Treatment of keloid scars with pulsed dye laser and intralesional steroid

Pruritus in keloid scars: mechanisms and treatments

Keloids occur after cutaneous injury and can cause distress due to physical appearance and associated symptoms such as pain and pruritus. Keloid-associated pruritus is a common manifestation and has negative impacts on quality of life. The mechanism underlying this type of pruritus is multifactorial and thought to involve small nerve fiber damage, neurogenic inflammation, and a Th2-predominant inflammatory response. Various agents have been shown to reduce keloid pruritus, including intralesional corticosteroids, botulinum toxin A, 5-fluorouracil, and bleomycin. Other treatment modalities such as cryotherapy and hyperbaric oxygen therapy are also effective. Future treatments targeting the mechanisms involved in keloid-associated itch could provide improvements in pruritus and quality of life in these patients, but further studies on the efficacy of these agents are needed.

Current Practice in Keloid Treatment: a Survey of Dutch Dermatologists and Plastic Surgeons

BACKGROUND

Several therapeutic options are available for the treatment of keloids, but it remains unclear which treatment options are most commonly used by practitioners.

OBJECTIVE

To explore the prevailing treatment for different keloid phenotypes among dermatologists and plastic surgeons in the Netherlands.

METHODS

Members of the Dutch society for Plastic surgery and the Dutch society for Dermatology and Venereology were asked to participate. Questions elaborated on the treatment for a small and a large keloid on the mandibula and multiple keloids on the chest.

RESULTS

One hundred forty-three responses were obtained. Heterogeneity in treatment was extremely high for the small, large, and multiple keloids with 27, 35, and 33 various first choices, respectively. Intralesional corticosteroids were most often chosen for all 3 different keloid phenotypes. These were mostly (61%) administered as monotherapy for the small keloid and mostly combined with other treatments for the large keloid (19%) and multiple keloids (43%). Surgery was chosen regularly (22%) for the large keloid, mostly combined with intralesional corticosteroids (10%) or brachytherapy (8.4%).

CONCLUSION

Keloid treatment is very heterogeneous among dermatologists and plastic surgeons, even in a relatively small country as the Netherlands. Moreover, the treatment choice depends on the keloid phenotype.

Lasers and Intense Pulsed Light for the Treatment of Pathological Scars: A Network Meta-Analysis

BACKGROUND

Laser and intense pulsed light (IPL) therapies have shown promising effects on pathological scars, but the comparative effectiveness of laser and IPL therapies has not yet been studied.

OBJECTIVES

The aim of this study was to compare and rank the efficacy of laser and IPL therapies to determine the most effective treatment method for pathological scars.

METHODS

Relevant studies published up to February 2022 were identified by searching PubMed, Web of Science, Cochrane Library, CNKI, and Wanfang databases. We defined Vancouver Scar Scale score as the primary outcome. Both frequentist and Bayesian approaches were used to perform a network meta-analysis.

RESULTS

We included 25 trials with a total of 1688 participants. The rankings based on the surface under the cumulative ranking curve for the Vancouver Scar Scale score based on the Bayesian approach suggested IPL + CO2 (96.43%) > pulsed dye laser (PDL) + 1064-nm Nd:YAG (yttrium aluminum garnet) laser (86.21%) > PDL + CO2 (82.15%) > CO2 (58.97%) > 1064-nm Nd:YAG (57.03%) > PDL (52%) > 532-nm Nd:YAG (33.28%) > Er:YAG + IPL (28.38%) > Er:YAG (26.56%) > IPL (15.03%) > control (13.97%). The ranking results based on the frequentist approach were basically consistent with those based on the Bayesian approach.

CONCLUSIONS

The results of the network meta-analysis showed that the combination of IPL and CO2 laser has the highest probability of being the most effective intervention. However, our conclusions must be interpreted with caution due to the relatively few evaluation indicators included in our study. Future well-designed randomized controlled trials with large sample sizes are required to confirm our conclusions.

LEVEL OF EVIDENCE: 4

Pruritus in Keloid Scars: Mechanisms and Treatments

Keloids are scars that extend beyond the margins of an insulting cutaneous injury. Keloids are often thought to be primarily a cosmetic issue, as they are typically quite raised and pigmented. However, these scars also present with functional symptoms of pruritus and pain that significantly impact quality of life. The symptom of pruritus is frequently overlooked by dermatologists, and treatments are often primarily focused on the gross appearance of the scar. This review describes the prevalence and importance of pruritus in keloids. In addition, the putative mechanisms underlying the development of keloid pruritus, which include neuronal and immunological mechanisms, are discussed. Furthermore, this review describes keloid treatments that have been shown to reduce pruritus, treatments that specifically target the itch, and emerging therapies.

