Melasma, Novel Treatment Modalities

Objective: To observe the clinical effects of sequential treatments of pulsed dye laser (PDL) and ablative fractional carbon dioxide laser on early stage hypertrophic burn scars. Methods: From January 2016 to December 2017, 221 patients with 228 hypertrophic scars in all parts of body within 6 months post healing, conforming to the study criteria and treated in our department, were included in this prospective study. They were first treated by PDL, repeated at an interval of one month until the vascularity score of scar fell below 2 points, and then treated by ablative fractional carbon dioxide laser, repeated at an interval of 3 months. Their start time and numbers of treatment and follow-up time were recorded. Before the first treatment (hereinafter referred to as before treatment) and at the last follow-up (hereinafter referred to as after treatment), the vascularity, thickness, and pliability of scars were scored by a self-made scar rating scale. The scores of patients with the observation time between 6 to18 months post healing were compared among scars of patients grouped by age, body site of scar, starting time of treatment and numbers of treatment. The laser speckle contrast imaging technique was used to measure the blood flow value of scars. The itching symptom of the scars was evaluated by the Verbal Rating Scale. The satisfaction to the final effects of the doctors and patients was investigated and scored separately by Likert scale after treatment. The therapeutic or adverse reactions were recorded during the treatment. Data were processed with paired t test, Mann-Whitney U test, Wilcoxon signed rank sum test, Kruskal-Wallis H test, and Spearman rank correlation analysis. Results: (1) The patients were treated on (64±36) d post healing, by PDL for (2.5±1.3) times and by ablative fractional carbon dioxide laser for (2.2±1.2) times. The follow-up time was (331±189) d. (2) The vascularity, thickness, pliability scores and total scores of scars were (1.4±0.9), (2.0±0.8), (1.7±0.8), and (5.0±2.1) points respectively after treatment, which were significantly lower than those before treatment [(4.1±0.7), (3.1±0.8), (3.0±0.9), and (10.2±2.0) points respectively, t=43.332, 24.968, 28.063, 46.394, P<0.01]. (3) Among the 123 scars from 120 patients with observation time between 6 to 18 months post healing, there were no statistically significant differences in the vascularity, thickness, pliability scores and total scores of scars among patients with different ages after treatment (χ(2)=4.339, 1.826, 1.375, 2.879, P>0.05). There was only significant difference in the pliability scores of scars among different body sites (χ(2)=13.530, P<0.05). There were statistically significant differences in the vascularity, thickness, pliability scores and total scores of scars with different starting time of treatment (χ(2)=30.725, 25.233, 25.119, 35.798, P<0.01). There were significantly positive correlation between starting time of treatment and the vascularity, thickness, pliability scores and total scores of scars (r=0.492, 0.442, 0.446, 0.532, P<0.01). There were statistically significant differences in the vascularity, pliability scores and total scores of scars with different numbers of treatment (Z=4.883, 4.910, 5.049, P<0.05). There were significantly negative correlation between number of treatment and the vascularity, thickness, pliability scores and total scores of scars (r=-0.176, -0.131, -0.191, -0.201, P<0.05). (4) The blood flow values were determined in 18 scars of 18 patients. The results showed that the blood flow values of scars after treatment were significantly decreased compared with those before treatment (t=7.230, P<0.01). (5) The pruritus scores of scars of patients after treatment were significantly decreased compared with those before treatment (Z=12.818, P<0.01). (6) There were significant differences between the satisfaction scores of doctors and the scores of patients after treatment (t=12.130, P<0.01). (7) After PDL treatment, there were some edema and purpura reactions for all the patients, and 11 (5.0%) patients had blisters. After ablative fractional carbon dioxide laser treatment, 4 (1.8%) patients had blisters, 5 (2.3%) patients suffered inflammatory reaction and erosion, and 9 (4.1%) patients suffered pigmentation. Conclusions: The scores of hypertrophic burn scars can be obviously improved by sequential treatments of PDL and ablative fractional carbon dioxide laser. The effects can be more obvious with the earlier starting time and more numbers of treatment. The laser treatments can also decrease the blood flow values and alleviate the pruritus of scars, with high satisfaction of both patients and doctors.

