Figure 2 - uploaded by Helen Elizabeth Douglas
Content may be subject to copyright.
Changes in scar appearance at 6 weeks posttreatment. Clinical images of two immature scars before treatment (a, c) and 6 weeks post-treatment (b, d). Treatment areas are lower right diagonal areas shown in insets. Scars visibly improve.
Source publication
Aim:
To investigate the effect of ablative fractional CO2 laser (AFCO2L) on burns scar appearance and dermal architecture at 6 weeks and up to 3-years post-treatment.
Methods:
Twenty adult patients with a burn-related scar were recruited. Inclusion criteria were a minimum scar area of 10 × 10 cm and Vancouver scar scale (VSS) score of >5 and ≥6...
Citations
... Douglas et al. found that the VSS score after CO 2 fractional laser therapy was not significantly different from that before surgery. 27 The reason may be that the evaluation of VSS is subjective, and scars may be evaluated by different therapists due to the generally lengthy time span of treatment, thus having a greater impact on the results. 28,29 In addition, it is worth mentioning that the dose of laser therapy was not stan- The study also showed that the pruritus degree of post-burn HS in children was significantly reduced after CO 2 fractional laser therapy. ...
Objective
To evaluate and explore the efficacy of CO2 fractional laser in treating post‐burn hypertrophic scars in children through Meta‐analysis.
Methods
English databases (PubMed, Web of Science and The National Library of Medicine), as well as Chinese databases (China National Knowledge Infrastructure and Wanfang Data) were searched. RevMan 5.3 software was used to data analysis.
Results
A total of 10 pieces of literature were included, involving 413 children. Meta‐analysis showed that: (1) The average Vancouver Scar Scale after surgery was significantly lower than that before surgery [weight mean difference (WMD) = −3.56, 95% confidence interval (CI):−4.53,−2.58, p < 0.001]; (2) After CO2 fractional laser, pigmentation [WMD = −0.74, 95% CI:−1.10,−0.38, p < 0.001], pliability [WMD = −0.92, 95% CI:−1.20,−0.65, p < 0.001], vascularity [WMD = −0.77, 95% CI:−1.09,−0.46, p < 0.001], height [WMD = −0.57, 95% CI:−0.95,−0.19, p < 0.001] were improved compared with those before surgery. (3) The average Visual Analogue Scale (VAS) after surgery was significantly lower than that before surgery [WMD = −3.94, 95% CI:−5.69,−2.22, p < 0.001]. (4) Both Patient and Observer Scar Assessment Scale (POSAS)‐Observer [WMD = −3.98, 95% CI:−8.44,0.47, p < 0.001] and POSAS‐Patient [WMD = −4.98, 95% CI:−8.09,−1.87, p < 0.001] were significantly lower than those before surgery. (5) Erythema and vesicles were the most common complications after CO2 fractional laser therapy, with an incidence of 4.09%.
Conclusion
CO2 fractional laser is beneficial to the recovery of hypertrophic scar after burn in children, and can effectively improve the scar symptoms and signs in children, with desirable clinical efficacy.
... 11,15 Laser therapy and other resurfacing modalities have been introduced in multiple international burns centres in Australia with evidence that it reduces length of hospital stay, anaesthetic time and non-laser reconstructive procedures. 16,17 There are many types of devices currently used in the treatment of hypertrophic burns scars. Lasers have a variety of therapeutic targets depending on the device and mechanism, including reducing abnormal scar development as well as promoting healthy tissue growth. ...
... 18,19 The use of CO 2 lasers in hypertrophic burn scar management has been shown to reduce scar thickness, improve symptoms of pain, pruritis and aesthetics of the scar, even in mature scars that were resistant to other management options. 17,19,[21][22][23][24][25] While there are many studies assessing the use of IPL devices and CO 2 lasers individually in the treatment of hypertrophic scars, 23,26 there are few studies assessing the combined use of both IPL devices and CO 2 lasers. Studies that have assessed the combined use of both devices have found positive impacts on the improvement of scars, compared to the use of individual devices. ...
