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Laser therapy for hypertrophic scars and keloids

Laser therapy for hypertrophic scars and keloids
Literature review current through: Jan 2024.
This topic last updated: Dec 04, 2023.

INTRODUCTION — Hypertrophic scars and keloids are fibroproliferative disorders that result from aberrant wound healing in predisposed individuals following trauma, inflammation, surgery, or burns [1]. Treatments range from conservative or minimally invasive interventions, such as compression, silicone sheeting, topical or intralesional corticosteroids, and intralesional chemotherapy agents, to surgical excision with various reconstructive techniques and radiation therapy [2,3]. Because of the high risk of recurrence, especially for keloids, multiple or combination therapies are often required to 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. Other treatment modalities are discussed separately.

(See "Keloids and hypertrophic scars".)

(See "Hypertrophic scarring and keloids following burn injuries".)

PRINCIPLES OF LASERS — Lasers are devices that release coherent wavelengths of light in the form of photons. The light energy is produced and amplified in a lasing cavity flanked by two parallel mirrors. Within the cavity is a lasing medium, consisting of a solid, liquid, or gas compound that is stimulated by an external power source [3]. This organized stream of photons exits the cavity and is guided towards a focusing lens to produce a laser beam. The wavelength of photons is determined by the choice of lasing medium.

Lasers can be delivered continuously, in short high-energy pulses, or in nanosecond pulses, called Q-switching. The number of photons, measured in Joules (J), constitutes the amount of energy delivered by the laser. Power is the rate of energy delivered, measured in watts (W = J/s). Fluence is the energy delivered per unit area (J/cm2), while irradiance is measured as the power per unit area (W/cm2).

Only the light that is absorbed by chromophores produces tissue effects. The selective absorption of light by skin chromophores (ie, hemoglobin, oxyhemoglobin, melanin, intracellular water) and spatial confinement of the destructive effect were first described in the theory of selective photothermolysis in 1983 [4]. Most of the subsequent developments in laser technology for cutaneous disorders have been based on this theory.

Lasers are categorized into ablative and nonablative types [5] (see "Ablative laser resurfacing for skin rejuvenation" and "Nonablative skin resurfacing for skin rejuvenation"):

Ablative-type lasers reach their targets in the dermis by ablating the epidermis. The prolonged recovery period and risks of complications, such as dyspigmentation and further scarring, stimulated the development of fractional and nonablative lasers [5]. Fractional lasers create microscopic columns of ablation, thereby approaching the effect of ablative techniques while reducing the risk of complications and shortening the time to recovery.

Nonablative lasers target chromophores in the dermal layer while preserving the epidermis, yielding coagulation of tissues rather than vaporization.

CLASSIFICATION AND CLINICAL FEATURES OF HYPERTROPHIC SCARS AND KELOIDS — The classification and clinical features of hypertrophic scars and keloids are summarized in the table (table 1). Hypertrophic scars are raised lesions with a varying degree of erythema that do not typically exceed the margins of the original wound (picture 1). They usually develop two to six months after the initial insult and show a tendency to regress at 18 to 24 months following injury [6]. Keloids can occur months or years after injury, extend beyond the limits of the initial injury, and show no tendency to regress (picture 2). Associated symptoms, pain, pruritus, functional limitations, and disfigurement can greatly affect the patient's quality of life. (See "Keloids and hypertrophic scars", section on 'Clinical presentation'.)

INDICATIONS AND GOALS OF TREATMENT — We generally agree with the indications for laser therapy outlined in expert consensus-based international guidelines for the prevention and treatment of pathologic scarring [7-9]:

Immature or linear, hypertrophic, erythematous scars resulting from surgery or trauma that present with persistent erythema for more than one month, despite preventive treatment with silicone gel or sheeting, hypoallergenic paper tape, or onion extract preparations, may be treated with a pulsed dye laser (PDL) once monthly for two to three months (see 'Pulsed dye laser' below). Fractional laser therapy is reserved for scars that are refractory to PDL.