Efficacy and safety of laser combination therapy and laser alone therapy for keloid: a systematic review and meta-analysis

To evaluate the efficacy and safety of laser alone therapy and laser combination therapy (mainly combined with other kinds of laser or steroids) for keloid.PubMed, Embase and Web of Science were searched for relevant articles from inception to June 2020. Comprehensive Meta-Analysis software 2.0 (CMA) was used to perform the meta-analysis.A total of 29 articles were included in this meta-analysis. During the mean follow-up of 14 (1-84) months, the overall improvement rates of baseline Vancouver scar scale (VSS) score and itch were 0.454 (95%CI 0.351-0.561, I² = 0) and 0.786 (95%CI 0.613-0.895, I² = 0) in the laser combination therapy group. The improvement rates of scar height and flexibility in the laser combination therapy group were 0.629 (95%CI 0.519-0.727, I² = 52.089) and 0.784 (95%CI 0.251-0.975, I² = 89.420). The average improvement rate of the scar score in laser combination therapy was 0.338 (0.201-0.510); however, there were insufficient data for laser alone therapy comparison. The laser combination therapy had a greater pain improvement rate, 0.580 (0.389-0.750) versus 0.420 (0.224-0.645), compared to laser alone therapy, and a greater degree of good or excellent (> 50%) improvement in the overall scar, 0.636 (95%CI 0.347-0.852) versus 0.149 (95%CI 0.032-0.482), with laser alone therapy. Moreover, a lower regrowth rate of 0.187 (0.129-0.263) versus 0.249 (0.060-0.631), a lower post-treatment pigmentation rate of 0.125 (0.091-0.169) versus 0.135 (0.058-0.282), and a lower infection rate of 0.047 (0.009-0.209) versus 0.076 (0.012-0.351) were observed in the laser combination therapy compared with those rates in the laser alone therapy.The overall effect of laser combination therapy was better than that of laser alone therapy, and the incidence of adverse reactions was lower in laser combination therapy than in laser alone therapy.

Combination of 1,064-nm Neodymium-doped Yttrium Aluminum Garnet Laser and Steroid Tape Decreases the Total Treatment Time of Hypertrophic Scars: An Analysis of 40 Cases of Cesarean-Section Scars

BACKGROUND

The 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (Cutera, Inc., Brisbane, CA) and steroid tape (fludroxycortide tape) have been used to treat keloids and hypertrophic scars.

OBJECTIVE

To evaluate the efficacy of contact-mode 1,064-nm Nd:YAG laser therapy and steroid tape for hypertrophic cesarean-section scars versus conservative therapy (steroid tape only).

MATERIALS AND METHODS

A medical record review identified 40 consecutive Japanese patients who had hypertrophic scars (total Japan Scar Workshop Scar Scale [JSS] 2015 evaluation scores of 9 to 12) for more than 1 year after a vertical cesarean section and who were treated at our scar-specialist clinic from July 2015 to December 2017. All 40 patients continued treatment until the total JSS score dropped below 3. Recurrence was defined as a ≥1-point increase in the total JSW score 6 months after achieving a total JSS score <3.

RESULTS

The patients had a mean age of 34.2 years. The test (n = 25) and control (n = 15) groups took on average 16.9 and 24.3 months to achieve a total JSS score <3, respectively (p < .01). In the following 6 months, none of the scars recurred.

CONCLUSION

Nd:YAG laser treatment effectively decreased the total treatment time of hypertrophic cesarean-section scars. An algorithm for treating mild and severe hypertrophic cesarean-section scars is proposed.

Necrostatin-1, RIP1/RIP3 inhibitor, relieves transforming growth factor β-induced wound-healing process in formation of hypertrophic scars

BACKGROUND

Hypertrophic scars (HS) are common pathologic processes emerged during wound-healing process. The receptor-interacting protein kinase (RIP) might participate in keloid formation.

AIMS

This study aimed to investigate Necrostatin-1 (Nec-1), a RIP1/RIP3 inhibitor, in the formation of hypertrophic scar.

METHODS

Human hypertrophic scar fibroblasts (HSF) were extracted from patients with hypertrophic scar. Transforming growth factor-β1 (TGF-β1) was performed to induce wound-healing process including cell proliferation (CCK-8, Flow cytometry, and Western blot), migration (Transwell assay, Western blot), collagen production (Western blot), and extracellular matrix dysfunction (Western blotting and immunofluorescence).

RESULTS

Our results reported that Nec-1 inhibited TGF-β1-induced cell proliferation and promoted G0/G1 phase arrest in HSF. In addition, Nec-1 attenuated TGF-β1-induced cell migration and inhibited the expression of MMP2 and MMP9 in TGF-β1-induced HSF. Besides, Nec-1 also reduced TGF-β1-induced collagen production and α-smooth muscle actin expression in HSF.

CONCLUSIONS

The present data in this study showed the potential role of Nec-1 as a novel treatment for HS.