Introduction
Hypertrophic scarring is a common and debilitating consequence of burn scars. While there is limited evidence for current treatment options, laser therapy has been shown to be effective, low risk and minimally invasive. This study assesses the use of carbon dioxide lasers and intense pulsed light devices in the treatment of hypertrophic burn scars.
Methods
In this case series, patients were recruited from a hypertrophic burn scar waitlist and completed a Patient and Observer Scar Assessment Scale prior to and six weeks after laser therapy. The Nordlys (intense pulsed light) and CO 2 RE (carbon dioxide) systems from Candela Medical were used, with a range of settings used depending on the assessment of the burn scar. The differences between scores were calculated for the total Patient and Observer Scar Assessment Scale score, pain, itch, colour, stiffness, thickness, irregularity and the overall opinion of the scar. Statistical analysis was completed using a paired, two-tailed student T test.
Results
A total of 31 patients were recruited for this trial with a range of scar locations, surface areas and mechanism of burn injury. The calculated difference in mean showed a significant reduction for the overall Patient and Observer Scar Assessment Scale score (1.93, p < 0.0001), pain (1.39, p = 0.0002), itch (1.84, p = 0.0002), colour (1.97, p < 0.0001), stiffness (2.47, p < 0.0001), thickness (2.1, p < 0.0001), irregularity (1.89, p < 0.0001) and overall opinion (1.58, p = 0.0003).
Conclusion
Current management options for hypertrophic scarring have limited evidence. Laser therapy presents a minimally invasive procedure that can be completed under topical anaesthetic and has shown to be effective following a single treatment of combined carbon dioxide laser and intense pulsed light device therapy.
Lay Summary
Many people will suffer a burn injury throughout their life and up to almost 3 out of 4 people with burn injuries will suffer from hypertrophic scars (a thickened, red and itchy scar). These scars cause distress both due to their appearance and their reduction of function, particularly over a joint or muscle. Laser therapy, in which different wave lengths of light (pulsed light) or gas (carbon dioxide) target the scar, has been found to be effective and have minimal side effects in the management of hypertrophic scars. While individual lasers have been assessed and found to be effective and low risk, the combined use of multiple lasers on the same scar has not been extensively studied. We studied the effectiveness of both light and gas laser therapies on hypertrophic scars. Patients with hypertrophic scars completed a questionnaire that focused on their perspective of their scar (pain, itch, stiffness, thickness, irregularity, overall opinion) prior to the treatment. The patients then underwent laser therapy (with local anaesthetic gel) with either pulsed light and/or carbon dioxide (gas) laser. The type of laser used was decided by the clinician performing the therapy depending on scar location and thickness. Patients then re-completed the subjective survey six weeks following the laser therapy, and the results compared. We learnt that laser therapy (both light, gas and a combination of both) are effective (and low risk) in reducing the subjective burden of the scar for the patient.
... However, new and advanced methods have been developed to treat burn scars. Lasers, especially fractional and ablative nonfractional lasers, can play an important role in the treatment of scars, especially burn scars [5][6][7]. On the other hand, autologous fat grafting is considered a new and promising method for skin rejuvenation and scar treatment [8]. ...
... In the group treated with fractional CO 2 laser, there was a significant improvement between the two groups before and after the procedure in the mean variables of the Vancouver scar scale (7.40 ± 1.35 vs. 5.90 ± 1.97, p value = 0.007), cutometry R7 (0.59 ± 0.17 vs. 0.48 ± 0.13, p value = 0.032), complete density sonography (10.89 ± 6.04 vs. 17.27 ± 8.19, p value = 0.018), and dermal density sonography (7.95 ± 5.29 vs. 14.18 ± 8.46, p value = 0.020) (Figs. 1,4,5). ...
