Laser in the management of burn scars

Minority pediatric burn survivors undergo more burn operations: A single center's five-year experience

Burn injuries remain a significant source of trauma in the United States and disproportionately affect racial and ethnic minorities. Although disparities are well documented in adults, less is known regarding those in pediatric populations. To address this gap in literature, we aim to better characterize burn injuries, inpatient treatments, and post-discharge outcomes in minority pediatric burn patients. We hypothesize minority patients undergo more surgery and re-admissions than non-minority patients for burn care. This is a single institution retrospective chart review of pediatric patient admissions with burn injuries from July 1st, 2016 to July 1st, 2021. Demographics, details of injury, inpatient surgical and non-surgical care, and post-discharge outcomes were collected. Patients identifying as Hispanic/Latino, Black, and Asian were coded as minority patients. Univariate analysis was utilized. A total of 332 patients with average age of 4.9 years (SD: 4.4) and average total burn surface area (TBSA) of 8.5% (SD: 10.0) were collected. Minority patients were significantly more likely to experience accidental burn injury (p < 0.01), inhalational injury (p < 0.01), surgical management (p < 0.01), and to undergo skin graft (p < 0.01) than White patients. Minority patients were significantly more likely to undergo laser treatment after discharge (p < 0.01) than White patients. Our study shows minority pediatric patients are at risk for non-intentional burn injuries that undergo surgical management such as skin grafting and longitudinal reconstructive procedures including laser therapy more often. Short-term goals should include facilitating improved physical and psychosocial outcomes in this often-underserved patient population.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Picosecond Nd:YAG versus Fractional CO2 Lasers in Management of Postburn Scars

Background

The picosecond laser was primarily designed to enhance tattoo removal. Because it has a new innovative mechanism for energy delivery, it has been modified to be used in other conditions such as skin resurfacing, which was usually treated with fractional CO2 laser. Comparing both technologies in managing postburn scars has not been widely addressed.

Methods

The current prospective comparative randomized intrapatient study was done on 15 patients who presented with unsightly postburn scarring. As a split study, one-half of the affected areas were treated using the picosecond Nd: YAG laser. The other areas were treated with a fractional CO2 laser. After three treatment sessions, the results were analyzed both objectively and subjectively.

Results

The assessment by the image analysis system (Antera camera) showed improvement in all the parameters in both groups. The melanin relative variation decreased from 11.65 ± 2.86, 15.85 ± 5.63 to 10.60 ± 1.96, 12.56 ± 3.98, respectively in picosecond laser sites and fractional CO2 sites. The percentage change in overall opinion decreased in in favor of the fractional CO2 laser sites, which is a statistically significant improvement. Instead, color scores revealed a greater reduction in the picosecond sites in comparison with the fractional CO2 sites, as it decreased from 7.67 ± 1.76, 7.73 ± 1.83 to 2.87 ± 1.06, 6 ± 1.2, respectively.

Conclusions

When compared with fractional CO2 lasers, picosecond Nd:YAG shows comparable improvements in scars' erythema, texture, and height, with some superiority in the management of hyperpigmented scars.

Scars

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

Serial Casting as an Effective Method for Burn Scar Contracture Rehabilitation: A Case Series

Guidelines and protocols for orthoses in burn scar contracture rehabilitation are limited. The current study aims to determine the optimal frequency of casting, potentially facilitating the development of a serial casting protocol. Previous literature supporting casting has low generalizability due to methodology limitations. Seven patients with burn scar contracted joints, who did not respond to traditional therapy, were recruited in this study. Patients were serially casted once, three times, or five times a week. Joint range of motion was maximized with stretching and exercise techniques before every new cast application. Across all patients, active range of motion increased from 65.8 ± 27.8° to 108.1 ± 23.3° with casting; or from 57.8 ± 16.2% to 96.7 ± 2.9% of normal. Similarly, scars improved from 9.5 ± 1.5 to 4.9 ± 1.4 on the Modified Vancouver Scar Scale score. This therapeutic effect was achieved within an average of 8.5 ± 3.7 d and 4.0 ± 2.2 new cast applications. Given the study findings, the procedures outlined could be used to develop a standardized serial casting protocol for burn scar contracture rehabilitation.

Flexible application of scar tissue flaps in scar contracture release surgery: A retrospective study

BACKGROUND

Complete release of scar contracture often relies on surgery, but if the surgery injures normal skin tissue triggers new wounds and scarring, which adds insult to injury for the patient.

