Laser therapy for hypertrophic scars and keloids
- C Scott Hultman, MD, MBA, FACS
C Scott Hultman, MD, MBA, FACS
- Ethel and James Valone Distinguished Professor of Surgery; Division Chief and Program Director
- UNC Plastic Surgery
- Shunsuke Yoshida, MD, MS
Shunsuke Yoshida, MD, MS
- UNC Plastic & Reconstructive Surgery
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — General Dermatology
- Professor of Dermatology and Public Health
- University of Colorado School of Medicine
- Colorado School of Public Health
- Chief, Dermatology Service
- US Department of Veterans Affairs
- Eastern Colorado Health Care System
- Moise L Levy, MD
Moise L Levy, MD
- Section Editor — Pediatric Dermatology
- Professor of Pediatrics and Medicine (Dermatology)
- Dell Medical School, University of Texas, Austin
- Clinical Professor of Dermatology and Pediatrics
- Baylor College of Medicine
Hypertrophic scars and keloids are cutaneous lesions resulting from an excessive tissue response to dermal injury (eg, surgical procedures, trauma, burns, inflammatory skin conditions) and characterized by local fibroblast proliferation and overproduction of abnormal collagen. The clinical features and classification of hypertrophic scars and keloids are summarized in the table (table 1).
Hypertrophic scars present as raised lesions with varying degree of erythema depending upon the maturation stage that typically do not exceed the margins of the original wound. They usually develop two to six months after the initial insult and show a tendency to regress at 18 to 24 months following injury . Associated symptoms include pain, pruritus, and functional limitations. Keloids can occur months or years after injury, extend beyond the limits of the initial injury, and show no tendency to regress.
Many treatments have been tried, with limited success, to reduce the symptoms associated with abnormal scarring, such as redness, pain, pruritus, or functional limitations, and to improve the clinical appearance. These treatments range from minimally invasive interventions (eg, massage, moisturizing agents, pressure garments, silicone sheeting) to topical or intralesional corticosteroids, surgical excision with various reconstructive techniques, or radiation therapy [2,3]. Unfortunately, recurrence rates are high, and multiple or combination therapies are often required to reduce the scar volume and achieve functional and/or cosmetic improvement.
Laser therapy is a relatively new treatment modality for keloids and hypertrophic scars. In particular, the utilization of specific laser platforms has emerged as a successful strategy in the treatment of symptomatic hypertrophic scars following burn injury.
This topic will discuss the available modes of laser therapy for the treatment of hypertrophic scars and keloids, with a focus on treatment of hypertrophic burn scars. Other treatment modalities for hypertrophic scars and keloids are discussed separately. The principles of laser therapy and the use of laser for the treatment of other skin conditions are also discussed separately.
- Oliveira GV, Chinkes D, Mitchell C, et al. Objective assessment of burn scar vascularity, erythema, pliability, thickness, and planimetry. Dermatol Surg 2005; 31:48.
- Friedstat JS, Hultman CS. Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized controlled trials. Ann Plast Surg 2014; 72:S198.
- Tredget EE, Levi B, Donelan MB. Biology and principles of scar management and burn reconstruction. Surg Clin North Am 2014; 94:793.
- Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220:524.
- Jin R, Huang X, Li H, et al. Laser therapy for prevention and treatment of pathologic excessive scars. Plast Reconstr Surg 2013; 132:1747.
- Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol 2008; 58:719.
- Hultman CS, Edkins RE, Lee CN, et al. Shine on: Review of Laser- and Light-Based Therapies for the Treatment of Burn Scars. Dermatol Res Pract 2012; 2012:243651.
- Khandelwal A, Yelvington M, Tang X, Brown S. Ablative fractional photothermolysis for the treatment of hypertrophic burn scars in adult and pediatric patients: a single surgeon's experience. J Burn Care Res 2014; 35:455.
- Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts and future directions. Burns 2010; 36:443.
- Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg 2002; 110:560.
- Waibel J, Beer K. Ablative fractional laser resurfacing for the treatment of a third-degree burn. J Drugs Dermatol 2009; 8:294.
- Alster TS. Improvement of erythematous and hypertrophic scars by the 585-nm flashlamp-pumped pulsed dye laser. Ann Plast Surg 1994; 32:186.
- 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.
- Bailey JK, Burkes SA, Visscher MO, et al. Multimodal quantitative analysis of early pulsed-dye laser treatment of scars at a pediatric burn hospital. Dermatol Surg 2012; 38:1490.
- Alster TS, Williams CM. Treatment of keloid sternotomy scars with 585 nm flashlamp-pumped pulsed-dye laser. Lancet 1995; 345:1198.
- Alster T. Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. Dermatol Surg 2003; 29:25.
- Kuo YR, Jeng SF, Wang FS, et al. Flashlamp pulsed dye laser (PDL) suppression of keloid proliferation through down-regulation of TGF-beta1 expression and extracellular matrix expression. Lasers Surg Med 2004; 34:104.
- Chan HH, Wong DS, Ho WS, et al. The use of pulsed dye laser for the prevention and treatment of hypertrophic scars in chinese persons. Dermatol Surg 2004; 30:987.
- Reish RG, Eriksson E. Scars: a review of emerging and currently available therapies. Plast Reconstr Surg 2008; 122:1068.
- Vrijman C, van Drooge AM, Limpens J, et al. Laser and intense pulsed light therapy for the treatment of hypertrophic scars: a systematic review. Br J Dermatol 2011; 165:934.
- Manstein D, Herron GS, Sink RK, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004; 34:426.
- Tannous Z. Fractional resurfacing. Clin Dermatol 2007; 25:480.
- Qu L, Liu A, Zhou L, et al. Clinical and molecular effects on mature burn scars after treatment with a fractional CO(2) laser. Lasers Surg Med 2012; 44:517.
- Ozog DM, Liu A, Chaffins ML, 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.
- Haedersdal M. Fractional ablative CO(2) laser resurfacing improves a thermal burn scar. J Eur Acad Dermatol Venereol 2009; 23:1340.
- Haedersdal M, Moreau KE, Beyer DM, et al. Fractional nonablative 1540 nm laser resurfacing for thermal burn scars: a randomized controlled trial. Lasers Surg Med 2009; 41:189.
- Waibel J, Wulkan AJ, Lupo M, et al. Treatment of burn scars with the 1,550 nm nonablative fractional Erbium Laser. Lasers Surg Med 2012; 44:441.
- van Drooge AM, Vrijman C, van der Veen W, Wolkerstorfer A. A randomized controlled pilot study on ablative fractional CO2 laser for consecutive patients presenting with various scar types. Dermatol Surg 2015; 41:371.
- Taudorf EH, Danielsen PL, Paulsen IF, et al. Non-ablative fractional laser provides long-term improvement of mature burn scars--a randomized controlled trial with histological assessment. Lasers Surg Med 2015; 47:141.
- Sadick NS, Weiss R, Kilmer S, Bitter P. Photorejuvenation with intense pulsed light: results of a multi-center study. J Drugs Dermatol 2004; 3:41.
- Fodor L, Carmi N, Fodor A, et al. Intense pulsed light for skin rejuvenation, hair removal, and vascular lesions: a patient satisfaction study and review of the literature. Ann Plast Surg 2009; 62:345.
- Erol OO, Gurlek A, Agaoglu G, et al. Treatment of hypertrophic scars and keloids using intense pulsed light (IPL). Aesthetic Plast Surg 2008; 32:902.
- Hultman CS, Friedstat JS, Edkins RE. Efficacy of intense pulsed light for the treatment of burn scar dyschromias: a pilot study to assess patient satisfaction, safety, and willingness to pay. Ann Plast Surg 2015; 74 Suppl 4:S204.
