Current trends and future considerations in scar treatment Jill S Waibel, MD1,2,3 and Ashley Rudnick1
n Abstract
The goal of scar therapy is the restoration of the patient to their preinjury state. A combination of injected antimetabolites, surgery, laser, and laser-assisted delivery of drugs is needed for minimally invasive surgical correction of scars. As a result, laser therapy is emerging as an essential treatment element. It has been noted that fractional lasers normalize both the clinical and histological appearance of scars. Laser- and light-based therapies complement existing approaches of surgery and physical therapy, resulting in significant gains with minimal associated morbidity. Emerging and future laser technologies are creating a new paradigm in the management of scar rehabilitation. Semin Cutan Med Surg 34:13-16 © 2015 Frontline Medical Communications
S
cars are an essential part of the wound healing process. There is an association between scarring and the depth of dermal injury or burn. Dunkin et al showed that there is a threshold depth of dermal injury when scarring develops which is 0.56 +/- 0.03 mm.1 Scarring is a tissue response acquired during the second trimester of fetal development at the same time as cellular immunity.2 Abnormal healing that results in hypertrophic scars or keloids may produce significant morbidity and impair quality of life due to contracture, neuropathic pain, pruritus, and decreased protection from mechanical trauma.3 Conventional management of scars has included massage, compression garments, silicone sheeting, steroid injection, surgical adjacent tissue transfer (z-plasty), and direct excision.4-7 Scar rehabilitation requires a combination of therapies including injectable antimetabolites, surgery, lasers and laser-assisted delivery to restore skin to its former condition of health (Table). Laser organ (skin) repair Laser treatment of scars represents a major innovation that heals in ways not previously possible. Lasers are effective and have a Miami Dermatology and Laser Institute, Florida. Assistant Professor, Miller School of Medicine, Miami University, Florida. 3 Subsection Chief of Dermatology, Baptist Hospital, Miami, Florida. Disclosures: Dr Waibel reports she was a paid investigator in clinical trials with Alma, Cutera, Lumenis, and Sebacia. She also reports she was a paid investigator for and received equipment from Harvest and Lutronic. She is also a co-investor of intellectual property with the University of Miami and may gain royalties from future commercialization of the technology. Ms Rudnick has nothing to disclose. Correspondence: Jill S. Waibel, MD; Miami Dermatology and Laser Institute; 7800 SW 87th Avenue Suite B200; Miami, Florida 33173. E-mail:
[email protected]. 1 2
1085-5629/13$-see front matter © 2015 Frontline Medical Communications DOI: 10.12788/j.sder.2015.0129
low adverse-event profile.8-10 Lasers can repair the skin to almost normal. The ablative fractional lasers are the mainstay of laser scar rehabilitation. The human body can heal the small wound the fractional laser creates (120 microns) which results in almost normal skin both clinically and histologically. Laser tissue repair works on all types of scars – surgical, acne, burn, and traumatic – to treat and modify the problematic characteristics of scars including erythema, hyperpigmentation, atrophy, hypertrophy, and often decrease tension and increase range of motion.11-13 Surgical scars Any time surgery is performed, whether plastic surgery or for a medical cause, the defect will result in a scar. Both hypertrophic and atrophic surgical scars may be improved with laser treatment. Atrophic scars may be treated at more superficial depths whereas the hypertrophic scars need deeper fractional laser penetration. Surgical scars can be addressed either with preventative or corrective measures. Surgical scars are often erythematous. Using a pulsed-dye laser on a surgical scar as early as the day of suture removal can prevent surgical scar formation. As soon as the physician notes that a surgical scar’s healing is suboptimal, it can be treated with a combination of lasers. Acne scars Inflammation is the single greatest reason for acne scar development. Because the skin is affected at a deeper level, the greater the inflammation of the skin, the more likely scarring is to occur. Acne scar treatment requires a multiprocedural approach, including punch biopsies (boxcar and rolling scars), z-plasty (rolling scars), subscision, fractional laser resurfacing, dermal fillers, tissue stimulators, Chemical Reconstruction of Skin Scars (CROSS) technique, and topical retinoids. Topographical features of acne scarring include perpendicular bundles of collagen which anchor the skin of the scars down. Deep acne scars need deep laser resurfacing for maximum