-sparing regimens for laser therapy of hypertrophic burn scars. A retrospective review of patients who received laser therapy at a pediatric burn center from April 2014 to May 2015 was performed. Overall, 88 of the 92 procedures reviewed were included. A statistically significant difference was not found between the likelihood of postoperative pain when intraoperative opioid regimens (n = 63) were given compared with opioid-sparing regimens (n = 25) X (1, n = 88) = 2.870, P = .0902. There was also no difference between short-acting (n = 48), long-acting (n = 9), or combination (n = 6) intraoperative opioids compared with opioid-sparing regimens (n = 25) in the likelihood of postoperative pain. Despite the small sample size, the low number of postoperative pain cases is encouraging. Ultimately, these data provide a foundation for developing anesthetic guidelines for pediatric laser procedures. Specifically, clinicians should consider the potential to deliver adequate perioperative care via an opioid-sparing regimen ± adjuvant.

Hypertrophic scarring: the greatest unmet challenge after burn injury.

Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.

Current Strategies in the Treatment of Scars and Keloids.

Hypertrophic scars (HTSs) and keloids are a major health concern for aesthetic and functional reasons. Despite a plethora of rapidly evolving treatment options and technical advances, the management of pathologic scarring remains difficult. The development of standardized treatment algorithms has been problematic for years due to the lack of sound randomized controlled trials. Expert panels are more and more establishing guidelines to provide an evidence-based framework on a national and international level. This article aims to evaluate the current strategies and upcoming trends in the therapy and prevention of unpleasant scars and keloids from a clinical perspective. There is strong evidence to support a growing role of early combination treatments, particularly the application of 5-fluoruracil adjunct to intralesional steroid injections. Furthermore, the use of fractional ablative laser technologies such as the CO2 laser has recently yielded promising results with respect to aesthetic outcomes and patient satisfaction at tolerable side effects.

Laser and face peel procedures in non-Caucasians.

Facial resurfacing procedures are becoming increasingly popular. The percentage of non-Caucasian individuals seeking these treatments continues to rise. Patients with darker skin types (Fitzpatrick skin types IV-VI) face unique challenges for successful facial skin resurfacing. Common issues encountered by non-Caucasian patients include dyschromias, acne scars, photoaging, keloid and hypertrophic scars, benign cutaneous tumors, and hair-related disorders. This article discusses the most frequently used lasers and chemical peels used to address these problems.

Scar treatment variations by skin type.

Patients and clinicians use skin color attributes such as color uniformity, color distribution, and texture to infer physiologic health status. Normalization of skin color, surface texture, and height are important treatment goals in the treatment of scars. Skin color, structure, and response to trauma, vary with ethnicity. The incidence of hypertrophic and keloid scar formation is influenced by these inherent skin attributes. Skin type influences the response to various modalities including laser therapy and surgical intervention, and skin differences must be considered in treatment planning to achieve optimal results.

Are there any good treatments for keloid scarring after sternotomy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with hypertrophic and keloid scarring of the sternotomy wound, is surgical excision with or without adjuvant treatment of any benefit in reducing the size of the scar? Altogether, more than 15 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One of the studies showed no difference between surgery and adjunctive triamcinolone or colchicine. One study showed that incomplete excision resulted in higher recurrence rates. Postoperative radiation was found to be useful in two of the studies, although one study showed that it was not useful. One randomized control trial showed improvement after laser compared to no treatment. Two other trials showed no difference between laser, silicone gel, intralesional steroid or 5-fluorouracil. One trial showed that perioperative systemic steroid application gave rise to no improvement but in fact worsened scar formation. We conclude that small keloids can be treated radically by surgery with adjuvant therapy (radiation or corticosteroid injections) or by non-surgical therapy (corticosteroid injections, laser and anti-tumour/immunosuppressive agents, such as 5-fluorouracil). Large and multiple keloids are difficult to treat radically and are currently only treatable by multimodal therapies that aim to relieve symptoms.

Laser treatment of facial scars.