The use of ablative lasers based on the fractional approach is a novel strategy for the treatment of postoperative and acne scars in addition to wrinkles. To evaluate and compare the efficacy of carbon dioxide ablative fractional laser (AFL) and the pulsed dye laser (PDL) for the improvement of surgical scars. Fourteen Korean patients with surgical scars were enrolled for this study. Half of each scar was treated with a 10,600-nm AFL and the contralateral half with the 595-nm PDL. For early intervention of the postoperative scar, the laser treatments were begun after 2 weeks from the Mohs micrographic surgery. Both PDL and AFL produced statistically significant improvements. However, comparatively, there was no statistical difference between them. In each variable, AFL was more effective than PDL in the improvement of pliability and thickness. In contrast, PDL was superior to AFL in the improvement of vascularity and pigmentation. Pulsed dye laser and AFL treatments for surgical scar provide significant improvement. Pulsed dye laser was more effective in color of scar compared with AFL, which showed marked improvement in the contour of scar. Overall improvement was not statistically different in the Vancouver Scar Scale.

BackgroundThe anterior neck is the site of open thyroidectomy and where postoperative scarring can cause distress to patients. Both fractional and pulsed-dye lasers are effective and safe methods for preventing and improving surgical scars.ObjectiveThis study evaluated the improvement in scar appearance with laser intervention during the wound healing process. We evaluated the effect of nonablative fractional and pulsed-dye lasers on fresh thyroidectomy scars.MethodsPatients were treated 3 times at 4-week interval with a follow-up visit at the 6th month. Scars were divided into 2 halves for each optional treatment. At every visit, a questionnaire evaluating the scar and patient satisfaction was completed.ResultsThirty patients completed the 6-month process. The mean Vancouver Scar Scale scores improved significantly from 8.0 to 4.6 and 8.2 to 4.7 with nonablative fractional and pulsed-dye lasers, respectively (p<0.001). However, there was no significant difference between the 2 methods (p=0.840).ConclusionThere remains no consensus on the optimal treatment of scars. The present study indicates nonablative fractional and pulsed-dye lasers significantly improve scars. Nonablative fractional lasers are non-inferior to pulsed-dye lasers. Further studies are required to corroborate this finding.

Despite history of multiple treatment modalities, repigmentation of hypopigmented scars remains a difficult clinical problem. The purpose of this review is to evaluate the literature on laser and combination laser plus adjunct topical therapy for hypopigmented burn and traumatic scars. A search on PubMed and on Oxford Academic was conducted with additional relevant literature obtained from reference lists. Treatment regimens that address hypopigmentation within scars were reviewed. A combination of nonablative fractional or ablative fractional laser treatment with topical prostaglandin analogue with or without topical retinoid were found to result in superior repigmentation. Reliable improvement of hypopigmentation in scars after laser treatment is challenging. Laser can achieve success in some cases. Ultraviolet laser can achieve modest repigmentation; however, results are short-lived and require continued re-treatment. Modest improvement in pigmentation is seen with nonablative fractional laser or ablative fractional laser alone and enhanced repigmentation is demonstrated when combining fractional laser resurfacing with topical application of synthetic prostaglandin analogues and other known modulators of melanogenesis.

Introduction: An estimated 100 million patients acquire scars of any type every year, a few of which will lead to hypertrophic, contracting scars or keloids. Management remains challenging and encompasses surgical and non-surgical treatment options. The introduction of fractional photothermolysis (FP) in 2004,marked a major advancement in treatment. Unlike classic non-fractional ablative lasers, FP uses well focused laser beams to create small columns of ablation called microscopic treatment zones (MTZ).FP has since been discovered to be particularly useful in relieving scar contractures with efficacy on improving functionality and cosmetic outcomes. We aim to present a case of a contracting scald burn over the buttocks improving exceptionally following pulsed dye (595 nm) laser and fractional resurfacing using an ablative CO2 (10600 nm) laser associated with transepidermal triamcinolone delivery. Materials and Methods: Case presentation of the management of a hypertrophic scar following a scald burn. Results: A 12 year old boy suffered a third degree scald burn on the right buttock requiring a split thickness skin graft. The follow-up was complicated by a contracting, hypertrophic scar with a negative impact on his soccer playing due to diminished running ability. we started treatment with pulsed dye laser (595 nm, handpiece of 12 mm, pulse duration of 6 ms, fluence of 5 à 6 J/cm2),fractional resurfacing treatments using an ablative fractional CO2 laser(10600 nm, Deep-Fx, 30 to 50 mJ/MTZ, 5% coverage)followed by topical triamcinolone application by the principle of fractional laser-assisted drug delivery. We applied a hydrocolloid dressing 24/7,wearing compression shorts and to massage the scar regularly. After a total of 19 treatments, we observed a smooth scar without any signs of contraction and a normal range of motion of the hip joint. The patient was highly satisfied with the functional and aesthetic result. Conclusion: Lasers are a safe and effective treatment option for traumatic scars. Choosing the appropriate laser with the appropriate dosimetry is one of the cornerstones to a good scar-management.