OBJECTIVE

To explore a method that uses scar tissue to repair the defect after the release of scars and try to avoid damage to normal skin tissue.

MATERIALS AND METHODS

Forty-eight scar contracture patients admitted to our hospital from October 2014 to October 2019 were treated with scar tissue flaps (including Subcutaneous pedicle rhomboid flap, Z-plasty flap, 5-flap, and their combination model) and minor defects in combination with little scattered skin grafts. Medical and demographic data were collected on each patient. Assessed the joint range of motion (ROM) preoperatively and postoperatively, and complication was recorded. The rate of scar contracture recurrence was recorded at a follow-up of 6-24 months.

RESULTS

Twenty-eight cases of scar contracture located in the joint sites, 20 in the trunk. All the surgical outcomes were satisfied, with significant improvement in contracture scarring and joint status. Postoperative joint range of motion (ROM) showed a significant improvement in comparison with preoperative mobility, whereas the difference was statistically significant (p < 0.05). After 24 months of follow-up, five joints showed recontraction, with a recurrence rate of 10.42%.

CONCLUSION

Scar contracture could be efficiently treated by properly designing incisions and making the most of the scar tissue flap, to minimize and avoid damage to the normal skin.

Comparison of stationary and dynamic fractional CO2 laser modalities of large burns treatment: Experimental laboratory model

OBJECTIVES

To experimentally compare two fractional ablative CO₂ laser handpieces intended for the treatment of large area burn scars. Each handpiece coverage rate, depth of penetration and application time were measured and compared in a simulation model of large area burns scars using a dynamic/roller handpiece (small footprint) and a stationary/stamping handpiece (large footprint).

METHODS

A 30 W fractional ablative CO₂ laser was applied using 2 different handpieces and footprints on a A4 size paper stack. The handpieces were a stationary (stamping) handpiece with 7 × 7 (49 pixels/square shape) and dynamic (roller) handpiece with 7 × 1 (7 pixels/single row shape). For both handpieces the laser settings were fixed at "High" power (30 W), providing an energy level of 100 mJ/pixel. Both handpieces were applied perpendicular to the surface, with the process repeated for the dynamic handpiece with an angled operation. The depth of laser penetration was assessed by the number of pages of paper having visible holes and burn area coverage time measured under each handpiece/condition.

RESULTS

The application time was faster and the penetration deeper for the dynamic handpiece compared to the stationary handpiece in both the perpendicular and angled conditions. This study has practical implications for lasers operators to improve time efficacy in large area scars with improved clinical endpoints.

CONCLUSION

The fractional ablative dynamic handpiece demonstrated superior application efficiency compared to the stationary handpiece in the simulated treatment of large surface area burn scars, reducing treatment time with improved depth of penetration.

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.

A meta-ethnography of developing and living with post-burn scars

INTRODUCTION

Post-burn scarring is often cosmetically unappealing and create discomfort. This makes it crucial to understand the experience of individuals living with scars which can offer insights into their recovery. This review sought to develop an in-depth understanding of living with post-burn scars.

DESIGN

A systematic review and meta-ethnography approach were employed. We utilized an interpretive approach to inductively generate codes. These codes were examined iteratively using a constant comparison strategy following which they were re-interpreted to formulate themes which formed the basis of undertaking a narrative synthesis.

RESULTS

Twenty-five studies were retained. The analytical process yielded two themes: emergence of a new identity and living with the redefined self. The experience of living with scars is entwined with the initial trauma as the scars served as a permanent reminder of the injury. Emergence of a new identity involved a process of meaning making, mourning the loss of the old self, confronting the new self, reconciling the remains of the old self with the new, rebuilding a new identity, and navigating through functional restrictions. These processes were particularly challenging for persons involved in self-immolation. Positive coping and changing one's perspective emerged as strategies to facilitate living with the redefined self.

CONCLUSION

Living with scars is a challenging process which is more difficult for persons whose injuries are due to self-immolation (act of burning oneself). The findings highlight a latent yet ongoing process towards subjective recovery. Clinicians need to be aware of the processes and incorporate these into rehabilitation programmes.

CLINICAL RELEVANCE

Burn survivors need ongoing professional support to adjust to and live with the scars. Victims of self-immolation should be considered for early psychosocial support.