Widespread, hypertrophic burn scars that failed to improve with treatment with silicone gel or sheeting, pressure garments, and/or onion extract preparations for 8 to 12 weeks may be treated with fractional laser therapy. (See 'Fractional laser resurfacing' below.)

Minor keloids that failed to improve within 8 to 12 weeks with silicone gel sheeting and intralesional corticosteroids may be treated with ablative fractional laser or PDL therapy.

Major keloids that failed to improve with intralesional corticosteroids and fluorouracil may be treated with ablative fractional laser or PDL therapy.

The goals of laser therapy for abnormal scarring are twofold [10]:

Accelerating the time to maturation of a hypertrophic scar

Improving the outcomes predicted by nonoperative, conventional management for hypertrophic scars and keloids

CONTRAINDICATIONS — There are no absolute contraindications to laser treatment for hypertrophic scars and keloids [11]. Pulsed dye laser (PDL) fluence levels can be altered based upon the individual patient's skin phototype. Thus, patients with darkly pigmented skin should not be excluded from laser treatment. Relative contraindications to ablative laser treatment include fresh healing wounds with unstable epidermal coverage in the first one to three months after injury and active infection [12]. In addition, history of herpes simplex virus infection should prompt prophylactic antiviral treatment before laser therapy is offered.

LASER AND LIGHT PLATFORMS

Pulsed dye laser

Overview — Pulsed dye laser (PDL) at 585 and 595 nm wavelengths selectively targets hemoglobin in the dermal blood vessels of neovascularized scar tissue [13,14]. The resulting tissue hypoxia leads to neocollagenesis, collagen fiber heating, dissociation of disulfide bonds, and subsequent collagen fiber realignment [15]. At the cellular level, PDL decreases fibroblast proliferation, type III (but not type I) collagen deposition, and histamine release [16-18]. The main clinical effects of PDL therapy are decreases of the scar erythema and pruritus [19,20]. Additional benefits include reduced scar height and volume and improved texture and pliability [21].

Timing and technique — In the authors' experience, PDL can be successfully used at six months postinjury, and possibly sooner, to reverse or diminish the inflammatory response in hypertrophic burn scars [13,15]. Although PDL therapy has been shown to completely resolve persistent erythema up to 17 years following burn injury, the greatest gains in improvement of hypertrophic burn scars appear to occur when laser sessions are started less than 12 to 18 months after injury [10,15,22]. PDL is usually less effective in scars with depths greater than 1.2 mm [15].

We typically use a vascular-specific 595 nm PDL [10]. Most authors use PDL wavelengths of 585 or 595 nm with fluences of 5 to 8 J/cm2, 7 to 10 mm spot size, cryogenic cooling at 30 ms spray/20 ms delay, and pulse duration of 1.5 ms [10,13,15,21]. Fluence is also selected on the basis of the patient's skin phototype, with lower fluences used for patients with darkly pigmented skin, in an effort to reduce the risk of blistering and postprocedure hypo- or hyperpigmentation [13].

Studies have shown that scars respond better to lower, short-pulse fluences, which induce local damage to the vascular endothelium followed by the formation of mural platelet thrombi [23]. Higher fluences do not appear to increase the rate of favorable responses to treatment [24].

The clinical endpoint of PDL therapy for each session is a purplish discoloration of the targeted area. Adjustments can be made at subsequent treatments in small increments (eg, 0.5 to 1 J/cm2), based upon the clinical response. Asking patients about the occurrence of post-treatment blistering will allow for proper adjustments in fluence for the upcoming laser session. The subsequent laser session should be placed on hold until the skin is fully healed.

PDL treatments should continue until the erythema, hyperemia, and pruritus responses reach a plateau. On average, this takes approximately four sessions [21], at which time fractional carbon dioxide (fCO2) laser treatment can be started to improve scar texture and pliability [10,20]. The optimal interval between laser treatments has not been established. Intervals ranging from four weeks to two to three months have been used, with most studies suggesting six weeks as the optimal interval [3,13,15,22,24-26].

