Didac Barco presents two cases that effectively demonstrate how to use laser devices to treat traumatic scars and contractures
Scar formation is the normal and natural response of tissue to wound healing following injury, enabling fibrous tissue to replace normal skin after trauma. Scars can have a significant cosmetic, physical, and psychological impact on patients1 . Acne is an extremely common skin condition, affecting all skin types and ages; if left untreated, it can result in permanent scars on the face and other areas of the body2 . Acne scars can create textural changes in the superficial and deep dermis and are commonly associated with erythema and/or pigmentation2 . Many different treatment modalities and approaches have been used to improve the appearance of acne scarring, including retinoids, microdermabrasion, dermal fillers, and even surgical techniques such as subcision and skin grafting3 . Each treatment approach has varying degrees of clinical improvement, risks, and tolerability. As with acne scars, burn scars can also be a significant source of cosmetic and psychological distress to affected patients, prompting many to seek treatment4 . These scars are particularly difficult to treat because of their tendency to worsen with hypertrophy and contracture. Besides the cosmetic effects, there are other morbidities and physical impairments associated with burn scars. Non-surgical treatments include compression garments, silicone gel, and intralesional therapy with steroids and other medications5 .
According to the 2020 International Consensus Recommendations for Laser Treatment of Traumatic Scars and Contractures, there is tremendous potential for laser techniques as first-line therapy in the management of traumatic scars and contractures6 . Lasers can improve various characteristics of scars, including erythema, hyperpigmentation, atrophy, and hypertrophy. It may decrease tension to increase functionality, with minimal downtime and with an overall low risk compared to conventional treatment6 . Early intervention with fractional ablative CO2 laser treatments on acute traumatic wounds has shown reorganisation of the underlying skin structure on histological evaluation and a significant decrease of scar formation clinically7 . Intense pulsed light (IPL) treatment has also shown positive outcomes on keloid and hypertrophic scars with different etiologies8, as well as for immature burn scars with regard to vascularity, pliability, and height9 . Both laser and light-based therapies have been shown to ameliorate specific aspects of burn scars10.
Candela’s CO2RE® laser system is a second-generation fractional CO2 laser system for surgical procedures in the area of dermatology, plastic surgery, and treatment of vaginal atrophy and rejuvenation. The CO2RE system enables superficial ablative treatments at variable densities for a peel-like effect, as well as deep ablative treatments for dermal remodelling. It also offers six different ablative treatment modes: four modes for fractional skin resurfacing and treatment of wrinkles and fine lines (Lite, Mid, Deep and Fusion Modes), one mode for fully ablative resurfacing (Classic Mode), and one mode for incisions (Surgical Mode). CO2 laser energy quickly superheats water molecules in the skin tissue, contributing to controlled ablation that provides a precise skin-peeling effect and promotes collagen formation and retraction of the dermis and epidermis.
The Nordlys™ system is a multi-platform device that incorporates dual-filtering Selective Waveband Technology (SWT®) to filter out the shorter and longer infrared wavelengths that correspond with the absorption spectrum of a specific skin chromophore, while minimising heating to the surrounding tissues and without the need for skin cooling. A fractional 1550 nm handpiece (Frax 1550™) is also available on the Nordlys system for skin resurfacing, as well as for the treatment of striae, acne scars, and surgical scars.
The laser beam width can be adjusted between 4–12 mm to quickly treat large areas or treat smaller areas with the non-ablative fractional laser. In our clinic, we use both the fractional CO2RE laser treatments and the Nordlys Frax 1550 laser treatments to resurface the skin tissue of scars, as well as an SWT handpiece to address the vascular component and pigmentation of the tissue. We present here two case studies of the treatment of acne scars and burn scars.
A 31-year-old healthy Caucasian female with Fitzpatrick Skin Type II presented to our clinic with boxcar and ice pick acne scars on her face (Figure 1). The patient underwent two CO2RE laser treatment sessions, 6 months apart. Each session consisted of two modes of treatment. Initially, a classic resurfacing mode was utilised by pulsing in a pinpoint fashion on the centre of each scar. This was followed by fractional resurfacing that was then applied all over the affected area using Deep Mode (5% Fractional Coverage and 70 mJ/ pinpoint laser beam energy). As post-treatment preventative care, topical fusidic acid ointment (Fucidin) was applied after the CO2 treatment as a prophylactic antibiotic ointment. Significant improvement of the scar tissue was observed after the two treatments.