Extensive facial scarring after ablative laser resurfacing in a patient with frontal fibrosing alopecia

INTRODUCTION: Scars are one of the important complications of the wound healing process that cause physical, psychological and cosmetic effect on the patients. Scar revision and laser treatment have been used over the past century for the improvement of many different types of scars. The purpose of this study is to evaluate the effectiveness of early combined carbon dioxide ablative fractional laser (AFL) and the pulsed dye laser (PDL) after scar revision. MATERIALS AND METHODS: 14 patients underwent scar revision were enrolled for this study. All patients were treated with combined a 10,600 nm AFL and 595 nm PDL. The laser treatments were performed 2 weeks after scar revision surgery, which is the early remodeling phase, at 4 weeks intervals. Four treatments were performed. Vancouver Scar Scale (VSS) scores were evaluated before treatment and 5 months after final laser treatment. RESULTS: Each VSS scores presented statistically significant improvements except height (Fig. 1). There were no adverse complications such as wound disruption, hyperpigmentation and hypopigmentation during the follow up periods. CONCLUSION: This study shows that early combined ablative fractional CO2 and pulse dye laser treatments after scar revision are an effective and safe method to minimize scar formation. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

The appearance and symptoms of scars can cause significant distress to patients. To assess and compare efficacy of the 1,500-nm nonablative fractional laser (NAFL) and 10,600-nm ablative fractional laser (AFL) in reducing symptoms and improving the appearance of traumatic or surgical scars. Single-center prospective, randomized, blinded, split-scar study was conducted on 100 patients with a scar obtained through trauma or surgery. Three treatments of NAFL or AFL were administered to each half of the scar at 4-week intervals. Scars were self-rated by the patient using the Patient and Observer Scar Assessment Scale and a satisfaction score and objectively evaluated by blinded dermatologists using the Manchester Scar Scale and visual analog scale. Blinded observers found no statistically significant difference in scar appearance. Patient rating showed improvement of scar appearance (p < .0001). Pain was worse after treatment with AFL (p = .0492). Overall, there was no statistically significant evidence of one laser being superior or inferior to the other for patient and blinded observer scores (p = .3173 and p = .2513, respectively). Scar treatment with AFL or NAFL is associated with high patient satisfaction. Objective evaluation of scars did not identify improvement in scar appearance.

Melasma is a chronic and relapsing hyperpigmentation disease with a multifactorial pathogenesis involving epidermal, dermal, and vascular components. It carries a significant psychosocial burden and affects mostly women, who have an intermediate-to-dark phototype of skin. Light plays a dual role in melasma, which is a factor of both therapy and exacerbation. This narrative review summarizes the latest developments in light-based therapeutic systems, such as intense pulsed light (IPL), Q-switched and picosecond lasers, non-ablative and ablative fractional lasers, and photobiomodulation. IPL and low-fluence Q-switched Nd:Yttrium aluminum garnet lasers would continue to be used in epidermal and mixed melasma, whereas non-ablative fractional lasers would be used on the dermal side since they produce collagen-remodeling effects. The importance of environmental light (high-energy visible light, ultraviolet A-1) in disease persistence is another clinical implication of this review that argues the need to implement effective photoprotective measures. The photonic risk index is a proposed new framework that will help in making device settings more individualized, complication risk stratified, and follow-up intervals better. The future directions mentioned here are artificial intelligence-assisted diagnosis, laser-assisted drug delivery, smart photoprotection 2.0, and heat-minimizing engineering solutions – the future of real precision-guided photodermatology.