Efficacy — The efficacy of PDL 585 and 595 nm for the treatment of hypertrophic scars has been evaluated in a few randomized and nonrandomized trials and systematic reviews [27-29]. However, the heterogeneity in the type and settings of the laser devices, patients' characteristics, outcome measures, and length of follow-up makes the comparison among studies difficult. In addition, most studies have significant methodologic flaws that limit the conclusions that can be drawn.

In a 2022 Cochrane systematic review, the analysis of pooled data from two randomized trials found that treatment with 585 nm PDL was associated with 50 percent or higher self-assessed improvement at 32 weeks compared with no treatment [27]. However, the impact of PDL on scar severity remains uncertain when compared with other treatments, such as intralesional corticosteroids or intralesional fluorouracil [27].

Fractional laser resurfacing

Overview — Fractional laser resurfacing was first introduced for the treatment of photoaging and is largely used for cosmetic indications [30,31]. With this technique, microscopic columns of skin called microscopic treatment zones (MTZs) are treated with either ablative or nonablative lasers, resulting in the generation of microscopic thermal wounds while sparing the tissue surrounding each wound (figure 1). (See "Ablative laser resurfacing for skin rejuvenation" and "Nonablative skin resurfacing for skin rejuvenation".)

fCO2 10,600 nm and erbium-doped yttrium aluminum garnet (Er:YAG) 2940 nm ablative lasers are the primary lasers used for hypertrophic scars [32]. These devices produce MTZs that are 70 to 100 microns in diameter and 250 to 800 microns in depth. Since the target chromophore of the fCO2 10,600 nm laser is intracellular water, treatment results in tissue vaporization and coagulation of surrounding extracellular proteins [3]. In contrast, nonablative lasers induce coagulation only.

At the molecular level, fractional laser treatment induces fibroblast apoptosis, upregulation of matrix metalloproteinases and heat shock proteins, downregulation of transforming growth factors and basic fibroblast growth factor, and alteration of types I and III procollagen levels [33-35]. These changes are seen throughout the dermis, beyond the MTZs, with the spared skin surrounding the MTZs contributing to rapid and controlled wound healing with relative normalization of collagen structure and composition [33].

Timing and technique — Thick and stiff hypertrophic scars may regain pliability by applying an fCO2 laser. Once scar vascularity decreases (often within a few months after beginning PDL therapy), we use a fractional 10,600 nm fCO2 laser to improve abnormal texture, thickness, and stiffness of more mature scars by ablative destruction and resurfacing [10].

Settings for an fCO2 laser include depth, density, pulse energy, shape, and size. The depth of penetration corresponds to pulse energy level and should be tailored to scar thickness. Whether laser depth should penetrate beyond the scar thickness is still being investigated [3]. Density sets the number of MTZs per unit area. Recommended density is less than 10 percent [3]. An inverse relation between density and pulse energy should be applied for safety. Pulse shape and size can be adjusted to fit the scar.

Thick scars are primarily treated using a handpiece with a density of 5 to 15 percent, frequency of 300 to 600 Hz, and 15 to 30 mJ per micropulse, yielding a depth of 375 to 825 micrometers [13,32,35]. Higher energy levels, in terms of mJ/micropulse (which mandate reducing density), are used for thicker scars on the extremity and torso, while lower energy levels (which can permit higher density) are used for thin scars, areas that have been grafted with split-thickness skin grafts, areas on the face, and when treating young patients.

Textural abnormalities can be successfully treated with surface ablation using a handpiece at a frequency of 150 Hz and 70 to 90 mJ per micropulse. Other parameters used for this modality are 90 to 125 mJ, corresponding to a penetration depth of 66 to 112 micrometers, density setting of 3 to 5 percent, frequency of 200 Hz, and 1.3 mm spot size [32,35]. Lower densities are favored in patients with lightly pigmented skin.

