The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery.

Since the advent of lasers for cutaneous applications 35 years ago, the uses for this modality have steadily increased over time. While lasers in dermatology are predominantly used for hair removal, tattoo removal, treatment of vascular lesions and resurfacing, other applications are constantly being tested. Most recently, there has been burgeoning interest in the use of lasers for the treatment of scars. In particular, the lasers most often being used for this purpose include the pulsed dye laser (PDL), the carbon-dioxide laser and the fractional laser.

The experienced laser surgeon can utilize combinations of lasers and achieve marked improvement in scarring as depicted in Figures 1 through 4. This patient underwent treatment with a CO2 laser followed by pulsed dye laser and fractional laser over approximately 6 months with almost complete resolution of scarring. Her pre-treatment (Figure 1), during treatment (Figures 2 and 3), and post-treatment photos (Figure 4) are depicted on pages 67 and 68.

Carbon dioxide Laser

While the classic treatment for improving the appearance of surgical scars has been dermabrasion, the carbon dioxide (CO2) laser over the past decade has increased in popularity as a result of its more controlled and precise ability to effect tissue ablation. This is due to its selective thermal injury, with water being the target chromophore.

Study Findings

In a prospective study by Nehal et al,1 photographic evaluation and textural analysis showed comparable improvement with both dermabrasion and CO2 laser for facial surgical scars with regard to surface texture and clinical appearance. Duration of postoperative erythema and reepithelialization were similar for both modalities. Of note, the CO2 laser-treated halves were bloodless and had less post-operative crusting.

The CO2 laser is particularly effective as the final stage of scar revision after other techniques designed to alter the appearance of the final scar are utilized.2

In a prospective study of 30 patients with various surgical, traumatic, acne and varicella scars, Bernstein et al3 found that treatment with the CO2 laser resulted in greater than 50% improvement by photographic analysis in all surgical scars. Greater than 75% improvement was reported in 20 of the 24 surgical scars, and all six traumatic, acne and varicella scars had greater than 50% improvement.

Pulsed Dye Laser

The pulsed dye laser has proven highly effective in fading acne4 and post-operative scars.5 Even in challenging scenarios such as patients with acne excoriée, treatment of facial scarring and ulceration with a combination of psychodynamic therapy and the 585-nm pulsed dye laser resulted in clinical improvement of scars. In particular, it has been used for many years to reduce the erythematous component of scars,6 but has occasionally been used with success on atrophic, retracted scars as well.7

Within the last decade, we have seen an increase in the use of multiple laser types to achieve even greater cosmetic improvement as was the case with our patient.

Study Findings

In 1998, Alster et al8 treated 20 patients with nonerythematous hypertrophic scars with a high-energy, pulsed CO2 laser. Additionally one-half of each scar was additionally treated with the 585-nm PDL laser. Erythema spectrometry measurement and global assessment scores showed that combination CO2 and PDL laser treatment resulted in more significant improvement than CO2 laser irradiation alone. It is important to note that single pulsed dye laser treatment at the time of suture removal does not appear to confer significant clinical benefit with regards to appearance.9

The pulsed dye laser has also been shown to be effective in dark-skinned individuals, although certain pulse widths appear to be more effective. In a study of 19 Thai patients,10 a pulse width of 0.45 ms of PDL was more effective in decreasing scar size and improving scar pliability than was 40 ms. However, the change in pulse width had no significant effect on scar erythema.

Fractional Laser

Fractional photothermolysis is a novel concept using arrays of microscopic thermal damage to stimulate a therapeutic response. It has the potential to avoid the extended recovery periods and prolonged erythema or ablative lasers, yet achieve more noticeable clinical improvement than non-ablative lasers. It has shown particular promise in the improvement of acne scars for most skin types, which by most accounts is a therapeutically challenging condition despite currently available technologies.

Study Findings

A prospective study by Alster et al11 studied 53 patients (Fitzpatrick skin types I to V) with mild to moderate atrophic facial acne scars. They received monthly treatments with a 1550-nm erbium-doped fiber laser (Fraxel). Clinical improvement averaged 51% to 75% in nearly 90% of patients after three laser treatments. Side effects included transient erythema and edema in most patients, but no dyspigmentation, ulceration or scarring.

A study of 27 Korean patients with acne scars led to significant improvement at 3 months post-treatment.12 Adverse events were similar to the previously noted study.

Most recently, fractional thermolysis has been used with some success in the treatment of striae distensae.13 Two female patients with abdominal striae distensae were treated using a 1550-nm Frxel SR laser with multiple treatments 1 month apart at 16 mJ and 125 microthermal zones for a total density of approximately 2000 microthermal zones/cm2 for each treatment.

In addition, the fractional laser has shown promise in the resurfacing of thermal burns.1

Conclusion

Scars occur as a result of various causes including acne, surgery, trauma and burns. Multiple modalities have been used to improve their cosmetic appearance with varying degrees of success. Over the past 20 years, numerous advances have been made in laser technology, which has added to the armamentarium available to clinicians to achieve scar revision. The bulk of this work has been achieved to date by the PDL, carbon dioxide laser and fractional laser. More extensive reviews on this topic are available.15,16

Dr. Bisaccia is a practicing dermatologist and Professor of Clinical Dermatology at the Columbia University College of Physicians and Surgeons in New York City.

Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, OH.

Dr. Lee is a fellow in an ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.

Dr. Rogachefsky is a practicing dermatologist and is the program director of the ACGME-Approved procedural dermatology fellowship at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.