Scar treatment dependent on technique

Functional and aesthetic improvement is the ultimate goal of treatment for hypertrophic scars and keloids, but many patients continue to have functional impairments and symptoms such as burning, itching, and pain post treatment.

Intralesional steroid injections - applied topically or injected into the lesion - are considered to be one of the best treatment options. This treatment includes a uniform injection of 10–40 mg/ml of triamcinolone acetonide suspension through a 25- to 27-gauge needle. One of the long-standing challenges is precise placement of the drug to avoid adverse sequelae such as fat atrophy, but its effectiveness is limited.

So, other treatments, such as pressure therapy, cryotherapy, interferon, fluorouracil, topical silicone, and pulsed-dye laser treatment have been adopted or are under study.

Effective topical delivery of any pharmaceutical agent requires the ability to penetrate the epidermis, and fractional laser therapy creates precise, uniform columns of tissue vaporization which can be used to facilitate drug delivery past the epidermal barrier.

Fractional lasers have emerged as a therapeutic option for the aesthetic restoration and functional enhancement of traumatic scars. They create zones of ablation at variable depths, which induce a molecular cascade, including heat shock proteins and other factors, that lead to a rapid healing response and prolonged neocollagenesis with subsequent collagen remodeling. The likely result is the removal of a portion of fibrotic scar tissue and a relative normalization of collagen structure and composition.

At the same time, fractional ablative lasers create vertical channels in the skin referred to as a microthermal zone that facilitates topical drug delivery deep into the skin. Laser-assisted drug delivery has been shown to enhance photosensitizer penetration in photodynamic therapy as well as the penetration of topical anaesthetics, opioids, non-steroidal anti-inflammatory drugs, and chemotherapeutic-drugs such as fluorouracil or imiquimodⁱ.

Combining ablative fractional laser therapy with enhanced topical corticosteroid delivery presents the potential to combine two valuable scar therapies in a simple, cost-effective strategy.

Researchers at Louisiana State University Health Sciences Center in New Orleans conducted review of research assesses the efficacy and safety of laser-assisted topical steroid delivery as a treatment option for hypertrophic scars and keloids. The review was presented at the American Society for Dermatologic Society annual meeting last October in Chicagoⁱⁱ.

They identified three studies through a MEDLINE search – one was a retrospective study and two were prospective cohort studies.

FIRST-LINE THERAPY RESISTANT KELOIDS

The retrospective study involved 23 patients with keloids resistant to first line therapyⁱⁱⁱ, lesions were treated with an ablative fractional erbium laser every other week for a median of nine treatments followed by topical betamethasone cream applied twice a day under occlusion with transparent film dressings.

The 23 patients had 70 keloids and were treated in the laser center of the Department of Dermatology at the University Hospital of Nice in France from January 2010 to June 2012.

The median percentage improvement was 50% (range -43 to 84), although response was less for keloids located on the ear and neck.  

NEXT:  FRACTIONAL ABLATIVE CO2 LASER FOR HYPERTROPHIC SCARS

“Combining ablative fractional laser therapy with enhanced topical corticosteroid delivery presents the potential to combine two valuable scar therapies in a simple, cost-effective strategy.”

FRACTIONAL ABLATIVE CO2 LASER FOR HYPERTROPHIC SCARS

The first prospective study included 15 patients with hypertrophic scars treated with three to five laser treatment sessions at two- to three-month intervals using fractional ablative CO2 laser followed by immediate postoperative topical application of triamcinolone acteonide suspension at a concentration of 10 or 20 mg/ml^iv.

Based on a 0-3 point scale, average overall improvement was assessed to be 2.73/3.0. The highest average overall improvement score was 3.00, which 11 of 15 patients attained. Improvement was observed in appearance, dyschromia, degree of hypertrophy, and texture; most improvement was noticed in texture and the least improvement in dyschromia.

TREATING VACCINATION-RELATED KELOIDS

The final prospective study^v involved 10 patients with keloids on the shoulder as a result of BCG vaccination. All lesions were first treated using an erbium-YAG laser. Following laser therapy, all lesions were divided in two with one half treated with an intralesional injection of triamcinolone acetonide (10 mg/ml) and the other half treated with topical desoxymethasone 0.25% ointment under occlusion for 3-hours. Patients received four treatment sessions, six weeks apart.

Treatment outcomes were evaluated using the Vancouver Scar Scale (VSS ). The mean score before treatment was 8.59 ± 1.23 for the corticosteroid injection site and 8.31 ± 2.09 for the topical site. After treatment, VSS decreased on both sides of the lesion by approximately 50%  ̶̶̶̶  4.56 ± 1.09 and 5.02 ± 0.87, respectively (P > 0.05).

TAKE-A-WAYS

Lead author of the review Rawaa Almukhtar, Ph.D., resident in training in dermatology at Louisiana State University Health Sciences Center in New Orleans, said the studies included in the review all showed that “laser-assisted topical steroid delivery was well tolerated in patients with minimum pain and minimum adverse events observed."  

Dr. Almukhtar

“Studies suggest that fractional laser-assisted delivery of topical steroid can offer an efficient, safe, and effective treatment option for the management of hypertrophic scars and keloids,” she said. “Combination of fractional laser and topical steroid therapy optimizes dispersion of steroid molecules with minimal discomfort.”  But she added that more research is needed to determine the optimal treatment parameters and steroid dosing.

“Studies are also needed to directly compare laser-assisted steroid delivery to ablative fractional laser therapy on one hand and to intralesional steroid therapy on the other hand,” she said.

REFERENCES

• Cavalié M, Sillard L, Montaudié H, Bahadoran P, Lacour J-P, Passeron T. Treatment of keloids with laser-assisted topical steroid delivery: a retrospective study of 23 cases. Dermatol Ther. 2015 Mar-Apr;28(2):74-8. doi: 10.1111/dth.12187. Epub 2014 Dec 4.

• Almukhtar R, Lee B, LeBlanc K. Use of Laser-assisted Topical Steroid Delivery for Treatment of Hypertrophic Scars and Keloids. Annual Meeting of the American Society for Dermatologic Society, Chicago, 5-8 October 2017. Page 172.

• Cavalié M, Sillard L, Montaudié H, Bahadoran P, Lacour J-P, Passeron T. Treatment of keloids with laser-assisted topical steroid delivery: a retrospective study of 23 cases. Dermatol Ther. 2015 Mar-Apr;28(2):74-8. doi: 10.1111/dth.12187. Epub 2014 Dec 4.

• Waibel JS, Wulkan AJ, Shumaker PR. Treatment of hypertrophic scars using laser and laser assisted corticosteroid delivery. Lasers Surg Med. 2013 Mar;45(3):135-40. doi: 10.1002/lsm.22120. Epub 2013 Mar 4. PMID: 23460557

• Park, J.H., Chun, J.Y. & Lee, J.H. Laser-assisted topical corticosteroid delivery for the treatment of keloids. Lasers Med Sci 2017: 32: 601. https://doi.org/10.1007/s10103-017-2154-5