The efficacy and safety of fractional CO2 laser therapy in the treatment of burn scars: A meta-analysis

Although we have numerous publications about the effect of fractional CO₂ laser therapy for burn scars, quantitative data about its efficacy and safety are sparse. The purpose of this meta-analysis was to assess the efficacy and safety of fractional CO₂ laser therapy for the treatment of burn scars. Pertinent studies were identified by a search of PubMed, Embase and Web of Science up to 20 September 2020. Weighted mean difference (WMD) was conducted to combine the results, and a random-effect model was used to pool the results. Publication bias was estimated using Begg and Egger’s regression asymmetry test. Twenty articles were included. Our pooled results suggested that fractional CO₂ laser therapy significantly improved the Vancouver Scar Scale (VSS) score (WMD = −3.24, 95%CI: −4.30, −2.18; P < 0.001). Moreover, the Patient and Observer Scar Assessment Scale (POSAS)-patient (WMD = −14.05, 95%CI: −22.44, −5.65; P = 0.001) and Observer (WMD = −6.31, 95%CI: −8.48, −4.15; P < 0.001) also showed significant improvements with the treatment of fractional CO₂ laser therapy. Fractional CO₂ laser significantly reduced scar thickness measured with ultrasonography (WMD = −0.54, 95%CI: −0.97, −0.10; P < 0.001). For other outcomes, including pigmentation, vascularity, pliability, and height of scar, vascularity and relief, laser therapy was associated with significant improvements. However, only the cutometer measure R2 (scar elasticity) (WMD = −0.06, 95%CI: −0.10, −0.01; P = 0.023) was significantly improved with the laser therapy, but cutometer measures R0 (scar firmness) (WMD = 0.03, 95%CI: −0.04, 0.09; P = 0.482) was not. Side effects and complications induced by fractional CO₂ laser were mild and tolerable. Fractional CO₂ laser therapy significantly improved both the signs and symptoms of burn scars. Considering potential limitations, more large-scale, well-designed RCTs are needed to verify our findings.     

Effects of combined Pulsed Dye Laser and Fractional CO2 Laser treatment of burn scars and correlation with plasma levels of collagen type I,MMP-2 and TIMP-1

Hypertrophic burn scars remain a significant burden for patients and a challenge for clinicians.The aimAssessement of the efficacy of combined Pulsed Dye Laser and Ablative Fractional CO₂ Laser therapy on hyperthophic scars and correlation with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen.Patients and methodsTwenty five pediatric subjects were enrolled into the study. Control group consisted of age-matched subjects admitted for surgical repair of inguinal hernia. For the assessment of the results of laser treatment we used the Vancouver scar scale (VSS), and Patient-Observer Scar Assessment Scale (POSAS). We also correlated clinical results with plasma levels of MMP-2, TIMP-1 and alpha-1 type I collagen.ResultsAll subjects reported the laser treatment resulted in improvement and were somewhat satisfied or very satisfied with their experience. No adverse events were reported. The levels of MMP-2, TIMP-1 and alpha-1 type I collagen in our patients with scars before laser threatment were higher in comparison to controls. We also found statistically significant decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scarsConclusionsOur study clearly shows that combined CO2-AFL treatment for burn scars improve texture, colour, function and alleviate pruritus. We believe that decrease in the levels of MMP-2, TIMP-1 and alpha-1 type I collagen after laser treatment of burn scars, reflects reduced dynamic of scar.     

Effectiveness and safety of ablative fractional CO2 laser for the treatment of burn scars: A case-control study