The use of carbon dioxide and intense pulsed light laser for the treatment of hypertrophic burn scars: A case series

Introduction

Hypertrophic scarring is a common and debilitating consequence of burn scars. While there is limited evidence for current treatment options, laser therapy has been shown to be effective, low risk and minimally invasive. This study assesses the use of carbon dioxide lasers and intense pulsed light devices in the treatment of hypertrophic burn scars.

Methods

In this case series, patients were recruited from a hypertrophic burn scar waitlist and completed a Patient and Observer Scar Assessment Scale prior to and six weeks after laser therapy. The Nordlys (intense pulsed light) and CO2RE (carbon dioxide) systems from Candela Medical were used, with a range of settings used depending on the assessment of the burn scar. The differences between scores were calculated for the total Patient and Observer Scar Assessment Scale score, pain, itch, colour, stiffness, thickness, irregularity and the overall opinion of the scar. Statistical analysis was completed using a paired, two-tailed student T test.

Results

A total of 31 patients were recruited for this trial with a range of scar locations, surface areas and mechanism of burn injury. The calculated difference in mean showed a significant reduction for the overall Patient and Observer Scar Assessment Scale score (1.93, p < 0.0001), pain (1.39, p  =  0.0002), itch (1.84, p  =  0.0002), colour (1.97, p < 0.0001), stiffness (2.47, p < 0.0001), thickness (2.1, p < 0.0001), irregularity (1.89, p < 0.0001) and overall opinion (1.58, p  =  0.0003).

Conclusion

Current management options for hypertrophic scarring have limited evidence. Laser therapy presents a minimally invasive procedure that can be completed under topical anaesthetic and has shown to be effective following a single treatment of combined carbon dioxide laser and intense pulsed light device therapy.

Lay Summary

Many people will suffer a burn injury throughout their life and up to almost 3 out of 4 people with burn injuries will suffer from hypertrophic scars (a thickened, red and itchy scar). These scars cause distress both due to their appearance and their reduction of function, particularly over a joint or muscle. Laser therapy, in which different wave lengths of light (pulsed light) or gas (carbon dioxide) target the scar, has been found to be effective and have minimal side effects in the management of hypertrophic scars. While individual lasers have been assessed and found to be effective and low risk, the combined use of multiple lasers on the same scar has not been extensively studied. We studied the effectiveness of both light and gas laser therapies on hypertrophic scars. Patients with hypertrophic scars completed a questionnaire that focused on their perspective of their scar (pain, itch, stiffness, thickness, irregularity, overall opinion) prior to the treatment. The patients then underwent laser therapy (with local anaesthetic gel) with either pulsed light and/or carbon dioxide (gas) laser. The type of laser used was decided by the clinician performing the therapy depending on scar location and thickness. Patients then re-completed the subjective survey six weeks following the laser therapy, and the results compared. We learnt that laser therapy (both light, gas and a combination of both) are effective (and low risk) in reducing the subjective burden of the scar for the patient.

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

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

Effects of photobiomodulation on re-epithelialization of burn wound: protocol for a randomized controlled trial

Background

Burns are a global public health problem and cause approximately 180,000 deaths annually, mainly in low- and middle-income countries. Topical antibiotics and occlusive dressing are standard treatments for burns not requiring a skin graft. However, physiotherapy has low-cost phototherapeutic and electrophysical resources (e.g., light-emitting diode [LED]) that may accelerate burn healing. This study aims to compare the re-epithelialization rate of second-degree burns, pain, pruritus, skin temperature, quality of wound healing, and scar quality and mobility among individuals undergoing treatment with red LED, infrared LED, and simulated photobiomodulation.

Methods

This is a double-blinded, three-arm parallel-group, randomized controlled superiority trial. Individuals of both sexes, aged over 18 years, and with second-degree burns will be included. The sample will be divided into three groups of 13 individuals: two will receive LED therapy (red or infrared) and one placebo. Pain, pruritus, skin temperature, and wound size will be assessed daily. Interventions will take place until complete healing, when scar mobility and quality will be evaluated. Data will be presented as mean and 95% confidence interval and analyzed using mixed linear models.

Discussion

This randomized controlled trial has minimal risk of bias and intends to identify the ideal type, procedures, and doses of photobiomodulation to heal burns, which are not standardized in clinical practice. Positive results will allow the implementation of the technique in burn and wound guidelines.

