By Abby S. Van Voorhees, MD, April 01, 2014
In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with Peter Shumaker, MD, about his recent JAMA Dermatology article, “Laser Treatment of Traumatic Scars With an Emphasis on Ablative Fractional Laser Resurfacing: Consensus Report.”
Dr. Van Voorhees: Debilitating scar contractures caused by traumatic injury have traditionally been managed with surgical strategies. What has been the standard of care until recently?
Dr. Shumaker: It is important to emphasize that surgical strategies are, and will remain, a critical component of the standard of care for ongoing rehabilitation after trauma and initial reconstruction. As I understand them, current standard paradigms for contracture mitigation and management among the surgical specialties include dedicated physical therapy and adjunctive interventions such as pressure dressings, splints, scar massage, non-ablative lasers, and intralesional steroids. If functional deficits remain after sufficient time to allow for spontaneous scar maturation (approximately a year or so to allow for spontaneous improvement), then surgical procedures such as flaps and grafts are often considered. This delay is incorporated because revision surgery itself is often beset by additional morbidity and relatively high recurrence rates. In my experience, laser therapy (especially ablative fractional resurfacing) is an exceptional complement to traditional scar management paradigms, fitting nicely between conservative measures such as physical therapy and more aggressive revision surgery. I have found that fractional resurfacing can be implemented relatively early in the treatment course, perhaps even mitigating contracture formation and limiting the duration and extent of disability.
Dr. Van Voorhees: What allowed us to think that lasers would be beneficial? Why don’t lasers cause additional scarring?
Dr. Shumaker: Non-ablative lasers such as the pulsed dye laser have been successfully integrated into scar management for decades. Likewise, full-field ablative lasers like the traditional carbon dioxide laser have been used in the treatment of some scar types for many years. However, these modalities have not generally been effective for significant scar contractures with associated functional deficits, related in part to inadequate penetration depths and excess thermal damage when used aggressively. The advent of fractional photothermolysis, particularly ablative fractional resurfacing in 2007, is a breakthrough that has revolutionized scar treatment. However, it was not entirely intuitive that a controlled ablative injury would consistently result in beneficial remodeling of severe scars. Like so many other medical advances, this application was developed by some astute early users, partly through serendipity. [pagebreak]
With ablative fractional resurfacing, laser operators can now achieve tunable depths of penetration unavailable to previous devices while maintaining a large degree of safety due to adjacent tissue sparing. When treatment parameters are selected judiciously, new or worsening scarring appears to be exceedingly rare. While narrow beam diameters and tissue sparing undoubtedly contribute to these favorable characteristics, the exact nature of the response has yet to be fully elucidated.
Dr. Van Voorhees: Which lasers have been tried and what are each of their main benefits?
Dr. Shumaker: Patients who have suffered trauma and related reconstruction frequently have complex injuries and multiple laser modalities are routinely incorporated into their treatment concurrently or in series to help address specific issues. The most common laser applications in my practice include microfractional ablative laser resurfacing for scar contractures and textural abnormalities, vascular-specific lasers such as the pulsed dye laser for erythematous scars, Q-switched lasers for traumatic tattoos, and laser hair reduction to improve the comfort and fit of prosthetics, among other issues. Almost all of these applications require multiple treatments for cumulative benefits. Also, adjunctive treatments such as topical and intralesional corticosteroids and silver nitrate application can be very useful.
Dr. Van Voorhees: How do you choose? What are the criteria?
Dr. Shumaker: Virtually any type of cutaneous scar, in virtually any location, can be enhanced in some fashion with laser therapy. Every treatment is custom-designed for the patient on a particular visit based on their priorities and the individual scar characteristics. Patients frequently have multiple scar types including both hypertrophic and atrophic scars with varying degrees of erythema, textural abnormalities, dyschromia, poor pliability, and limited range of motion. Therefore the laser selected depends not only on the patient but on the particular area of concern. Furthermore, a particular area may receive treatment from several different types of lasers over time. The figure in the article introduces a comprehensive paradigm for laser selection.
Dr. Van Voorhees: Let’s take the lasers you use most commonly in this type of situation — where do you find them most helpful?
Dr. Shumaker: Fractional resurfacing can address multiple issues at once including dyschromia, texture, and even erythema. However, ablative fractional resurfacing appears to be much more effective than non-ablative resurfacing for thicker scars and scar contractures. Scar symptoms such as pain and itch also seem to improve during the treatment course.
Vascular-specific lasers such as the pulsed dye laser are very helpful for scars with erythema. In addition to improved redness, scar flattening and decreased symptoms such as pain and itch are commonplace during a course of treatment. [pagebreak]
Severe scarring such as after a burn might include hypertrophy, erythema, and joint contracture. In this case a treatment course might include alternating sessions of both laser types, as well as adjunctive corticosteroids. It is important to emphasize that scar tissue does not tolerate cumulative thermal injury to the same extent as normal skin. Both fractional and vascular lasers can be used safely on virtually any body location, and though multiple modalities might be used in a single treatment session for the same patient, they must be combined judiciously to avoid excessive thermal injury and worsening scarring.
Dr. Van Voorhees: How long after the trauma is it best to wait to begin laser resurfacing?
Dr. Shumaker: The short answer is that it depends on the extent of the injury, degree of healing, and other factors. Relatively small, linear surgical scars can probably be treated at almost any time point with a variety of laser types. In our experience in patients with extensive injuries such as from large surface area burns or improvised explosive devices, fractional laser treatment can usually begin approximately two to three months after injury or reconstruction. It even appears that ablative fractional resurfacing may facilitate healing in scars associated with relatively small chronic wounds. Beyond that point, the treatment appears to be effective in patients with scars of virtually any age, even decades after injury.
Dr. Van Voorhees: Do you feel that ablative fractional laser resurfacing should be more commonly utilized? What are the risks?
Dr. Shumaker: Ablative fractional resurfacing and other related procedures could potentially help improve the lives of millions of patients worldwide who suffer from debilitating scars. Though the procedure is not without risks, including infection and excessive thermal injury resulting in worsening scarring, in our experience a conservative approach to treatment has resulted in an extremely low rate of complications.
These are not special “scar lasers” but the same devices present in offices throughout the country that are commonly used for “cosmetic” procedures, applied in a different manner. A greater awareness of the functional benefits of these devices for traumatic and surgical scars and a related shift in the reimbursement landscape will certainly increase access to the procedure. Our experience in the military population includes enhanced rehabilitation, greater function, and even earlier return to full duty. I am confident that this would translate in the civilian world into improved quality of life and an overall savings by decreasing disability and shortening rehabilitation time.
Dr. Shumaker is chairman of dermatology at the Naval Medical Center in San Diego. His article was published online by JAMA Dermatology on Dec. 11, 2013; JAMA Dermatol. 2013 Dec 11. doi: 10.1001/jamadermatol.2013.7761.