... On the other hand, the use of fractional CO 2 lasers is widely applied in dermatology, such as in the treatment of striae distensae [18][19][20][21], atrophic acne scars [22][23][24][25], and burn scars [26][27][28]. Several studies have been performed on the methods used to treat skin scars [1,5,8,9]. Among the methods used to treat skin scars in previous studies, the role of fractional CO 2 laser should be mentioned [22,23,25,28,29]. ...
Background
The appearance of skin scars is known as one of the main side effects of skin burns. Stromal vascular fraction (SVF), as a rich source of cell populations with tissue regeneration properties, plays an important role in the healing of skin lesions. Fractional CO2 lasers have occupied a special place in treating skin lesions, particularly skin scars, since their introduction. Our study aimed to compare the combination of SVF and fractional CO2 laser with fractional CO2 laser alone in the treatment of burn scars.
Method
This double-blind clinical trial study was conducted on ten patients with burn scars that were treated three times with a fractional CO2 laser at site of burn lesions, and one of the two areas studied was randomly injected with SVF. Two months after completion of the procedure, patients' scars were assessed using the Vancouver scar scale (VSS), biometric criteria, and physician and patient satisfaction ratings.
Results
The results confirmed a significant improvement in VSS, cutometry, R7 criteria, complete density sonography, and skin density sonography in the fractional CO2 laser-treated group. The VSS criteria, epidermal thickness sonography, complete density sonography, and skin density sonography in the group treated with the combination of fractional CO2 laser and SVF also showed significant improvement. The VSS criteria and melanin index of Mexameter in the group treated with SVF in combination with fractional CO2 laser were significantly better than the group treated with fractional CO2 laser alone. Also, physician and patient satisfaction in the group treated with SVF injection in combination with fractional CO2 laser was significantly higher than the other group.
Conclusion
The results confirm the efficacy of SVF injection in combination with fractional CO2 laser in the treatment of burn scars and can be considered as a treatment option for better management of these lesions.
Trial registration: The study protocol was retrospectively registered at Iranian Registry of Clinical Trials with code: IRCT20210515051307N1, Registration date: 2021-11-14, URL: https://www.irct.ir/trial/56337.
... 10,11 We have previously conducted a randomized controlled trial with AFCO 2 L, and the results showed clinical improvement in pliability, pain, and itch. 2,7 This was evidenced by the significant improvement in collagen orientation of deep dermis in the treated tissues. 7 Subsequently, we performed another trial to investigate whether early laser intervention promotes scar evolution (ELIPSE) by assessing the impact of AFCO 2 L on early scar evolution, clinical outcomes, and scar biology. ...
... 2,7 This was evidenced by the significant improvement in collagen orientation of deep dermis in the treated tissues. 7 Subsequently, we performed another trial to investigate whether early laser intervention promotes scar evolution (ELIPSE) by assessing the impact of AFCO 2 L on early scar evolution, clinical outcomes, and scar biology. ...
... The ELIPSE results revealed improvement in patient-reported scar thickness and irregularity. 7 Factoring in the other elements of the POSAS, however, did not illustrate a significant change overall. Similarly, as reported in our previous work, the VSS was unable to detect any improvement in scar outcome over the study period. ...
Aim:
To investigate the impact of ablative fractional carbon dioxide laser (AFCO2L) on patient-reported outcomes measures, subjective scar appearance, dermal architecture, and gene transcription in early burn scars.
Methods:
Fifteen adult patients with a burn-related scar were recruited. Inclusion criteria were two non-contiguous scar areas of 1% total body surface area, similar baseline Vancouver scar scale (VSS) score and 3months since the time of injury. All participants acted as their own control. Scars were randomized to treatment or control. Treatment scars received three AFCO2L treatments at 6-week intervals. Outcome measures were recorded at baseline, 3, 6, and 12-months post-treatment. Measures included blinded VSS, Patient Observer Scar Assessment Scale (POSAS), Brisbane Burn Scar Impact Profile (BBSIP), blinded scar photo assessment, histological tissue analysis, and RNA sequencing analysis.
