Evaluation of Fractional CO₂ Versus Long Pulsed Nd:YAG Lasers in Treatment of Hypertrophic Scars and Keloids: A Randomized Clinical Trial

Abstract

Background Keloids and hypertrophic scars are challenging to both patients and physicians. They can be aesthetically disfiguring, functionally debilitating, and emotionally distressing. Lasers have introduced new mechanisms to improve scars both on aesthetic and symptomatic levels. Aim of Work Comparing the efficacy of fractional CO2 laser, long‐pulsed Nd:YAG laser and their combination in the treatment of hypertrophic scars and keloids on clinical, histopathological, and biochemical basis. Patients and Methods Thirty patients with hypertrophic scars and keloids were enrolled in the study. Three scars in each patient were randomly assigned to treatment modalities (i) Fractional CO2, (ii) Nd:YAG laser, (iii) Combined CO2 and Nd:YAG lasers. For each treatment area four sessions, 4–6 weeks apart were performed. Clinical evaluation was done before and 1 month following last session using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). Routine hematoxylin and eosin, Masson's trichrome, and Orcein stains were used to evaluate the appearance and pattern of dermal collagen and elastic fibers. Image analysis was used to quantitatively assess the density of collagen and elastic fibers. Biochemical evaluation of tissue level of transforming growth factor‐β I (TGF‐β I) and TGF‐β III was performed using enzyme‐linked immunosorbent assay studies. Results Both VSS and POSAS showed significant improvement following treatment with the three used modalities. Collagen fibers showed significant improvement as regards appearance and pattern while it was insignificant as regards density. Elastic fibers density improvement was only significant in fractional CO2 (treatment area A). Hypertrophic scars showed more significant improvement with fractional CO2 laser, while in keloids there was no significant difference between the three modalities regarding improvement. Level of TGF‐β I showed significant reduction after treatment in all treatment modalities, while TGF‐β III levels showed insignificant elevation in all treatment modalities. Side effects were significantly higher in treatment area C (combined treatment). Conclusion Long pulsed Nd:YAG laser is effective and safe treatment of hypertrophic scars and keloids. Fractional CO2 laser yields better improvement in hypertrophic scars, while in keloids both fractional CO2 and Nd:YAG lasers achieve comparable improvement. Combination in the same session did not add significant additional benefit and the side effects profile was higher. Limitations small sample size and short follow‐up period. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Fractional CO 2 laser to improve noticeable scars after skin cancer surgery: An appraisal by the patients, laypersons, and experts

“…This study would evaluate whether the fCO 2 laser is really superior to other lasers or if the lasers all entail similar effectiveness. A recently published study showed a slight superiority of the fCO 2 laser over a long pulsed Nd:YAG (neodymium‐doped yttrium aluminum garnet) laser in treatment of hypertrophic scars 19 . However, this study had not been conducted in the format of a split‐scar study.…”

Hypertrophic scars and keloids—Treatment with fractional lasers

“…A recent randomized control trial, concluded that fractional CO 2 laser treatment improved the VSS, increased dermal collagen and elastic fibers in hypertrophic and keloid scars compared to a long/pulse Nd:YAG laser 5 . In the case of combined treatments, Sabry et al 69 showed that there was a significant reduction in VSS 1 month after CO 2 laser monotherapy or CO 2 laser followed by topical 5‐fluorouracil (5‐FU) or verapamil with no significant side effects.…”

“…Triamcinolone acetonide (TAC), 78–81 desoxymethasone 0.25%, 82 5‐FU, 5,83 betamethasone, 84 verapamil hydrochloride, 69 have all been applied over scars effectively in conjunction with lasers to overcome common side effects due to continuous subcutaneous use. In addition, comparisons between 5‐FU and topical corticosteroids have encountered similar clinical outcomes, but fewer dermal atrophy and telangiectasia occurrence for the 5‐FU LADD treatment 83 .…”

“…Ideally, surgical and nonsurgical treatment options should cooperate to give the best outcome possible on a case‐by‐case basis. Nonsurgical therapies have become of paramount importance, intended to inhibit scar recurrence, 3 to slow scar progression, 4 to improve aesthetics, 5 and to restore function 6 . Frequently these therapies are used alone or in combination with surgical procedures.…”

Early Treatment Effects of Nonablative Fractional Lasers (NAFL) on Hypertrophic Scars in an Animal Model

“…Numerous advances involving surgical procedures, silicone gel sheets, steroid injections, and pressure therapy have helped to decipher the process of scar formation and wound healing; however, these therapies have had only limited effects. Recently, several attempts to apply the laser therapy for HTS treatment have been made [5,6]. For the first time, Alster [7] reported an average improvement of 57% after the first treatment and 83% after the second treatment with pulsed dye lasers (PDLs) for hypertrophic surgical and traumatic scars based on an overall clinical assessment scale.…”