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

Advancements in laser technologies for skin rejuvenation: A comprehensive review of efficacy and safety

INTRODUCTION

Laser technology has fundamentally transformed the landscape of dermatology, offering nuanced solutions for skin rejuvenation and resurfacing. This paper aims to explore the spectrum of laser technologies, from ablative to non-ablative and fractional lasers, their mechanisms, benefits, and tailored applications for diverse skin conditions. As we delve into the intricacies of each technology, we also consider the scientific advancements that have made these treatments safer and more effective, promising a new horizon in skin rejuvenation.

OBJECTIVE

This comprehensive analysis seeks to evaluate recent advancements in laser technology for skin rejuvenation, focusing on efficacy, safety, and patient satisfaction.

METHODS

The selection criteria for studies in this publication focused on recent, peer-reviewed articles from the last 20 years, emphasizing advancements in laser technologies for skin rejuvenation. Our comprehensive review involved searches in PubMed, Cochrane, Scopus and Google Scholar using keywords like "skin rejuvenation," "laser technology," "efficacy," "safety," and "dermatology." This approach focused on inclusion of recent research and perspectives on the efficacy and safety of laser treatments in the field of dermatology.

RESULTS

Our literature review reveals advancements in laser skin resurfacing technologies, notably fractional lasers for minimal downtime rejuvenation, ablative lasers for precise tissue vaporization, and non-ablative lasers for coagulation effect promoting collagen with reduced recovery. Hybrid and picosecond lasers are highlighted for their versatility and effectiveness in addressing a wide array of skin concerns. The findings also emphasize the development of safer treatment protocols for ethnic skin, significantly reducing risks like hyperpigmentation and scarring, thus broadening the scope of effective dermatological solutions.

CONCLUSION

This extensive review of advancements in laser technologies for skin rejuvenation underscores a remarkable evolution in dermatological treatments, offering an expansive overview of the efficacy, safety, and patient satisfaction associated with these interventions. Furthermore, the exploration of combination treatments and laser-assisted drug delivery represents a frontier in dermatological practice, offering synergistic effects that could amplify the therapeutic benefits of laser treatments.

Treatment of hypopigmented burn hypertrophic scars with short-term topical tacrolimus does not lead to repigmentation

OBJECTIVES

Dyschromia is an understudied aspect of hypertrophic scar (HTS). The use of topical tacrolimus has successfully shown repigmentation in vitiligo patients through promotion of melanogenesis and melanocyte proliferation. It was hypothesized that HTSs treated with topical tacrolimus would have increased repigmentation compared to controls.

METHODOLOGY

Full-thickness burns in red Duroc pigs were either treated with excision and meshed split-thickness skin grafting or excision and no grafting, and these wounds formed hypopigmented HTSs (n = 8). Half of the scars had 0.1% tacrolimus ointment applied to the scar twice a day for 21 days, while controls had no treatment. Further, each scar was bisected with half incurring fractional ablative CO2 laser treatment before topical tacrolimus application to induce laser-assisted drug delivery (LADD). Pigmentation was evaluated using a noninvasive probe to measure melanin index (MI) at Days 0 (pretreatment), 7, 14, and 21. At each timepoint, punch biopsies were obtained and fixed in formalin or were incubated in dispase. The formalin-fixed biopsies were used to evaluate melanin levels by H&E staining. The biopsies incubated in dispase were used to obtain epidermal sheets. The ESs were then flash frozen and RNA was isolated from them and used in quantitative reverse transcription polymerase chain reaction for melanogenesis-related genes: Tyrosinase (TYR), TYR-related protein-1 (TYRP1), and dopachrome tautomerase (DCT). Analysis of variance test with Šídák's multiple comparisons test was used to compare groups.

RESULTS

Over time, within the grafted HTS and the NS group, there were no significant changes in MI, except for Week 3 in the -Tacro group. (+Tacro HTS= pre = 685.1 ± 42.0, w1 = 741.0 ± 54.16, w2 = 750.8 ± 59.0, w3 = 760.9 ± 49.8) (-Tacro HTS= pre = 700.4 ± 54.3, w1 = 722.3 ± 50.7, w2 = 739.6 ± 53.2, w3 = 722.7 ± 50.5). Over time, within the ungrafted HTS and the NS group, there were no significant changes in MI. (+Tacro HTS= pre = 644.9 ± 6.9, w1 = 661.6 ± 3.3, w2 = 650.3 ± 6.2, w3 = 636.3 ± 7.4) (-Tacro HTS= pre = 696.8 ± 8.0, w1 = 695.8 ± 12.3, w2 = 678.9 ± 14.0, w3 = 731.2 ± 50.3). LADD did not lead to any differential change in pigmentation compared to the non-LADD group. There was no evidence of increased melanogenesis within the tissue punch biopsies at any timepoint. There were no changes in TYR, TYRP1, or DCT gene expression after treatment.

CONCLUSION

Hypopigmented HTSs treated with 0.1% tacrolimus ointment with or without LADD did not show significantly increased repigmentation. This study was limited by a shorter treatment interval than what is known to be required in vitiligo patients for repigmentation. The use of noninvasive, topical treatments to promote repigmentation are an appealing strategy to relieve morbidity associated with dyschromic burn scars and requires further investigation.

