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Turn on the bright lights: Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn scars
Charles S. Hultman, MD, MBA, Cindy Wu, MD, MBA, Renee Edkins, RN, NP, Daniel Krochmal, MD, Catherine Calvert, PhD.
University of North Carolina, Chapel Hill, NC, USA.
Introduction: Hypertrophic burn scars can produce significant morbidity, including severe itching, chronic pain, stiffness, and contracture, and best practices for management continue to evolve. Laser therapies have been added to treatment algorithms, but indications and efficacy have not been fully defined. We studied the effect of laser treatment on hypertrophic burn scars, using provider-rated and patient-reported scar scales.
Methods: We conducted an IRB-approved, prospective, before-after, cohort study in symptomatic burn patients with hypertrophic scars. Indications for treatment included hyperemia, pruritis, paresthesias, dysthesias, and stiffness. Procedures were performed at least 6 months after burn injury and were repeated monthly, until clinical improvement peaked. Areas treated included burn scars, skin grafts, donor sites. Specific laser platforms used were 1) 595 nm V-beam pulsed dye laser (PDL) and 2) fractional CO2 ablative laser. In general, PDL was used to treat immature, erythematous scars that were pruritic, whereas the CO2 laser was used to treat mature, thick scars with abnormal texture and decreased pliability. All procedures occurred in an accredited operating suite, with anesthesia delivered by anesthesiologists. Main outcome measures were 1) the Vancouver Scar Scale, which assesses objective changes in pigmentation, erythema, pliability, height (range 0-15) and 2) our own patient-reported scar scale, which documents subjective changes in pain, itching, tingling, stiffness (range 0-12). Scores before and after treatment were compared by Student’s T test, with statistical significance assigned to p values < 0.05.
Results: From January-October 2011, we treated 131 patients over 329 sessions (2.5 sessions/patient), including 265 treatments with PDL (mean surface area: 65.1 cm2) and 108 treatments with CO2 (mean surface area: 99.7 cm2). Mean age was 25.6 years, and TBSA for the burn was 16.4%. Etiology included flame (65), scald (33), contact (12), electrical (9), chemical (5), other (7). All Fitzpatrick skin types (1-6) were treated, with a mode of 2 and a mean of 3.6. Laser treatments occurred a median of 16 months and a mean of 44 months after burn injury. Steroid injections were used in 8% of patients, and only 2 patients underwent simultaneous tissue rearrangement for contracture release. Vancouver Scar Scale decreased significantly from 10.5 (SD 2.3) to 5.1 (SD 2.1) after treatment (p<0.0001). Our own patient-reported, functional scar scale also decreased significantly from 5.48 (SD 2.4) to 2.14 (SD 2.1) (p<0.0001). Complications occurred in 15 patients: laryngospasm (1), cellulitis (1), blistering (2), hypopigmentation (8), post-inflammatory hypopigmentation (2), perioral herpetic infection (1), representing a complication rate/session of 4.6%. Length of follow-up was a mean of 4.1 months.
Conclusions: In this prospective, before-after cohort study, we demonstrate that laser therapy significantly improves the signs and symptoms of hypertrophic burn scars, as measured by objective and subjective instruments. Determining the optimal timing and type of therapy will most likely require a randomized, controlled trial, in order to provide definitive recommendations regarding the management of hypertrophic burn scars.
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