Treatment of Pain in Keloids Using Only a Long-Pulsed 1064 nm Nd:YAG Laser

BACKGROUND AND OBJECTIVE

Keloids are benign lesions arising from overproduction of the extracellular matrix and abnormal collagen deposition by dermal fibroblasts. This altered wound healing typically occurs in response to dermal trauma. Keloid treatment poses a challenge due to the variable nature of treatment response, which can be affected by the size, appearance, and associated symptoms of erythema, pruritus, and pain. Recently, successful treatment of keloids has been reported using the Nd:YAG laser in conjunction with 5-fluorouracil and intralesional corticosteroids. We present a series of patients with symptomatic keloids, who we treated with only a 1064 nm Nd:YAG laser.

STUDY DESIGN/MATERIALS AND METHODS

Eight patients of Fitzpatrick skin types I-VI presented for treatment of keloids with associated symptoms of pain. The keloids were most commonly located on the trunk, and seven patients had intralesional steroid injections prior to presentation with persistence of symptoms. Patient treatment consisted of two passes under a long-pulsed 1064 nm Nd:YAG laser with a 10 mm spot size, a fluence of 18-19 J/cm² , and 60 ms pulse duration every 3-8 weeks. Patient-reported pain scores were collected before and after treatment.

RESULTS

Following treatment, transient erythema and mild edema were noted at the treatment site. All patients reported improvement in the symptoms of pain, with an average of a 5-point reduction using a 10-point scale (R: 2-10). Five out of eight patients had total resolution of their pain. An average of 3.25 treatments (R:1-5) were needed for patients to first notice an improvement in the pain. A Wilcoxon signed-rank test showed that treatment with a 1064 nm laser elicited a statistically significant improvement in pain in individuals with keloids (Z = 2.46, P = 0.01). No patients in our study suffered any scarring or pigment changes as a result of these treatments.

CONCLUSION

Keloids are a common condition with variable rates of treatment satisfaction. Lasers have been used in an attempt to improve clinical appearance and associated symptoms. We report a significant reduction in pain for patients treated exclusively with a 1064 nm Nd:YAG laser. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Keloids: a review of therapeutic management

Keloid scar formation arises from a disorganized fibroproliferative collagen response that extends beyond the original wound margins because of excessive production of extracellular matrix (ECM). Despite treatment options for keloid scars including medical and surgical therapies, such as intralesional steroid injection and surgical excision, the recurrence rate remains high. Herein we consolidate recently published narrative reviews, systematic reviews, and meta-analyses to provide an overview of updated treatment recommendations for keloidal scar formation. PubMed search engine was used to access the MEDLINE database to investigate updates regarding keloid incidence and treatment. More than 100 articles were reviewed. Keloid management remains a multimodal approach. There continues to be no gold standard of treatment that provides a consistently low recurrence rate; however, the increasing number of available treatments and synergistic combinations of these treatments (i.e., laser-based devices in combination with intralesional steroids, or 5-fluorouracil (5-FU) in combination with steroid therapy) is showing favorable results. Future studies could target the efficacy of novel treatment modalities (i.e., autologous fat grafting or stem cell-based therapies) for keloid management. This review article provides updated treatment guidelines for keloids and discusses insight into management to assist patient-focused, evidence-based clinical decision making.

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

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

Keloids: Current and emerging therapies

Keloids are pathological scars that grow over time and extend beyond the initial site of injury after impaired wound healing. These scars frequently recur and rarely regress. They are aesthetically disfiguring, can cause pain, itching, discomfort as well as psychological stress, often affecting quality of life. Many treatment modalities, including surgical and non-surgical, have been explored and have been reported to be beneficial; however, none have been absolutely satisfactory or optimal for the treatment of all keloid subtypes to date. This poses a major challenge to clinicians. Often, a combinational therapeutic approach appears to offer the best results with higher patient satisfaction compared to monotherapy. The aetiopathogenesis of keloids is not fully elucidated; however, with recent advances in molecular biology and genetics, insight is being gained on the complex process of scar formation and hence new therapeutic and management options for keloids. In this paper, we explore the literature and summarise the general concepts surrounding keloid development and review both current (corticosteroids, surgical excision, silicone-based products, pressure therapy, radiotherapy, cryotherapy, laser therapy, imiquimod and 5-fluorouracil) and emerging (stem cell therapy, mitomycin C, verapamil, interferons, bleomycin, botulinum toxin type A and angiotensin-converting enzyme inhibitors) treatments. Increased knowledge and understanding in this area may potentially lead to the discovery and development of novel therapeutic options that are more efficacious for all keloid types.