Trial registration

Brazilian Clinical Trials Registry (ReBEC) RBR-8bfznx6. Registered on October 13, 2021

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

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

Early Laser for Burn Scars (ELABS): protocol for a multi-centre randomised, controlled trial of both the effectiveness and cost-effectiveness of the treatment of hypertrophic burn scars with Pulsed Dye Laser and standard care compared to standard care alone [version 1; peer review: 2 approved]

This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact. This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.

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.

Effectiveness of a combination therapy using non-ablative fractional laser and intralesional triamcinolone injection for thyroidectomy scar treatment: a prospective, randomized, blinded pilot study

BACKGROUND

The occurrence of thyroid cancer has increased dramatically, and postoperative scars are placed at easily visible locations. Many patients show stronger desire for scar prevention. So far, numerous approaches have been discussed for the treatment of scars; this study is conducted to verify whether the early application of combined therapy contributes to minimal scar formation.

METHODS

Between March 2019 and December 2019, total of 64 patients with thyroidectomy scars of a size greater than 4.5 cm located on the anterior neck were enrolled in this prospective pilot study. Subjective and objective evaluation were carried out using the Patient and Observer Scar Assessment Scale (POSAS) at one, two, and six months after operation. Results were compared between a treatment group and a non-treatment group.

RESULTS

In PSAS score, the mean values of pain, itching sensation, pliability, thickness, and relief were significantly higher in the laser and steroid treatment group (p = 0.009, p = 0.000, p = 0.013, p = 0.002, and p = 0.007). The value of color of the scars showed no significant differences (p = 0.504). In OSAS score, parameter of thickness, relief, and surface area score was significantly higher score in the combination group (p = 0.029, 0.035, and 0.020), while vascularity, pigmentation, and pliability were not significantly different between two groups (p = 0.548, p = 0.983, and p = 0.128).

CONCLUSION

This study demonstrates that early combination therapy contributes to scar improvement to a meaningful extent based on POSAS. We believe that the combined therapy has a synergy effect on scar management, which improves the patients' quality of life in relation to their postoperative scars.

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.

A Single Institution Experience with Standardized Objective and Subjective Scar Evaluation While Undergoing Fractional Ablative Carbon Dioxide Laser Treatment

Laser treatment of burn scar has increased in recent years. Standard components of scar evaluation during laser scar revision have yet to be established. Patients who began laser scar revision from January 2018-2020, underwent at least three treatments, and completed evaluations for each treatment were included. Patients underwent fractional ablative carbon dioxide laser scar revision and pre- and post-procedure scar evaluations by a burn rehabilitation therapist, including Patient and Observer Scar Assessment Scale, Vancouver Scar Scale, our institutional scar comparison scale, durometry, and active range of motion measurements. Twenty-nine patients began laser scar revision and underwent at least three treatments with evaluations before and after each intervention. All patients improved in at least one scar assessment metric after a single laser treatment. After second and third treatments, all patients improved in at least three scar assessment metrics. Range of motion was the most frequently improved. Durometry significantly improved after a third treatment. Patients and observers showed some agreement in their assessment of scar, but observers rated overall scar scores better than patients. Patients acknowledged substantial scar improvement on our institutional scar comparison scale. Burn scar improves with fractional ablative laser therapy in a range of scar ages and skin types, as early as the first session. Improvements continue as additional sessions are performed. This work suggests baseline evaluation components for patients undergoing laser, and a timeline for expected clinical improvements which may inform conversations between patients and providers when considering laser for symptomatic hypertrophic scar.

Smartphone-based optical palpation: towards elastography of skin for telehealth applications

Smartphones are now integral to many telehealth services that provide remote patients with an improved diagnostic standard of care. The ongoing management of burn wounds and scars is one area in which telehealth has been adopted, using video and photography to assess the repair process over time. However, a current limitation is the inability to evaluate scar stiffness objectively and repeatedly: an essential measurement for classifying the degree of inflammation and fibrosis. Optical elastography detects mechanical contrast on a micrometer- to millimeter-scale, however, typically requires expensive optics and bulky imaging systems, making it prohibitive for wide-spread adoption in telehealth. More recently, a new variant of optical elastography, camera-based optical palpation, has demonstrated the capability to perform elastography at low cost using a standard digital camera. In this paper, we propose smartphone-based optical palpation, adapting camera-based optical palpation by utilizing a commercially available smartphone camera to provide sub-millimeter resolution imaging of mechanical contrast in scar tissue in a form factor that is amenable to telehealth. We first validate this technique on a silicone phantom containing a 5 × 5 × 1 mm³ embedded inclusion, demonstrating comparative image quality between mounted and handheld implementations. We then demonstrate preliminary in vivo smartphone-based optical palpation by imaging a region of healthy skin and two scars on a burns patient, showing clear mechanical contrast between regions of scar tissue and healthy tissue. This study represents the first implementation of elastography on a smartphone device, extending the potential application of elastography to telehealth.

