Laser management of hypertrophic burn scars: a comprehensive review

Abstract

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.

Keywords

Burn / Cicatrix / Hypertrophic / Contracture / Keloid / Laser therapy / Pruritus / Quality of life / Scar

References

[1] Bombaro KM, Engrav LH, Carrougher GJ, Wiechman SA, Faucher L, Costa BA, et al. What is the prevalence of hyper-trophic scarring following burns? Burns 2003; 29: 299-302.

[2] Fu X, Dong J, Wang S, Yan M, Yao M. Advances in the treatment of traumatic scars with laser, intense pulsed light, radiofrequency, and ultrasound. Burns Trauma 2019; 7: 1. doi: 10.1186/s41038-018-0141-0. eCollection 2019.

[3] Willows BM, Ilyas M, Sharma A. Laser in the management of burn scars. Burns 2017; 43: 1379-89.

[4] Anderson RR, Parrish JA. Selective photothermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220: 524-7.

[5] Castro DJ, Abergel RP, Meeker C, Dwyer RM, Lesay MA, Uitto J.Effects of the Nd:YAG laser on DNA synthesis and collagen production in human skin fibroblast cultures. Ann Plast Surg 1983; 11: 214-22.

[6] Issler-Fisher AC, Waibel JS, Donelan MB. Laser modulation of hypertrophic scars: Technique and practice. Clin Plast Surg 2017; 44: 757-66.

[7] Issler-Fisher AC, Fisher OM, Smialkowski AO, Li F, van Schalk-wyck CP, Haertsch P, et al. Ablative fractional CO2 laser for burn scar reconstruction: An extensive subjective and objective short-term outcome analysis of a prospective treatment cohort. Burns 2017; 43: 573-82.

[8] Hultman CS, Friedstat JS, Edkins RE, Cairns BA, Meyer AA. Laser resurfacing and remodeling of hypertrophic burn scars: The results of a large, prospective, before-after cohort study, with long-term follow-up. Ann Surg 2014; 260: 519-29, discussion 529-32.

[9] Allison KP, Kiernan MN, Waters RA, Clement RM. Pulsed dye laser treatment of burn scars. Alleviation or irritation? Burns 2003; 29: 207-13.

[10] Anderson RR, Donelan MB, Hivnor C, Greeson E, Ross EV, Shumaker PR, et al. Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: Consensus report. JAMA Dermatol 2014; 150: 187-93.

[11] Donelan MB, Parrett BM, Sheridan RL. Pulsed dye laser therapy and z-plasty for facial burn scars: The alternative to excision. Ann Plast Surg 2008; 60: 480-6.

[12] Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: Review of laser-and light-based therapies for the treatment of burn scars. Dermatol Res Pract 2012; 2012: 243651.

[13] Khandelwal A, Yelvington M, Tang X, Brown S. Ablative frac-tional photothermolysis for the treatment of hypertrophic burn scars in adult and pediatric patients: A single surgeon’s experi-ence. J Burn Care Res 2014; 35: 455-63.

[14] Zuccaro J, Ziolkowski N, Fish J. A systematic review of the effectiveness of laser therapy for hypertrophic burn scars. Clin Plast Surg 2017; 44: 767-79.

[15] Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Frac-tional photothermolysis: A new concept for cutaneous remod-eling using microscopic patterns of thermal injury. Lasers Surg Med 2004; 34: 426-38.

[16] Lowe NJ, Lask G, Griffin ME, Maxwell A, Lowe P, Quilada F.Skin resurfacing with the Ultrapulse carbon dioxide laser. Observations on 100 patients. Dermatol Surg 1995 Dec; 21(12): 1025-9.

[17] Khatri KA, Ross V, Grevelink JM, Magro CM, Anderson RR. Comparison of erbium:YAG and carbon dioxide lasers in resur-facing of facial rhytides. Arch Dermatol 1999; 135: 391-7.

[18] Goldberg DJ, Whitworth J. Laser skin resurfacing with the Q-switched Nd:YAG laser. Dermatol Surg 1997; 23: 903-6; discus-sion 906-7.

[19] Jin R, Huang X, Li H, Yuang Y, Li B, Cheng C, et al. Laser therapy for prevention and treatment of pathologic excessive scars. Plast Reconstr Surg 2013; 132: 1747-58.