PURPOSE OF REVIEW: Facial scars can develop as a result of trauma, surgery, burns, acne, or other conditions. These scars are often quite distressing to patients. Lasers were first used to treat these scars in the 1990s. Recently, new laser technology has been used to prevent and treat scars. This literature review and the report of the senior author's recent experience summarize the recent advances in laser treatment of scars. RECENT FINDINGS: With the development of new laser technology, the treatment options for hypotrophic scars and developing scars have increased. Furthermore, there are expanded options for treatment of established hypertrophic scars. Recent studies have shown that nonablative and fractionated lasers can be effective for treating hypotrophic and developing scars. Scar improvements may be due to direct effects of the laser and/or histochemical effects, including production of heat shock proteins and tumor growth factors. Nonablative and fractionated lasers have a shorter recovery period than CO2 resurfacing lasers. This can vary from a few hours to up to 7 days. SUMMARY: Recent new laser technology has increased the options for treatment of scars. These have been shown to be beneficial for hypotrophic, incipient, and established scars. The benefits of laser therapy may be due to direct and/or histochemical effects.

Pulsed dye laser in burn scars: current concepts and future directions.

Hypertrophic scarring after partial-thickness burns is common, resulting in raised, erythematous, pruritic, and contracted scars. Treatment of hypertrophic scars, especially on the face, is challenging and has high failure rates. Excisional treatment has morbidity and can create iatrogenic deformities. After an extensive experience over 10 years with laser therapy for the treatment of difficult scars, the pulsed dye laser (PDL) has emerged as a successful alternative to excision in patients with hypertrophic burn scars. Multiple studies have shown its ability to decrease scar erythema and thickness while significantly decreasing pruritus and improving the cosmetic appearance of the scar. The history of laser therapy and the mechanism of action and results of the PDL in burn scars will be reviewed. The PDL should become an integral part of the management of burn scarring and will significantly decrease the need for excisional surgery.

Pulsed dye laser therapy and z-plasty for facial burn scars: the alternative to excision.

Hypertrophic scarring after partial thickness facial burns is common when epithelialization takes longer than 3 weeks. Well-healed areas continue to mature unfavorably, resulting in raised, erythematous, and contracted scars. Excisional treatment of such scars has morbidity and can create iatrogenic deformities. The flashlamp-pumped, pulsed dye laser (PDL) in combination with z-plasty can be used as a successful alternative to excision in patients with facial hypertrophic burn scars. Fifty-seven patients with hypertrophic facial burn scars (mean age 12 years; range, 2-21 years) were treated with the PDL over the past 8 years. Thirty-four patients (60%) were also treated with z-plasties to relieve scar tension. There was one complication of postoperative blistering. Patients were divided into 3 groups based on time from burn to initial laser treatment. Group I (<1 year) had 11 patients and the laser diminished scar proliferation in these patients. Group II (1-4 years) included 24 patients and treatment resulted in reversal of hypertrophic scarring and elimination of erythema. Group III (>5 years) consisted of 22 patients. The PDL was effective in treating their stable and persistent erythema as long as 17 years after burn injury. No scars required excision in this cohort of 57 patients. The PDL should become an integral part of the management of facial burn scarring and will significantly decrease the need for excisional surgery.

[Current methods of treatment and prevention of pathologic scars]. / A kóros hegek kezelésének és megelozésének lehetoségei napjainkban.

The aetiology of pathologic scarring is unknown today regarding the keloids. The authors have analyzed the literature and own experience retrospectively according to the evidence based treatments and prevention of the hypertrophic and keloid scars. The corticosteroids have been used intralesionally since the beginning of the 1960-ies. It was followed by the pressure garment therapy in order to treat the widespread burns scars in the early 1970-ies. The silicone gel sheeting is being used since the 1980-ies. The basic treatment of keloids changed, radiotherapy was combined with the above mentioned methods because of its high recurrence rate. Newer methods, cryosurgery as well as lasers were used to treat keloids. The number of effective topical agents was increased. The researchers have been looking for other, intralesionally usable medicine and genetic causes for more than ten years. The clinicians have had the standard protocols of the adjunct and alternative methods too. After having the standard and internationally accepted scar assessment system (Vancouver-scar scale and score), the controlled, randomized trials were practicable. The prospective evaluation of the efficacy of different protocols with adequate follow-up became performable. The comparison of different methods is difficult because of the lack of its standard outcome.

[International clinical recommendations on scar management]. / Internationale Klinische Empfehlungen zur Narbenbehandlung.

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence- based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicon gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practice and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.