Contemporary Aspects of Burn Care

The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930-1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.

LncRNA TRHDE-AS1 inhibit the scar fibroblasts proliferation via miR-181a-5p/PTEN axis

Hypertrophic scar (HS), a fibroproliferative disorder caused by abnormal wound healing after skin injury, which is characterized by excessive deposition of extracellular matrix and invasive growth of fibroblasts. Recent studies have shown that some non-coding RNA implicated the formation of HS, but the mechanism remains unclear. In this study, we found that lncRNA TRHDE-AS1 was downregulated in HS tissues and HSFs, and the level of lncRNA TRHDE-AS1 negatively correlated with the level of miR-181a-5p in HS tissue and HSFs. Overexpressed lncRNA TRHDE-AS1 significantly suppressed miR-181a-5p level, while promoted HSFs apoptosis and inhibited HSFs proliferation. Further study shown that PTEN was a direct target of miR-181a-5p, and lncRNA TRHDE-AS1 served as a molecular sponge for miR-181a-5p to regulate the expression of PTEN. Overexpression of PTEN could eliminate lncRNA TRHDE-AS1-mediated proliferation suppression of HSFs. In conclusion, our study suggested that lncRNA TRHDE-AS1/miR-181a-5p/PTEN axis plays an important role in promoting hypertrophic scar formation, which may be effectively used as a therapeutic target for hypertrophic scar treatment.

Surgical treatment of joint burn scar contracture: a 10-year single-center experience with long-term outcome evaluation

Background

Burn patients often have functional problems due to joint scar contracture. Patients suffering from such contracture often experience considerable limitations in daily life. Therefore, surgical treatment is often necessary. Skin grafts, especially full-thickness skin grafts and flaps remain the most commonly used surgical methods in clinical practice. However, there are no clear guidelines stating which technique is the most effective treatment. Herein, we conducted a retrospective cohort study over 10 years of experience at a single center to investigate whether flaps or FTSGs exhibit a better long-term effect.

Methods

We performed a retrospective chart review of patients with joint burn scar contracture and collected data related to patient demographic profiles, and detailed descriptions of the scars, surgical procedures, and follow-up were collected. We performed follow-up evaluation of three aspects: adverse events (recontracture, ache, and pruritus), satisfaction scores for function and aesthetics, and scar quality (Vancouver Scar Scale score).

Results

Follow-up results 1 year after surgery from 88 patients were analyzed. In total, 4 (10%) patients in the flap group and 13 (27.1%) patients in the FTSG group had recontracture; the incidence of recontracture was lower in the flap group than in the FTSG group (P=0.043). The functional satisfaction score of the flap group was higher than that of the FTSG group (P=0.027). Moreover, follow-up results 5 year after surgery for 47 patients were analyzed. In total, 1 (4.8%) patient in the flap group and 7 (26.9%) patients in the FTSG group had recontracture; the incidence of recontracture was significantly lower in the flap group than in the FTSG group (P=0.044). The functional satisfaction score in the flap group was higher than that of the FTSG group (P=0.041). In this study, no significant differences in scar quality were observed between the two groups.

Conclusions

If conditions permit, the application of different types of flaps may represent a better choice than FTSGs in terms of reducing the recontracture rate and improving joint function.

High- Versus Low-Density Fractional Laser in the Treatment of Hypertrophic Postburn Scars: A Randomized Clinical Trial

BACKGROUND

Fractional CO2 laser has been shown effective in improving pigmentation, pruritus, and tightness of hypertrophic burn scars. However, there is no consensus on the optimal treatment parameters.

OBJECTIVE

To compare effectiveness of different densities of fractional CO2 laser in the treatment of mature hypertrophic burn scars.

MATERIALS AND METHODS

The study included 25 patients, each with 3 or more mature hypertrophic burn scars. Scars were randomly assigned to treatment with low-, medium-, and high-density fractional CO2 laser. Each scar received 3 sessions of laser at 1-month interval. The degree of improvement was assessed clinically using Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) scores, and histologically through evaluation of collagen (Masson's Trichrome stain) before and 1 month after end of therapy.

