Lasers for the treatment of nail psoriasis: a systematic review

This systematic review assesses the evidence concerning laser treatments for nail psoriasis (NP), a prevalent condition among individuals with cutaneous psoriasis that notably affects their quality of life. Traditional treatments have limitations in terms of drug delivery and poor patient adherence, leading to interest in laser therapies for their targeted approach, extended treatment intervals, and the potential to enhance topical medication effectiveness. The MEDLINE, Embase, Web of Science, and Cochrane Library databases were searched. English-language randomized and non-randomized controlled trials with full-text availability were included. Data on the laser type, treatment protocol, Nail Psoriasis Severity Index (NAPSI) outcomes, and adverse events were extracted, and nail bed and matrix features and patient satisfaction were assessed. The primary effect measure was a percentage reduction in NAPSI scores from baseline. Nineteen studies involving the pulse dye laser (PDL), long-pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laser and fractional carbon dioxide laser (FCL) were identified. Lasers, particularly those used in conjunction with topical agents, have shown favorable results. PDL effectively lowered NAPSI scores, and the Nd:YAG laser had comparable effectiveness but more discomfort. FCL also shows promise, particularly for topical drug delivery. PDL and Nd:YAG laser treatment were more effective at reducing nail bed features, whereas FCL was effective at reducing both nail bed and matrix features. Overall, lasers are promising treatment alternatives for NP, with similar NAPSI outcomes to topical therapies and intralesional injections.

Devices for treatment of nail psoriasis

INTRODUCTION

Nail psoriasis (NP) affects a significant proportion of cutaneous psoriasis patients, often leading to functional impairment and psychosocial distress. Despite available treatment options, challenges persist in achieving efficacy and with drug delivery, prompting investigation into novel therapeutic devices.

EVIDENCE ACQUISITION

A literature search was performed using the PubMed database for devices and lasers for NP on 17 October 2023 using the following search terms: device OR laser AND "nail psoriasis." Twenty-two articles were included describing treatment with pulsed dye laser, fractional carbon dioxide (CO2) laser, long-pulsed Nd:YAG laser, excimer laser, photodynamic therapy, intense pulsed light, and microneedling device.

EVIDENCE SYNTHESIS

While some recent studies on use of therapeutic devices have shown promising results for NP treatment, current evidence supports an algorithmic approach including topical therapies, intralesional kenalog injections, and systemic therapies, depending on number of nails affected, presence of psoriatic arthritis, cutaneous psoriasis, comorbidities, and effect on quality of life. Laser therapy, although promising, requires further validation through extensive randomized trials before its inclusion in treatment regimens.

CONCLUSIONS

These exploratory findings highlight emerging therapies that may expand the spectrum of options available. Use of lasers for NP treatment could provide dermatologists with a broader arsenal for customizing treatment plans that address individual patient needs, taking into account comfort, cost, and compliance to enhance overall patient outcomes.

Interventions for postburn pruritus

BACKGROUND

Postburn pruritus (itch) is a common and distressing symptom experienced on healing or healed burn or donor site wounds. Topical, systemic, and physical treatments are available to control postburn pruritus; however, it remains unclear how effective these are.

OBJECTIVES

To assess the effects of interventions for treating postburn pruritus in any care setting.

SEARCH METHODS

In September 2022, we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus. We also searched clinical trials registries and scanned references of relevant publications to identify eligible trials. There were no restrictions with respect to language, publication date, or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that enrolled people with postburn pruritus to compare an intervention for postburn pruritus with any other intervention, placebo or sham intervention, or no intervention.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 25 RCTs assessing 21 interventions with 1166 randomised participants. These 21 interventions can be grouped into six categories: neuromodulatory agents (such as doxepin, gabapentin, pregabalin, ondansetron), topical therapies (such as CQ-01 hydrogel, silicone gel, enalapril ointment, Provase moisturiser, beeswax and herbal oil cream), physical modalities (such as massage therapy, therapeutic touch, extracorporeal shock wave therapy, enhanced education about silicone gel sheeting), laser scar revision (pulsed dye laser, pulsed high-intensity laser, fractional CO2 laser), electrical stimulation (transcutaneous electrical nerve stimulation, transcranial direct current stimulation), and other therapies (cetirizine/cimetidine combination, lemon balm tea). Most RCTs were conducted at academic hospitals and were at a high risk of performance, attrition, and detection bias. While 24 out of 25 included studies reported change in burn-related pruritus, secondary outcomes such as cost-effectiveness, pain, patient perception, wound healing, and participant health-related quality of life were not reported or were reported incompletely. Neuromodulatory agents versus antihistamines or placebo There is low-certainty evidence that doxepin cream may reduce burn-related pruritus compared with oral antihistamine (mean difference (MD) -2.60 on a 0 to 10 visual analogue scale (VAS), 95% confidence interval (CI) -3.79 to -1.42; 2 studies, 49 participants). A change of 2 points represents a minimal clinically important difference (MCID). Due to very low-certainty evidence, it is uncertain whether doxepin cream impacts the incidence of somnolence as an adverse event compared to oral antihistamine (risk ratio (RR) 0.64, 95% CI 0.32 to 1.25; 1 study, 24 participants). No data were reported on pain in the included study. There is low-certainty evidence that gabapentin may reduce burn-related pruritus compared with cetirizine (MD -2.40 VAS, 95% CI -4.14 to -0.66; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that gabapentin reduces the incidence of somnolence compared to cetirizine (RR 0.02, 95% CI 0.00 to 0.38; 1 study, 40 participants). No data were reported on pain in the included study. There is low-certainty evidence that pregabalin may result in a reduction in burn-related pruritus intensity compared with cetirizine with pheniramine maleate (MD -0.80 VAS, 95% CI -1.24 to -0.36; 1 study, 40 participants). A change of 2 points represents a MCID. There is low-certainty evidence that pregabalin reduces the incidence of somnolence compared to cetirizine (RR 0.04, 95% CI 0.00 to 0.69; 1 study, 40 participants). No data were reported on pain in the included study. There is moderate-certainty evidence that ondansetron probably results in a reduction in burn-related pruritus intensity compared with diphenhydramine (MD -0.76 on a 0 to 10 numeric analogue scale (NAS), 95% CI -1.50 to -0.02; 1 study, 38 participants). A change of 2 points represents a MCID. No data were reported on pain and adverse events in the included study. Topical therapies versus relevant comparators There is moderate-certainty evidence that enalapril ointment probably decreases mean burn-related pruritus compared with placebo control (MD -0.70 on a 0 to 4 scoring table for itching, 95% CI -1.04 to -0.36; 1 study, 60 participants). No data were reported on pain and adverse events in the included study. Physical modalities versus relevant comparators Compared with standard care, there is low-certainty evidence that massage may reduce burn-related pruritus (standardised mean difference (SMD) -0.86, 95% CI -1.45 to -0.27; 2 studies, 166 participants) and pain (SMD -1.32, 95% CI -1.66 to -0.98). These SMDs equate to a 4.60-point reduction in pruritus and a 3.74-point reduction in pain on a 10-point VAS. A change of 2 VAS points in itch represents a MCID. No data were reported on adverse events in the included studies. There is low-certainty evidence that extracorporeal shock wave therapy (ESWT) may reduce burn-related pruritus compared with sham stimulation (SMD -1.20, 95% CI -1.65 to -0.75; 2 studies, 91 participants). This equates to a 5.93-point reduction in pruritus on a 22-point 12-item Pruritus Severity Scale. There is low-certainty evidence that ESWT may reduce pain compared with sham stimulation (MD 2.96 on a 0 to 25 pressure pain threshold (PPT), 95% CI 1.76 to 4.16; 1 study, 45 participants). No data were reported on adverse events in the included studies. Laser scar revision versus untreated or placebo controls There is moderate-certainty evidence that pulsed high-intensity laser probably results in a reduction in burn-related pruritus intensity compared with placebo laser (MD -0.51 on a 0 to 1 Itch Severity Scale (ISS), 95% CI -0.64 to -0.38; 1 study, 49 participants). There is moderate-certainty evidence that pulsed high-intensity laser probably reduces pain compared with placebo laser (MD -3.23 VAS, 95% CI -5.41 to -1.05; 1 study, 49 participants). No data were reported on adverse events in the included studies.