[20] Oh BH, Hwang YJ, Lee YW, Choe YB, Ahn KJ. Skin char-acteristics after fractional photothermolysis. Ann Dermatol 2011; 23: 448-54.

[21] Kim HS, Lee JH, Park YM, Lee YJ. Comparison of the effec-tiveness of nonablative fractional laser versus ablative fractional laser in thyroidectomy scar prevention: A pilot study. J Cosmet Laser Ther 2012; 14: 89-93.

[22] Hantash BM, Bedi VP, Kapadia B, Rahman Z, Jiang K, Tanner H, et al. In vivo histological evaluation of a novel ablative fractional resurfacing device. Lasers Surg Med 2007; 39: 96-107.

[23] Uebelhoer NS, Ross EV, Shumaker PR. Ablative fractional resur-facing for the treatment of traumatic scars and contractures. Semin Cutan Med Surg 2012; 31: 110-20.

[24] DeBruler DM, Blackstone BN, Baumann ME, McFarland KL, Wulff, BC, Wilgus TA, et al. Inflammatory responses, matrix remodeling, and re-epithelialization after fractional CO2 laser treatment of scars. Lasers Surg Med 2017; 49: 675-85.

[25] Ozog DM, Liu A, Chaffins ML, Ormsby AH, Fincher EF, Chipps LK, et al. Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser. JAMA Dermatol 2013; 149: 50-7.

[26] Qu L, Liu A, Zhou L, He C, Grossman PH, Moy RL, et al. Clin-ical and molecular effects on mature burn scars after treatment with a fractional CO(2) laser. Lasers Surg Med 2012; 44: 517-24.

[27] El-Zawahry BM, Sobhi RM, Bassiouny DA, Tabak SA. Ablative CO2 fractional resurfacing in treatment of thermal burn scars: An open-label controlled clinical and histopathological study. J Cosmet Dermatol 2015; 14: 324-31.

[28] Azzam OA, Bassiouny DA, El-Hawary MS, El Maadawi ZM, Sobhi RM, El-Mesidy MS. Treatment of hypertrophic scars and keloids by fractional carbon dioxide laser: A clinical, histological, and immunohistochemical study. Lasers Med Sci 2016; 31: 9-18.

[29] Shumaker PR, Kwan JM, Badiavas EV, Waibel J, Davis S, Uebelhoer NS. Rapid healing of scar-associated chronic wounds after ablative fractional resurfacing. Arch Dermatol 2012; 148: 1289-93.

[30] Waibel J, Beer K. Ablative fractional laser resurfacing for the treatment of a third-degree burn. J Drugs Dermatol 2009; 8: 294-7.

[31] Oliaei S, Nelson JS, Fitzpatrick R, Wong BJ. Laser treatment of scars. Facial Plast Surg 2012; 28: 518-24.

[32] Parrett BM, Donelan MB. Pulsed dye laser in burn scars: Current concepts and future directions. Burns 2010; 36: 443-9.

[33] Cheng ET, Nowak KC, Koch RJ. Effect of blended carbon dioxide and erbium:YAG laser energy on preauricular and ear lobule keloid fibroblast secretion of growth factors: A serum-free study. Arch Facial Plast Surg 2001; 3: 252-7.

[34] Martin MS, Collawn SS. Combination treatment of CO2 frac-tional laser, pulsed dye laser, and triamcinolone acetonide injec-tion for refractory keloid scars on the upper back. J Cosmet Laser Ther 2013; 15: 166-70.

[35] Cohen JL, Safety GR. Efficacy evaluation of pulsed dye laser treatment, CO2 ablative fractional resurfacing, and com-bined treatment for surgical scar clearance. J Drugs Dermatol 2016; 15: 1315-9.

[36] Hultman CS, Edkins RE, Cairns BA, Meyer AA. Logistics of building a laser practice for the treatment of hypertrophic burn scars. Ann Plast Surg 2013; 70: 581-6.

[37] Shumaker PR, Kwan JM, Landers JT, Uebelhoer NS. Functional improvements in traumatic scars and scar contractures using an ablative fractional laser protocol. J Trauma Acute Care Surg 2012; 73: S116-21.

[38] Choe JH, Park YL, Kim BJ, Kim MN, Rho NK, Park NS, et al. Prevention of thyroidectomy scar using a new 1,550-nm frac-tional erbium-glass laser. Dermatol Surg 2009; 35: 1199-205.