Efficacy — The use of ablative and nonablative fractional laser resurfacing for the treatment of hypertrophic scars and keloids has been evaluated in a small number of randomized trials and uncontrolled studies with mixed results [11,13,25,26,36].

In a split-lesion trial, 25 patients with scars from surgery or trauma received three treatments with an ablative fCO2 10,600 nm laser at eight-week intervals in one of two selected test areas [37]. At six-month follow-up, mild improvement by physician global assessment was noted in only seven patients, with no difference between the treated and untreated areas. Adverse effects occurred in three patients and included persistent erythema, postinflammatory pigmentary changes, and scarring after ulceration.

In a prospective study of 187 patients with burn scars, fCO2 laser treatment (n = 167) was compared with conservative scar treatment (n = 20) [38]. After an average follow-up time of 11.5 months, a greater improvement in ultrasound-measured scar thickness, Vancouver Scar Scale (VSS) score, and subjective scores (Patient and Observer Scar Assessment Scale [POSAS], neuropathic pain score, and pruritus score) was reported in the laser treatment group compared with the control group. Moreover, patients in the fCO2 laser group consistently reported increases in overall quality-of-life scores, whereas quality-of-life scores decreased over time in the conservative treatment group.

In a prospective study of 49 pediatric patients with hypertrophic burn scars, fCO2 laser treatment improved pigmentation, thickness, pliability, and texture (as assessed by POSAS) [39]. Laser-assisted glucocorticoid delivery was incorporated in over 90 percent of treated patients.

A randomized split-wound trial evaluated the effect of sequential treatments with a nonablative 1540 nm erbium-glass fractional laser (immediately before surgery, at suture removal, and six weeks after surgery) on wound healing and scar formation in 32 patients [40]. At three months, the treated scar halves showed modest improvement in scar redness, pliability, and overall assessment by patients and clinicians.

Other lasers

Laser diode – Laser diode is a common type of laser in which the light is produced by semiconductor amplification. The 830 nm diode laser was introduced in the 1990s as a low-level light therapy to treat scars and keloids [41]. The mechanism of action is similar to PDL, with hemoglobin and melanin as its chromophores [42]. We use a workstation with intense pulsed light (IPL)/neodymium-doped yttrium aluminum garnet (Nd:YAG)/light sheer diode with a filter of 515 to 590 nm and a fluence of 18 to 24 J/cm2 to target hyperpigmented lesions.

Long-pulsed alexandrite laser – The long-pulsed 755 nm alexandrite laser is commonly used for hair removal. The delivered energy is absorbed by melanin in the hair shafts, and the surrounding follicular structures sustain secondary damage, leading to destruction of the stem cells in the bulge region of the hair follicle [43]. In patients with large scars, the alexandrite laser may be used to treat retained ingrown hair follicles, which cause folliculitis and are refractory to destruction by the PDL, IPL, or diode laser. (See "Removal of unwanted hair", section on 'Laser and intense pulsed light'.)

Intense pulsed light — Technically not a laser, IPL delivers focused, controlled, noncoherent light energy through a coupling gel across the 515 to 1200 nm spectrum and at a fluency of up to 40 J/cm2 [13]. Specific filters in the handpiece allow the user to select from a window of wavelengths (eg, 755 nm for collagen stimulation, 695 nm for superficial leg vein coagulation, 515 nm for treatment of rosacea telangiectasias). For hypertrophic scars, IPL may be an alternative to more expensive platforms, such as PDL and fCO2 laser [13]. However, evidence for its efficacy is limited.

In one observational study, 109 patients with hypertrophic scars due to surgical, traumatic, or burn wounds were treated with an average of eight IPL treatments administered at two- to four-week intervals [44]. Based on comparison of sequential digital photographs, excellent or good improvement in scar height, erythema, and hardness was observed in 57 percent of patients.