BackgroundBurn scars are a major clinical challenge. The aim of this study was to determine the effectiveness and safety of one treatment with the ablative fractional CO₂ laser (AFL-CO₂) compared to standard burn scar treatment.MethodFrom December 2014 to October 2018 patients were prospectively recruited and treatment effects analyzed by assessing various outcome parameters from the date of first consultation and after treatment. A case control study was conducted looking at the impact of one AFL-CO₂ treatment compared to a cohort subjected to conventional conservative treatment. Adverse effects were noted at follow up.Results187 patients were included, with 167 in the AFL-CO₂, and 20 in the control cohort. Baseline demographics and scar characteristics showed no significant differences. Ultrasound measured scar thickness as well as the Vancouver Scar Scale (VSS) revealed a significant reduction in the treatment cohort, but no significant improvement in the control group. The POSAS-O was significantly improved in both cohorts. Subjective parameters (POSAS-P, DN4-Pain, and modified D4Pruritus scores) decreased significantly in the AFL-CO₂ cohort but remained unchanged in the control group. The BSHS-B quality of life score increased significantly in the AFL-CO₂ group, but worsened at the follow up of the untreated patients. Sub-domain analyses found the biggest differences in Affect, Body Image, Heat Sensitivity, Treatment and Work. Complications occurred in 5 patients (2.9%).ConclusionsThis study demonstrates that AFL-CO₂ is an effective and safe treatment modality for burn scars improving thickness, symptoms and quality of life of burn survivors when compared to conventional scar treatment.     

The effect of burn rehabilitation massage therapy on hypertrophic scar after burn: A randomized controlled trial

ObjectiveTo evaluate the effect of burn rehabilitation massage therapy on hypertrophic scar after burn.MethodOne hundred and forty-six burn patients with hypertrophic scar(s) were randomly divided into an experimental group and a control group. All patients received standard rehabilitation therapy for hypertrophic scars and 76 patients (massage group) additionally received burn scar rehabilitation massage therapy. Both before and after the treatment, we determined the scores of visual analog scale (VAS) and itching scale and assessed the scar characteristics of thickness, melanin, erythema, transepidermal water loss (TEWL), sebum, and elasticity by using ultrasonography, Mexameter^®, Tewameter^®, Sebumeter^®, and Cutometer^®, respectively.ResultsThe scores of both VAS and itching scale decreased significantly in both groups, indicating a significant intragroup difference. With regard to the scar characteristics, the massage group showed a significant decrease after treatment in scar thickness, melanin, erythema, TEWL and a significant intergroup difference. In terms of scar elasticity, a significant intergroup difference was noted in immediate distension and gross skin elasticity, while the massage group significant improvement in skin distensibility, immediate distension, immediate retraction, and delayed distension.ConclusionOur results suggest that burn rehabilitation massage therapy is effective in improving pain, pruritus, and scar characteristics in hypertrophic scars after burn.     

A novel technique to determine pressure in pressure garments for hypertrophic burn scars and comfort properties

Current recommendations state that pressure garments should be worn for up to 2 years for hypertrophic burn scars. Thermo-physiological properties of pressure garments were assessed by the thermo-physiological tests and a comparison of the fabric with a sportwool which is a single-jersey knitted fabric was performed. In this novel technique, it was aimed to determine the exact pressure of pressure garments on the applied body part. For the theoretical part of this study, the Laplace equation was used with an optimum pressure of 20 mmHg and a relationship between change in length versus circumference was calculated. To determine the change in length a ruler was prepared for each predetermined circumference value using this relationship. Grid printed fabric samples were prepared with an interval of 2 cm in width direction to be used for the calculation of mean pressure on a Mannequin Leg. The resultant mean pressure calculated experimentally on Mannequin Leg as 24 mmHg was compared to the optimum pressure of 20 mmHg. It was observed that the two values were not statistically significantly different.     

Fractional ablative laser therapy for the treatment of severe burn scars: A pilot study of the underlying mechanisms

Ablative fractional resurfacing is clinically an efficient treatment for burn scar management. The aim of this pilot study was to investigate the poorly understood mechanisms underlying ablative fractional CO2 laser (AFL-CO2) therapy in relation to biomarkers S100 and 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1). S100 stains for Langerhans cells and neuronal cells, potentially representing the pruritus experienced. 11β-HSD1 catalyses the interconversion of cortisol and cortisone in cells, promoting tissue remodelling. Immunohistochemical analysis of S100 and 11β-HSD1 protein expression in the dermis and epidermis of the skin was performed on normal skin, before and after AFL-CO2 therapy. Data assessing outcome parameters was collected concurrently with the skin biopsies. 13 patients were treated with AFL-CO2 therapy. Langerhans cells decreased by 39% after 2nd treatment. Neuronal cells were overexpressed before treatment in the scar tissue by 91% but levels returned to that resembling normal skin. 11β-HSD1 expression in keratinocytes was significantly higher after laser treatment compared to before in scar tissue (p <0.01). No clear correlation was found in dermal fibroblast numbers throughout the treatment course. Whilst the role of the explored mechanisms and their association with clinical outcomes cannot conclusively be stated, this pilot study demonstrates promising trends that encourages investigation into this relationship.     