RESULTS

High-density parameters showed significant higher improvement in VSS and POSAS assessment scores (p-value < .001). Pliability and relief are the most improved parameters. Histopathological evaluation revealed a significant drop in the mean area percent of collagen in the 3 used parameters, with highest improvement with high-density laser treatment (p-value < .001).

CONCLUSION

High-density fractional CO2 laser treatment provides more improvement in burn scars both clinically and histopathologically.

Electrochemical treatment of ex vivo human abdominal skin and potential use in scar management: A pilot study

INTRODUCTION

Scar treatments aim to address pathologic collagen deposition; however, they can be expensive or difficult to control. Electrochemical therapy (ECT) offers a simple alternative treatment. The purpose of this study is to examine the acid-base and histological changes in ex vivo human abdominal skin following ECT.

METHODS

Forty-two ex vivo human panniculus tissue sections collected from six individuals were tumesced with normal saline. ECT was performed by inserting two platinum needle electrodes connected to a DC power supply into each specimen. Voltage was varied (3-6 V) and applied for 5 minutes. Each specimen was sectioned across both electrode insertion sites and immediately stained with pH sensitive dye. The width of dye color change for each dosimetry pair was calculated. Hematoxylin and eosin staining was used to evaluate samples.

RESULTS AND DISCUSSION

ECT caused a spatially localised and dose-dependent increased area of acidic and basic pH around the anode and cathode, respectively. A significantly greater mean width of pH change was generated at the cathode compared to the anode in all treatment groups. Histological evaluation displayed broad condensation and hyalinisation of dermal collagen.

CONCLUSION

ECT triggered dermal pH alterations and changed the underlying structural framework of the specimen. This technology may serve as a low-cost, minimally invasive local soft-tissue remodeling technique with potential application in scar management.

LEVEL OF EVIDENCE

5.

LAY SUMMARY

Electrochemical therapy is a novel treatment that causes spatially selective dermal injury in areas of interest. This study measures the effects of electrochemical therapy when applied to abdominal skin. Electrochemical therapy appears to have beneficial effects by causing a highly localised reduction in collagen content or local softening of tissue, which is consistent with other studies on scar therapies, including chemexfoliation, radiofrequency technologies, and lasers. However, electrochemical therapy can be performed at a fraction of the costs of these aforementioned modalities.

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.

Five Essential Principles for First Web Space Reconstruction in the Burned Hand

BACKGROUND

Burn injuries commonly affect the hand, and the development of adduction contractures of the first web space is frequent and deleterious, both functionally and aesthetically. Many corrective techniques and algorithmic approaches have been described to treat this problem, but there is no consensus on the optimal management.

METHODS

A retrospective review at a single high-volume pediatric burn center was undertaken to evaluate the clinical course of these patients. All pediatric patients undergoing initial release of burn scar contracture of the first web space from 2005 through 2015 were included in a retrospective cohort study.

RESULTS

The authors identified 40 patients with 57 burned hands. The initial approach to management was variable. Z-plasty or other local flap was the first technique used in 28 hands (49 percent), split-thickness skin graft in 19 hands (33 percent), full-thickness skin graft in seven hands (12 percent), groin flaps in two hands (4 percent), and a reverse radial forearm flap in one hand (2 percent). The mean numbers of total reconstructive procedures per hand including the initial procedure were as follows: groin flap, 4.0; full-thickness skin graft, 3.1; split-thickness skin graft, 2.1; Z-plasty, 1.4; and reverse radial forearm flap, 1.0.

CONCLUSIONS

Successful reconstruction of the first web space must be addressed in the context of the entire hand. It is the authors' preference to use split-thickness skin grafting whenever a skin deficiency is present-only then should leading edge contractures be addressed with Z-plasty. Based on their experience, the authors recommend five principles that are essential to successfully treat postburn contractures of the first web space.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Er:YAG laser in hysterectomized women with stress urinary incontinence: a VELA retrospective cohort, non-inferiority study