LAY SUMMARY

Keloids are problematic scars that are difficult to treat and manage. The aetiopathogenesis of keloids is not clear; however, recent advances in molecular biology and genetics are beginning to shed light on the underlying mechanisms implicated in keloid scar formation which will hopefully lead to the development of treatment options for all keloid types. This review summarises current and emerging therapies.

Extracorporeal shockwave therapy for treatment of keloid scars

The purpose of this investigation was to study the effectiveness of extracorporeal shockwave therapy (ESWT) for the treatment of keloid scars, and compared the results with intralesional steroid injection. Thirty-nine patients were randomly divided into 22 in ESWT group and 17 in steroid group. The ESWT group received 3 ESWT treatments in 6 weeks. The steroid group received three intra-lesional triamcinolone injections in 6 weeks. The evaluations included gross morphology, functional outcome, local blood flow perfusion, biopsy for histopathological examination, and immunohistochemical analysis. Both groups showed significant improvements in appearance with less discoloration, flattening and softer consistency, and more elasticity of the lesions. There is a significant reduction in keloid height after treatment in both groups, and significant differences are noticed between two groups after treatment. The volume of keloid was decreased after treatment but there is no statistically significant difference between two groups. Both groups showed comparable functional scores, POSAS patient, and observer scales. The blood flow perfusion rates were statistically not significant between two groups before and after treatments. Histopathological findings revealed no significant difference in cell count, cell activity, and cell concentration between two groups. After ESWT, the significant decreases in collagen type I, type III, and Masson Trichrome stain were observed as compared with steroid group. However, very little changes were noticed in angiogenesis, inflammatory cytokines, proliferating and regeneration, and apoptosis, with no statistical significance noticed between two groups before and after treatment. This study revealed that ESWT showed comparable functional outcome and POSAS patient and observer scales as compared with steroid injection for keloid scars. Treatment of keloid scars with ESWT resulted in significant decreases in collagen fibers and increases in MMP-13 enzyme.

Treatment of keloid scars using light-, laser- and energy-based devices: a contemporary review of the literature

Keloid scars are common and have a predilection for young, ethnic skin often with a family history. Keloids can be painful and pruritic and cause significant emotional distress when particularly visible or prominent. In this article, we review the evidence underlying the use of laser- and energy-based devices for treatment of keloid scars, either as monotherapy or in conjunction with other therapies such as corticosteroids, surgery and silicone gel in the treatment of keloid scars.

Combined effects of long-pulsed neodymium-yttrium-aluminum-garnet laser, diprospan and 5-fluorouracil in the treatment of keloid scars

Keloids are benign tumors that originate from scar tissues, but they usually overgrow beyond the original wounds. In a three-month single-center clinical trial, 69 patients were randomly divided into three groups. Patients in group 1 were treated with intralesional injection of diprospan (2 mg betamethasone disodium phosphate and 5 mg betamethasone dipropionate in 1 ml) with one-month intervals for three months. Patients in groups 2 and 3 were injected with a combination of 0.5 ml 5-fluorouracil (5-FU; 25 mg/ml) and diprospan as above for three months also. Prior to each injection, the keloids of patients in group 3 were additionally irradiated by a 1,064-nm neodymium-yttrium-aluminum-garnet (Nd:YAG) laser with a single pulse at an energy density of 90-100 J/cm² and a pulse width of 12 msec. Clinical responses were evaluated by patient self-assessment and overall assessment by an observer according to the clinical signs of erythema, pruritus and pliability. A total of sixty-two patients completed the tests of the present study. At 2 and 3 months, the patients in all treatment groups showed an acceptable improvement in nearly all measurements. At the end of the study, the erythema and toughness score was significantly reduced and itch reduction was significantly greater in the diprospan + 5-FU + Nd:YAG group when compared to those in the other groups (P<0.05 for all indexes). The acceptable responses (good to excellent improvements) reported by blinded observers were as follows: 12% in the diprospan group, 48% in the diprospan + 5-FU group and 69% in the diprospan + 5-FU + Nd:YAG group. All of the results indicated that the combination of diprospan + 5-FU + Nd:YAG was the most efficacious therapy for keloid scars.

Evidence-Based Scar Management: How to Improve Results with Technique and Technology

BACKGROUND

Scars represent the visible sequelae of trauma, injury, burn, or surgery. They may induce distress in the patient because of their aesthetically unpleasant appearance, especially if they are excessively raised, depressed, wide, or erythematous. They may also cause the patient symptoms of pain, tightness, and pruritus. Numerous products are marketed for scar prevention or improvement, but their efficacy is unclear.

METHODS

A literature review of high-level studies analyzing methods to prevent or improve hypertrophic scars, keloids, and striae distensae was performed. The evidence from these articles was analyzed to generate recommendations. Each intervention's effectiveness at preventing or reducing scars was rated as none, low, or high, depending on the strength of the evidence for that intervention.