Results:
No significant difference was found in VSS, scar erythema, or pigmentation. Patient POSAS improved in scar thickness and texture following AFCO2L. All elements of BBSIP improved in control and laser groups. AFCO2L-treated scars were scored better than control scars by blinded raters. RNA sequencing illustrated that AFCO2L induced sustained changes in fibroblast gene expression.
Conclusions:
AFCO2L treated scars had significantly altered scar thickness and texture 6 months post-laser and were rated better than controls on blinded photo analysis after 3 treatments. RNASeq results suggest laser treatment alters the transcriptome of treated fibroblasts for at least 3 months after treatment. Expansion of this research to study in more depth fibroblast changes in response to laser, as well as assessing the impact on daily activity and quality of life, will be beneficial.
... In 2006, the revolutionary concept of fractional laser therapy was introduced, whereby microscopic thermal treatment zones (MTZs) are created and surrounded by untreated tissue, in order to stimulate collagen remodeling and regeneration of skin tissue (7). Nowadays, ablative fractional CO 2 laser treatment has been found to be highly beneficial and safe for the treatment of hypertrophic scars (8)(9)(10). Compared to laser, the intense pulsed light (IPL) is a non-coherent broadband light with the spectrum between 400-1200 nm. ...
Background and Objectives
Hypertrophic scarring is a complex process, and numerous methods have been introduced to treat scars. This study aims to evaluate the effect of combined CO2 fractional laser and narrowband intense pulsed light (IPL) compared to IPL alone in the treatment of hypertrophic scars.
Materials and Methods
This was a prospective, randomized controlled study enrolled 138 patients with hypertrophic scars. The participants were randomly divided into two groups: CO2-IPL and IPL group, and received three sessions at 10–14-week intervals for 3-month follow-up. Two independent plastic surgeons evaluated the treatments using the Patient and Observer Scar Assessment Scales (POSAS). Overall satisfaction was evaluated using the Patient Satisfaction Scale (PSS).
Results
101 subjects completed the study. Compared to single IPL, the combination CO2-IPL group showed a significant improvement in itching, color, stiffness, thickness, and irregularity, except for pain, and an enhancement in vascularization, pigmentation, thickness, relief, and pliability of the scar, assessed by POSAS (p < .01). 100% patients in the combination group were satisfied compared to 84% in IPL alone.
Conclusion
The combination of CO2 fractional laser and narrowband IPL efficiently improved the appearance and profile of hypertrophic scars, offering a comprehensive and reliable approach for scar therapy.
... However, new and advanced methods have been developed to treat burn scars. Lasers, especially fractional and ablative non-fractional lasers, can play an important role in the treatment of scars, especially burn scars [5][6][7]. On the other hand, autologous fat grafting is considered a new and promising method for skin rejuvenation and scar treatment [8]. ...
... In the group treated with a fractional CO2 laser in combination with SVF, patient and physician assessment scores were higher than in the group treated with a fractional CO2 laser alone, and this difference was signi cant (Table 3). Several studies have been performed on the methods used to treat skin scars [1,5,8,9]. Among the methods used to treat skin scars in previous studies, the role of fractional CO2 laser should be mentioned [22,23,25,28,29]. ...
Background
The appearance of skin scars is known as one of the main side effects of skin burns. Stromal vascular fraction (SVF), as a rich source of cell populations with tissue regeneration properties, plays an important role in the healing of skin lesions. Fractional CO2 lasers, have occupied a special place in treating skin lesions, particularly skin scars, since their introduction. Our study aimed to compare the combination of SVF and fractional CO2 laser with fractional CO2 laser alone in the treatment of burn scars.
Method
This double-blind clinical trial study was conducted on 10 patients with burn scars that were treated three times with a fractional CO2 laser at site of burn lesions, and one of the two areas studied was randomly injected with SVF. Two months after completion of the procedure, patients' scars were assessed using the Vancouver Scar Scale (VSS), biometric criteria, and physician and patient satisfaction ratings.
