Burn Scars

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AbstractFractional resurfacing may be an effective treatment for burn scars because of its unique healing properties and depth of penetration. This case report shows the successful use of fractional resurfacing to treat burn scars. Although more exten-sive clinical trials are needed, fractional resurfacing could prove to be a therapeutic option for the extensive cutaneousscarring in burn patients.

IntroductionThe American Burn Association (ABA) estimates that morethan 1 million burn injuries occur annually in the UnitedStates. Treating burns poses a great clinical challenge in

that the scars formed following thermal or chemical injury aresome of the worst scars seen in clinical practice. If a patientsurvives a burn injury, there can be both physical and psy-chologically devastating effects.

There have been many approaches to the treatment of burnscars with only moderate success. Fractional photothermol-ysis has successfully treated a wide variety of dermatologicconditions including rhytids, pigmented lesions, melasma,acne scars, surgical scars, and actinic keratoses. Other bene-fits of fractional resurfacing include the safe treatment of allskin types and anatomical areas.

Case ReportA 37-year-old woman who had been burned in a grease firepresented for an evaluation of options for the treatment of her scars. The patient had been treated in a burn unit for

burns that covered more than 30% of her body. Treatmentsfor the burns included debridement and skin grafting. Fol-lowing the grafting of her hands, she had scar contractures of the left hand interdigital spaces.

Upon presentation, the patient examination (Figure 1) re-vealed scattered hypertrophic scars on her face that severelydisfigured her appearance. She also had keloidal scarring of herhands with pigment irregularities (Figure 2). The facial scarswere initially treated with a series of 3 intralesional cortisoneinjections, 5 mg/mL of triamcinolone acetonide (Kenalog®,Bristol Myers Squibb). Although this treatment improved appearance, the scars did not resolve to a degree that was cos-metically acceptable. Following the intralesional injections,

additional treatment options were considered including ex-cision of the scars, pulsed dye laser treatments, and fractionalresurfacing. Excision of the scars was thought to be impracti-cal since the extent of the scarring spanned several cosmeticunits and the patient’s skin had formed hypertrophic scarringfrom the initial injury. Pulsed dye lasers presented an oppor-tunity to shrink the scars but they would not adequately re-store the surface of the skin. After a discussion of the relativerisks and benefits of each of these procedures, it was decidedto proceed with a course of fractional laser treatments.

CASE REPORTS:FRACTIONAL LASER RESURFACING FOR THERMAL BURNS

 Jill Waibel MD, Kenneth Beer MDWest Palm Beach, FL and Jupiter, FL

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COPYRIGHT © 2008 JOURNAL OF DRUGS IN DERMATOLOGY

 Figure 1. Facial scars following thermal burns.

 Figure 2. Hand scars following thermal burns.

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Treatments were begun approximately 20 months after the in-jury using the Reliant Fraxel® SR laser (Reliant Technology)with a wavelength of 1550 nm. A Zimmer cooler (ZimmerMedizinSystems) was utilized to enhance the patient’s com-fort during the fractional resurfacing sessions. A total of 5

 fractional laser treatments were performed, each approxi-mately 1 month apart. Treatment parameters utilized 40-45 mJon the face and 30-35 mJ on the hands.

Following the 5 treatments, the appearance of the skin on herface had significantly improved and treatments were stopped(Figure 3). In addition, the skin of her hands was markedlyimproved (Figure 4). The patient was extremely pleasedwith her appearance and noted improvement of the con-tractures on her hands.

DiscussionScarring from thermal injuries occurs from a variety of sourcesincluding electrical burns, thermal burns from scalding water,

grease, and direct burns from fires. Unfortunately, theseburns frequently involve the face where they can have sig-nificant morbidity. These burns also tend to involve childrenor young adults who frequently suffer the sequelae for the du-ration of their lives.

Lasers have been utilized to treat scars for several years andthe utility for this indication has been well documented.1

Fractional lasers utilize light energy in the 1550 nm range toremove microthermal zones of skin, leaving island of skin in-tact and able to protect and replenish the skin.2 The process

of fractional resurfacing stimulates collagen formation in thedermis and causes remodeling at this level. Whereas frac-tional laser resurfacing has largely been used to resurfaceskin for aesthetic indications including photodamage, itsuse for the treatment of atrophic and surgical scars suggests

that it may be highly useful in other types of scarring.3,4

There is a great deal of experience with fractional resurfacingof the skin and the histological data documents the type anddepth of injuries caused when fractional resurfacing lasers areused to treat atrophic scars. Whereas traditional ablativeresurfacing is able to treat scars, the prolonged recovery timeand frequent complications limits their usage.5 Clinical trialson the use of fractional resurfacing for the treatment of burnsare needed to determine the optimal parameters for treat-ments including energy settings, time intervals between treat-ments, number of treatments, wavelength, and spot size.Although there are numerous burn injuries that may benefitfrom this treatment within the civilian community, its use inmilitary medicine may unleash its full potential.

It is interesting to speculate on why fractional resurfacing pro-vided such an outstanding result in this patient. Perhaps thefact that islands of viable skin remain to repair the mi-crothermal damage which results in remodeling of the collagen fibers and promotes normal collagen formationrather than keloid formation. Alternatively, the results mayhave to do with the unique nature of a fractional laser woundthat causes the increased expression of heat shock proteinsand/or activates epidermal stem cells to replace damagedepidermal and dermal tissue.

ConclusionWe report a case treated with the Reliant Fraxel® device andthe significant improvement achieved. Whether other types of fractional resurfacing devices, including carbon dioxide frac-tional resurfacing, may be superior to the system we utilizedshould be determined in a clinical trial. The mechanism of ac-tion for scar correction using fractional laser resurfacing mayprovide insights into future treatments for scars and aging skin.Clinical trials to determine optimal parameters for treatmentand to define the mechanism of action should be pursued.

FRACTIONAL LASER RESURFACING

FOR THERMAL BURNS

 JOURNAL OF DRUGS IN DERMATOLOGY

 JANUARY 2008 • VOLUME 7 • ISSUE 1

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 Figure 3. Facial scars following treatment with Fraxel; near total

resolution.

 Figure 4. Hand scars following treatment with Fraxel; near totalresolution.

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FRACTIONAL LASER RESURFACING

FOR THERMAL BURNS

 JOURNAL OF DRUGS IN DERMATOLOGY

 JANUARY 2008 • VOLUME 7 • ISSUE 1

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DisclosureDrs. Beer and Waibel report that they are speakers as well asinvestigators for Reliant.

References1. Alster T, Zaulyanov L. Laser Scar Revision: A Review. Dermatol

Surg . 2007;33:131-140.

2. Alster T, Tanzi E, Lazarus M. The use of fractional laser pho-tothermolysis for the treatment of atrophic scars. Dermatol Surg .2007;33:295-299.

3. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis:treatment of facial and nonfacial cutaneous photodamage with a1,550-nm erbium-doped fiber laser. Dermatol Surg . 2007;33:23-28.

4. Behroozan DS, Goldberg LH, Dai T, et al. Fractional photother-molysis for the treatment of surgical scars: a case report. J CosmetLaser Ther. 2006; 8:35-8.

5. Tanzi E, Alster T. Comparison of a 1450-nm diode laser and a1320–nm Nd:YAG laser in the treatment of atrophic facial scars:

a prospective clinical and histologic study. Dermatol Surg . 2004;30:152-157.

Kenneth Beer MD1500 N. Dixie HighwayWest Palm Beach, FL 33401

ADDRESS FOR CORRESPONDENCE