Pulsed Dye Laser Treatment of Hypertrophic Burn Scars
By: Tina S. Alster, M.D. and Christopher A. Nanni, M.D.

Hypertrophic burn scars are notoriously difficult to treat because of their
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extensive tissue involvement and tendency to worsen with

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hypertrophy and contracture formation. Various therapies have been advocated in the past, including surgical excision and grafting, dermabrasion, and corticosteroids, with distinct cosmetic limitations. The 585-nm pulsed dye laser has been shown prevously to be effective in the treatment of a variety of traumatic and surgical scars with improvement in scar texture, color, and pliability with minimal side effects.
Sixteen patients with 40 hypertrophic burn scars resulting from chemical peels, carbon dioxide laser procedures, and accidental thermal injury were treated with a 585-nm pulsed dye laser. Sequential photographic and clinical assessments were recorded in all patients. Histologic evaluations of skin punch biopsies before and after laser irradiation were performed when possible.
Symptomatic improvement of scars was reported after one treatment. Decreased scar erythema with improved texture and pliability was obsereved after an average of 2.5 treatments. No correlation was found between scar duration, location, or etiology and response to treatment. Normal number of dermal fibroblasts with decreased
sclerosis was observed on histologic examination of laser-irradiated scars.
The 585-nm pulsed dye laser irradiation of hypertrophic burn scars can effectively improve scar pliability and texture and decrease erythema and associated symtoms yielding cosmetically and functionally acceptable clincal results.

The presence of scars limits social interaction, impacts self-esteem, and affects daily activivties by limiting range of motion. Because thermally induced scars are typically recalcitrant to treatment owing to their proliferative nature, their appropriate management remains a challenge to physicians from a variety of specialties.

Treatments for burn scars have included a multitude of chemical, physical and surgical options. The use of intralesional corticosteroids has been a cornerstone of both treatment and prophylaxis of hypertrophic scars, but in addition to the pain associated with the injections, skin atrophy, telangiectasias, and dyspigmentation frequently occur. Surgical excision of excess scar tissue with skin grafting has helped to improve function and tissue mobility over affected joints; however, cosmesis is often suboptimal. The benefits of silicone gel and semiocclusive wound dressings can be explained by the possible hydration of scar tissue, but results are variable and delayed. Pressure dressings have been utilized to produce localized tissue anoxia, which could affect scar thickness, but results with their use are also slow and variable. Carbon dioxide laser vaporization of hypertrophic scars and keloids has commonly led to scar recurrence, whereas 585-nm pulsed dye laser treatments have yeilded significant clinical improvement without scar worsening. This study was designed to determine the effectiveness of 585-nm pulsed dye laser irradiation specifically on burn scars induced by chemical agents or thermal injury by fire or prior carbon dioxide laser resurfacing treatment.

MATERIALS AND METHODS

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Sixteen consecutive patients (15 female, 1 male, aged 16 to 77 years old) with 40 scarred antaomic regions were included in the study (Click to See Table 1). All patients had suffered burns from carbon dioxide laser resurfacing, chemical peels, or fire within 1 month to 16 years prior to presentation (Click to See Table 2). All but one patient had received prior treatments with topical and/or intralesional corticosteroids, silicone gel sheeting, excision and/or grafting, and pressure/massage therapy. The patients with most extensive and longstanding scars tended to have had more previous treatments.

A 585-nm flashlamp-pumped dye laser was used. Laser pulses were delivered to the scars in a nonoverlapping manner, producing an immediate purpuric, tissue response. Antibiotic ointment was applied to the irradiated scars twice daily for 1 week after pulse dye laser irradiation. Patients returned for evaluation at 6 to 8-week intervals with the end-study evaluation 6 months following the final laser treatment. Retreatment was performed if healing from the previous treatment was complete(no evidence of post treatment hyperpigmentation) and if additional
treatment was indicated by clinical examination.

Skin punch biopsies (3-mm diameter) were obtained from scars prior to and 6 to 8 weeks after pulse dye laser irradiation. Skin samples were processed with hematoxylin and eosin and Leder stains and evaluated for epidermal changes, dermal sclerosis, fibroblasts, and mast cells.

RESULTS

All patients demonstrated improvement in the clinical appearance of their laser-treated scars after an

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average of 2.75 laser sessions. Fifty percent of the patients reported that their scars were pruritic prior to treatment, with two patients requiring oral antihistamine therapy for control. All the patients reported cessation of pruritis within one or two laser sessions. Of the four patients who had tenderness and burning within their scars before treatment, only one reported continued, albeit improved, symptoms after treatment. Scar pliablity was significantly improved after laser treatment. Most scars softened from firm to pliable or supple. The degree of pliability was not significantly influenced by scar location, duration, or origin.

CONCLUSIONS

Laser treatment of scars must take into account a variety of factors including scar type, color, duration, location, and previous intervention. Although carbon dioxide laser technology using infared light vaporize intracellular water can effectively debulk excess tissue, hypertrophic scars and keloids typically recur following this type of "mechanical" ablation. The 585-nm pulsed dye laser has been used with a high degree of success to treat erythematous hypertrophic scars and keloids resulting from surgery, trauma, and acne without epithelial disruption. It is seen that the treatment of burn scars effectively reduces scar erythema and associated symptons and improves scar pliability and skin-surface texture. Because many burn patients have already obtained previous treatment with little or no apparent benefit, they are reluctant to undergo another invasive or painful treatment. The relative ease and obvious improvement of scars to pulsed dye laser irradiation is, therefore, a viable treatment option. The effect of concomitant treatments, such as intralesional corticosteroids and 5-fluorouracil, should be studied in future investigations to determine whether a synergistic theraputic benefit exists.

ACKNOWLEDGMENT
We gratefully acknowledge the histopathologic analyses performed by Carmen M. Williams, M.D.

DISCLAIMER
Copyright © Burn Survivors Throughout The World, Inc.