improvement. The goals of laser resurfacing are to stimulate neocollagenesis to “plump” up these areas of collagen loss. Given the dermal pathology present with acne scarring, particularly with atrophic scars, treatment modalities should be capable of affecting dermal remodeling at least 1 mm below the skin. There has been limited success in the treatment of acne scars; however, with the advent of deep-reaching fractional lasers, greater success has been achieved (Figure 1). In a case series of 2-3 treatment sessions using an ablative fractional CO2 laser for moderate-to-severe acne scarring, clinical improvements of 26%-50% in texture and atrophy were noted. Improvements in scar depths of 43%-79.9% were achieved resulting in a mean depth improvement of 66.8%. A greater degree of improvement was achieved with ablative fractional laser technology as opposed to previous studies with nonablative fractional laser technology, resulting from deeper Vol. 34, March 2015, Seminars in Cutaneous Medicine and Surgery 13
n n n Current trends and future considerations in scar treatment
n TablE Scar treatment algorithm Type of scar
Scar treatment
Small scar
Inject antimetabolite (triamcinolone acetonide 5-fluoruracil) in small quantities – usually 1 cc or less
Scar under tension
Surgery – z-plasty, w-plasty, release
Red scar
Vascular laser
All scars
Fractional laser
Large hypertropic scar
Fractional laser and laser-assisted delivery of antimetabolite
Depressed scar
Fractional laser and laser-assisted delivery of tissue stimulator
dermal penetration when using the fractionated CO2 device.14 Correlating with this clinical data, in vivo studies by Hantash et al with this device have shown tissue ablation and thermal effects as deep as 1 mm.15 Burn and traumatic scars Burn and traumatic wounds are the most challenging to treat because these are typically the worst scars seen in clinical medicine. Scars that are formed after explosion injury (often seen in the military with Intelligent Electronic Devices [IEDs]) and burn injuries cause thermal damage to the tissue that extends both laterally and deep into the skin. Scars that heal from this injury have a plethora of different morbidities in the same scar including residual ulcers, erythema, hypopigmentation, hyperpigmentation, increased scar thickness, and decreased range of motion. In addition, many patients suffer with intense pain and pruritus. These scars take the most expertise to treat and often need to use multiple lasers in the same treatment session. The treatment must be customized to the characteristics of the scar. Erythematous and hypertrophic scars are seen frequently in the first year after injury. Vascular-specific laser and light devices, especially the 595-nm pulsed-dye laser (PDL) is already well established.16 A PDL may be applied alone for small hypertrophic scars, but is often combined with fractional laser therapy in either concurrent or alternating treatment sessions.
A
B
n Figure 1. A) Erythematous and atrophic deep acne back
scars. B) One year after two vascular and fractional ablative laser treatment sessions
14 Seminars in Cutaneous Medicine and Surgery, Vol. 34, March 2015
Hypertrophic burn and traumatic scars are best improved by either ablative or nonablative fractional lasers. The injury produced by an ablative fractional laser has the capacity to induce a more robust collagen remodeling response than the injury caused by a nonablative fractional laser (Figure 2).17 Ablative lasers have a significantly greater potential depth of thermal injury compared to nonablative lasers, 1.8 mm compared to 4.0 mm, respectively. In addition, tissue ablation appears to induce a modest immediate photomechanical release of tension in some restrictive scars. Often patients have an increase in range of motion within 24-48 hours after one fractional ablative therapy treatment. Flat or atrophic scars from burns and trauma also respond to fractional laser therapy. Approach to scar treatment
In general, the treatment of scars should be tailored to address the specifics of a particular scar including the thickness, age, and location of the scar, patient’s skin type, and the patient’s comorbid medical conditions. In general, an erythematous scar is either treated with a pulsed-dye laser or an intense-pulsed light device to decrease the redness. Next, either a CO2 or Erbium fractional ablative laser is used matching the depth in microns to the approximate depth of the scar. In general, it is recommended to use low densities of about 10%. Surgery still has a role in the treatment of scars. Decreasing tension via z-plasty or w-plasty tissue transfer
A
B
n Figure 2. A) One month after acute chemical burn from roofing injury treated with vascular and fractional lasers. B) After 4 laser sessions for prevention and treatment of hypertrophic scarring.