The concurrent use of probiotic microorganism and collagen hydrogel/scaffold enhances burn wound healing: An in vivo evaluation

Treatment of burn wounds is technically demanding and several attempts have been taken to improve wound healing. Silver sulfadiazine antibiotic has been shown to have some beneficial effects on wound healing via reduction in infection. This study was designed to investigate the impact of collagen hydrogel-scaffold dressing with or without topical use of Saccharomyces cerevisiae on cutaneous burn wound healing in rat. Four circular 1 cm cutaneous wounds were created in the dorsum back of rats, 48 h post-burning. Thirty male rats were divided into the three major groups (1–3, n = 10), then the wounds in each group were equally divided into two subgroup treatments (6 treatments), (1) including (a) silver sulfadiazine (SSD) as positive control (PC) and (b) untreated wounds as negative control (NC) (2) including (c) S. cerevisiae and (S.C.) and (d) collagen scaffold (CS), (3) including (e) collagen hydrogel-scaffold (CH-S) and (f) S. cerevisiae with collagen hydrogel-scaffold (CH-S-S). In each group, the animals were euthanized at 12 and 22 days post-injury (DPI) and the skin samples were used for histopathological and biomechanical investigations. Collagen scaffold and hydrogel modulated the inflammation, especially when combined together. Moreover, they increased wound healing, epithelialization and biomechanical performance of wound area and also reduced the scar size. The best results gained when the combination of collagen scaffold and hydrogel were mixed with probiotic. The CH-S biological dressing along with probiotic microorganism (S.C.) significantly increased collagen content compared to the negative controls. Moreover, the CH-S-S treated lesions demonstrated greater ultimate load and stiffness compared to the untreated wounds. In conclusion, application of S. cerevisiae with a bi-phase biological dressing (CH-S) improved the morphological and biomechanical characteristics of the healing burned wounds in rats and the results were comparable to the positive control.     

Inflammatory and infectious complications of laser therapy in treatment of hypertrophic burn scars: Correlations in literature review & case reports

IntroductionHypertrophic burn scars contribute to morbidity through secondary symptoms of pain, pruritus, and scar contracture. Traditional treatment methods are now augmented by the use of monochromatic light therapies, which are generally accepted as safe and effective. However, little literature is available regarding the complications of laser treatments of hypertrophic burn scars and even less regarding inflammatory and infectious complications.MethodsA literature search using PubMed was performed to identify literature pertaining to infectious and inflammatory complications of cutaneous laser treatments. Additionally, we reviewed cases of inflammatory and infectious complications occurring at our institution after laser treatment of hypertrophic burn scars.ResultsWe identified 1 publication related to complications of laser therapy in the treatment of burn scars. In this series of 163 laser sessions, the reported incidence of adverse events was 25.1%, of which 6 cases 3.7% were related to inflammatory and infectious processes. In the 391 laser sessions performed at our institution (December, 2015 and July, 2016) 9 cases of inflammatory and infectious complications were noted yielding an incidence of 2.3%. Cases included 3 each of cellulitis, Systemic Inflammatory Response Syndrome (SIRS), and complicated SIRS.ConclusionWe found the most common inflammatory complication was SIRS with MSSA positive wound cultures. Three cases underwent hospitalization along with fluids and vasopressors, despite negative blood cultures. In light of the high prevalence of MSSA in the natural skin flora and negative blood cultures, the inability to establish a true source of infection lead to declaring these cases “complicated SIRS” and not sepsis. Correlative factors that may have led to complications reported in our cases were: preoperative evidence of infection, no preoperative antibiotics administered, no postoperative antibiotic dressings, combined procedures, and large treatment areas. The true mechanism of inflammatory and infectious complication is yet to be determined, but we postulate that these factors place a greater challenge on an already burdened immune system. Determining whether this is a true causal mechanism, leading to an aggravated inflammatory response, benefits from further investigation.Applicability of research to practiceWe urge institutions preforming such procedures to advise patients on preoperative wound preparation. We recommend that each individual with a preexisting history of infection and/or preoperative culture evidence of infection receive antibiotics, particularly when undergoing combined procedures or procedures involving higher surface areas. Although complications are rare, the benefits of these precautionary measures outweigh the risks when it comes to prevention and management.     