RESULTS

For the prevention of hypertrophic scars, silicone, tension reduction, and wound edge eversion seem to have high efficacy, whereas onion extract, pulsed-dye laser, pressure garments, and scar massage have low efficacy. For the treatment of existing hypertrophic scars, silicone, pulsed-dye laser, CO2 laser, corticosteroids, 5-fluorouracil, bleomycin, and scar massage have high efficacy, whereas onion extract and fat grafting seem to have low efficacy. For keloid scars, effective adjuncts to excision include corticosteroids, mitomycin C, bleomycin, and radiation therapy. No intervention seems to have significant efficacy in the prevention or treatment of striae distensae.

CONCLUSION

Although scars can never be completely eliminated in an adult, this article presents the most commonly used, evidence-based methods to improve the quality and symptoms of hypertrophic scars, as well as keloid scars and striae distensae.

Keloids and Hypertrophic Scars: A Spectrum of Clinical Challenges

Since their earliest description, keloids and hypertrophic scars have beleaguered patients and clinicians alike. These scars can be aesthetically disfiguring, functionally debilitating, emotionally distressing, and psychologically damaging, culminating in a significant burden for patients. Our current understanding of keloid pathophysiology has grown and continues to advance while molecular biology, genetics, and technology provide ever-deepening insight into the nature of wound healing and the pathologic perturbations thereof. Greater understanding will lead to the development and application of refined therapeutic modalities. This article provides an overview of our current understanding of keloids, highlighting clinical characteristics and diagnostic criteria while providing a comprehensive summary of the many therapeutic modalities available. The proposed mechanism, application, adverse events, and reported efficacy of each modality is evaluated, and current recommendations are summarized.

Efficacy of IPL device combined with intralesional corticosteroid injection for the treatment of keloids and hypertrophic scars with regards to the recovery of skin barrier function: A pilot study

BACKGROUND

Keloids and hypertrophic scars are prevalent and psychologically distressful dermatologic conditions. Various treatment modalities have been tried but without complete success by any one method.

OBJECTIVE

We evaluated the efficacy of a combination of intense pulsed light (IPL) device and intralesional corticosteroid injection for the treatment of keloids and hypertrophic scars with respect to the recovery of skin barrier function.

METHODS

Totally 52 Korean patients were treated by the combined treatment at 4-8-week intervals. Using digital photographs, changes in scar appearance were assessed with modified Vancouver Scar Scale (MVSS), physicians' global assessment (PGA) and patient's satisfaction score. In 12 patients, the stratum corneum (SC) barrier function was assessed by measuring transepidermal water loss (TEWL) and SC capacitance.

RESULTS

Most scars demonstrated significant clinical improvement in MVSS, PGA and patient's satisfaction score after the combined therapy. A significant decrease of TEWL and elevation of SC capacitance were also documented after the treatment.

CONCLUSION

The combination therapy (IPL + corticosteroid injection) not only improves the appearance of keloids and hypertrophic scars but also increases the recovery level of skin hydration status in terms of the skin barrier function.

Nd:YAG Laser Treatment for Keloids and Hypertrophic Scars: An Analysis of 102 Cases

Background:

The present retrospective cohort study was performed to determine the efficacy of contact-mode 1064 nm neodymium-yttrium-aluminum-garnet (Nd:YAG) laser laser for keloids and hypertrophic scars. The indication and limitations of this modality are discussed.

Methods:

The cohort consisted of 102 consecutive Japanese patients (23 males and 79 females) with keloids and hypertrophic scars for more than 1 year. They were treated every 3–4 weeks for 1 year with a long-pulsed 1064 nm Nd:YAG laser (Cutera, Brisbane, Calif.) in contact mode. Thirty-eight patients had hypertrophic scars and 64 had keloids. The scars were evaluated before the treatment commenced and 1 month after the last session by using the Japan Scar Workshop Scar Scale 2011. Recurrence was assessed at 6 months after the termination of treatment.

Results:

The average total Japan Scar Workshop score of the keloid and hypertrophic scar region groups dropped significantly after 1 year of treatment compared with before treatment (all P < 0.05). None of the hypertrophic scars or keloids deteriorated. However, 3 of the 34 anterior chest keloids (8.8%) did not respond. The following recurrence rates were observed 6 months after stopping laser treatment: 1 of the abdomen hypertrophic scars (4%), 18 of the anterior chest keloids (52.9%), 5 of the upper arm keloids (35.7%), and 4 of the scapula keloids (25%).

Conclusions:

Hypertrophic scars responded significantly better to 1064 nm Nd:YAG laser treatment than keloids. However, keloid recurrence occurred when there was remaining redness and induration, even if only a small part of the scar was affected.

Laser and light-based treatment of Keloids--a review

BACKGROUND

Keloids are an overgrowth of fibrotic tissue outside the original boundaries of an injury and occur secondary to defective wound healing. Keloids often have a functional, aesthetic, or psychosocial impact on patients as highlighted by quality-of-life studies.

