Functional and aesthetic improvement is the ultimate goal of treatment for hypertrophic scars and keloids, but many patients continue to have functional impairments and symptoms such as burning, itching, and pain post treatment.
Intralesional steroid injections — applied topically or injected into the lesion — are considered to be one of the best treatment options. This treatment includes a uniform injection of 10–40 mg/ml of triamcinolone acetonide suspension through a 25- to 27-gauge needle. One of the long-standing challenges is precise placement of the drug to avoid adverse sequelae such as fat atrophy, but its effectiveness is limited.
So, other treatments, such as pressure therapy, cryotherapy, interferon, fluorouracil, topical silicone, and pulsed-dye laser treatment have been adopted or are under study.
Effective topical delivery of any pharmaceutical agent requires the ability to penetrate the epidermis, and fractional laser therapy creates precise, uniform columns of tissue vaporization which can be used to facilitate drug delivery past the epidermal barrier.
Fractional lasers have emerged as a therapeutic option for the aesthetic restoration and functional enhancement of traumatic scars. They create zones of ablation at variable depths, which induce a molecular cascade, including heat shock proteins and other factors, that lead to a rapid healing response and prolonged neocollagenesis with subsequent collagen remodeling. The likely result is the removal of a portion of fibrotic scar tissue and a relative normalization of collagen structure and composition.
At the same time, fractional ablative lasers create vertical channels in the skin referred to as a microthermal zone that facilitates topical drug delivery deep into the skin. Laser-assisted drug delivery has been shown to enhance photosensitizer penetration in photodynamic therapy as well as the penetration of topical anaesthetics, opioids, non-steroidal anti-inflammatory drugs, and chemotherapeutic-drugs such as fluorouracil or imiquimodi.
Combining ablative fractional laser therapy with enhanced topical corticosteroid delivery presents the potential to combine two valuable scar therapies in a simple, cost-effective strategy.
Researchers at Louisiana State University Health Sciences Center in New Orleans conducted review of research assesses the efficacy and safety of laser-assisted topical steroid delivery as a treatment option for hypertrophic scars and keloids. The review was presented at the American Society for Dermatologic Society annual meeting last October in Chicagoii.
They identified three studies through a MEDLINE search – one was a retrospective study and two were prospective cohort studies.
FIRST-LINE THERAPY RESISTANT KELOIDS
The retrospective study involved 23 patients with keloids resistant to first line therapyiii, lesions were treated with an ablative fractional erbium laser every other week for a median of nine treatments followed by topical betamethasone cream applied twice a day under occlusion with transparent film dressings.
The 23 patients had 70 keloids and were treated in the laser center of the Department of Dermatology at the University Hospital of Nice in France from January 2010 to June 2012.
The median percentage improvement was 50% (range -43 to 84), although response was less for keloids located on the ear and neck.