Pulsed dye laser therapy and z-plasty for facial burn scars: the alternative to excision

Hypertrophic scarring after partial thickness facial burns is common when epithelialization takes longer than 3 weeks. Well-healed areas continue to mature unfavorably, resulting in raised, erythematous, and contracted scars. Excisional treatment of such scars has morbidity and can create iatrogenic deformities. The flashlamp-pumped, pulsed dye laser (PDL) in combination with z-plasty can be used as a successful alternative to excision in patients with facial hypertrophic burn scars. Fifty-seven patients with hypertrophic facial burn scars (mean age 12 years; range, 2-21 years) were treated with the PDL over the past 8 years. Thirty-four patients (60%) were also treated with z-plasties to relieve scar tension. There was one complication of postoperative blistering. Patients were divided into 3 groups based on time from burn to initial laser treatment. Group I (<1 year) had 11 patients and the laser diminished scar proliferation in these patients. Group II (1-4 years) included 24 patients and treatment resulted in reversal of hypertrophic scarring and elimination of erythema. Group III (>5 years) consisted of 22 patients. The PDL was effective in treating their stable and persistent erythema as long as 17 years after burn injury. No scars required excision in this cohort of 57 patients. The PDL should become an integral part of the management of facial burn scarring and will significantly decrease the need for excisional surgery.     

Sustainable effect of skin stretching for burn scar excision: long-term results of a multicenter randomized controlled trial

Purpose

Primary wound closure of large defects after burn scar excision may be facilitated by intraoperative stretching of the adjacent skin. In a randomized controlled trial (RCT), the effect of skin stretching for wound closure after scar excision (SS) was compared to scar excision without additional techniques (SE). Short-term results already showed that in the SS group larger scars could be excised in a one-step procedure. In this paper, the long-term scar outcome using reliable and valid measurement tools was evaluated.

Basic procedures

The percentage of total remaining scar area (i.e. remaining scar compared to preoperative scar), the percentage of linear scarring (i.e. surface area of linear scar compared to excised scar) and scar hypertrophy was measured at 3 and 12 months postoperatively.

Main findings

At 12 months postoperatively, the percentage of total remaining scar area was significantly lower in the SS group (26%) compared to the SE group (43%). The percentage of linear scarring (SS: 21%, SE: 25%) and the incidence of hypertrophy (SS: 29%, SE: 40%) were not significantly different between the treatment groups.

Conclusions

This RCT demonstrates the long-term beneficial and sustainable effect skin stretching for wound closure after scar excision without leading to wider linear scars or more scar hypertrophy.     

Combination treatment utilizing fractional ablative and continuous wave CO2 lasers for hypertrophic burn scars

BackgroundHypertrophic scars are devastating outcomes of severe burn injuries, producing physical and mental burdens. Adequate treatment is of benefit to relieve these burdens. Laser therapy has shown scar reducing effects. In this study, we compared outcomes after combination of two different lasers or single laser treatment to treat severe hypertrophic burn scars.MethodsForty patients with hypertrophic burn scars were included in one of two therapeutic groups: continuous wave CO₂ laser and fractional ablative CO₂ laser group (group 1, n = 20) or fractional ablative CO₂ laser alone group (group 2, n = 20). Hypertrophic scars were evaluated by the observer-rated Vancouver Scar Scale (VSS) before and after treatment and by patient-completed questionnaires after treatment. Comparative analyses were performed before and after treatment, and time-dependent improvement was also analyzed.ResultsForty patients (54 hypertrophic scars) completed the laser treatment protocols. Group 1 exhibited significantly more improvement in VSS vascularity, pliability, and height indices than group 2 (p < 0.05). Time-dependent analysis of total VSS scores suggested that group 1 experienced more improvement during a shorter treatment period (p < 0.05). For patient-reported outcomes, group 1 noted better grades than group 2 in four indices, namely scar appearance, scar thickness, pain, and pruritus (p < 0.05).ConclusionEffective scar reduction was achieved using combination laser treatment, with significant improvement in multiple observer- and patient-reported outcomes. The shorter treatment period of the combination method can be a merit, as prolonged hypertrophic scars may increase morbidity. Nonetheless, cautious treatment protocols are necessary to avoid undesirable sequelae related to laser application.     