AUTHORS' CONCLUSIONS

There is moderate to low-certainty evidence on the effects of 21 interventions. Most studies were small and at a high risk of bias related to blinding and incomplete outcome data. Where there is moderate-certainty evidence, practitioners should consider the applicability of the evidence for their patients.

Increased susceptibility to ischemia causes exacerbated response to microinjuries in the cirrhotic liver

Fractional laser ablation is a technique developed in dermatology to induce remodeling of skin scars by creating a dense pattern of microinjuries. Despite remarkable clinical results, this technique has yet to be tested for scars in other tissues. As a first step toward determining the suitability of this technique, we aimed to (1) characterize the response to microinjuries in the healthy and cirrhotic liver, and (2) determine the underlying cause for any differences in response. Healthy and cirrhotic rats were treated with a fractional laser then euthanized from 0 h up to 14 days after treatment. Differential expression was assessed using RNAseq with a difference-in-differences model. Spatial maps of tissue oxygenation were acquired with hyperspectral imaging and disruptions in blood supply were assessed with tomato lectin perfusion. Healthy rats showed little damage beyond the initial microinjury and healed completely by 7 days without scarring. In cirrhotic rats, hepatocytes surrounding microinjury sites died 4-6 h after ablation, resulting in enlarged and heterogeneous zones of cell death. Hepatocytes near blood vessels were spared, particularly near the highly vascularized septa. Gene sets related to ischemia and angiogenesis were enriched at 4 h. Laser-treated regions had reduced oxygen saturation and broadly disrupted perfusion of nodule microvasculature, which matched the zones of cell death. Our results demonstrate that the cirrhotic liver has an exacerbated response to microinjuries and increased susceptibility to ischemia from microvascular damage, likely related to the vascular derangements that occur during cirrhosis development. Modifications to the fractional laser tool, such as using a femtosecond laser or reducing the spot size, may be able to prevent large disruptions of perfusion and enable further development of a laser-induced microinjury treatment for cirrhosis.

Ablative fractional CO2 laser treatment promotes wound healing phenotype in skin macrophages

OBJECTIVES

Ablative fractional laser (AFL) treatment is a well-established method for reducing signs of skin photoaging. However, the biological mechanisms underlying AFL-induced healing responses and skin rejuvenation remain largely unknown. It is known that macrophages play an important role in orchestrating healing, normalization, and remodeling processes in skin. Macrophage phenotypes are characterized by inflammatory markers, including arginase-1 (Arg1), major histocompatibility class II molecules (MHC II), and CD206. This study aims to explore AFL's effect on macrophage phenotype by evaluating changes in inflammatory markers and the potential concurrent accumulation of Arg1 in the skin.

METHODS

Mice (n = 9) received a single AFL treatment on the left side of the back skin (100 mJ/microbeam, 5% density) while the right side of the back remained untreated as control. Treated and untreated skin from each mouse were collected Day 5 posttreatment for flow cytometry and histology analysis. Flow cytometry evaluated the immune infiltration of macrophages and the expression of macrophage inflammatory markers (Arg1, MHC II, and CD206). In addition, Arg1 presence in the skin was evaluated through antibody staining of histology samples and quantification was performed using QuPath image analysis software.

RESULTS

Following AFL, the number of macrophages increased 11-fold (p = 0.0053). Phenotype analysis of AFL-treated skin revealed an increase in the percentage of macrophages positive for Arg1 (p < 0.0001) and a decrease in the percentage of macrophages positive for MHC II (p < 0.0001) compared to untreated skin. No significant differences were observed in percentage of CD206-positive macrophages (p = 0.8952). Visualization of AFL-treated skin demonstrated a distinct pattern of Arg1 accumulation that correlated with the microscopic treatment zones (MTZ). Quantification of the percentage of Arg1-positive area in epidermis and dermis showed a significant increase from 3.5% ± 1.2% to 5.2% ± 1.7 (p = 0.0232) and an increase from 2.2% ± 1.2% to 9.6% ± 3.3 (p < 0.0001) in whole skin samples.

CONCLUSION

AFL treatment polarizes macrophages toward a wound healing phenotype and induces Arg1 accumulation in the MTZ. We propose that the polarized wound healing macrophages are a major source for the increased Arg1 levels observed in the skin following treatment.

Safety and Effectiveness of Laser or Intense Pulsed Light Treatment for Early Surgical Scar: A Systematic Review and Meta-analysis

OBJECTIVE

We aimed to investigate the safety and efficacy of laser or intense pulsed light therapy for early treatment of surgical scar.

METHODS

A literature search was conducted for relevant prospective, randomized controlled trials published in PubMed, Embase, Web of Science, Cochrane Library, CNKI, WanFang Database, and VTTMS between January 2006 and January 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used to extract literature data. The risk of bias was assessed by RevMan. Safety was assessed based on the presence of serious adverse reactions (blisters, infections, burns above the second degree), while effectiveness was assessed using the Vancouver Score Scale.

RESULTS

1512 related articles were preliminarily retrieved, including 1211 English articles and 301 Chinese articles. According to the inclusion criteria and exclusion criteria, 12 articles were selected for this analysis. In total, 475 patients were included (laser group, 238; control group, 236). All studies confirmed that the laser group was superior to the control group. In the subgroup analysis of 7 articles, the standardized mean difference was 1.99 (P = 0.0001).

CONCLUSIONS

This meta-analysis demonstrates that laser or intense pulsed light therapy is a safe and effective approach for early surgical scar treatment, resulting in improved scar appearance and minimal adverse reactions.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Fractional ablative CO2 laser and oral isotretinoin-A prospective randomized controlled split-face trial comparing concurrent versus delayed laser treatment for acne scars

BACKGROUND

Therapeutic dogma has been to treat acne scars with ablative fractional laser no less than 6 months after isotretinoin (ITN) cessation.

OBJECTIVE

To evaluate the safety and efficacy of fractional ablative CO2 laser (FACL) in patients treated concurrently with ITN.

METHODS

We conducted a prospective split-face randomized control trial in patients treated with FACL concurrently with ITN versus patients treated with FACL 6 months post-ITN treatment. Patients received 3 monthly sessions of FACL with concurrent ITN treatment on half of the face; the other side of the face received the same FACL treatment regimen 6 months post-ITN cessation. Patients were followed for adverse effects up to 6 months post-FACL treatment. Final cosmesis was scored using the Quantitative Global Acne Scarring Grading System (GASGS) by three independent dermatologists.