A small observational study evaluated the efficacy of IPL for the treatment of burn scar dyschromias in 20 patients 1 to 15 years after the injury [45]. After one to three IPL treatments, 16 patients reported mild to moderate improvement in color, whereas four patients had no response. Complications occurred in seven patients and included significant pain, blistering, and postinflammatory hyperpigmentation.

IPL combined with fCO2 laser versus fCO2 laser alone or no treatment was evaluated in a small, randomized trial including 23 patients with large hypertrophic scars [46]. Compared with no treatment, both fCO2 laser plus IPL and fCO2 laser alone equally improved all scar domains assessed by the Manchester Scar Scale. However, the combined therapy was associated with a greater improvement in scar color and texture at six months.

MULTIMODAL TREATMENTS

Laser-assisted corticosteroid delivery – Laser-assisted corticosteroid delivery, when used with either pulsed dye laser (PDL) or fractional carbon dioxide (fCO2) laser, can be a very powerful adjunct. A synergistic effect may occur, which reduces the energy required to achieve scar improvement as well as the need for future sessions. When combining lasers with topical and/or intralesional corticosteroids, we often observe decreased vascularity and thickness and improved pliability and texture, but sometimes at the expense of pigmentation.

The pinholes created by the laser beam are thought to maximize drug absorption by providing an avenue for precise placement of the drug while avoiding adverse sequelae, such as fat atrophy. At the authors' institutions, the lasered pinhole sites are covered evenly using triamcinolone acetonide suspension 10 or 40 mg/mL, titrated to the patient's body weight at a dose of 1 mg/kg.

In a few small, uncontrolled studies of patients with mature hypertrophic scars, the application of topical corticosteroid suspensions in combination with fractional laser therapy resulted in improved scar texture and appearance without significant adverse events [32,47].

Z-plasty – Z-plasty is a surgical technique that creates local transposition flaps to relieve tension along a scarred wound (see "Z-plasty"). Combining PDL therapy with Z-plasty appears to have a synergistic effect in the treatment of hypertrophic burn scars, in which tension is deemed to play a role in hypertrophy, and may reduce the need for surgical excision [15].

OUR APPROACH — In the authors' experience, a combination treatment with pulsed dye laser (PDL) and fractional carbon dioxide (fCO2) laser is more effective than treatment with a single type of laser in improving the pigmentation, pliability, height, vascularity, pain, and pruritus of hypertrophic burn scars (picture 3A-G). This approach is suitable for burn and nonburn scars (due to trauma, surgery, and infection). We typically use PDL to decrease inflammation, erythema, and pruritus in the early stages of hypertrophic burn scar maturation, which may peak at six months after injury, and fCO2 laser for later stages when improvement in stiffness, contour, and pliability are desired, as shown in the algorithm (algorithm 1).

Treatment begins within the first 6 to 36 months after burn injury with the use of PDL to reduce the scar hyperemia and thickening [10,13,48]. A six-month period following injury usually allows us the appropriate amount of time to determine which scars are likely to mature with conventional medical therapy, thus avoiding overtreatment. Burn scars without significant pruritus, erythema, hypertrophy, or stiffness can be safely and effectively treated without laser therapy.

Subsequent treatment with fCO2 ablative laser can be started at 12 months after injury or following the conclusion of PDL treatment. Laser treatments are delivered at four- to six-week intervals until a plateau in improvement is observed. Generally, only one modality is used per session, but more than one platform can be used on different sites in the same session.

The treatment of hypertrophic burn scars with a combination of lasers has been evaluated in a prospective, before-after study [10]. In this study, 147 patients with hypertrophic burn scars involving a mean body surface area of 16 percent underwent an average of three laser treatments with PDL, fCO2 laser, intense pulsed light (IPL), and intralesional steroid injections when indicated. Outcomes were measured by the Vancouver Scar Scale (VSS), which assesses scar pigmentation, erythema, pliability, and height, and by the University of North Carolina "4P" Scar Scale (UNC4P), which assesses patient-reported pain, pruritus, paresthesias, and pliability. A reduction in both VSS and UNC4P scores was observed after a mean follow-up time of 4.4 months.