OBJECTIVES

Our goal is to provide clinicians and scientists an overview of the data available on laser and light-based therapies for treatment of keloids, and highlight emerging light-based therapeutic technologies and the evidence available to support their use.

METHODS

We employed the following search strategy to identify the clinical evidence reported in the biomedical literature: in November 2012, we searched PubMed.gov, Ovid MEDLINE, Embase and Cochrane Reviews (1980-present) for published randomized clinical trials, clinical studies, case series and case reports related to the treatment of keloids. The search terms we utilized were 'keloid(s)' AND 'laser' OR 'light-emitting diode' (LED) OR 'photodynamic therapy' (PDT) OR 'intense pulsed light' OR 'low level light' OR 'phototherapy.'

RESULTS

Our search yielded 347 unique articles. Of these, 33 articles met our inclusion and exclusion criteria.

CONCLUSION

We qualitatively conclude that laser and light-based treatment modalities may achieve favourable patient outcomes. Clinical studies using CO2 laser are more prevalent in current literature and a combination regimen may be an adequate ablative approach. Adding light-based treatments, such as LED phototherapy or PDT, to laser treatment regimens may enhance patient outcomes. Lasers and other light-based technology have introduced new ways to manage keloids that may result in improved aesthetic and symptomatic outcomes and decreased keloid recurrence.

Pilot Study of the Efficacy of 578 nm Copper Bromide Laser Combined with Intralesional Corticosteroid Injection for Treatment of Keloids and Hypertrophic Scars

Background

Treatments including intralesional corticosteroid injection, pressure therapy, cryotherapy, and various laser therapies have had limited success for keloids and hypertrophic scars.

Objective

This trial evaluated the efficacy of a combination of 578 nm copper bromide laser and the more traditional intralesional corticosteroid injection for the treatment of keloids and hypertrophic scars with respect to scar color.

Methods

Keloids or hypertrophic scars of 12 Korean patients were treated five times by the combined treatment at 4-week intervals. Clinical improvement was assessed by the physicians' global assessment (PGA) comparing pre- and post-treatment photographs, as well as 4 weeks after the last treatment. Erythema intensity was quantified using a mexameter.

Results

Most scars showed significant clinical improvement in PGA and decreased erythema intensity after 5 treatments. All patients showed improvements in symptoms like pruritus.

Conclusion

The combined treatment is effective for keloids and hypertrophic scars, especially when the telangiectatic portion of the scars is prominent. The adjunctive use of 578 nm copper bromide laser decreased the telangiectatic side effects of an intralesional corticosteroid injection by reducing the vascular components of scars.

The utility of the potassium titanyl phosphate laser in modulating vocal fold scar in a rat model

OBJECTIVES/HYPOTHESIS

We hypothesize that the KTP laser has the potential to augment wound healing in a rat model, and this modality may serve as a therapeutic tool for the management of vocal fold fibrosis.

STUDY DESIGN

Prospective, laboratory animal study.

METHODS

Rats were subjected to either vocal fold injury ± KTP laser treatment at low energy to simulate clinically relevant endpoints. In addition, cohorts were subjected to therapeutic KTP laser alone. Endpoints included the analyses of gene expression data related to the acute inflammatory response and extracellular matrix deposition and organization.

RESULTS

Therapeutic KTP treatment was associated with an additive effect on inflammatory gene expression in the context of the injured rat vocal fold mucosa. A similar additive effect was observed for matrix metalloproteinase gene expression, similar to data previously reported in the dermatology literature. However, histologically, the KTP had little effect on established vocal fold fibrosis.

CONCLUSIONS

These data are the first to attempt to provide mechanistic insight into the clinical utility of angiolytic lasers for vocal fold scar. Similar to previous data obtained in the skin, it appears that these effects are mediated by MMPs.

Laser therapy in ethnic populations

Today, laser therapy is standard treatment for a wide variety of dermatologic complaints. From skin rejuvenation to the management of complex vascular malformations, laser treatment has proved to be an effective, innovative solution to once-challenging dilemmas. However, laser application in those with darker complexions remains a topic of great concern. Although contemporary devices may use longer-wavelength lasers and cooling devices to isolate target tissues within patients with high levels of epidermal melanin, significant risk remains. Today's laser surgeon must have a thorough understanding of patient concerns, lesion character and response to treatment, as well as the unique needs of those with darker skin. In this article, we discuss critical issues in patient assessment, proper evaluation of common skin complaints, and laser therapy use for a variety of lesions in the ethnic population.