An alternative method for paediatric anaesthetic induction: critical incidents and historical antecedents*

This prospective study was undertaken to examine the safety and to review the historical antecedents of an alternative method of paediatric anaesthetic induction other than halothane by mask. Two-thousand and five ASA I, II and III patients, 1 month-16 years of age initially received 70% N₂O in O₂ via a flavour-scented mask for 1–3 min, until adequate sedation was achieved. Venous cannulation was then undertaken, followed by an intravenous induction with thiopentone, and either atracurium or suxamethonium. The anaesthetist noted the occurrence of specific critical incidents during induction: excitement, coughing, vomiting, airway obstruction, laryngospasm, bradycardia for age, hypotension and/or hypoxaemia. The frequencies of all eight specific critical incidents on induction were extremely low in all ages. The studied alternative method of paediatric anaesthetic induction may be safer and more applicable in diverse clinical settings than a conventional halothane mask induction.     

Assisted therapy with platelet-rich plasma for burn patients: A meta-analysis and systematic review

IntroductionPlatelet-rich plasma (PRP) therapy has been used in different medical fields, but its effectiveness in burn wound healing remains debatable. In this study, we performed a systematic review and meta-analysis of the available evidence on burn patients treated with PRP to evaluate the safety and efficacy of the treatment.MethodsRandomized controlled trials evaluating the efficacy of PRP in patients with burn injuries were selected. Eligible retrospective studies were abstracted and assessed for the risk of bias by two reviewers and results of mean time to complete epithelization and wound closure rate in the included studies were analyzed. Studies on the correlation between PRP and burn wound healing published in English or Chinese before March 2020 were retrieved from PubMed.ResultsEight studies (including 449 patients) met our inclusion criteria. Qualitative analysis revealed that compared with the control group, the PRP group had significantly better wound closure rates at weeks 2 (mean difference (MD): 12.79 [95% confidence interval (CI): 7.08, 18.49]; I2: 0%; p < 0.0001) and 3 (MD: 12.66 [95% CI: 5.97, 19.34]; I2: 55%; p = 0.0002) and time to complete epithelialization (MD: −3.45 [95% CI: −4.87, −2.04] (days); I2: 0%; p < 0.00001). There was no significant difference in infection rate or graft take rate.ConclusionsPRP application can accelerate wound closure, however, it has no effect on the rates of wound infection and graft take rate.     

Silicone gel: a new treatment for burn scars and contractures

A new method of treatment for burn scar management is outlined using silicone gel sheets (Spenco Corporation MD-3071). The method has been applied to 42 patients with burns of varying degree and maturity. The results have been successful in all cases. The mode of action of the gel is unknown, but it does not rely on pressure. The method can easily be tailored to the individual needs of the scar and the patient. Individual initiative and a flexible approach to its use are advocated.     

Tissue expansion for correction of scars due to burn and other causes: A retrospective comparative study of various complications

Background

Tissue expansion is associated with a relatively high complication rate. The aim of this study was to quantify the complication risk of burn scar patients who underwent tissue expansion in comparison to patients with other indications such as skin tumors. Furthermore it was attempted to compare the complication rates in children and adults.

Methods

A retrospective analysis was performed on 148 expanders implanted in 73 patients during the years 1994–2011. Two patient cohorts (burn scar cohort n = 31 and other indication cohort n = 42) were identified and analyzed.

Results

27 male and 46 female patients with a median age of 21 years were included. No statistically significant difference for complication risk between the burn and other indication cohorts could be found (p = 0.1412). Statistical analyses revealed a higher complication rate (52%) in the lower limb compared to all other anatomic sites (29%) (p = 0.1746). In addition, statistical analyses revealed a significantly higher total complication rate in children younger than 10 years (p = 0.0043). Moreover a greater TBSA was accompanied by a higher complication rate (p = 0.0258).

Conclusion

This set of data suggests that the burn scar patient is at no greater risk to suffer complications from tissue expansion. Other factors like age, TBSA and anatomical site have far more influence on the expander complication rate than the initial indication for tissue expansion.