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Surgery and Cosmetics

James M. Spencer, MD, MS

Laser-Assisted Topical Medication Delivery for Hypertrophic Scars

James M. Spencer, MD, MS

Monday, March 03, 2014

Intralesional triamcinolone acetonide or injections of 5 fluoruracil have been mainstays of the management of hypertrophic and keloidal scars for decades. Triamcinolone acetonide is a common first-line therapy, injected at a concentration of 10-40 mg/ml depending on the thickness of the scar. Response rates for keloids are reported to be in the 50-100% range but with a 5-year recurrence rate of up to 50%.1 Intralesional 5 fluorouracil (IL 5 fu) has the theoretical advantage of preventing overcorrection with atrophy, but efficacy is less well documented. In one study, 0.5 ml IL 5 fu 50 mg/ml produced a 75% clearance rate of keloids, but long-term follow-up was not given.2 Frequently, however, the scars themselves are quite firm and injection is difficult and results are not always satisfying. Recently, laser assisted intralesional medication application has been tested with great success.1

The role of lasers in the management of hypertrophic and keloidal scars has traditionally involved the use of the 595 nm pulsed dye laser. This is theorized to affect the microvasculature of the scar and thus diminish the scar. Recently, nonablative and ablative fractional lasers have become available and tested on scars. The ablative fractional lasers include the CO2 and erbium-doped yttrium aluminum garnet (YAG) lasers. These essentially drill multiple tiny holes in the affected area with islands of normal skin between the holes for rapid healing. While these lasers can provide excellent results for atrophic acne scars, their effect on hypertrophic and keloidal scars is less well documented. However, a recent consensus paper on laser therapy for traumatic scars written by eight independent self-selected academic, military dermatology, and plastic surgery physicians, all with extensive experience in laser therapy for scars, concluded fractionated laser represents a promising tool to affect both appearance and function.3 They specifically state "… particularly ablative fractional resurfacing, deserves a prominent role in future scar paradigms, with the possible inclusion of early intervention for contracture avoidance and assistance with wound healing."

In laser-assisted intralesional medication application, an ablative fractionated laser (either CO2 or erbium YAG) is used to create multiple channels within the scar after which medication is drizzled on top of the scars and runs down the channels. This seems to provide much better penetration of medication than injection alone. The depth of the laser channels is set to approximate the thickness of the scar so the bottom of the scar is reached. In a case series of 15 patients with hypertrophic scars secondary to burns, surgery, or traumatic injury, a fractionated CO2 laser was used to ablate multiple channels approximately to the bottom of the scar.4 Triamcinolone acetonide 10-20 mg/cc was then drizzled on top of the scars and allowed to run down the channels. Treatment was performed three to five times at 2-3 month intervals. Overall, an improvement of 2.73 out of a 3-point scale was seen with the greatest improvements seen in hypertrophy and texture, and the least change seen in dyschromia. Laser-assisted topical medication delivery for hypertrophic scars is a novel therapy that seems safe and efficacious, however prospective randomized studies with an objective measure of scar volume need to be performed.

References

1. Berman B, Bieley HC. Keloids. J Am Acad Dermatol 1996;33:117-123.

2. Hatamipour E, Mehrabi S, Hatamipour M, Ghafarian Shirazi HR. Effects of combined intralesional 5-lfuorouracil and topical silicone on keloids: a double blind randomized clinical trial study. Acta Med Iran 2011;49:127-130.

3. Anderson RR, Donelan MB, Hivnor C,et al. Laser treatment of scars with an emphasis on ablative fractional resurfacing. Consensus Report. JAMA Dermatol 2013; epub ahead of print.

4. Waibel JS, Wulkan AJ, Shumaker PR. Lasers Surg Med 2013;45:135-140.

 

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