[Current methods of treatment and prevention of pathologic scars]

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

Levels of evidence for the treatment of keloid disease

INTRODUCTION

Keloid disease presents a significant burden for patients and a significant therapeutic challenge for clinicians. Multiple treatments have been proposed, but with the increasing drive towards effective use of resources, therapeutic options need to be evaluated in terms of the levels of evidence supporting their use.

AIM

To retrieve and review the primary clinical studies evaluating keloid disease therapy over the last 25 years and assign levels of evidence for the treatment modalities evaluated.

METHOD

A Medline search was conducted to identify all primary clinical studies evaluating the treatment of keloid disease, published in English since 1980 (excluding single case reports). Studies were assigned a level of evidence (LOE-1, highest quality to LOE-5, lowest) adapted from the Oxford Centre for Evidence-based Medicine.

RESULTS

13 (12%) of 112 studies retrieved were assigned LOE-2, 99 (88%) assigned LOE-4. There were no LOE-1 studies. Ten of the LOE-2 studies evaluated silicone-based therapy or laser therapy. Most studies evaluating steroids, cryosurgery, laser therapy and post-surgical adjuvant therapy provide level 4 evidence.

CONCLUSION

High quality research in evaluating keloid therapy is lacking. There is a definite need for well designed and properly reported randomised controlled trials, to provide clinicians with a sound body of evidence on which to inform decision making.

Abnormal wound healing: keloids

Wound healing is a complex and carefully regulated physiologic response to a traumatic injury. Deregulation of this coordinated process can lead to exuberant scar formation as seen in keloids and hypertrophic scars. Despite their common occurrence, keloids remain one of the most challenging dermatologic conditions to successfully treat and may have significant psychosocial impact for the patient. In this review, we discuss the clinical features, genetics, epidemiology, and treatment of keloids.

Laser treatment of keloids and hypertrophic scars

BACKGROUND

Lasers have been used in the treatment of hypertrophic scars and keloids for more than 20 years. Different laser systems have been examined; among them pulsed dye lasers are currently considered the laser of choice in these settings.

OBJECTIVES

The purpose of this study is to review the pertinent literature and provide updated information on different laser therapies available for treatment of keloids and hypertrophic scars.

METHODS

A Medline literature search was performed for relevant publications.

RESULTS

In this review the results of published studies in the treatment and prevention of hypertrophic scars and keloids are presented. Suggested mechanisms of action are reviewed. A review of the optimal laser parameters to modulate treatment outcome will be discussed. Different lasers are effective in not only the treatment but also the prevention of hypertrophic scars and keloids, among them PDL is more promising. Most of the suggested theories are based on the selective photothermolysis in which the light energy emitted from a vascular laser is absorbed by hemoglobin, generating heat and leading to coagulation necrosis, neocollagenesis, collagen fiber heating with dissociation of disulfide bonds and subsequent collagen fiber realignment.

CONCLUSION

The optimal laser is currently 585 nm PDL, although the recent results of Q-switched 532 nm frequency-doubled Nd:YAG are promising. Early use of lasers are beneficial, especially in those who are prone to develop these lesions.

Treatment of Keloids and Hypertrophic Scars

Management of hypertrophic scars and keloids has advanced from crude, invasive methods such as gross excision and radiation to intralesional or topical agents that act on a cellular level. There is no universally accepted treatment regimen and no evidence-based literature to guide management. Our objectives are to present a list of available treatment regimens, their proposed mechanisms of action, and supporting evidence and to perform a meta-analysis of clinical trials to identify treatments with a better-than-even likelihood of improvement. We conducted a PubMed search through October 2005, identifying clinical studies of various treatments for hypertrophic scars and keloids. We graded the quality of each study, delineated the results into favorable vs nonfavorable, and calculated the statistical significance of the findings. The meta-analysis of 70 treatment series for various clinical measures showed a 70% chance of improvement with treatment; however, the mean amount of improvement to be expected was around 60%. There was no statistically significant difference between treatments. Most treatments for keloidal and hypertrophic scarring offer minimal likelihood of improvement. The magnitude of likely permanent improvement in any sign or symptom may be clinically meaningful but far short of cure. Novel therapies deserve further investigation but remain without proven benefit to date.

Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars

BACKGROUND

Cryotherapy combined with intralesional triamcinolon injection is the most common traditional therapy for hypertrophic scars and keloids. The literature contains few articles on the use of bleomycin tattoo for treatment of these conditions.

OBJECTIVE

This study compares the efficacy of bleomycin tattoo with that of cryotherapy combined with intralesional triamcinolon injection for the treatment of keloids and hypertrophic scars.

MATERIALS AND METHODS

Forty-five patients with hypertrophic scars or keloids were randomly divided into two groups. Group A was treated with bleomycin tattoo, and group B, with cryotherapy combined with intralesional triamcinolon injection. There were four therapeutic sessions at 1-month intervals. All patients were followed for 3 months after the end of treatment.