RESULTS

The GASGS of the concurrent ITN-FACL treated side of the face was significantly lower than the side treated with delayed laser therapy (4.7 ± 2.5 vs. 7.7 ± 2.9, respectively, p < 0.001).

LIMITATIONS

The laser's settings were standardized, and not adjusted per patient skin type.

CONCLUSION

Per our prospective trial, concurrent treatment of FACL -ITN is superior to delayed FACL treatment 6 months post-ITN cessation. Fractional ablative laser treatment is effective in improving acne scars, which persist despite isotretinoin therapy.

Non-coding RNAs in hypertrophic scars and keloids: Current research and clinical relevance: A review

Hypertrophic scars (HS) and keloids (KD) are lesions that develop as a result of excessive fibroblast proliferation and collagen deposition in response to dermal injury, leading to dysregulation of the inflammatory, proliferative, and remodeling phases during wound healing. HS and KD affect up to 90 % of the population and are associated with lower quality of life, physical health, and mental status in patients. Efficient targeted treatment represents a significant challenge, primarily due to our limited understanding of their underlying pathogenesis. Non-coding RNAs (ncRNAs), which constitute a significant portion of the human transcriptome with minimal or no protein-coding capacity, have been implicated in various cellular physiologies and pathologies and may serve as diagnostic indicators or therapeutic targets. NcRNAs have been found to be aberrantly expressed and regulated in HS and KD. This review provides a summary of the expression profiles and molecular mechanisms of three common ncRNAs, including microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and circular RNAs (circRNAs), in HS and KD. It also discusses their potential as biomarkers for the diagnosis and treatment of these diseases and provides novel insights into epigenetic-based diagnosis and treatment strategies for HS and KD.

Fractional erbium:yttrium aluminum garnet laser in the treatment of morphea mouse model

OBJECTIVE

To assess the efficiency and the mechanism of fractional erbium:yttrium aluminum garnet (Er:YAG) laser for the treatment of morphea in mouse model.

BACKGROUND

Morphea is a rare autoimmune disease characterized by excessive collagen deposition in skin. Fractional Er:YAG laser treatment is a promising treatment to improve morphea, despite limited studies about the therapeutic effect and underlying mechanism.

METHODS

The mouse model of morphea was established by subcutaneously injecting with bleomycin (BLM). A total of 24 mice received fractional Er:YAG laser treatment once a week for 4 weeks. Objective measurement employed was ultrasonic imaging to measure dermal thickness. Subjective measures included scoring according to the adjusted Localized morphea Cutaneous Assessment Tool (LoSCAT); hematoxylin and eosin (H&E) staining to evaluate the histological grade of fibrosis; and quantitative morphometric studies to determine the expression of transforming growth factor-β1 (TGF-β1) and matrix metalloproteinase-1 (MMP1) by immunohistochemistry.

RESULTS

In this self-controlled study, fractional Er:YAG laser treatment significantly ameliorate the severity of morphea, including lower clinical score (p < 0.01), decreased dermal thickness (p < 0.001), declined histological grade of fibrosis (p < 0.001), increased MMP1 (p < 0.001), and reduced TGF-β1 (p < 0.01) expression.

CONCLUSIONS

We found that fractional Er:YAG laser treatment of morphea has good clinical, ultrasonic, and histopathologic efficacy, which may be a promising treatment in the future.

Treatment of Hypertrophic Burn Scars With Laser Therapy: A Review of Adverse Events

ABSTRACT

Hypertrophic scarring, characterized by excessive scar tissue formation, is a debilitating outcome that significantly impairs physical and psychosocial recovery after burn injury. Hypertrophic scarring affects a substantial proportion of burn survivors, with reported prevalence as high as 70%. Fractional CO 2 laser (FCL) therapy, a therapy commonly used in acne scar treatment or skin rejuvenation, has become popular in treating hypertrophic scars. Little is known regarding FCL's adverse events for burn scar treatment. We hypothesize that FCL is a safe treatment modality with minimal adverse events in the management of hypertrophic burn scars. This is a retrospective chart review of adverse events after FCL at 2 centers within a single institution. Burn patients undergoing FCL between May 1, 2019, and June 1, 2021 were included. Demographics, injury etiology, laser treatment details, and adverse events were collected. A total of 170 patients, 77 (45.3%) males and 93 (54.7%) females, underwent 544 FCL therapies for burn scars. The average number of treatments per patient was 3 ± 2.23, with a range of 1 to 17 sessions. From the total 544 laser therapy sessions, 13 adverse events (2.4%) were reported. There were 5 reports (0.9%) of increased postprocedural pain and 1 report (0.2%) of increased paresthesia/numbness to laser site. Three instances (0.6%) of increased erythema and 4 reports (0.7%) of epidermal sloughing or blistering were reported. All but 5 patients (2.9%) reported improvements to scar symptoms. This study demonstrates minimal adverse events associated with FCL for hypertrophic burn scar treatment.

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.

CO2 Laser for Esthetic Healing of Injuries and Surgical Wounds with Small Parenchymal Defects in Oral Soft Tissues

A number of studies have recently demonstrated the effectiveness of CO2 laser irradiation for the repair and regeneration of scar tissue from injuries or surgical wounds. However, such studies of the oral mucosa are highly limited. Previous studies using CO2 laser irradiation have indicated that two factors contribute to esthetic healing, namely, artificial scabs, which are a coagulated and carbonized blood layer formed on the wound surface, and photobiomodulation therapy (PBMT) for suppressing wound scarring and promoting wound healing. This review outlines basic research and clinical studies of esthetic healing with the use of a CO2 laser for both artificial scab formation by high-intensity laser therapy and PBMT in the treatment of injuries and surgical wounds with small parenchymal defects in oral soft tissues. The results showed that the wound surface was covered by an artificial scab, enabling the accumulation of blood and the perfusion necessary for tissue regeneration and repair. Subsequent PBMT also downregulated the expression of transformation growth factor-b1, which is involved in tissue scarring, and decreased the appearance of myofibroblasts. Taken together, artificial scabs and PBMT using CO2 lasers contribute to the suppression of scarring in the tissue repair process, leading to favorable esthetic and functional outcomes of wound healing.

Influence of scar age, laser type and laser treatment intervals on adult burn scars: A systematic review and meta-analysis

AIM

The study aims to identify whether factors such as time to initiation of laser therapy following scar formation, type of laser used, laser treatment interval and presence of complications influence burn scar outcomes in adults, by meta-analysis of previous studies.

METHODS

A literature search was conducted in May 2022 in seven databases to select studies on the effects of laser therapy in adult hypertrophic burn scars. The study protocol was registered with PROSPERO (CRD42022347836).

