Jill Waibel

Treatment of Hypertrophic Scars Using Laser and Laser Assisted Corticosteroid Delivery

Hypertrophic scars and contractures are common following various types of trauma and procedures despite skilled surgical and wound care. Following ample time for healing and scar maturation, many millions of patients are burdened with persistent symptoms and functional impairments. Cutaneous scars can be complex and thus the approach to therapy is often multimodal. 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.

Laser Treatment of Traumatic Scars With an Emphasis on Ablative Fractional Laser Resurfacing: Consensus Report

IMPORTANCE Despite expert wound care and assiduous management with traditional therapy, poor cosmetic outcomes, restricted motion, and symptoms such as pain and itch are a pervasive problem of disfiguring and debilitating scars. The advent of ablative fractional photothermolysis within the past decade and its application to the treatment of traumatic scars represents a breakthrough in the restoration of function and cosmetic appearance for injured patients, but the procedure is not widely used. OBJECTIVE To provide a synthesis of our current clinical experience and available literature regarding the laser treatment of traumatic scars with an emphasis on fractional resurfacing. EVIDENCE REVIEW Eight independent, self-selected academic and military dermatology and plastic surgery physicians with extensive experience in the use of lasers for scar treatment assembled for a 2-day ad hoc meeting on January 19 and 20, 2012. Consensus was based largely on expert opinion, but relevant literature was cited where it exists. FINDINGS After consensus was appraised, we drafted the manuscript in sections during the course of several months. The draft was then circulated among all panel members for final review and comment. Our consensus is that laser treatment, particularly ablative fractional resurfacing, deserves a prominent role in future scar treatment paradigms, with the possible inclusion of early intervention for contracture avoidance and assistance with wound healing. CONCLUSIONS AND RELEVANCE Laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars. Changes to existing scar treatment paradigms should include extensive integration of fractional resurfacing and other combination therapies guided by future research.

Laser Assisted Drug Delivery: A Review of An Evolving Technology

Topically applied drugs have a relatively low cutaneous bioavailability.

Treatment of Burn Scars With the 1,550 nm Nonablative Fractional Erbium Laser

Scarring is a major source of morbidity in patients with burns. Burn scars are difficult to treat and are among the worst scars seen in clinical medicine. Fractional laser resurfacing is a promising treatment option because of its unique wound healing response and depth of penetration.

Rapid Healing of Scar-Associated Chronic Wounds After Ablative Fractional Resurfacing

BACKGROUND Skin compromised by traumatic scars and contractures can manifest decreased resistance to shearing and other forces, while increased tension and skin fragility contribute to chronic erosions and ulcerations. Chronic wounds possess inflammatory mediator profiles and other characteristics, such as the presence of biofilms, that can inhibit healing. OBSERVATIONS Three patients with multiple traumatic scars related to blast injuries initiated a course of ablative fractional laser therapy for potential mitigation of contractures, poor pliability, and textural irregularity. Patients also had chronic focal erosions or ulcerations despite professional wound care. All patients experienced incidental rapid healing of their chronic wounds within 2 weeks of their initial ablative fractional laser treatment. Healing was sustained throughout the treatment course and beyond and was associated with gradual enhancements in scar pliability, texture, durability, and range of motion. CONCLUSIONS The unique pattern of injury associated with ablative fractional laser treatment may have various potential wound-healing advantages. These advantages include the novel concept of photomicrodebridement, including biofilm disruption and the stimulation of de novo growth factor secretion and collagen remodeling. If confirmed, ablative fractional resurfacing could be a potent new addition to traditional wound and scar treatment paradigms.

Laser-assisted delivery of vitamin C, vitamin E, and ferulic acid formula serum decreases fractional laser postoperative recovery by increased beta fibroblast growth factor expression

Laser‐assisted drug delivery is an emerging technology to achieve greater penetration by existing topical medications to reach desired targets in the tissue. The objective of this research was to study whether laser‐assisted delivery of Vitamin C, E, and Ferulic immediately postoperatively of fractional ablative laser could improve wound healing. Secondary objectives were to evaluate the potential molecular markers involved in this wound‐healing process.

Percutaneous bone marrow transplantation using fractional ablative Erbium: YAG laser

Topical application of therapeutic agents has been a mainstay in Dermatology for the treatment of skin disorders but is not commonly used for systemic delivery. For a topically applied agent to reach distant body sites it must first overcome the barrier function of the skin and then penetrate into deeper structures before reaching the systemic circulation. This has limited the use of topically applied agents to those having specific charge, solubility and size restrictions. Pretreatment of the skin with ablative fractional laser appears to enhance the uptake of some topically applied drugs but the ability to effectively deliver agents to distant sites is largely unproven. In this report we used a fractional ablative Erb:YAG (Erbium/Yttrium Aluminum Garnet) laser to facilitate the transfer of bone marrow stem cells through the skin in a murine bone marrow transplant model. Chimerism could be detected in the peripheral blood of recipient C57BL/6 mice that were pretreated with ablative fractional laser and had topically applied enhanced green fluorescent protein (GFP) labeled bone marrow cells from syngeneic donor transgenic mice. This study indicates that fractional laser can be used to deliver stem cells through the skin and remain functionally intact.

Developing technology: ablative fractional lasers enhance topical drug delivery.

Response to topical drug therapy depends on uptake of the compound, which is limited by the skin’s permeability barrier. The uptake of most drugs is poor, typically only 1% to 5% of a topically applied dose, and many delivery strategies have been developed to aid drug uptake. Commonly used techniques have included tape-stripping to remove the stratum corneum (SC), electroporation, iontophoresis, microneedling, and sonophoresis. These techniques have various advantages and disadvantages, and in general, are cumbersome in practice.

Current trends and future considerations in scar treatment

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.

Laser Modulation of Hypertrophic Scars: Technique and Practice

In this review, the authors discuss the use of laser photothermolysis and laser resurfacing in the management of hypertrophic burn scars. They provide details regarding preoperative selection, intraoperative decision making, and postoperative care.