Laser-assisted drug delivery is an emerging technology to achieve greater penetration by existing topical medications to reach desired targets in the tissue. The objective of this research was to study whether laser-assisted delivery of Vitamin C, E, and Ferulic immediately postoperatively of fractional ablative laser could improve wound healing. Secondary objectives were to evaluate the potential molecular markers involved in this wound-healing process. A double blinded, prospective, single center, randomized split face trial of Vitamin C, E, and Ferulic topical formula #740019 to decrease postoperative recovery time in fractional ablative laser resurfacing for photo damage. Fifteen healthy men and women of ages 30-55 years were treated with the Vitamin C, E, and Ferulic acid serum to one side of face and vehicle to the other side of face, within 2 minutes immediately after fractional ablative CO2 laser surgery and daily during the healing process. Patients were evaluated daily on days 1-7 using photographs, patient questionnaires, and molecular evaluation. Clinically, postoperative Vitamin C, E, and Ferulic delivery resulted in decreased edema versus vehicle on postoperative day 7 and decreased erythema versus vehicle on postoperative days 3 and 5. Molecularly, the expression of basic fibroblast growth factor (bFGF) was significantly increased at day 5 on the lesion treated with Vitamin C, E, and Ferulic acid serum compared to vehicle control on the other side. This is first study to show that Vitamin C, E, and Ferulic acid correlate with more rapid wound healing post-fractional ablative laser. Elevated bFGF could be involved in the Vitamin C, E, and Ferulic acid-induced rapid wound healing.

Isotretinoin is widely used for moderate to severe acne vulgaris. Despite its broad application, isotretinoin carries a risk of permanent scarring and keloid formation following various skin procedures. As a result, a delay of at least 6-12 months after completing or discontinuing isotretinoin treatment is commonly recommended before undergoing skin procedures. This study aims to evaluate the necessity of delaying skin procedures performed concurrently with or soon after isotretinoin treatment at different dosages in patients with acne vulgaris, based on the dermatological side effects associated with combination therapy. A literature search was conducted using PubMed, Scopus, Web of Science, and Embase databases for original studies up until June 2023. A total of 34 eligible studies, including 1563 patients treated with isotretinoin, were reviewed to assess the timing of various skin procedures, safe dosages, and potential adverse effects, such as keloid formation and persistent hyperpigmentation which were reported in a few cases. Based on our review, there is insufficient evidence to support delaying laser hair removal, ablative fractional lasers, nonablative fractional lasers, superficial to medium-depth chemical peels, manual dermabrasion, cutaneous surgeries, fractional microneedling radiofrequency, microdermabrasion, and dermaroller treatments. However, fully ablative lasers, mechanical dermabrasion, and ablative radiofrequency procedures are not recommended during isotretinoin use. Further studies are needed to establish the safety and optimal interval for these procedures. For all skin procedures, especially more aggressive and deeper ones, a lower dose of isotretinoin is recommended.

Although effective for atrophic acne scars, ablative fractional CO₂ laser (AFCL) causes unavoidable downtime and carries the potential for post-inflammatory hyperpigmentation (PIH). To evaluate the efficacy and safety of hydroxybutyl chitosan (HBC) in wound healing and to investigate the possible molecular mechanisms of HBC. Eighteen participants were enrolled in a split-face study, with each hemiface randomly assigned to receive either HBC or positive control therapy (PC: desonide cream, epidermal growth factor gel, and fusidic acid cream in combination) following AFCL. Clinical assessments included erythema, edema, pain, the time to decrustation, the skin barrier function, and melanin were assessed. In parallel, a mouse skin wound healing model was employed to investigate the effects of HBC. The expression of interferon regulatory factor 7 (IRF7) and cathepsin S (Ctss), as well as M1 and M2 macrophage polarization, was evaluated by immunohistochemistry and Western blot analysis of mouse skin tissues. Although HBC exhibited a slightly delayed onset of wound healing compared to the PC protocol, it achieved comparable outcomes by Days 7 and 28 between the groups. HBC showed more early pain but no steroid-related irritation and better moisturization. In mice, HBC demonstrated effects comparable to PC drugs, promoting macrophage M2 polarization and upregulating IRF7 and Ctss expression. HBC is effective and safe for promoting wound healing post AFCL. HBC upregulates IRF7 and Ctss expression and promotes macrophage M2 polarization. The expression of IRF7/CTSS may be correlated with M2 polarization of macrophages. ChiCTR2200063765.