RESULTS

Eleven studies were included in the meta-analysis, with a total of 491 patients. Laser therapy significantly improved overall VSS/POSAS, vascularity, pliability, pigmentation and scar height of burn scars. Vascularity improvement was greater when laser therapy was performed >12 months (-1.50 [95%CI = -2.58;-0.42], p = 0.01) compared to <12 months after injury (-0.39 [95%CI = -0.68; -0.10], p = 0.01), the same was true for scar height ((-1.36 [95%CI = -2.07; -0.66], p<0.001) vs (-0.56 [95%CI = -0.70; -0.42], p<0.001)). Pulse dye laser (-4.35 [95%CI = -6.83; -1.86], p<0.001) gave a greater reduction in VSS/POSAS scores compared to non-ablative (-1.52 [95%CI = -2.24; -0.83], p<0.001) and ablative lasers (-0.95 [95%CI = -1.31; -0.59], p<0.001).

CONCLUSION

Efficacy of laser therapy is influenced by the time lapse after injury, the type of laser used and the interval between laser treatments. Significant heterogeneity was observed among studies, suggesting the need to explore other factors that may affect scar outcomes.

Efficacy of fractional CO2 laser in combination with stromal vascular fraction (SVF) compared with fractional CO2 laser alone in the treatment of burn scars: a randomized controlled clinical trial

BACKGROUND

The appearance of skin scars is known as one of the main side effects of skin burns. Stromal vascular fraction (SVF), as a rich source of cell populations with tissue regeneration properties, plays an important role in the healing of skin lesions. Fractional CO2 lasers have occupied a special place in treating skin lesions, particularly skin scars, since their introduction. Our study aimed to compare the combination of SVF and fractional CO2 laser with fractional CO2 laser alone in the treatment of burn scars.

METHOD

This double-blind clinical trial study was conducted on ten patients with burn scars that were treated three times with a fractional CO2 laser at site of burn lesions, and one of the two areas studied was randomly injected with SVF. Two months after completion of the procedure, patients' scars were assessed using the Vancouver scar scale (VSS), biometric criteria, and physician and patient satisfaction ratings.

RESULTS

The results confirmed a significant improvement in VSS, cutometry, R7 criteria, complete density sonography, and skin density sonography in the fractional CO2 laser-treated group. The VSS criteria, epidermal thickness sonography, complete density sonography, and skin density sonography in the group treated with the combination of fractional CO2 laser and SVF also showed significant improvement. The VSS criteria and melanin index of Mexameter in the group treated with SVF in combination with fractional CO2 laser were significantly better than the group treated with fractional CO2 laser alone. Also, physician and patient satisfaction in the group treated with SVF injection in combination with fractional CO2 laser was significantly higher than the other group.

CONCLUSION

The results confirm the efficacy of SVF injection in combination with fractional CO2 laser in the treatment of burn scars and can be considered as a treatment option for better management of these lesions.

TRIAL REGISTRATION

The study protocol was retrospectively registered at Iranian Registry of Clinical Trials with code: IRCT20210515051307N1, Registration date: 2021-11-14, URL: https://www.irct.ir/trial/56337 .

Carbon dioxide laser treatment of burn-related scarring: Results of the ELIPSE (Early Laser Intervention Promotes Scar Evolution) prospective randomized controlled trial

AIM

To investigate the impact of ablative fractional carbon dioxide laser (AFCO2L) on patient-reported outcomes measures, subjective scar appearance, dermal architecture, and gene transcription in early burn scars.

METHODS

Fifteen adult patients with a burn-related scar were recruited. Inclusion criteria were two non-contiguous scar areas of 1% total body surface area, similar baseline Vancouver scar scale (VSS) score and 3months since the time of injury. All participants acted as their own control. Scars were randomized to treatment or control. Treatment scars received three AFCO2L treatments at 6-week intervals. Outcome measures were recorded at baseline, 3, 6, and 12-months post-treatment. Measures included blinded VSS, Patient Observer Scar Assessment Scale (POSAS), Brisbane Burn Scar Impact Profile (BBSIP), blinded scar photo assessment, histological tissue analysis, and RNA sequencing analysis.

RESULTS

No significant difference was found in VSS, scar erythema, or pigmentation. Patient POSAS improved in scar thickness and texture following AFCO2L. All elements of BBSIP improved in control and laser groups. AFCO2L-treated scars were scored better than control scars by blinded raters. RNA sequencing illustrated that AFCO2L induced sustained changes in fibroblast gene expression.

CONCLUSIONS

AFCO2L treated scars had significantly altered scar thickness and texture 6 months post-laser and were rated better than controls on blinded photo analysis after 3 treatments. RNASeq results suggest laser treatment alters the transcriptome of treated fibroblasts for at least 3 months after treatment. Expansion of this research to study in more depth fibroblast changes in response to laser, as well as assessing the impact on daily activity and quality of life, will be beneficial.

Fractional CO 2 Laser versus Fractional CO 2 Laser Plus Betamethasone/Calcipotriol Ointment in the Treatment of Nail Psoriasis

BACKGROUND

Nail psoriasis has a major negative impact on the physical and psychological aspects of the patient's life. Treatment is often unsatisfactory because of the difficult penetration of the drug into the nail.

OBJECTIVE

To compare the efficacy of fractional CO 2 laser monotherapy versus combined fractional CO 2 laser and calcipotriol/betamethasone ointment preparation in treatment of nail psoriasis.

PATIENTS AND METHODS

Thirty patients with nail psoriasis with at least 2 affected fingernails were recruited for this study. Target NAPSI (tNAPSI) score was calculated at the start of the study and at 3 months after the last laser session. One affected fingernail of each patient received 6 sessions of fractional CO 2 laser with 4-week intervals. Another affected fingernail of each patient received topical betamethasone/calcipotriol ointment once daily in addition to the 6 fractional CO 2 laser sessions.

RESULTS

In the monotherapy group, there was significant improvement in the nail matrix score, nail bed score, and tNAPSI score. In the combined therapy group, there was significant improvement in nail bed score and tNAPSI score, but nail matrix score showed no statistically significant improvement. Overall, there was no statistically significant difference between the 2 studied groups.

CONCLUSION

Fractional CO 2 laser can be an effective and promising new treatment for nail psoriasis.

Scar Management and Dyschromia: A Summary Report from the 2021 American Burn Association State of the Science Meeting

Burn scars, and in particular, hypertrophic scars, are a challenging yet common outcome for survivors of burn injuries. In 2021, the American Burn Association brought together experts in burn care and research to discuss critical topics related to burns, including burn scars, at its State of the Science conference. Clinicians and researchers with burn scar expertise, as well as burn patients, industry representatives, and other interested stakeholders met to discuss issues related to burn scars and discuss priorities for future burn scar research. The various preventative strategies and treatment modalities currently utilized for burn scars were discussed, including relatively noninvasive therapies such as massage, compression, and silicone sheeting, as well as medical interventions such as corticosteroid injection and laser therapies. A common theme that emerged is that the efficacy of current therapies for specific patient populations is not clear, and further research is needed to improve upon these treatments and develop more effective strategies to suppress scar formation. This will necessitate quantitative analyses of outcomes and would benefit from creation of scar biobanks and shared data resources. In addition, outcomes of importance to patients, such as scar dyschromia, must be given greater attention by clinicians and researchers to improve overall quality of life in burn survivors. Herein we summarize the main topics of discussion from this meeting and offer recommendations for areas where further research and development are needed.

Early Fractional Ablative Laser for Skin Cancer Excision Scars: A Randomized Split-Scar Study

BACKGROUND

Fractional ablative laser resurfacing has been shown to improve the final cosmetic appearance of surgical scars, but optimal timing is unknown.

