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LASER TREATMENT OF SCARSIntroductionIncreasingly patients who are unhappy about the presence of a scar are seeking referral to laser practitioners for treatment. However there are very few papers in the world literature that describe the role of lasers for improving scars. Patients dislike their scars for a number of reasons. At the initial consultation it is important for the clinician to ascertain which aspects of the scar the patient wishes to improve. The doctor should remember that the features the patient dislikes may not be those that are immediately apparent to the examining eye. It is a biological fact that injuries involving the deeper layers of the dermis of human skin heal with scars. There are a number of features of scars that can be improved by current treatment modalities. However none of these treatments can eradicate a scar completely. All scars take time to mature and fade. Usually this is complete within six months, but it can take as long as two years. Scars may become red, pigmented, depressed, stretched, atrophic, hypertrophic, or keloid. Treatment usually consists of a combination of the following:
Various lasers can be used to improve different aspects of a scar. It is vital that the clinician who assesses the scar has experience of all the possible treatments. Vascular LasersA scar that is excessively red may respond to a vascular laser. I have used both the KTP laser and the pulsed dye laser for red and hypertrophic scars. Both of these lasers reduce the redness and the results seem to be permanent. I prefer to use the KTP laser as it does not cause any bruising in the skin. When used in conjunction with a cooling device the patient suffers very little discomfort. The KTP laser is particularly good at treating the widely dilated vessels in and around a scar. I have found that these telangiectatic vessels are particularly common in hypertrophic and keloid scars that have responded to steroid injections. Some patients with hypertrophic scars have also noticed a decrease in thickness and itching in their scars after treatment with the KTP laser. It maybe that reducing the vascularity of the scar with the laser expedites the maturation process leading to flattening and softening. The optimum timing of laser treatment is not clear. Most of the scars that I have treated were more than 12 months old. There is some evidence that treating hypertrophic scars at around 6 – 12 weeks produces the best results. Stretch MarksPatients often come to see me requesting laser treatment for stretch marks (striae). A vascular laser will reduce the redness of immature striae, though the colour usually fades spontaneously within about 12 months. The end result is a shiny white scar. Laser treatment cannot eradicate the scarring and the final appearance will be identical to that of a mature stria. Q-switched lasersSometimes scars contain areas of blue-black discolouration due to ingrained dirt such as coal duct or road gravel. These can be excised but surgery creates additional scarring. Treatment with a suitable tattoo laser will remove the pigment without creating a further scar. Two or three treatment sessions my be necessary. Resurfacing lasersA number of authors have advocated laser resurfacing of scars to reduce contour irregularity. Carbon dioxide and Erbium:YAG lasers may be used to flatten a raised scar or to even out the skin around a pitted scar. These lasers vaporise the epidermis and cause thermal damage to the underlying dermis. Healing takes place by migration of epidermal cells. As there are no skin appendages (hair follicles and sweat glands) in scar tissue, the only source of healing epidermis is from the adjacent intact skin surface. Thus wide areas of confluent scarring are not suitable for laser resurfacing. AcneThe greatest experience is with resurfacing of acne scarring. Patients present with several different types of acne scars. Some may develop hypertrophic acne scars, which are best treated with a vascular laser. More commonly the scars are depressed. In mild cases of skin pitting the results of laser resurfacing can be very good. However the very deep ‘ice pick’ scars cannot be eradicated with the laser. Resurfacing to the level of the deepest pits would create further dermal scarring. The deeper scars can be excised several weeks prior to laser resurfacing but the new scars may also become depressed and widened. Patients contemplating laser resurfacing must be fully informed of all the risks of the treatment, such as infection, including herpes, recurrent active acne, alteration of skin pigmentation and prolonged erythema. These patients are often desperate for treatment to improve their scars. In my experience they may fail to heed the warnings of the long recovery time following laser resurfacing and may have unrealistic expectations of the results. SummaryLasers do have a role to play in the treatment of scars but this role is not yet clearly defined. It is important that the laser clinician takes a cautious approach and that the patient does not have unrealistic expectations of the outcome. In selected cases such as red scars the result of laser treatment may be very good. However no laser can completely eradicate a scar. Mrs S Pape MB ChB FRCS (Ed Plast)
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The Disfigurement Guidance Centre |
