Treatment of Hypertrophic Scars Using Laser and Laser Assisted Corticosteroid Delivery

Keywords:medical, laser, fiber,  Time:16-03-2016

Intralesional corticosteroids have long been a staple in the treatment of hypertrophic and restrictive scars. Recent advances in laser technology and applications now provide additional options for improvements in function, symptoms, and cosmesis. Fractional ablative lasers create zones of ablation at variable depths of the skin with the subsequent induction of a wound healing and collagen remodeling response. Recent reports suggest these ablative zones may also be used in the immediate post-operative period to enhance delivery of drugs and other substances. We present a case series evaluating the efficacy of a novel combination therapy that incorporates the use of an ablative fractional laser with topically applied triamcinolone acetonide suspension in the immediate post-operative period.

This is a prospective case series including 15 consecutive subjects with hypertrophic scars resulting from burns, surgery or traumatic injuries. Subjects were treated according to typical institutional protocol with three to five treatment sessions at 2- to 3-month intervals consisting of fractional ablative laser treatment and immediate post-operative topical application of triamcinolone acetonide suspension at a concentration of 10 or 20 mg/ml. Three blinded observers evaluated photographs taken at baseline and six months after the final treatment session. Scores were assigned using a modified Manchester quartile score to evaluate enhancements in dyschromia, hypertrophy, texture, and overall improvement.

The unprecedented survival of individuals who sustain acute burns and other trauma both on and off the battlefield has increased the necessity for effective modalities in the treatment and rehabilitation of patients [1]. Due to a complex interplay of factors such as injury mechanism and tissue tension, elevated levels of IL-4 and other procollagen cytokines may result in a net excess of collagen contributing to the newly formed hypertrophic scar [2]. Treating severe cutaneous scars is complex, and despite the best surgical care and adequate healing time, many millions of patients continue to have functional impairments and symptoms such as burning, itching, and pain. When treating hypertrophic scars, both functional and aesthetic improvement is the ultimate goal. Multiple therapeutic options have previously been described including surgical revision, laser therapy, pressure therapy, siliconegel sheets, intralesional injections, pressure garments, and adjuvant topical drug treatments [3–8]. Successful outcomes have been achieved with vascular-specific lasers when treating severe hypertrophic scars [9–11]. Alster first reported improvement after two treatments with pulsed dye lasers for hypertrophic surgical and traumatic scars. The authors also noted reductions in erythema, elevation, itching, and pain [12]. Fractional lasers were developed within the last decade and have mainly been applied to cosmetic indications such as the mitigation of rhytides [13,14]. However, there is increasing evidence that fractional lasers are an emerging therapeutic option for the aesthetic restoration and functional enhancement of traumatic scars at virtually any location on the body [14–18]. Fractional lasers create zones of ablation at variable depths determined by the treatment settings. The unique fractional injury induces a molecular cascade including heat shock proteins and other factors that lead to a rapid healing response and prolonged neocollagenesis with subsequent collagen remodeling [14]. The mechanism of improvement after ablative fractional laser therapy therefore likely includes the removal of a portion of fibrotic scar and a relative normalization of collagen structure and composition [19].