Fractional laser resurfacing for thermal burns

Journal of Drugs in Dermatology, Jan, 2008 by Jill Waibel, Kenneth Beer

Abstract

Fractional resurfacing may be an effective treatment for burn scars because of its unique healing properties and depth of penetration. This case report shows the successful use of fractional resurfacing to treat burn scars. Although more extensive clinical trials are needed, fractional resurfacing could prove to be a therapeutic option for the extensive cutaneous scarring in burn patients.

Introduction

The American Bum Association (ABA) estimates that more than 1 million burn injuries occur annually in the United States. Treating burns poses a great clinical challenge in that the scars formed following thermal or chemical injury are some of the worst scars seen in clinical practice. If a patient survives a burn injury, there can be both physical and psychologically devastating effects.

There have been many approaches to the treatment of burn scars with only moderate success. Fractional photothermolysis has successfully treated a wide variety of dermatologic conditions including rhytids, pigmented lesions, melasma, acne scars, surgical scars, and actinic keratoses. Other benefits of fractional resurfacing include the safe treatment of all skin types and anatomical areas.

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Case Report

A 37-year-old woman who had been burned in a grease fire presented for an evaluation of options for the treatment of her scars. The patient had been treated in a burn unit for burns that covered more than 30% of her body. Treatments for the burns included debridement and skin grafting. Following the grafting of her hands, she had scar contractures of the left hand interdigital spaces.

Upon presentation, the patient examination (Figure 1) revealed scattered hypertrophic scars on her face that severely disfigured her appearance. She also had keloidal scarring of her hands with pigment irregularities (Figure 2). The facial scars were initially treated with a series of 3 intralesional cortisone injections, 5 mg/mL of triamcinolone acetonide (Kenalog[R] Bristol Myers Squibb). Although this treatment improved appearance, the scars did not resolve to a degree that was cosmetically acceptable. Following the intralesional injections, additional treatment options were considered including excision of the scars, pulsed dye laser treatments, and fractional resurfacing. Excision of the scars was thought to be impractical since the extent of the scarring spanned several cosmetic units and the patient's skin had formed hypertrophic scarring from the initial injury. Pulsed dye lasers presented an opportunity to shrink the scars but they would not adequately restore the surface of the skin. After a discussion of the relative risks and benefits of each of these procedures, it was decided to proceed with a course of fractional laser treatments.

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Treatments were begun approximately 20 months after the injury using the Reliant Fraxel[R] SR laser (Reliant Technology) with a wavelength of 1550 nm. A Zimmer cooler (Zimmer MedizinSystems) was utilized to enhance the patient's comfort during the fractional resurfacing sessions. A total of 5 fractional laser treatments were performed, each approximately 1 month apart. Treatment parameters utilized 40-45 mJ on the face and 30-35 mJ on the hands.

Following the 5 treatments, the appearance of the skin on her face had significantly improved and treatments were stopped (Figure 3). In addition, the skin of her hands was markedly improved (Figure 4). The patient was extremely pleased with her appearance and noted improvement of the contractures on her hands.

Discussion

Scarring from thermal injuries occurs from a variety of sources including electrical burns, thermal burns from scalding water, grease, and direct burns from fires. Unfortunately, these burns frequently involve the face where they can have significant morbidity. These burns also tend to involve children or young adults who frequently suffer the sequelae for the duration of their lives.

Lasers have been utilized to treat scars for several years and the utility for this indication has been well documented. (1) Fractional lasers utilize light energy in the 1550 nm range to remove microthermal zones of skin, leaving island of skin intact and able to protect and replenish the skin. (2) The process of fractional resurfacing stimulates collagen formation in the dermis and causes remodeling at this level. Whereas fractional laser resurfacing has largely been used to resurface skin for aesthetic indications including photodamage, its use for the treatment of atrophic and surgical scars suggests that it may be highly useful in other types of scarring. (3,4)

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There is a great deal of experience with fractional resurfacing of the skin and the histological data documents the type and depth of injuries caused when fractional resurfacing lasers are used to treat atrophic scars. Whereas traditional ablative resurfacing is able to treat scars, the prolonged recovery time and frequent complications limits their usage. (5) Clinical trials on the use of fractional resurfacing for the treatment of burns are needed to determine the optimal parameters for treatments including energy settings, time intervals between treatments, number of treatments, wavelength, and spot size. Although there are numerous burn injuries that may benefit from this treatment within the civilian community, its use in military medicine may unleash its full potential.