COPENHAGEN – The fractional CO2 laser at 10,600 nm has emerged as the premier tool for improving the texture and elasticity of hypertrophic burn scars, Dr. Gerd G. Gauglitz asserted at the annual congress of the European Academy of Dermatology and Venereology.
“When it comes to improving the smoothness and the little elevations that are so bothersome to the burn patient, and especially when it comes to the stiffness of the scar, I think the fractional CO2 laser is the approach that has no competition. There might be other devices to come in the future, but I think the results we now see with the fractional CO2 laser are amazing,” said Dr. Gauglitz of Ludwig-Maximilian University, Munich.
It’s an opinion shared by other experts, he noted. For example, last year a panel of eight prominent American academic and military dermatologists and plastic surgeons with extensive experience in laser therapy of traumatic scars – including Dr. R. Rox Anderson of the Wellman Center for Photomedicine in Boston – published a consensus report that concluded “laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars” (JAMA Dermatol. 2014 Feb;150:187-93).
Moreover, an international expert panel that issued updated clinical recommendations on scar management in 2014 declared that broader application of laser therapy constitutes “one of the most significant advances in scar management over the last 10 years.” The panel, which included Dr. Gauglitz, noted that “positive data for fractional lasers support their use for burn scar treatment” (Dermatol Surg. 2014 Aug;40:817-24).
That being said, the current level of evidence supporting the use of fractional CO2 laser therapy for hypertrophic burn scars is poor, Dr. Gauglitz pointed out. No clear data-driven recommendations exist as to the optimal number of laser sessions, between-treatment intervals, or device settings. This was the impetus for his ongoing prospective, controlled study, evaluating a specific treatment protocol in 20 patients with severe, mature hypertrophic burn scars of an average 12.7 years duration.
For purposes of the study, as well as in his own clinical practice, Dr. Gauglitz utilizes the UltraPulse fractional CO2 laser to improve hypertrophic burn scars. He believes it offers compelling advantages over the alternative SuperPulse and continuous wave fractional CO2 laser technologies. The UltraPulse features the narrowest zone of thermal damage, meaning greater precision, less pain and down time; and a favorable safety profile. Most importantly, it has greater penetration capacity, causing microscopic thermal wounds to a depth of 4 mm below the skin surface, which is important for purposes of collagen remodeling, he explained.
When using CO2 lasers for burn scars, “clinically, we see completed reepithelialization after the procedure and then an ongoing collagen-remodeling phase lasting for up to 9 months. We see improvements in dermal architecture and creation of a collagen subtype profile that’s closer to nonwounded healthy skin,” according to the dermatologist.
Because other studies have relied heavily upon nonstandardized before and after photos and the Vancouver Scar Scale, with relatively short-term follow-up, Dr. Gauglitz and coinvestigators sought to advance the field by incorporating a variety of more objective measures, including the PRIMOS (Phaseshift Rapid in Vivo Measurement of the Skin) three-dimensional device widely utilized for wrinkle measurement, as well as the Cutometer, which evaluates skin elasticity. The investigators are also formally measuring the quality of life impact of their laser regimen.
The study consists of two parts. At the EADV congress, Dr. Gauglitz presented the results of the first part, which involved a single treatment of a 12-by-8 cm2 area, with a comparable untreated control area, and a 6-month follow-up. In the ongoing second part of the study, the same patients are undergoing three treatment sessions on a larger scarred area, with 3-month intervals between sessions. Again, a comparable untreated area of the body serves as the control.
Each treatment session involves three passes with the UltraPulse laser. The first is done at the most intense setting, known by the proprietary name of SCAAR FX (Synergistic Coagulation and Ablation for Advanced Resurfacing). This is aimed at inducing the collagen-remodeling process. The setting is 70-140 mJ/cm2, 250 Hz, with a density of 1%. The second pass utilizes the small-spot ACTIVE FX setting, designed to provide superficial ablative therapy to remove fine elevated scars. This involves 40-90 mJ/cm2 at high density and 300 Hz. The final pass is set at large-spot Active FX and employs 125 mJ/cm2 at low density and 125 Hz; the purpose is to smooth the scar and make the skin surface more homogeneous.