[39] Nouri K, Jimenez GP, Harrison-Balestra C, Elgart GW. 585-nm pulsed dye laser in the treatment of surgical scars starting on the suture removal day. Dermatol Surg 2003; 29: 65-73, discussion 73.

[40] Sobanko JF, Vachiramon V, Rattanaumpawan P, Miller CJ. Early postoperative single treatment ablative fractional lasing of Mohs micrographic surgery facial scars: A split-scar, evaluator-blinded study. Lasers Surg Med 2015; 47: 1-5.

[41] Karmisholt KE, Wenande E, Thaysen-Petersen D, Phillipsen PA, Paasch U, Haedersdal M. Early intervention with non-ablative fractional laser to improve cutaneous scarring-A randomized controlled trial on the impact of intervention time and fluence levels. Lasers Surg Med 2018; 50: 28-36.

[42] Tong AK, Tan OT, Boll J, Parrish JA, Murphy GF. Ultrastructure: Effects of melanin pigment on target specificity using a pulsed dye laser (577 nm). J Invest Dermatol 1987; 88: 747-52.

[43] Cavalie M, Sillard L, Montaudie H, Bahadoran P, Lacour JO, Passeron T. Treatment of keloids with laser-assisted topical steroid delivery: A retrospective study of 23 cases. Dermatol Ther . 2015; 28: 74-8.

[44] Waibel JS, Wulkan AJ, Shumaker PR. Treatment of hypertrophic scars using laser and laser assisted corticosteroid delivery. Lasers Surg Med 2013; 45: 135-40.

[45] Waibel JS, Wulkan AJ, Rudnick A, Daoud A. Treatment of hypertrophic scars using laser-assisted corticosteroid versus laser-assisted 5-fluorouracil delivery. Dermatol Surg 2019; 45: 23-30.

[46] Forster B, Klein A, Szeimies RM, Maisch T. Penetration enhance-ment of two topical 5-aminolaevulinic acid formulations for photodynamic therapy by erbium:YAG laser ablation of the stratum corneum: Continuous versus fractional ablation. Exp Dermatol 2010; 19: 806-12.

[47] Haedersdal M, Sakamoto FH, Farinelli WA, Doukas AG, Tam J, Anderson RR. Fractional CO(2) laser-assisted drug delivery. Lasers Surg Med 2010; 42: 113-22.

[48] Lee WR, Shen SC, Pai MH, Yang HH, Yuan CY, Fang JY. Fractional laser as a tool to enhance the skin permeation of 5-aminolevulinic acid with minimal skin disruption: A compar-ison with conventional erbium:YAG laser. J Control Release 2010; 145: 124-33.

[49] Ali FR, Al-Niaimi F. Laser-assisted drug delivery in dermatol-ogy: From animal models to clinical practice. Lasers Med Sci 2016; 31: 373-81.

[50] Issa MC, Kassuga LE, Chevrand NS, Pires MT. Topical delivery of triamcinolone via skin pretreated with ablative radiofre-quency: A new method in hypertrophic scar treatment. Int J Dermatol 2013; 52: 367-70.

[51] Kaushik SB, Alexis AF. Nonablative fractional laser resurfacing in skin of color: Evidence-based review. J Clin Aesthet Dermatol 2017; 10: 51-67.

[52] Alexis AF. Lasers and light-based therapies in ethnic skin: Treat-ment options and recommendations for Fitzpatrick skin types V and VI. Br J Dermatol 2013; 169(Suppl 3): 91-7.

[53] Conejo-Mir JS, Corbi R, Linares M. Carbon dioxide laser abla-tion associated with interferon alfa-2b injections reduces the recurrence of keloids. J Am Acad Dermatol 1998; 39: 1039-40.

[54] Garg GA, Sao PP, Khopkar US. Effect of carbon dioxide laser ablation followed by intralesional steroids on keloids. J Cutan Aesthet Surg 2011; 4: 2-6.

[55] Koike S, Akaishi S, Nagashima Y, Dohi T, Hyakusoku H, Ogawa R. Nd:YAG laser treatment for keloids and hypertrophic scars: An analysis of 102 cases. Plast Reconstr Surg Glob Open 2015; 2(12): e272.