The Asian patient with Fitzpatrick skin types III-V is rarely highlighted in publications on cutaneous disorders or cutaneous laser surgery. However, with changing demographics, Asians will become an increasingly important group in this context. Although high melanin content confers better photoprotection, photodamage in the form of pigmentary disorders is common. Melasma, freckles, and lentigines are the epidermal disorders commonly seen, whilst nevus of Ota and acquired bilateral nevus of Ota-like macules are common dermal pigmentary disorders. Post-inflammatory hyperpigmentation (PIH) occurring after cutaneous injury remains a hallmark of skin of color. With increasing use of lasers and light sources in Asians, prevention and management of PIH is of great research interest. Bleaching agents, chemical peels, intense pulsed light (IPL) treatments, and fractional skin resurfacing have all been used with some success for the management of melasma. Q-switched (QS) lasers are effective for the management of epidermal pigmentation but are associated with a high risk of PIH. Long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and IPL sources pose less of a PIH risk but require a greater number of treatment sessions. Dermal pigmentary disorders are better targeted by QS ruby, QS alexandrite, and QS 1064-nm Nd:YAG lasers, but hyper- and hypopigmentation may occur. Non-ablative skin rejuvenation using a combination approach with different lasers and light sources in conjunction with cooling devices allows different skin chromophores to be targeted and optimal results to be achieved, even in skin of color. Deep-tissue heating using radiofrequency and infra-red light sources affects the deep dermis and achieves enhanced skin tightening, resulting in eyebrow elevation, rhytide reduction, and contouring of the lower face and jawline. For management of severe degrees of photoaging, fractional resurfacing is useful for wrinkle and pigment reduction, as well as acne scarring. Acne, which is common in Asians, can be treated with topical and oral antibacterials, hormonal treatments, and isotretinoin. Infra-red diode lasers used with a low-fluence, multiple-pass approach have also been shown to be effective with few complications. Fractional skin resurfacing is very useful for improving the appearance of acne scarring. Hypertrophic and keloid scarring, another common condition seen in Asians, can be treated with the combined used of intralesional triamcinolone and fluorouracil, followed by pulsed-dye laser. Esthetic enhancement procedures such as botulinum toxin type A and fillers are becoming increasingly popular. These are effective for rhytide improvement and facial or body contouring. We highlight the differences between Asian skin and other skin types and review conditions common in skin of color together with treatment strategies.

Angiofibromas are the most recognized cutaneous manifestations of tuberous sclerosis complex. Angiofibromas can be associated with disfigurement, bleeding, pruritus, and erythema and may lead to significant psychosocial consequences for affected patients. Histopathologically, angiofibromas consist of a mixture of vascular and interstitial cells. Traditional treatment options include cryotherapy, electrocoagulation, radiofrequency ablation, dermabrasion, laser treatment, and topical agents such as podophyllotoxin. However, complications such as pain, postinflammatory hyperpigmentation, scarring, and the frequent recurrence rate reduce the utility of these treatment options. The introduction of topical rapamycin marked a turning point for treatment of facial angiofibromas; however, the lack of a standardized formulation, limited insurance coverage, and significant financial cost restrict universal access for patients and their caregivers. Both oral and topical β-blockers have proven extremely effective treatments for superficial vascular tumors such as hemangiomas and pyogenic granulomas. Topical β-blockers may potentially be useful for treatment of angiofibromas considering these lesions also contain a vascular component. Here we present an exploratory case report of a patient with tuberous sclerosis complex who had significant clinical improvement of her facial angiofibromas utilizing a "split-face" comparison protocol of topical timolol 0.5% gel after full-field treatment with ablative fractional laser resurfacing and pulsed-dye laser.

Comparison of four different lasers for acne scars: Resurfacing and fractional lasers