Results
The results confirmed a significant improvement in VSS, cutometry, R7 criteria, complete density sonography, and skin density sonography in the fractional CO2 laser- treated group. The VSS criteria, epidermal thickness sonography, complete density sonography, and skin density sonography in the group treated with the combination of fractional CO2 laser and SVF also showed significant improvement. The VSS criteria, and melanin index of Mexameter in the group treated with SVF in combination with fractional CO2 laser were significantly better than the group treated with fractional CO2 laser alone. Also, physician and patient satisfaction in the group treated with SVF injection in combination with fractional CO2 laser was significantly higher than the other group.
Conclusion
The results confirm the efficacy of SVF injection in combination with fractional CO2 laser in the treatment of burn scars and can be considered as a treatment option for better management of these lesions.
The study protocol was registered at Iranian Registry of Clinical Trials with code: IRCT20210515051307N1, Registration date: 2021-11-14, URL: https://www.irct.ir/trial/56337.
... Of these, 46 articles met our inclusion criteria (Figure 1), and 39 articles were available. We found that 12 were cohort studies [31][32][33][34][35][36][37][38][39][40][41][42], 3 were case-control studies [43][44][45], 5 were RCTs [46][47][48][49][50], 4 were non-randomized controlled trials [51][52][53][54], and 15 were in-patient controlled studies [55][56][57][58][59][60][61][62][63][64][65][66][67][68][69]. Table 2 summarizes the characteristics of the 39 studies. ...
... * In order to distinguish between the two Li's articles published in 2021, we have marked this one with an asterisk [43]. [31,[33][34][35][36]38,39,[41][42][43]45,46,50,52,[54][55][56][57][59][60][61][62]64,65,[67][68][69]. Each trial is represented by a green point, and the size of the point is proportional to the information in that trial. ...
... Overall, therapies that included IPL were found to work best. [31,[33][34][35][36]38,39,[41][42][43]45,46,50,52,[54][55][56][57][59][60][61][62]64,65,[67][68][69]. Each trial is represented by a green point, and the size of the point is proportional to the information in that trial. ...
Burns and scarring are considered some of the greatest problems in public health because of their frequent occurrence. Today, photo-electric technology shows promising results in the treatment of burn scars. Over the years, more clinical trials and more technologies for scarring have emerged. The aim of this study was to determine better timing and methods of photo-electric therapy for burn scars. This study was registered in PROSPERO (CRD42023397244), following the PRISMA statement, and was carried out in concordance with the PRISMA checklist. In October 2022, we searched PubMed.gov, Embase, and the Cochrane library (1980–present) for published studies related to the photo-electric treatment of burn scars. Two review authors independently selected the studies, extracted the data, assessed the risk of bias among the studies included, and carried out NIH assessments to assess the certainty of the evidence. A third review author arbitrated any disagreements. Our research included 39 studies. We found evidence suggesting that photo-electric therapy between six months and one year offers significantly better outcomes than treatment of scarring after one year. The evidence also suggests the use of IPL for the treatment of early burn scarring. However, it is important to emphasize that the scientific evidence remains insufficient. We need more clinical trials of higher quality and with less heterogeneity to confirm our results.
... This choice of control as standard care follows recommendation from a recent feasibility RCT conducted in the UK 53 and a consensus between co-applicants for this trial. In a rigorous RCT of the effects of ablative laser on scarring, SoC treatments were chosen as the control 54 . ...
This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact.
This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.
Trial registration: ISRCTN14392301 (registered on 14 th June 2021)
Contact for Public & Scientific Queries: Mark Brewin, sft.elabs@nhs.net
Public Title: Early Laser for Burn Scars (ELABS): a trial of the effectiveness and cost of the treatment of hypertrophic burn scars with laser
Countries of Recruitment: England & Scotland
Protocol Version: v11, October 2021
... 20 A recent randomised controlled trial also demonstrated improvements in burn scars after CO 2 laser in both VSS and histological parameters. 21 A large database study including 295 patients assessed the impact of burn scar severity (measured by the VSS) on increases in time to healing (TTH). 17 Investigators found that a VSS score increase of 0.11 points (P ≤ 0.001) was associated with an additional day of TTH, irrespective of differences in total burn surface area or surgical intervention. ...