A 20-year-old healthy Caucasian female with Fitzpatrick Skin Type IV presented to our clinic with 2-month old scars after an accidental burn on the right thigh (Figure 2). The scar tissue was treated using a multi-modality treatment protocol. During four monthly treatment sessions, the Nordlys SWT (PR530) handpiece (2.5 ms pulse duration and power of 5J) was used to address the vascular component of the scar tissue, while the Frax 1550 handpiece (12 mm spot size, 4.5 ms pulse duration and 55 J fluence) was used to address textural irregularities of the scar tissue. Three passes were applied to the affected area. After the four Nordlys treatments, an additional CO2RE treatment in Fusion Mode (20% Fractional Coverage, Core energy 50 mJ and Ring energy 30 mJ) was performed to resurface the scar tissue. Post-treatment care with topical fusidic acid ointment was administered.
The results we achieved in the acne scar patient were significant after only two CO2RE laser treatments, demonstrating a more homogenous skin and improved scar texture and tone. Using both classic resurfacing mode and fractional resurfacing mode, we were able to address the irregular scar tissue and create a better wound-healing environment for scar mitigation. The results achieved in our burn scar patient were also very impressive. The Nordlys SWT (PR530) handpiece was used to address the vascular component of the scar tissue and to target erythema, while the Frax 1550 handpiece promoted the elimination of damaged epithelia and shrinkage of collagen fibres immediately after ablation. The additional ablative CO2RE treatment provided treatment directly to the scar, inducing tissue rehabilitation. Optimal treatment for scar management routinely includes multiple modalities6 , and we take this approach in our clinic. The complementary treatment improved the overall scar condition with reduced redness and amelioration of skin hue and texture. There was an improvement in the appearance of the burn scar as well as the surrounding buttock skin tissue, while reducing the downtime, risk, and pain associated with surgical revision. There were no treatment complications, and both patients were very satisfied with their cosmetic outcome. Declaration of interest Dr. Didac Barco has received grants from Candela Medical, Inc. to share and write these clinical cases.
1. Khetarpal S, Dover JS, Arndt K. Surgical Scars. In: Evidence-Based Procedural Dermatology. M. Alam (ed.), Springer Nature Switzerland AG 2019.
2. Tan J, Kang S, Leyden J. Prevalence and risk factors of acne scarring among patients consulting dermatologists in the USA. J Drugs Dermatol. 2017:16:97-102.
3. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1: Non-energy-based techniques. Scars, burns & healing. 2017:13:3:2059513117695312.
4. Van Loey NE, Van Son MJ. Psychopathology and psychological problems in patients with burn scars. American journal of clinical dermatology. 2003:1:4:245-272.
5. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 2: Energy-based techniques. Scars, burns & healing. 2018;4:2059513118793420.
6. Seago M, Shumaker PR, Spring LK, et al. Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations. Lasers Surg Med. 2019 Dec 9.
7. Waibel JS, Gianatasio C, Rudnick A. Randomized, Controlled Early Intervention of Dynamic Mode Fractional Ablative CO2 Laser on Acute Burn Injuries for Prevention of Pathological Scarring. Lasers Surg Med. 2019 Oct 20.
8. Erol OO, Gurlek A, Agaoglu G, Topcuoglu E, Oz H. Treatment of hypertrophic scars and keloids using intense pulsed light (IPL). Aesthetic Plast Surg. 2008;32:902-909.
9. Sarkar A, Dewangan YK, Bain J, et al. Effect of intense pulsed light on immature burn scars: A clinical study. Indian J Plast Surg. 2014;47:381-385.
10. Hultman CS, Edkins RE, Lee CN, Calvert CT, Cairns BA. Shine on: review of laser-and light-based therapies for the treatment of burn scars. Dermatol Res Pract. 2012: 24365