Effect of Laser and Energy-based Device Therapies to Minimize Surgical Scar Formation: A Systematic Review and Network Meta-analysis

Utilization of lasers and energy-based devices for surgical scar minimization has been substantially evaluated in placebo-controlled trials. The aim of this study was to compare reported measures of efficacy of lasers and energy-based devices in clinical trials in preventing surgical scar formation in a systematic review and network meta-analyses. Five electronic databases, PubMed, Scopus, Embase, ClinicalTrials.gov, and the Cochrane Library, were searched to retrieve relevant articles. The search was limited to randomized controlled trials that reported on clinical outcomes of surgical scars with treatment initiation no later than 6 months after surgery and a follow-up period of at least 3 months. A total of 18 randomized controlled trials involving 482 participants and 671 postsurgical wounds were included in the network meta-analyses. The results showed that the most efficacious treatments were achieved using low-level laser therapy) (weighted mean difference -3.78; 95% confidence interval (95% CI) -6.32, -1.24) and pulsed dye laser (weighted mean difference -2.46; 95% CI -4.53, -0.38). Nevertheless, low-level laser therapy and pulsed dye laser demonstrated comparable outcomes in surgical scar minimization (weighted mean difference -1.32, 95% CI -3.53, 0.89). The findings of this network meta-analyses suggest that low-level laser therapy and pulsed dye laser are both effective treatments for minimization of scar formation following primary closure of surgical wounds with comparable treatment outcomes.

Review of laser and energy-based devices to treat rosacea in skin of color

The prevalence of rosacea in skin of color (SOC) populations is estimated to be as high as 10% in some countries. Traditionally, intense pulsed light (IPL) and pulsed dye laser (PDL) have been the laser and energy-based devices (EBDs) used to treat rosacea. However, not all laser and EBDs are safe for SOC (Fitzpatrick skin types IV-VI) due to increased absorption of energy in pigmented skin and increased risk of post-inflammatory hyperpigmentation and scarring. This review summarizes the use of the top seven laser and EBDs for treating rosacea in SOC.

Treatment of burn hypertrophic scar with fractional ablative laser-assisted drug delivery can decrease levels of hyperpigmentation

BACKGROUND

Laser treatments have been used to treat a variety of scar symptoms, including the appearance of scars following burn injury. One such symptom is hyperpigmentation. There are several qualitative and quantitative measures of assessing improvement in hyperpigmentation over time. The Patient and Observer Scar Assessment Scale (POSAS) and Vancouver Scar Scale (VSS) are two scales that describe characteristics of scar such as pigmentation level. These scales are limited by their qualitative nature. On the other hand, spectrophotometers provide quantitative measures of pigmentation. Prior studies have reported that laser can change scar pigmentation, but no quantitative values have been reported. The current study examines changes in scar melanin index after CO₂ fractional ablative laser scar revision (FLSR) via noninvasive probe measurement in patients of various Fitzpatrick skin types (FST).

MATERIALS AND METHODS

Patients with scars of various sizes and etiologies were treated with FLSR. A database was constructed including 189 patients undergoing laser treatment. From this pool, individuals were selected based on the criteria that they completed at least two laser sessions and had Melanin index measurements for both of these sessions and the pre-operative visit. This criteria resulted in 63 patients of various FST in the cohort. Melanin index, POSAS-Observer (O) and -Patient (P) pigmentation and color scores and VSS-pigmentation scores were examined over time. Demographic information (age of patient at time of first treatment, age of scar at time of first treatment, use of laser-assisted drug delivery (LADD), gender, FST, and Ethnicity) were collected from the medical record. Patients were grouped as "responder" if their Melanin index indicated decreased levels of hyperpigmentation after FLSR treatment in more than half of their total number of visits and "nonresponder" if it did not.

RESULTS

The majority of patients were responders (41/63). In responder patients, measurements of Melanin index showed significantly improved levels of hyperpigmentation in hypertrophic scars after two FLSR sessions (p < 0.05). Age of patient, gender, FST, age of scar, ethnicity, or type of drug delivered by LADD did not predict responder grouping. POSAS-O and -P pigmentation/color scores showed improved scores after two FLSR sessions within the responder group. POSAS-P color scores showed improved scores after two and three FLSR sessions in the nonresponder group. VSS pigmentation scores showed improved scores after three FLSR sessions in the responder group only.

CONCLUSION

Based on Melanin index values, FLSR leads to improvements in hyperpigmentation in certain patients.

Effect and Safety of ALA-PDT Combined with 1550 nm Fractional Therapy Laser in Treating Rosacea

Objective

To explore the clinical effect and safety of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) combined with 1550 nm fractional laser therapy in the treatment of rosacea.

Methods

114 patients with type I and type II rosacea treated in our hospital from March 2018 to April 2020 were recruited. They were randomly assigned (1 : 1 : 1) to receive ALA-PDT (photodynamic group), 1550 nm fractional laser (laser group), or ALA-PDT and 1550 nm fractional laser therapy (combination group). Outcome measures included skin lesion scores, efficacy, and adverse reactions.

Results

After treatment, patients in the three groups showed lower skin lesion scores than before treatment, and the combination group showed significantly lower results than the other groups (P < 0.05). There was no significant difference in the total efficacy among the three groups (P > 0.05), but the combination group outperformed the other groups in the comparison of the efficacy levels (P < 0.05). Edema with lupus erythematosus, pain, and burning sensation was found in some cases but disappeared within 2 to 4 days after symptomatic treatment without interference with subsequent treatment. No patients had pigmentation, hypopigmentation, scars, or other serious adverse reactions.

Conclusion

In the treatment of rosacea, ALA-PDT combined with a 1550 nm fractional laser can reduce redness and facilitate skin remodeling, with high efficacy and safety, so it is worthy of clinical promotion and application.

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.

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.