OBJECTIVE

To compare surgical scars treated with fractional carbon dioxide (CO 2 ) laser performed on Day 0 and Day 14.

METHODS

Prospective, randomized, split-scar, physician-blinded study of 30 surgical scars on the limbs. Scars halves received fractional CO 2 laser on either Day 0 or Day 14. Scar assessment at 6 months evaluated patient preference, physician modified Manchester Scar Scale (MMSS) score, and quantitative scar analysis on histology (fractal dimension [F D ] and lacunarity [L] analysis).

RESULTS

There was no significant difference in patient assessment (54% preferred Day 0 side, 46% preferred Day 14 side, p = .58) or physician assessment (mean MMSS 8.4 for Day 0 vs 8.7 for Day 14, p = .28). Fractal dimensions were similar for both interventions (mean 1.778 for Day 0 vs 1.781 for Day 14, p = .80). Lacunarity was similar for both interventions (mean 0.368 for Day 0 vs 0.345 for Day 14, p = .44).

LIMITATIONS

Single-center study with wounds limited to limbs of skin Phototype I-II subjects; 4 of whom were lost to follow-up.

CONCLUSION

Intraoperative CO 2 laser is noninferior to Day 14 laser resurfacing for surgical scar treatment.

Laser therapy as a treatment for chronic radiation fibrosis

BACKGROUND

Chronic radiation fibrosis (CRF) is a long-term sequala of radiation therapy that has a significant impact on patient quality of life. There is no standard of care or single therapeutic modality that has been found to be consistently effective.

OBJECTIVE

To describe our experience using fractional 10,600 nm carbon dioxide (CO₂ ) laser therapy and vascular laser therapy in a series of patients with CRF.

METHODS

Patients presenting to the dermatology service for CRF were evaluated for laser therapy eligibility. Patients were eligible if they had a clinical diagnosis of CRF confirmed by physical examination.

RESULTS

We identified five patients with CRF treated with fractional ablative CO₂ laser and vascular laser. Patients were a median age of 57 years old, and the amount of time between the initiation of radiotherapy and laser treatment ranged between 3 months and 40 years. The satisfactory response was achieved in all cases.

LIMITATIONS

Lack of standardized laser protocol, small sample size, lack of a control group, different anatomical locations CONCLUSION: Fractional ablative and vascular laser therapy may serve as an additional treatment for CRF, leading to functional improvements.

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.

Research trends and hotspot analysis of fractional carbon dioxide laser: A bibliometric and visualized analysis via Citespace

INTRODUCTION

There is limited basic research on carbon dioxide (CO₂ ) fractional laser, indicating blind spots in CO₂ fractional laser treatment of certain diseases. This study aimed to organize previous literature, summarize the current research, and speculate on possible future development.

METHODS

We searched document data on fractional CO₂ lasers from the Web of Science core collection database and retrieved 928 articles from 2004 to 2021. CiteSpace software was used to analyze the main institutions, authors, subject hotspots, and research frontiers in global CO₂ fractional laser research.

RESULTS

The results revealed that 928 related papers were published in the past 18 years (2004-2021), and the number has increased annually. The publications were written by 3239 authors from 626 institutions in 60 countries/regions. The United States (US) dominates this field (312 documents), followed by Italy (289), and South Korea (88). Lasers in Surgery and Medicine is the journal with the most publications and citations, and Uebelhoer is the central author. The main research hotspots include vulvovaginal atrophy, fractional photothermolysis, keloids, drug delivery, gene expressions, facial acne scarring, resurfacing, vitiligo, and photo damage.

CONCLUSION

Using CiteSpace, this paper draws a map of authors, institutions, and keywords in fractional CO₂ laser from 2004 to 2021; summarizes the main authors, institutions, research hotspots, and cutting-edge topics of global fractional CO₂ laser technology in recent years; and summarizes the current application status of global fractional CO₂ laser in disease treatment. It also provides new ideas for the future application and research of fractional CO₂ lasers.

Effect of the combination of photobiomodulation therapy and the intralesional administration of corticoid in the preoperative and postoperative periods of keloid surgery: A randomized, controlled, double-blind trial protocol study

Keloid scars are characterized by the excessive proliferation of fibroblasts and an imbalance between the production and degradation of collagen, leading to its buildup in the dermis. There is no “gold standard” treatment for this condition, and the recurrence is frequent after surgical procedures removal. In vitro studies have demonstrated that photobiomodulation (PBM) using the blue wavelength reduces the proliferation speed and the number of fibroblasts as well as the expression of TGF-β. There are no protocols studied and established for the treatment of keloids with blue LED. Therefore, the purpose of this study is to determine the effects of the combination of PBM with blue light and the intralesional administration of the corticoid triamcinolone hexacetonide on the quality of the remaining scar by Vancouver Scar Scale in the postoperative period of keloid surgery. A randomized, controlled, double-blind, clinical trial will be conducted involving two groups: 1) Sham (n = 29): intralesional administration of corticoid (IAC) and sham PBM in the preoperative and postoperative periods of keloid removal surgery; and 2) active PBM combined with IAC (n = 29) in the preoperative and postoperative periods of keloid removal surgery. Transcutaneous PBM will be performed on the keloid region in the preoperative period and on the remaining scar in the postoperative period using blue LED (470 nm, 400 mW, 4J per point on 10 linear points). The patients will answer two questionnaires: one for the assessment of quality of life (Qualifibro-UNIFESP) and one for the assessment of satisfaction with the scar (PSAQ). The team of five plastic surgeons will answer the Vancouver Scar Scale (VSS). All questionnaires will be administered one, three, six, and twelve months postoperatively. The keloids will be molded in silicone prior to the onset of treatment and prior to excision to assess pre-treatment and post-treatment size. The same will be performed for the remaining scar at one, three, six, and twelve months postoperatively. The removed keloid will be submitted to histopathological analysis for the determination of the quantity of fibroblasts, the organization and distribution of collagen (picrosirius staining), and the genic expression of TGF-β (qPCR). All data will be submitted to statistical analysis.

Trial registration: This study is registered in ClinicalTrials.gov (ID: NCT04824612).

Efficacy of Fractional Carbon Dioxide Laser (FCO2) with Intralesional 5-Fluorouracil (5-FU) in the Treatment of Keloids

Context:

Managing keloids remains a challenge in clinical practice. Many therapeutic options are available, but none is universally accepted or without recurrence. Therefore, an effort is required to choose the treatment with maximal outcomes.

Aims:

To evaluate the effectiveness of combining fractional carbon dioxide (FCO₂) laser and intralesional 5-fluorouracil (5-FU) for the treatment of keloids.

Materials and Methods:

In this prospective open-label study, 24 patients received FCO₂ laser treatment, started at baseline, for a total of six sittings. The patients also received 1 mL/cm²/keloid of 5-FU (50 mg/mL) intralesionally, following irradiation, at identical time points. The primary outcome evaluated was the clinical response concerning height, pliability, vascularity, and pigmentation, using the Vancouver Score Scale (VSS). Adverse reactions and recurrences were recorded as secondary outcomes.