Waibel et al
A
B
C
n Figure 3. A) At day of release from the burn unit 3 months postinjury with open wounds as a result of a hot air balloon hitting a power line. B) Four months after injury, you can see the growing hypertrophic scar one month after release from the burn unit. Hypertrophic scars grow 3-7 months after injury. C) After a series of laser treatments, notice the prevention of further scar formation and improvement of the previous scars. reorients the scars by changing their environment and gives clinical benefit. Once tension is relieved in a scar, the collagen is able to remodel which causes a decrease in hypertrophy and improvement in height and appearance of the scar. Laser and minimal surgery decreases morbidity, has better results, is cost-effective, and has truly revolutionized the treatment of scars. Prevention of scars by early laser intervention The hypertrophic scar process occurs 3-7 months after the initial injury. During this time, there is an increase in collagen production and a decrease in collagen decay factors. It may be possible to prevent hypertrophic scar development by lasing scars early. Once the epithelium is intact, we have several case reports that show there may be a benefit to laser therapy for scar prevention (Figure 3). A proposed mechanism of scar prevention is the laser changes the wound healing mileu and turns off some of the cytokine storm that creates the massive excess collagen deposition by fibroblasts in severe wounds. Currently, prospective clinical trials are underway to study this possible effect.18 Laser-assisted delivery for scar treatment Fractional ablative tunnels can be utilized for laser-assisted delivery systems (LADS) of a variety of drugs, topical agents, and
A
B
n Figure 4. A) Patient with burned-out tumid lupus with deep
atrophic scarring. B) After one treatment with fractional ablative laser and poly-L-lactic acid.
other living tissue. Laser-assisted drug delivery may allow for a greater and more precise depth of penetration by existing topical medications, more efficient transcutaneous delivery of large drug molecules, and even systemic drug administration via a transcutaneous route. These zones may be used immediately postoperatively to deliver drugs and other substances to synergistically create an enhanced therapeutic response. Ablative fractional laser-assisted delivery has been used to treat hypertrophic scars. Waibel and colleagues also studied LADS of 5-fluorouracil (5-FU) versus triamcinolone acetonide for hypertrophic scar treatment. Preliminary results indicate equal efficacy of the two agents for decreasing scar height, with 5-FU causing less atrophy and telangiectasia.19 Poly-L-lactic acid (PLLA) is a tissue stimulator which is typically injected into the subcutaneous or supraperiosteal plane for the purpose of facial volume correction. Laser-assisted delivery of PLLA combined with the properties of fractional ablative resurfacing stimulates fibroblast proliferation and neocollagenesis.10 Randomized controlled clinical trials and safety studies are needed in the field of laser-assisted delivery for the treatment of challenging cutaneous hypertrophic scars (Figure 4). Future scar treatments Although lasers are a powerful new tool in the treatment of scars; many children, civilians, and wounded warriors suffer a lifetime of disfiguring and painful scars. The future goal would be treatment of acute wounds to prevent scar formation. In an ongoing trial titled Scars Through Laser Assisted Delivery of Stem Cells, Care for the Critically Injured Burn Patient, we are studying to determine if fractional laser plus stem cells adipose, allogeneic, autologous is more effective than fractional laser alone in treating acute burn scars. Stem cells may have a promising role in the future of scar prevention. Conclusion Laser therapies may not only enhance traditional modalities of surgery, compression garments, silicone sheeting, and massage, but these emerging technologies may disrupt current algorithms and readjust our hopes of what we can achieve in terms of restoring form and function in scar patients. Laser- and light-based therapies complement existing approaches of surgical, occupational, and physical therapy, yielding incremental gains. Emerging and future laser technologies, combined with laser-assisted delivery, stem cell delivery, and topical administration of drugs may create Vol. 34, March 2015, Seminars in Cutaneous Medicine and Surgery 15
n n n Current trends and future considerations in scar treatment a new paradigm in the management of scars. Hippocrates stated the physician treats, nature cures. Lasers achieve better results by rehabilitating scars via nature’s own healing process. References
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