Further reduction in the VSS score was achieved in a subgroup of patients who underwent an average of five laser treatments and were followed up for a median time of 26 months [10]. The improvement was greater than would be predicted by standard decay curve modeling for untreated patients. Complications occurred in 13 percent of patients and included moderate to severe blistering, postinflammatory hyperpigmentation, and infection.

PREOPERATIVE MEASURES

Patient preparation — Some experts recommend skin preparation with chlorhexidine solution and moistening hair-bearing areas prior to treatment [21,32]. We apply laser treatments to clean, dry skin without specific preparation. Hypertropic scar tissue and keloid scars are usually devoid of hair. However, burn scars may contain trapped hair follicles, which may only be removed with aggressive therapies, such as alexandrite laser or even surgical excision. When removing hair follicles with alexandrite laser, the hair should be shortened to reveal the skin surface. Leaving a short segment of hair allows determination of fluence levels, especially when applying the laser for the first time.

Anesthesia — The type of anesthesia employed prior to laser therapy depends on several factors, including the mode of laser treatment (eg, ablative lasers are more painful than nonablative lasers), size of the scar, and age of the patient. Children may require general anesthesia, whereas adults can be treated with topical anesthesia [21].

Tumescent anesthesia has been tried and abandoned due to the pain experienced by patients during infiltration. In adults with relatively small treatment areas who undergo nonablative laser and some fractional ablative laser treatments, we use a lidocaine cream applied to the skin surface for 30 minutes prior to the procedure. In a prospective study, a lidocaine-prilocaine mixture applied to the skin prior to fractional carbon dioxide (fCO2) laser treatment for burn scars improved pain scores and reduced the need for postprocedural intravenous opioids [49].

Higher energy settings and treatment of large scars or scars located in sensitive areas, such as the hands and face, generally require intravenous sedation and analgesia or general anesthesia with spontaneous ventilation [10,32]. This obviates the need for an operating room with a qualified anesthesiologist monitoring patient care.

SAFETY MEASURES — Protective eyewear is required for all personnel in the treatment room, including the patient, and metal eye shields are placed on the orbit when treating periocular lesions [50]. Excessive thermal injury can be avoided by [3]:

Limiting to a single laser modality per treatment area per session

Applying fractional treatments at low densities with a relatively narrow beam diameter and pulse width

Minimizing the number of passes

When higher pulse energy settings are chosen, a concomitant decrease in treatment density is required. Treatment can safely include a rim of normal skin at the scar periphery.

When using fractional carbon dioxide (fCO2) laser, it is helpful to verify the laser density on a tongue depressor before using it on the patient. A test treatment in an inconspicuous area to judge the skin's response to pulsed dye laser (PDL) is a strategy that should also be considered [51].

Low, conservative fluence levels are recommended, especially when treating patients with darkly pigmented skin, in whom the test treatment may not be as revealing. Multiple treatments are almost always necessary, and changes in the settings can be made based on the previous treatment and the outcomes observed by the treating surgeon [3].

POSTOPERATIVE CARE

Ice packs are commonly used on the skin immediately following treatment [11]. Most experts suggest topical application of petrolatum or antibiotic ointments on laser-treated sites for one week [3,10,15].

Adequate analgesia is usually achieved with nonsteroidal anti-inflammatory agents, although some patients with chronic, intense pain may need a short course of narcotic pain medication [10].

Patients may resume normal activity almost immediately, including physical or occupational therapy, with the exception of full immersion in water in cases of treatment with an ablative laser [3,10]. Depending upon the discomfort level and the desired type of activity, patients may return to school or work after one to three days.

Because compression garments may cause some sheer of the treated tissue, we now recommend waiting for several days, until edema subsides, wounds re-epithelialize, and discomfort lessens, before getting back into these garments [10].

