Nathan S. Uebelhoer

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.

Functional improvements in traumatic scars and scar contractures using an ablative fractional laser protocol.

BACKGROUND Reports describing the use of ablative fractional resurfacing (AFR) for cosmetic improvements in skin dyschromia, rhytides, and textural irregularities are becoming increasingly common in the literature. However, the is little mention of its functional impact on patients with traumatic scars and scar contractures. We present our experience treating scars with AFR, highlighting four illustrative cases and providing a review on possible mechanisms. METHODS Up to three ablative fractional carbon dioxide laser treatments were performed at 1-month to 2-month intervals on four patients with functional deficits related to refractory scar contractures. Treatments were individualized and began as early as 2 months after injury or final reconstructive surgery. Cases were performed in the outpatient clinic using topical anesthetic supplemented by forced air cooling. Postprocedure care included diluted-vinegar compresses two to three times daily and application of ointment over the treatment area for approximately 3 days after the procedure. Postprocedure pain was minimal, and all patients were allowed to resume physical therapy as early as the day of treatment. RESULTS AFR was well tolerated without serious complications. Durable and cumulative improvements in range of motion or overall skin functionality were noted in all patients. AFR can be surgery sparing and facilitated earlier return to full or modified activities based on associated injuries. CONCLUSION AFR is a novel, well tolerated, and effective complement to traditional rehabilitative management for patients with traumatic scars and scar contractures. Potential paradigm shifts include earlier initiation of treatment and a focus on functional improvements. (J Trauma Acute Care Surg. 2012;73: S116–S121. Copyright

Superficial chemical peels and microdermabrasion for acne vulgaris.

Superficial chemical peels and microdermabrasion are used for many dermatologic conditions. A common condition treated with these modalities is acne vulgaris. In this review, we discuss the theory behind the technique of these procedures and describe the application and complications of each of these procedures in the office setting. The evaluation of patients before proceeding with the procedure and discuss pre- and postpeel regimens used for patients is discussed. We also analyze studies on both of these in-office procedures and comparative studies between the 2 most commonly used superficial chemical peeling agents, glycolic and salicylic acid.

Split-Face Treatment of Facial Dyschromia: Pulsed Dye Laser with a Compression Handpiece versus Intense Pulsed Light

BACKGROUND Many visible light lasers and intense pulsed light (IPL) devices are available to treat photodamaged skin. OBJECTIVES The objective was to perform a multiple-treatment split-face comparison evaluating a pulsed dye laser (PDL) with a compression handpiece versus IPL for photorejuvenation. METHODS Ten subjects were treated three times at 3- to 4-week intervals. One side of the face was treated with the PDL with compression handpiece, and the other with IPL. One month after final treatment, blinded evaluation assessed for improvements in dyschromias and texture. Patients provided self-assessment of improvement in dyschromias and texture. Time to complete final treatments and pain during all treatments were recorded for each device. RESULTS Improvement of the PDL was (mean) 86.5, 65, 85, 38, and 40% for dark lentigines, light lentigines, vessels <0.6 mm, vessels >0.6 mm, and texture, respectively, versus 82, 62.5, 78.5, 32.5, and 32%, respectively, for the IPL side. Patient-evaluated difference in improvement for vascular lesions significantly favored the PDL (p=.011). Mean third treatment times were 7.7 minutes for PDL versus 4.6 minutes for the IPL (p=.005). Mean pain ratings were 5.8 for the PDL and 3.1 for the IPL (p=.007). Purpura-free procedures depended on proper technical use of the compression handpiece when treating lentigines with the PDL. CONCLUSIONS The PDL with compression handpiece and IPL are highly effective for photorejuvenation.

Ablative fractional resurfacing for the treatment of traumatic scars and contractures.