Objective: To test whether the erbium-doped yttrium aluminum garnet (Er:YAG) SMOOTH^® laser treatment efficacy on stress urinary incontinence (SUI) in hysterectomized patients is non-inferior to its efficacy in non-hysterectomized patients.Methods: In this real-world, retrospective cohort study performed in Turkey, Croatia and Italy, we enrolled a consecutive sample of 35 hysterectomized and 34 non-hysterectomized patients with SUI. We used the Er:YAG SMOOTH^® laser (Fotona, Slovenia) with a wave length of 2940 nm. The primary outcome was median reduction of SUI symptoms measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short-Form (ICIQ-SF) with the non-inferiority margin defined as the minimum clinically important difference of ICIQ-SF (δ < 2.52 points).Results: In hysterectomized patients, the ICIQ-SF was reduced by 5 points (95% confidence interval 3-8; p < 0.001), a reduction of 45% (95% confidence interval 36-67%). After adjustment for baseline ICIQ-SF and five covariates, the reduction of symptoms in the hysterectomized group was not inferior to the reduction in the non-hysterectomized group.Conclusion: The Er:YAG SMOOTH^® laser treatment seems to improve the symptoms of SUI in hysterectomized women not clinically relevantly less than in non-hysterectomized women. It seems that the beneficial effect of Er:YAG SMOOTH^® laser treatment for SUI in hysterectomized women is time-limited.

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

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

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

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

Hypertrophic Scar Improvement by Early Intervention With Ablative Fractional Carbon Dioxide Laser Treatment

BACKGROUND AND OBJECTIVES

Ablative fractional laser treatment has been used to improve the color and texture of hypertrophic scars with safe and effective results. However, no consensus on the optimal time to initiate fractional laser treatment is available. The effect on early-stage scars remains controversial. This study was designed to assess the efficacy and safety of ablative fractional carbon dioxide (CO₂ ) laser treatments for hypertrophic burn scars and to analyze the efficacy and safety in the early period within 3 months after injury.

STUDY DESIGN/MATERIALS AND METHODS

We performed a retrospective study of 221 hypertrophic scar patients. According to the time of the first laser treatment after injury, patients were divided into five subgroups, including less than 1 month, 1-3 months, 3-6 months, 6-12 months, and more than 12 months postinjury. One month after the last laser treatment, the scars were assessed by photography, the Vancouver Scar Scale (VSS), durometry, and spectrocolorimetry.

RESULTS

The patients included 118 males and 103 females. The average age was 33.6 years. Fire/flame was the primary injury source. Thirty-six percent of the patients underwent at least one fractional CO₂ laser treatment. All the included patients, including those treated within 1 month after injury, had significantly decreased VSS scores after laser treatment. We also noted that hardness and redness scores were decreased after treatment for both scars treated within 3 months and those treated more than 12 months after injury. Seepage (17.6%), bleeding (22.2%), and swelling (9.0%) were the main adverse events after laser treatment.

CONCLUSIONS

This study demonstrated the safety and efficacy of ablative fractional CO₂ laser treatment applied to early-stage burn scars. The optimal time for laser application for burn patients can be within 1 month after injury. Durometry and spectrocolorimetry were effective for assessing scars as objective modalities. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Inhibition of sphingosine kinase 2 attenuates hypertrophic scar formation via upregulation of Smad7 in human hypertrophic scar fibroblasts

The aims of the present study were to investigate the role of sphingosine kinase 2 (Sphk2) in hypertrophic scar (HS) formation and its underlying mechanisms. The expression levels of Sphk2 and Smad7 in HS tissues and healthy skin tissues of patients undergoing plastic surgery were determined using immunohistochemical staining. Subsequently, the expression levels of Sphk2 and collagen I in human embryonic skin fibroblasts (control) and human HS fibroblasts (HSF) were detected using western blot analysis and immunofluorescence assay, respectively. Following Sphk2 silencing, Smad7 overexpression or both Sphk2 and Smad7 silencing, HSF proliferative ability was assessed using Cell Counting Kit‑8 assay and proliferation‑associated proteins were evaluated using western blot analysis. In addition, the level of apoptosis in HSF was assessed using flow cytometry and expression levels of apoptotic‑associated proteins were determined using western blotting. Furthermore, the expression levels of collagen I and proteins in the TGF‑β1/Smad signaling pathway were detected using western blot analysis. The results indicated that the expression of Sphk2 was significantly increased, while Smad7 expression was decreased in HS tissue. Moreover, the upregulation of Sphk2 and collagen I expression levels was identified in HSF. The present results also indicated that Sphk2 silencing or Smad7 overexpression inhibited proliferation, but promoted apoptosis of HSF, coupled with changes in the expression levels of proliferation‑associated proteins, with an increase in p21 and a decrease in cyclin D1 expression levels, and apoptosis‑associated proteins, with an increase in Bax and cleaved caspase‑3, and a decrease in Bcl‑2, which were reversed following transfection with both Sphk2 and Smad7 using small interfering RNA in HSF. In addition, the expression levels of transforming growth factor‑β1, phosphorylated (p)‑Smad2, p‑Smad3 and collagen I were reduced following Sphk2 silencing or Smad7 overexpression, which were abolished by silencing both Sphk2 and Smad7. Collectively, the present results indicated that inhibition of Sphk2 attenuated HS formation via upregulation of Smad7 expression, thus Sphk2 may serve as a potential therapeutic target for the treatment of HS.