RESULTS

Therapeutic response in lesions less than 100 mm2 was higher than 88% in both groups, but in larger lesions, the therapeutic response to bleomycin was significantly better than cryotherapy combined with intralesional triamcinolon injection (p = .03). In group A, no relationship was observed between therapeutic response and lesion size (p = .58); however, in group B smaller lesions (< 100 mm2) displayed better therapeutic response (p = .007).

CONCLUSIONS

Bleomycin tattoo may be more effective than cryotherapy combined with intralesional triamcinolon injection in treatment of larger keloids and hypertrophic scars (size > 100 mm2).

Treatment of Granuloma Annulare with the 585 nm Pulsed Dye Laser

BACKGROUND

Granuloma annulare is a chronic asymptomatic dermatosis that is typically manifested by annular papules arising on the dorsa of the hands, feet, elbows, and knees. Multiple treatment modalities have been used with variable efficacy, but no known cure exists. Obtaining long-term resolution of involved areas is often a therapeutic challenge.

OBJECTIVE

We report the results of treatment of a patient with localized erythematous granuloma annulare with a 585 nm flashlamp-pumped pulsed dye laser.

METHODS

A single granuloma annulare plaque present on the left wrist for 3 years was treated on three occasions with a 585 nm flashlamp-pumped pulsed dye laser initially and repeated at months 5 and 13.

RESULTS

After initial pulsed dye laser treatment, significant flattening and reduction of erythema were evident within the treated area. After a second treatment at month 5 and a third treatment at month 13, further improvement was evident, and long-term remission was achieved.

CONCLUSION

Localized granuloma annulare may be difficult to manage, presenting a therapeutic challenge. Thorough understanding of available treatment options, their relative efficacies, and risks of complication can facilitate successful management of this chronic disease. Pulsed dye laser therapy may be an effective and relatively safe treatment option for erythematous granuloma annulare, although prospective studies in additional patients would be desirable. Improvement of the condition in a single patient does not imply that others might improve, and variability in response is more likely.

Clinical management of skin scarring

Not all scars are the same. They vary from normal skin scars to distinct types of abnormal scars, such as hypertrophic and disfiguring keloids. Physicians need to identify different types of skin scars and treat them appropriately. Misdiagnosis and mismanagement of scars can be costly for both the patient and physician. Patients with scars often face aesthetic, physical, psychological, and social consequences that result in substantial emotional and financial costs. This article reviews the spectrum of abnormal scar types and problems associated with scarring.

Keloids - clinical diagnosis, pathogenesis, and treatment options. Keloide - klinische Diagnose, Pathogenese und Behandlungsoptionen

Keloids are defined as excessive scar tissue formation extending beyond the area of the original skin injury and occurring in predisposed individuals. They are considered to be a result of abnormal wound healing. The pathogenetic mechanisms that cause keloids remain unknown. Experiments with cells derived from keloid tissue revealed a number of abnormalities in cellular functions, such as in proliferation, apoptosis, or expression of growth factors and extracellular matrix proteins. Furthermore, several studies have reported altered keratinocyte-fibroblast interactions in keloids. Despite the diverse pathological changes in cellular functions and expression profiles of cells derived from keloid tissue, recent genetic studies have provided evidence that single genes may act as major regulators of keloid formation. We provide an overview of the pathogenetic mechanisms of keloid formation in the context of their clinical characteristics and current therapeutic approaches.

Laser therapy on darker ethnic skin

Like all medical procedures laser therapy comes with inherent risks and complications. Because of the increased risk in epidermal side effects when performing laser therapy on patients with darker skin, a higher level of laser expertise and clinical experience in treating darker ethnic skin is recommended to ensure that patients are treated safely. Test spots should always be done as an aid to selecting safe and efficacious treatment parameters. Because of the limited experience in treating patients with darker skin a conservative approach should always be used. Unfortunately, there are no national policies establishing credentialing requirements for those planning to practice laser surgery. The US Food and Drug Administration are responsible for granting individual laser manufacturers' permission to market their lasers for specific indications. The Food and Drug Administration also recommends operator training to use these lasers, but credentialing is a state function and consequently standards for laser therapy vary greatly from state to state. Until the bar is raised and national credentialing polices on laser therapy are established clinicians must police themselves and fully be aware of their capabilities and limitations to ensure that all patients regardless of skin color or ethnicity receive safe and effective treatments.

New Therapies for the Management of Keloids

A broad range of therapeutics is currently available for the treatment of keloids, but none have been shown to be completely effective in flattening existing keloids, reducing associated symptoms or preventing recurrence. Therefore, newer treatments not routinely used for keloids have been examined more recently, including laser therapy, intralesional interferon and imiquimod, which have had variable success as therapies for keloids. This article briefly reviews such experimental data and presents recommendations for management of keloids as well.

International clinical recommendations on scar management

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