After a decade of military conflict, thousands of wounded warriors have suffered debilitating and cosmetically disfiguring scars and scar contractures. Clearly, there is a need for effective scar treatment regimens to assist in the functional and cosmetic rehabilitation of these patients. Traditional treatments, including aggressive physical and occupational therapy and dedicated wound care, are essential. Adjunctive treatments with established laser technologies, such as vascular lasers and full-field ablative lasers, have had a somewhat limited role in scar contractures due to modest efficacy and/or an unacceptable side effect profile in compromised skin. Refractory scar contractures often require surgical revision, which can be effective, but is associated with additional surgical morbidity and a significant risk of recurrence. Furthermore, current scar treatment paradigms often dictate scar maturation for approximately a year to allow for spontaneous improvement before surgical intervention. Since 2009, the Dermatology Clinic at the Naval Medical Center San Diego has been treating scars and scar contractures in wounded warriors and others using ablative fractionated laser technology. Although traditionally associated with the rejuvenation of aged and photo-damaged skin, our clinical experience and a handful of early reports indicate that laser ablative fractional resurfacing demonstrates promising efficacy and an excellent side effect profile when applied to the functional and cosmetic enhancement of traumatic scars and contractures. This article discusses our clinical experience with ablative fractional resurfacing and its potential prominent role in rehabilitation from traumatic injuries, including a possible shift in scar treatment paradigms toward earlier procedural intervention. Potential benefits include the optimization of scar trajectory and higher levels of full or adapted function in a more favorable time course.

Treatment of acne scars using the plasma skin regeneration (PSR) system

Acne scarring is a common and difficult to treat condition. The plasma skin regeneration (PSR) system is a novel device that causes delayed ablation of the epidermis and controlled thermal modification to the underlying dermis. PSR has previously been shown to be a safe and effective treatment for facial rhytides and benign skin lesions. In this study, we investigated the safety and efficacy of single‐treatment, high‐energy, double‐pass PSR for the treatment of acne scarring.

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.

Use of a Fractional Ablative 10.6- μm Carbon Dioxide Laser in the Treatment of a Morphea-Related Contracture

1181 Dermoscopy of Pigmented Lesions of the Mucosa and the Mucocutaneous Junction: Results of a Multicenter Study by the International Dermoscopy Society (IDS) Andreas Blum, MD; Olga Simionescu, MD; Giuseppe Argenziano, MD; Ralph Braun, MD; Horacio Cabo, MD; Astrid Eichhorn, MD; Herbert Kirchesch, MD; Josep Malvehy, MD; Ashfaq A. Marghoob, MD; Susana Puig, MD; Fezal Özdemir, MD; Wilhelm Stolz, MD; Isabelle Tromme, MD; Ulrike Weigert, MD; Ingrid H. Wolf, MD; Iris Zalaudek, MD; Harald Kittler, MD 1191 Efficacy of Imiquimod Cream, 5%, for Lentigo Maligna After Complete Excision: A Study of 43 Patients Lena Ly, MBBS; John William Kelly, MBBS, FACD, MD; Rodney O’Keefe, MBBS, FRCPA; Tina Sutton, BSc, BMBS; John P. Dowling, MBBS, FRCPA; Sarah Swain, MBBS, FRCPA; Marguerite Byrne, MBBS; Nathan Curr, MBBS; Rory Wolfe, BSc, PhD; Alex Chamberlain, MBBS, FACD; Martin Haskett, MBBS, FACD

Functional Improvement After Ablative Fractional Laser Treatment of a Scar Contracture

D C Since first reported in 2004 [1], fractional laser therapy has been used for a range of skin indications, including photoaging, dyschromia, melasma, actinic keratoses, and acne scarring [2]. This technique involves the generation of noncontiguous columnar microscopic thermal wounds that penetrate the skin at depths up to approximately 2 mm with a single pulse. The adjacent untreated skin provides a reservoir of viable tissue, which permits rapid re-epithelialization and dermal remodeling while minimizing potential complications such as infection or worsening scarring [2] (Fig 1). Most laser scar therapy to date has focused on osmesis. Only a few reports in the literature describe functional improvements in traumatic cars and scar contractures after fractional laser treatment, often as incidental findings [3-6].

En coup de sabre presenting as a port-wine stain previously treated with pulsed dye laser.

We report the case of a patient with en coup de sabre (ECDS) who was given an initial diagnosis of acquired port-wine stain (PWS) and treated with pulsed dye laser (PDL). Treatment yielded unanticipated blistering despite the use of conservative settings. This case illustrates that the early stages of linear scleroderma can present with intense erythema and can be mistaken for a vascular malformation. Additionally, we believe that an exaggerated response to PDL treatment should be a clinical clue to treating the early hyperemic response of localized scleroderma and not a true vascular malformation.