Peter R. Shumaker

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.

Blood flow dynamics after laser therapy of port wine stain birthmarks

During laser therapy of port wine stain (PWS) birthmarks, regions of perfusion may persist. We hypothesize that such regions are not readily observable even when laser surgery is performed by highly experienced clinicians. The objective of this study was to use objective feedback to assess the acute vascular response to laser therapy.

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

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].

Modified Mohs Micrographic Surgery for Periocular Melanoma and Melanoma In Situ: Long‐Term Experience at Scripps Clinic

BACKGROUND Excision of invasive melanoma and melanoma in situ (MIS) using variations of the Mohs micrographic surgery (MMS) technique is becoming increasingly common in difficult areas, such as the periocular area, where standard surgical margins may not be feasible, and clinical margins are poorly defined. However, little long‐term data evaluating the treatment of periocular melanoma are available in the literature. OBJECTIVE To present our long‐term experience in the treatment of periocular melanoma using a staged, modified Mohs excision technique with rush permanent, paraffin‐embedded tissue sections. MATERIALS AND METHODS A total of 35 patients with periocular melanoma and MIS were treated using modified MMS during a 15‐year period. Twenty‐nine patients were available with adequate follow‐up of greater than 5 years duration. The mean follow‐up duration was 94 months. RESULTS There were a total of five recurrences (17.2%) detected an average of 85 months after excision. Four of the five recurrent tumors had been previously excised. The recurrence rate for primary tumors was 5% (1/20). The recurrence rate for previously excised tumors was 44.4% (4/9). CONCLUSION Margin‐control surgery is favored in the treatment of periocular melanoma to maximize the cure rate and minimize postoperative morbidity by sparing normal tissue. Ample follow‐up intervals are required to adequately assess recurrence rates. The best opportunity for cure is associated with the first tumor excision. The authors have indicated no significant interest with commercial supporters.

Residual Scarring From Hidradenitis Suppurativa: Fractionated CO2 Laser as a Novel and Noninvasive Approach

Hidradenitis suppurativa (HS) is a chronic, relapsing, inflammatory skin condition that can have a significant psychosocial impact, both with the active disease and with residual scarring. Although a wide variety of treatment options exist for HS, to our knowledge there are no reported modalities aimed specifically at treating HS scarring. We describe the case of an adolescent female who received medical management of intramammary HS followed by successful treatment with fractionated 10 600-nm carbon dioxide laser for her residual cribriform scarring. We believe there is great potential for the use of fractionated carbon dioxide laser to improve short- and long-term psychosocial outcomes of HS, promote physical scar remodeling, and possibly alter the disease process itself.

Ablative Fractional Laser Resurfacing Helps Treat Restrictive Pediatric Scar Contractures

Conventional management of debilitating pediatric scar contractures, including hand therapy and surgery, may often be beset by delayed treatment, suboptimal results, and additional surgical morbidity. Ablative fractional laser resurfacing is an emerging adjunctive procedural option for scar contractures because of its promising efficacy and safety profile. However, its use to improve function has not been studied in the pediatric population. Herein we report 2 pediatric patients with recalcitrant scar contractures, causing persistent functional deficits, treated with an ablative fractional laser protocol. Both patients experienced rapid and cumulative subjective and objective improvements in range of motion and function as measured by an independent occupational therapist without reported complications. We highlight ablative fractional laser resurfacing as a novel and promising tool in the management of function-limiting scar contractures in children and propose that the technique be incorporated into existing scar treatment paradigms, guided by future research.