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 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.

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

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

Advances in the treatment of traumatic scars with laser, intense pulsed light, radiofrequency, and ultrasound

Traumatic scarring is one of the most common complications after soft tissue injury caused by burns and trauma, which affects tens of millions of people worldwide every year. Traumatic scars diminish the quality of life due to disfigurement, symptoms of pain and itch, and restricted motion. The pathogenesis and pathophysiology of traumatic scar remain elusive. The management for traumatic scars is comprised of surgical and non-surgical interventions such as pressure therapy, silicone, corticosteroid, and radiotherapy, which are chosen by clinicians based on the physical examinations of scars. Recently, great progress in treating traumatic scars has been achieved by the development of novel technologies including laser, intense pulsed light (IPL), radiofrequency, and ultrasound. The aim of this review article was to summarize the advances of these technologies for traumatic scars intervention.

Treatment of burn scars in Fitzpatrick phototype III patients with a combination of pulsed dye laser and non-ablative fractional resurfacing 1550 nm erbium:glass/1927 nm thulium laser devices

Introduction:

Burn scars cause cosmetic disfigurement and psychosocial distress. We present two Fitzpatrick phototype (FP) III patients with burn scars successfully treated with combination pulsed dye laser (PDL) and non-ablative fractional lasers (NAFL).

Case 1:

A 30-year-old, FP III woman with a history of a second-degree burn injury to the bilateral arms and legs affecting 30% body surface area (BSA) presented for cosmetic treatment. The patient received three treatments with 595 nm PDL (7 mm, 8 J, 6 ms), six with the 1550 nm erbium:glass laser (30 mJ, 14% density, 4–8 passes) and five with the 1927 nm thulium laser (10 mJ, 30% density, 4–8 passes). Treated burn scars improved significantly in thickness, texture and colour.

Case 2:

A 33-year-old, FP III man with a history of a second-degree burn injury of the left neck and arm affecting 7% BSA presented for cosmetic treatment. The patient received two treatments with 595 nm PDL (5 mm, 7.5 J, 6 ms), four with the 1550 nm erbium:glass laser (30 mJ, 14% density, 4–8 passes) and two with the 1927 nm thulium laser (10 mJ, 30% density, 4–8 passes). The burn scars became thinner, smoother and more normal in pigmentation and appearance.

Discussion:

Our patients’ burn scars were treated with a combination of PDL and NAFL (two wavelengths). The PDL targets scar hypervascularity, the 1550 nm erbium:glass stimulates collagen remodelling and the 1927 nm thulium targets epidermal processes, particularly hyperpigmentation. This combination addresses scar thickness, texture and colour with a low side effect profile and is particularly advantageous in patients at higher risk of post-procedure hyperpigmentation.

Conclusion:

Our cases suggest the combination of 595nm PDL plus NAFL 1550 nm erbium:glass/1927 nm thulium device is effective and well-tolerated for burn scar treatment in skin of colour.

While all scars can be bothersome, burn scars can be particularly troubling. They can be large, itchy, painful and limit range of motion. Patients with medium and darker skin tones may be more likely to develop dark and discoloured scars due to burns and other scarring injuries. In our case series, we used two types of lasers to treat thick, darkly pigmented burn scars in two patients with medium and darker skin tones. While the pulsed dye laser targets the redness and thickened aspects of scars to restore a more normal appearance, the non-ablative fractional resurfacing laser creates microscopic zones of controlled injury to resurface scars, stimulate new collagen growth, improve texture and lighten excess pigmentation. Treatments were performed once a month for 6–12 months. Using these lasers in combination, our treatment method made our patients’ scars thinner, smoother and more evenly coloured over time, resulting in a more natural appearance. This multi-modal approach was a safe and effective no-downtime method for the improvement of scars in skin of colour patients.

[The role of CO2-laser in scarring management]

AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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