Results:

A significant reduction was observed in the VSS in terms of pliability and height after three treatment sessions. The mean VSS reduction was 65%, from 8.45 ± SD 0.93 at baseline to 3 ± SD 1.8 one month after the last treatment (P < 0.05). Most patients (79.1%; n = 19) showed a satisfactory response to treatment, with 57.8% (n = 11) achieving an excellent result. Adverse reactions included post-inflammatory hyperpigmentation in four patients and ulceration in two. Recurrences were reported in 21% of the patients who responded well.

Conclusions:

Combination therapy with FCO₂ laser and intralesional 5-FU showed a promising effect in the treatment of resistant keloids, with an acceptable safety profile and low recurrence rate.

Efficacy and safety of CO2 laser in the treatment of chronic wounds: A Retrospective Matched Cohort Trial

OBJECTIVES

Treating chronic cutaneous wounds is challenging, and debridement is a central concept in treating them. Studies have shown that CO₂ laser debridement can control local infection and promote the wound healing process. The present study aimed to investigate the efficacy and safety of fully ablative CO₂ laser debridement compared to routine surgical debridement in the treatment of chronic wounds.

METHODS

The retrospective cohort study was conducted on patients with chronic (>1 month) cutaneous wounds (≥1 cm² ) between December 1, 2017, and December 1, 2020, in the Wound Healing Center at Shanghai Ruijin Hospital, China. Patients treated with CO₂ laser debridement with a DEKA SmartXide2 C80 (DEKA) (the CO₂ laser group) were compared with matched control patients with similar baseline characteristics who had undergone routine surgical debridement (the routine group). The primary outcome was time-to-heal (days) for chronic wounds in two groups, and secondary outcomes included the wound area and BWAT (Bates-Jensen wound assessment tool) score before treatment, and at 1, 2, 3, and 4 weeks after treatment.

RESULTS

The study included 164 patients (82 in the CO₂ laser group and 82 matched in the routine group). The time-to-heal for patients in the CO₂ laser group (41.30 ± 17.11) was significantly shorter than that of the patients in the routine group (48.51 ± 24.32) (p = 0.015). At 3 and 4 weeks after treatment, the absolute wound area of the CO₂ laser group was significantly smaller than that of the routine group. Also, the CO₂ laser group exhibited a significantly lower relative area at 2, 3, and 4 weeks after treatment. The CO₂ laser group yielded significantly lower BWAT scores at 2, 3, and 4 weeks after treatment. Additionally, the relative BWAT score was significantly lower in the CO₂ laser group than the relative scores in the routine group at 2, 3, and 4 weeks after treatment. No adverse events related to the treatments were observed in either group during the study period.

CONCLUSIONS

The present study has shown that fully ablative CO₂ laser debridement has several advantages over routine sharp surgical debridement. It is superior at ameliorating wound status and reducing wound area, and it also significantly reduces the time-to-heal for chronic wounds, without causing any adverse events.

Treatment of Scars with Laser-Assisted Delivery of Growth Factors and Vitamin C: A Comparative, Randomised, Double-blind, Early Clinical Trial

BACKGROUND

Scarring can jeopardize the final result of plastic surgeries. Deep dermal injuries activate dermal fibroblasts that produce excessive amount of collagen and inflammatory cytokines and growth factors, which contributes to increased fibrous tissue and scarring tissue formation.

OBJECTIVES

The aim of this early study, double-blind, prospective, randomised clinical trial was to investigate the use of laser-assisted drug delivery (LADD) for scar improvement to support the establishment of LADD as standard therapy modality and to indicate suitable drugs for dermal administration.

MATERIAL AND METHODS

In total, 132 patients seeking scar treatment were consented and randomised. The control group (64 patients) received laser resurfacing immediately followed by skin surface application of Vitamin C and 68 patients received laser treatment followed by skin surface application of a cosmeceutical containing growth factors (GFs) and Vitamin C. Photographs were obtained before and three months after the procedure and submitted to three-dimensional reconstruction by the software Dermapix^®. Objective measurements provided by the software were statistically analysed and established the differences in the treatment result between the two groups.

RESULTS

There was a significant reduction in scar roughness and volume in both groups (p < 0.01). Mann-Whitney test confirmed that the group treated vitamin C and GFs presented significantly better results than the group treated with vitamin C alone (p < 0.01).

CONCLUSION

LADD has proven efficient as scars were reduced in both study groups. Furthermore, the addition of growth factors provided statistically significant better outcomes and resulted in more inconspicuous scars. No adverse reactions were observed.

CLINICAL TRIAL REGISTRATION

Plataforma Brasil under the number CAAE: 63710716.2.0000.5664.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

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.

Effects of multiple modes of UltraPulse fractional CO2 laser treatment on extensive scarring: a retrospective study

The main therapeutic options for extensive scarring (e.g., > 20% of the total body surface area, or TBSA) after burns and trauma have focused on conservative treatments, such as compression, moisturization, and topical agent application. However, these treatments may not achieve optimal effects due to the large size and complexity of the scars. UltraPulse fractional CO₂ laser treatment is a novel approach that is currently a subject of intense interest; this treatment is most widely used to improve texture, pliability, and pigmentation in all types of scars. However, no studies on the independent use of UltraPulse fractional CO₂ laser treatment for extensive scars have been reported. This retrospective study evaluated a total of 21 patients, whose scars covered 20 to 65% TBSA. Scar thickness was measured by ultrasonography before treatment. Personalized treatment modalities and parameters were set according to the scar type and thickness. Scar formation and treatment effects were evaluated by photography, the Patient and Observer Scar Assessment Scale (POSAS), and patients’ judgment of effectiveness. Where the scars covered joints, joint function was assessed by measuring the maximum range of motion (ROM). With laser therapy, scars became flatter and lighter; furthermore, pruritus, pain, and discomfort decreased significantly. POSAS scores significantly decreased after laser therapy, including the item scores for pain and pruritus. There were no instances of joint contracture, ROM reduction, apparent functional impairment, serious adverse events, or comorbidities. This study demonstrates the safety and efficiency of UltraPulse fractional CO₂ laser treatment for extensive scarring.

Laser Therapy for the Treatment of Morphea: A Systematic Review of Literature

Morphea, also known as localized scleroderma (LoS), comprises a set of autoimmune sclerotic skin diseases. It is characterized by inflammation and limited thickening and induration of the skin; however, in some cases, deeper tissues might also be involved. Although morphea is not considered a life-threatening disease, the apparent cosmetic disfigurement, functional or psychosocial impairment affects multiple fields of patients’ quality of life. Therapy for LoS is often unsatisfactory with numerous treatments that have only limited effectiveness or considerable side effects. Due to the advances in the application of lasers and their possible beneficial effects, the aim of this study is to review the reported usage of laser in morphea. We present a systematic review of available literature, performed with MEDLINE, Cinahl, Central, Scopus, Web of Science, and Google Scholar databases. We identified a total of twenty relevant studies (MEDLINE n = 10, Cinahl n = 1, Central n = 0, Scopus n = 2, Web of Science n = 5, Google Scholar n = 2) using laser therapy for LoS. Eight studies were focused on the use of PDL, six on fractional lasers (CO₂ and Er:YAG), four on excimer, and two on either alexandrite or Nd:YAG.