Sun avoidance and use of broad-spectrum sunscreens with a sun protection factor (SPF) of at least 30 is mandatory [3,10,11].

COMPLICATIONS — Complications following laser treatment are relatively common. Lower fluence and density settings should be selected initially to reduce the rate of adverse events. Moreover, it is advisable to perform a test treatment in an inconspicuous skin area to assess the skin's response in all patients undergoing scar treatment.

Pulsed dye laser – The overall complication rate for pulsed dye laser (PDL) therapy ranges from 0 to 20 percent [24]. Similar rates have been reported for other nonablative lasers [25,26]. Common adverse events include transient purpura and mild to moderate erythema or edema that usually resolves in 7 to 10 days [11,15,22,24]. However, in some cases, a mild erythema can persist up to three months post-treatment [11].

Occasionally, blistering or crusting may occur in the early post-treatment phase. Hypo- or hyperpigmentation may also occur, especially in patients with darkly pigmented skin [3,15,21,22,24,51]. Overtreatment of burn scars may induce scarring exacerbation, especially in skin with high pigmentation, in which melanin acts as a competing chromophore [52]. Intraprocedural cryogenic cooling of the skin may limit these adverse reactions.

Ablative fractional lasers – Ablative fractional lasers have a better adverse effect profile compared with ablative nonfractional devices, with reported rates of complications ranging from 2.5 to 25 percent [51,53,54]. Complications such as delayed wound healing, ulceration, postinflammatory hypo- and hyperpigmentation, and scarring, particularly in areas of thinner skin and decreased adnexal structures (such as the neck), have been reported with fractional lasers [55]. This may be due to bulk heating of tissue and penetration of laser energy beneath the dermis [35].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Keloids and hypertrophic scars".)

SUMMARY AND RECOMMENDATIONS

Indications – Indications for pulsed dye laser (PDL) or ablative fractional laser therapy include (see 'Indications and goals of treatment' above):

Immature or linear, hypertrophic, erythematous scars resulting from surgery or trauma that present with persistent erythema for more than one month despite preventive treatment with silicone gel or sheeting, hypoallergenic paper tape, or onion extract preparations

Widespread, hypertrophic burn scars that failed to improve with treatment with silicone gel or sheeting, pressure garments, and/or onion extract preparations for 8 to 12 weeks

Minor keloids that failed to improve within 8 to 12 weeks with silicone gel sheeting and intralesional corticosteroids

Major keloids that failed to improve with intralesional corticosteroids and fluorouracil

Lasers and light platforms – Lasers that are commonly used for the treatment of hypertrophic scars and keloids include PDL, fractional carbon dioxide (fCO2) laser, and intense pulsed light (IPL). (See 'Laser and light platforms' above.)

Laser-assisted corticosteroid delivery – Laser-assisted corticosteroid delivery, when used with either PDL or fCO2 laser, can be a very powerful adjunct to laser therapy. A synergistic effect may occur, which reduces the energy required to achieve scar improvement as well as the need for additional treatment sessions. (See 'Multimodal treatments' above.)

Approach – In the authors' experience, a combination treatment with PDL and fCO2 laser is more effective than treatment with a single type of laser in improving the appearance and reducing the symptoms associated with hypertrophic burn scars (picture 3A-G). We typically use PDL to decrease inflammation, erythema, and pruritus in the early stages of hypertrophic burn scar maturation and fCO2 laser for later stages when improvement in stiffness, contour, and pliability are desired (algorithm 1). (See 'Our approach' above.)

Complications – Common complications of PDL therapy include transient purpura and mild to moderate erythema or edema that resolves in 7 to 10 days. Occasionally, skin blistering or crusting may occur in the early post-treatment phase. Hypo- or hyperpigmentation may also occur, especially in patients with darkly pigmented skin. Delayed wound healing, ulceration, postinflammatory hyperpigmentation, and scarring may occur with fractional laser therapy. (See 'Complications' above.)

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Topic 99106 Version 7.0

References

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