- Ohshiro T, Ohshiro T, Sasaki K. Laser scar management technique. Laser Ther 2013; 22:255.
- Kassab AN, El Kharbotly A. Management of ear lobule keloids using 980-nm diode laser. Eur Arch Otorhinolaryngol 2012; 269:419.
- Gan SD, Graber EM. Laser hair removal: a review. Dermatol Surg 2013; 39:823.
- Bock O, Schmid-Ott G, Malewski P, Mrowietz U. Quality of life of patients with keloid and hypertrophic scarring. Arch Dermatol Res 2006; 297:433.
- Brewin MP, Lister TS. Prevention or treatment of hypertrophic burn scarring: a review of when and how to treat with the pulsed dye laser. Burns 2014; 40:797.
- Van Loey NE, Van Son MJ. Psychopathology and psychological problems in patients with burn scars: epidemiology and management. Am J Clin Dermatol 2003; 4:245.
- Hultman CS, Friedstat JS, Edkins RE, et al. 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.
- Gold MH, Berman B, Clementoni MT, et al. Updated international clinical recommendations on scar management: part 1--evaluating the evidence. Dermatol Surg 2014; 40:817.
- Gold MH, McGuire M, Mustoe TA, et al. Updated international clinical recommendations on scar management: part 2--algorithms for scar prevention and treatment. Dermatol Surg 2014; 40:825.
- Anderson RR, Donelan MB, Hivnor C, et al. Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report. JAMA Dermatol 2014; 150:187.
- Edkins RE, Hultman CS, Collins P, et al. Improving comfort and throughput for patients undergoing fractionated laser ablation of symptomatic burn scars. Ann Plast Surg 2015; 74:293.
- Hammes S, Augustin A, Raulin C, et al. Pupil damage after periorbital laser treatment of a port-wine stain. Arch Dermatol 2007; 143:392.
- Clayton JL, Edkins R, Cairns BA, Hultman CS. Incidence and management of adverse events after the use of laser therapies for the treatment of hypertrophic burn scars. Ann Plast Surg 2013; 70:500.
- Bouzari N, Davis SC, Nouri K. Laser treatment of keloids and hypertrophic scars. Int J Dermatol 2007; 46:80.
- Manuskiatti W, Fitzpatrick RE, Goldman MP. Energy density and numbers of treatment affect response of keloidal and hypertrophic sternotomy scars to the 585-nm flashlamp-pumped pulsed-dye laser. J Am Acad Dermatol 2001; 45:557.
- Hultman CS, Edkins RE, Wu C, et al. Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars. Ann Plast Surg 2013; 70:521.
- Tong AK, Tan OT, Boll J, et al. Ultrastructure: effects of melanin pigment on target specificity using a pulsed dye laser (577 nm). J Invest Dermatol 1987; 88:747.
- Lee SJ, Kim JH, Lee SE, et al. Hypertrophic scarring after burn scar treatment with a 10,600-nm carbon dioxide fractional laser. Dermatol Surg 2011; 37:1168.
- Campbell TM, Goldman MP. Adverse events of fractionated carbon dioxide laser: review of 373 treatments. Dermatol Surg 2010; 36:1645.
- Waibel JS, Wulkan AJ, Shumaker PR. Treatment of hypertrophic scars using laser and laser assisted corticosteroid delivery. Lasers Surg Med 2013; 45:135.
- LASER AND LIGHT-BASED PLATFORMS
- Pulsed dye laser
- - Efficacy
- Fractional laser resurfacing
- - Efficacy
- Intense pulsed light
- - Efficacy
- Other lasers
- GOALS OF TREATMENT
- INDICATIONS AND TIMING
- PREOPERATIVE MEASURES
- Patient preparation
- SAFETY MEASURES
- Pulsed dye laser
- Fractional CO2 laser
- Other lasers
- Our approach
- POSTOPERATIVE CARE
- ADJUVANT TREATMENTS