Ablative fractional CO2 laser surgery improving sleep quality, pain and pruritus in adult hypertrophic scar patients: a prospective cohort study

Background

Poor sleep quality is associated with a decrease in quality of life in patients with major burn scars, combined with pruritus and pain. Few interventions have been reported to improve the sleep quality of patients with scars. In the current prospective cohort study, we investigated the efficacy of CO₂-ablative fractional laser (AFL) surgery vs conventional surgery in post-burn patients with hypertrophic scars with sleep quality as the primary study outcome.

Methods

In total 68 consecutive patients undergoing scar surgical treatment were recruited, including a CO₂-AFL surgery cohort (n = 35) and a conventional surgery cohort (n = 33). A subgroup from the AFL cohort was selected. Sleep quality, pain and pruritus were evaluated. Multiple linear regression analyses were performed to reveal the effect of CO₂-AFL surgery.

Results

The CO₂-AFL surgery cohort had significantly lower Pittsburgh sleep quality index (PSQI) global scores than the conventional surgery cohort after the last surgical treatment. In the subgroup of patients receiving hardware sleep monitoring, CO₂-AFL markedly increased deep sleep time, deep sleep efficiency and reduced initial sleep latency. Compared to the conventional surgery cohort, the CO₂-AFL cohort presented significantly lower pain and pruritus scores. Correlation analysis showed pain and pruritus were significantly associated with PSQI scores, and there were also significant correlations between pain and pruritus scores. Multiple linear regression analysis showed that surgery method was negatively linearly correlated with visual analog scale (VAS) pain score, brief pain inventory (BPI) total, VAS pruritus score, 5-D itch scale total, four-item itch questionnaire (FIIQ) total and PSQI total.

Conclusions

CO₂-AFL surgery significantly improved sleep quality and reduced pain and pruritus of hypertrophic scar patients. The alleviation of sleep disorder was associated with improvement of deep sleep quality including deep sleep time and deep sleep deficiency.

Trial registration

The Chinese Clinical Trial Registry (ChiCTR200035268) approved retrospectively registration on 5 Aug 2020.

Laser in surgical scar clearance: An update review

Scar formation is a consequence of wound healing that developed from damaged tissue either from physical injury or surgical incision. A hypertrophic scar develops due to an abnormal healing response to trauma. It might lead to serious functional and cosmetic disability. There are numerous methods mentioned in the literature to treat such scars but to date, no single method has been known to cure them. In this review, we focused on differences between various types of nonsurgical management of hypertrophic scar focusing on the indication, mechanism of action, and efficacy of the pulsed dye laser (PDL), fractional carbon dioxide laser (fCO2), Er-YAG laser, and intense pulse light (IPL). The literature research included peer-reviewed articles (clinical trials or scientific reviews) which were identified by searching electronic databases like PubMed till January 2021 and reference lists of respective articles. Only articles published in the English language were included.

Patient- and Physician-Reported Outcome of Combined Fractional CO2 and Pulse Dye Laser Treatment for Hypertrophic Scars in Children

BACKGROUND

Hypertrophic scars are commonly seen in children and associated with pruritus, pain, functional impairment, and aesthetic disfigurement. Ablative fractional CO2 and pulse dye laser are emerging techniques to improve scar quality. Only limited data are available on children, nonburn scars, and patient-reported outcome. We aimed to investigate safety and outcome of repeated laser therapy for hypertrophic scars originating from burns and other conditions by means of patient- and physician-reported outcome measures.

METHODS

This was a retrospective before-after analysis of laser treatments in children with hypertrophic scars. Outcome was measured using Patient and Observer Scar Assessment Scale, Vancouver Scar Scale and Itch Man Scale. With respect to safety, laser- and anesthesia-related complications were analyzed.

RESULTS

Seventeen patients, aged 11.37 ± 4.82 years with 27 scars, underwent 102 distinct laser treatments, mainly combined CO2 and pulse dye laser (94%), with few CO2 only (6%). Vancouver Scar Scale total score before the first and after the first session decreased significantly from 7.65 ± 2.12 to 4.88 ± 1.73; Patient and Observer Scar Assessment Scale observer overall opinion also dropped from 5.88 ± 1.57 to 4.25 ± 1.70. Pruritus improved significantly. Patient age and timing of laser intervention did not have an impact on treatment response. Complications related to laser treatment were seen in 2% (wound infection, n = 2) and to anesthesia in 4% (insignificant n = 2, minor n = 1).

CONCLUSIONS

Combined laser therapy significantly improves quality, pain, and pruritus of hypertrophic scars in children. When provided by experienced laser and anesthesia teams, it is safe with a low rate of complications.

Fractionated Ablative Carbon Dioxide Laser Therapy Decreases Ultrasound Thickness of Hypertrophic Burn Scar: A Prospective Process Improvement Initiative

INTRODUCTION

Carbon dioxide (CO2) laser treatment is routinely used to treat hypertrophic burn scars (HBS). Although prior research has documented subjective improvement in HBS after treatment, there is little data evaluating objective changes in scar characteristics after therapy. The aim of our process improvement project was to evaluate changes to scar thickness (ST) using high-frequency ultrasound in patients with HBS undergoing CO2 laser therapy.

METHODS

Ultrasound measurements of ST were obtained from patients with HBS before initial and at each subsequent treatment. ST, reduction in ST per treatment, and percentage reduction in ST from baseline were tabulated. Post hoc analyses examining the effect of initial ST and scar maturity on outcome were performed. First, patients were grouped by baseline ST into thicker (group 1, initial ST ≥ median value) and thinner (group 2, initial ST < median value) scar groups. Second, patients were divided into quartiles based on time from injury to treatment. Outcomes at each time point were compared with either Mann-Whitney U or Kruskal-Wallis tests, with Bonferonni corrections performed for post hoc subgroup analyses. Significance was set at P < 0.05.

RESULTS

Twenty-one consecutive patients with HBS treated with CO2 laser were included. All patients completed 1 or more treatment, 48% completed 2 or more treatments, and 28% completed 3 treatments. Median initial ST was 0.71 cm (0.44-0.98 cm), and median scar maturity was 7.5 months (4.9-9.8 months). Overall, ST decreased over the treatment course (P < 0.001), with post hoc analysis demonstrating that 2 treatments were required to achieve a significant ST reduction (P < 0.01). On subgroup analysis comparing initial ST, ST decreased significantly in group 1 (thicker scars) overall (P < 0.001) but not in group 2 (P = 0.109). ST reduction was greatest after 1 treatment in group 1 (P = 0.022) and group 2 (P = 0.061). Percent reduction was greater in group 1 relative to group 2 after 1 treatment (P = 0.016). On subgroup analysis of scar maturity, there were no significant differences in either baseline ST or ST at any subsequent visit.

CONCLUSIONS

Fractionated ablative CO2 laser treatment improved ST after 1 to 2 treatments. Patients with thicker scars demonstrated greater ST reduction than those with thinner scars. Ultrasound adequately assessed treatment response.

Fractionally Ablative Er: YAG Laser Resurfacing for Thermal Burn Scars: a Split-Scar, Controlled, Prospective Cohort Study

BACKGROUND

Thermal burn scars can have catastrophic impact on the quality of life and personal image, and over time can lead to profound physical and psychological debilitation. There are no established treatments to significantly improve burn scars.

OBJECTIVE

To demonstrate the safety, efficacy, and tolerability of fractionally ablative Er:YAG resurfacing of mature burn scars.