Background:
Scar formation is a normal part of the proliferative phase in wound healing where collagen is remodelled to better approximate normal skin. When collagen is not effectively redistributed, excessive scarring may occur. Recently, CO2 laser has emerged as an adjunct in improving scar quality via remodelling and redistribution of dermal collagen fibres. Due to the paucity of literature related to its use in the hands and upper extremities, we created a study to examine its effects on hypertrophic scars focused on the hands and upper extremities.
Methods:
Patients treated with CO2 laser for hypertrophic scars of the hand and upper extremity were included. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to assess the progression of scar quality. Unpaired t-tests were performed to determine statistical difference between pre- and post-treatment scores on each scale. Pearson correlation coefficients were used to understand the relationship between number of treatments and scar quality.
Results:
Of the 90 patients enrolled, 54 patients completed serial scar assessment forms. All patient and observer-reported POSAS domains showed improvement (P < 0.05) apart from Itching. All VSS domains showed improvement (P < 0.05). There was moderate correlation between overall patient-reported opinion of scar quality and Discoloration, Stiffness and Thickness, and strong correlation between overall patient opinion and Irregularity (r = 0.715). All observer-reported domains were strongly correlated (r = 7.56-8.74) with overall observer opinion of scar quality.
Conclusion:
The results of this study may further substantiate CO2 laser as a treatment modality for excessive scarring in a variety of surgical subspecialties.
Lay summary:
Complex trauma and burns that impact the skin sometimes result in abnormal healing of the skin called, "hypertrophic scarring". In our study we assessed how using focused CO2 laser therapy impacts patients and health care provider assessment of wound progression. Our results were based upon patient reported and healthcare provider observations based upon two standardized forms the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). What we found is that after CO2 Laser Therapy, our 64 patients with 77 treated scars received on average almost 3 treatments and these treatments helped them with physical function and improved aesthetic appearance of their scars. The health care providers also found that the treatments improved functional and aesthetic end points. Overall, our study helps substantiate the body of evidence that using CO2 laser therapy improves aesthetics and function of hypertrophic scars in the upper extremity.
... In recent years, fractional ablative and non-ablative lasers have emerged as an adjunct therapeutic modality for the treatment of burn scars [6,7]. Fractional ablative carbon dioxide (CO 2 ) laser has been used in the management of scar tissue and provides an alternative to invasive operative treatments options [7][8][9][10]. ...
Objectives
To experimentally compare two fractional ablative CO2 laser handpieces intended for the treatment of large area burn scars. Each handpiece coverage rate, depth of penetration and application time were measured and compared in a simulation model of large area burns scars using a dynamic/roller handpiece (small footprint) and a stationary/stamping handpiece (large footprint).
Methods
A 30 W fractional ablative CO2 laser was applied using 2 different handpieces and footprints on a A4 size paper stack. The handpieces were a stationary (stamping) handpiece with 7×7 (49 pixels/square shape) and dynamic (roller) handpiece with 7×1 (7 pixels/single row shape). For both handpieces the laser settings were fixed at "High" power (30 W), providing an energy level of 100mJ/pixel. Both handpieces were applied perpendicular to the surface, with the process repeated for the dynamic handpiece with an angled operation. The depth of laser penetration was assessed by the number of pages of paper having visible holes and burn area coverage time measured under each handpiece/condition.
Results
The application time was faster and the penetration deeper for the dynamic handpiece compared to the stationary handpiece in both the perpendicular and angled conditions. This study has practical implications for lasers operators to improve time efficacy in large area scars with improved clinical endpoints.
Conclusion
The fractional ablative dynamic handpiece demonstrated superior application efficiency compared to the stationary handpiece in the simulated treatment of large surface area burn scars, reducing treatment time with improved depth of penetration.