METHODS

Sixteen subjects were enrolled and received 3 treatments of fractionally ablative Er:YAG resurfacing at monthly intervals. Twelve completed the study. Scars were scored with the Vancouver Scar Scale (VSS) by the patient and physician before and after treatment. Blinded photographic analysis (Visual Analog Scale [VAS]) and blinded histologic analysis of tissue before and after treatment was also performed.

RESULTS

Significant Improvement in VSS scores were seen in all 12 patients, reported by patients and the evaluating physician alike. Photographic analysis demonstrated subjective improvement in all 12 patients. Histologically, there was significant improvement in collagen architecture and the number of vessels per high-power field. The treatments were tolerated well by patients, and 1 superficial skin infection occurred.

CONCLUSION

Fractionally ablative Er:YAG laser resurfacing is a safe and effective modality in the treatment of thermal burn scars with subjective and objective improvement as seen from the patient and physician.

Lessons Learned from the First Decade of Laser-Assisted Drug Delivery

Laser-assisted drug delivery augments the distribution and penetration of topically applied treatments, leading to enhanced delivery and bioavailability. We discuss the therapeutic application of laser-assisted drug delivery in clinical practice in cases of non-melanoma skin cancer, vitiligo, melasma, scarring, and alopecia (female pattern hair loss, male pattern hair loss, alopecia areata) as well as for vaccination, local anaesthesia, analgesia, viral warts, infantile haemangiomas and cosmetic uses, and we review clinical studies that have used this technique over the last decade. Our review shows that the application of laser-assisted drug delivery enhances topical agent efficacy, potentially reducing the agent concentration and duration of topical treatment required. Future research into the use of laser-assisted drug delivery before topical therapies is needed to establish the optimal techniques to enhance drug delivery and thus improve patient outcomes.

Comparative Study between Nd-YAG laser, fractional CO2 Laser, and combined Nd-YAG with fractional CO2 Laser in the Management of keloid: clinical and molecular Study

BACKGROUND

Fractional CO2 laser and Nd-YAG laser have been reported to have promising results in the management of keloids. So far, there have been no comparative studies between these laser modalities.

AIMS

The study aimed to compare the efficacy of fractional CO2, Nd-YAG, and a combination of both in the management of keloids.

PATIENTS AND METHODS

Forty-five keloid patients were divided into 3 equal groups: the first received fractional CO2 only, the second received Nd-YAG only, and the third received a combination of both lasers. Each group received its designated treatment every 4 weeks for 4 sessions. The improvement was evaluated by the "Patient and Observer Scar Assessment Scale" (POSAS). Detection of procollagen I mRNA by RT-PCR analysis was done.

RESULTS

The assessment by POSAS showed the most significant clinical improvement in the combination group and a less significant improvement in the fractional CO2 group, while the least improvement was seen in the Nd-YAG group. Molecular assessment via procollagen I yielded matching results.

CONCLUSION

The study showed that the combination of fractional CO2 and Nd-YAG lasers has a synergistic effect being the most effective in the management of keloids, fractional CO2 being more effective than ND-YAG and Nd-YAG being the least effective.

Effects of combined Pulsed Dye Laser and Fractional CO2 Laser treatment of burn scars and correlation with plasma levels of collagen type I, MMP-2 and TIMP-1

Hypertrophic burn scars remain a significant burden for patients and a challenge for clinicians.

THE AIM

Assessement of the efficacy of combined Pulsed Dye Laser and Ablative Fractional CO₂ Laser therapy on hyperthophic scars and correlation with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen.

PATIENTS AND METHODS

Twenty five pediatric subjects were enrolled into the study. Control group consisted of age-matched subjects admitted for surgical repair of inguinal hernia. For the assessment of the results of laser treatment we used the Vancouver scar scale (VSS), and Patient-Observer Scar Assessment Scale (POSAS). We also correlated clinical results with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen.

RESULTS

All subjects reported the laser treatment resulted in improvement and were somewhat satisfied or very satisfied with their experience. No adverse events were reported. The levels of MMP-2, TIMP-1 and alpha-1 type I collagen in our patients with scars before laser threatment were higher in comparison to controls. We also found statistically significant decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scars CONCLUSIONS: Our study clearly shows that combined CO2-AFL treatment for burn scars improve texture, colour, function and alleviate pruritus. We believe that decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scars, reflects reduced dynamic of scar.

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.

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.

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.

Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence

Once scar tissues mature, it is impossible for the surrounding tissue to regenerate normal dermal tissue. Therefore, it is essential to understand the fundamental mechanisms and establish effective strategies to inhibit aberrant scar formation. Hypertrophic scar formation is considered a result of the imbalance between extracellular matrix synthesis and degradation during wound healing. However, the underlying mechanisms of hypertrophic scar development are poorly understood. The purpose of this review was to outline the management in the early stage after wound healing to prevent hypertrophic scar formation, focusing on strategies excluding therapeutic agents of internal use. Treatment aimed at molecular targets, including cytokines, will be future options to prevent and treat hypertrophic scars. More basic studies and clinical trials, including combination therapy, are required to investigate the mechanisms and prevent hypertrophic scar formation.

Laser management of hypertrophic burn scars: a comprehensive review

Hypertrophic scars often develop following burn-related injuries. These scars can be cosmetically unappealing, but associated symptoms of pruritus, pain and restricted range of motion can impair a person’s quality of life. Laser and light therapies offer a minimally invasive, low-risk approach to treatment, with a short postoperative recovery period. As laser technology developed, studies have shown decreased scar thickness, neuropathic pain and need for surgical excision, as well as improved scar pigmentation, erythema, pliability, texture, height and pruritus. In this review, we present the evolution of laser therapy for hypertrophic burn scars, how different types of lasers work, indications, perioperative considerations and guidelines for practice management.

When Wounds Are Good for You: The Regenerative Capacity of Fractional Resurfacing and Potential Utility in Chronic Wound Prevention

Significance: Fractional resurfacing involves producing arrays of microinjuries on the skin, by thermal or mechanical means, to trigger tissue regeneration. Originally developed for cosmetic enhancement, fractional resurfacing induces a broad array of improvements in the structural and functional qualities of the treated skin and is especially effective at returning defective skin to a more normal state. In addition to fascinating questions about the nature of this remarkable regenerative capacity, there may be potential utility in ulcer prevention by halting or even reversing the progressive decline in overall skin quality that usually precedes chronic wound development. Recent Advances: Photoaging and scarring are the two skin defects most commonly treated by fractional resurfacing, and the treatment produces profound and long-lasting improvements in skin quality, both clinically and at the cellular/histologic level. Chronic wounds usually occur in skin that is compromised by various pathologic factors, and many of the defects found in this ulcer-prone skin are similar to those that have seen improvements after fractional resurfacing. Critical Issues: The mechanisms responsible for the regenerative capacity of fractional resurfacing are mostly unknown, as is how ulcer-prone skin, which is usually afflicted by stressors external to the skin tissue itself, would respond to fractional resurfacing. Future Directions: Better understanding of the cellular and molecular mechanisms underlying the unique healing response to fractional resurfacing could reveal fundamental information about adult tissue regeneration, lead to improvements in current applications, as well as new therapies in other pathologic conditions.