SCMSJournal.com

ADVANCES IN LASER SCAR REHABILITATION

Mar

2015

Vol. 34. No. 1

Introduction

In 2008, Dr. Jill Waibel encouraged me to try a new laser technique in treating restrictive scars. She envisioned its benefit on the wounded warriors that we managed at the Naval Medical Center in an Diego, California, USA. Over the following few years we saw this technique grow into what we consider the standard of care as an adjunctive procedure in the scar rehabilitation of all patients with hypertrophic disabling scars. The management of burn and traumatic scars requires a multidisciplinary effort. Even with the most ideal protocols of the burn and trauma teams, various plastic surgeons, orthopedic surgeons, and then long-term physical therapy and subsequent surgical revisions, outcomes are often still lacking. With the addition of this specific type of laser surgery using a high-energy, low-density, submillisecond-pulsed ablative laser fractionated to roughly 200- 400 microns, more optimization of function can be achieved in the majority of cases. It can be safely applied in almost all phases of scar rehabilitation. Beginning within the first months post injury and at intervals of 6 to 12 weeks, these treatments have a low-risk profile and can be applied 20 or more times to a scar, seeing benefits with each treatment that are often persistent. In the US Navy, along with CDR Peter Shumaker, we had the privilege to treat hundreds of sailors and soldiers who had sustained injuries in combat. But we have also seen a positive effect of this treatment in children, pregnant women, scarring genetic diseases, connective tissue diseases, and many other conditions. Furthermore, we’ve been able to use it safely and effectively on medical missions into underserved areas of the world. This experience has connected dermatologists with the burn and trauma community in a new way and is the impetus for this edition on the laser treatment of scars. But most importantly, we had the opportunity to watch first-hand how meticulously applied laser technology could improve the quality of life in our wounded service members – whether the restrictive scar was just forming or was decades old. The purpose of this issue of Seminars in Cutaneous Medicine and Surgery is to convey the importance of understanding the latest treatment of scars. In this issue, we highlight the approach in treating burn and traumatic scars and how to optimize their functionality. I would like to express my thanks to the authors who worked so diligently to put their expertise in writing so that the millions of patients that need this treatment may benefit.

A review of scar assessment scales

Andrew C Krakowski, MD | Peter R Shumaker, MD | Stephanie I Feldstein, MD | Tuyet A Nguyen

At our current level of understanding, scars are an unavoidable result of disruption of the integument following trauma and other sources of injury in the postnatal period. Millions of people worldwide suffer from diminished quality of life due to varying degrees of disfigurement, functional impairment, and psychosocial comorbidity. Scars also represent a significant financial burden to the healthcare system at large. Substantial momentum currently exists in scar research associated with innovative techniques and devices devoted to treating scars. In order to properly ascertain and compare responses to various therapies, accurate and reproducible qualitative and quantitative assessments are vital. At least 10 different scar assessment scales and tools have been created to date in an attempt to quantify scar severity. However, a “gold standard” scar scale still does not yet exist. A major limitation of most scar scales is their focus on a relatively narrow group of individual subjective and objective features, while failing to address the overall cosmetic, functional, and psychological sequelae. Herein, we provide a brief review of current scar assessment scales, discuss some of the major advantages and limitations of each, and introduce several characteristics that might be addressed in a new “gold standard” scar scale. The assessment and treatment of scars, particularly large traumatic scars, is frequently a multidisciplinary effort. The creation of an “ideal” scar scale will undoubtedly require input from therapists, surgeons, dermatologists, and other professionals alike. Semin Cutan Med Surg 34:28-36 © 2015 Frontline Medical Communications

Treatment of ulcers with ablative fractional lasers

Andrew C Krakowski, MD | Jeffrey S Dover, MD | Laurel M Morton, MD | Nathan S Uebelhoer, DO | Tania J Phillips, MD

Chronic, nonhealing ulcers are a frustrating therapeutic challenge and investigation of innovative therapies continues to be an important research pursuit. One unique and newly applied intervention is the use of ablative fractional lasers. This technology has recently been employed for the treatment of hypertrophic, disfiguring and function-limiting scars, and was first shown to induce healing of chronic wounds in patients with persistent ulcers and erosions within traumatic scars. Recent reports suggest it may be applicable for other types of chronic wounds as well. The mechanism of action for this modality remains to be elucidated but possible factors include laser-induced collagen remodeling, photomicrodebridement and disruption of biofilms, and induction of a proper wound healing cascade. Semin Cutan Med Surg 34:37-41 © 2015 Frontline Medical Communications

Fractional epidermal grafting in combination with laser therapy as a novel approach in treating radiation dermatitis

Radiation injury to the skin is a major source of dysfunction, disfigurement, and complications for thousands of patients undergoing adjunctive treatment for internal cancers. Despite the great potential for affecting quality of life, radiation injury has received little attention from dermatologists and is primarily being managed by radiation oncologists. During our volunteer work in Vietnam, we encountered numerous children with significant scarring and depigmentation of skin from the outdated use of radioactive phosphorus P32 in the treatment of hemangiomas. This dangerous practice has left thousands of children with significant fibrosis and disfigurement. Currently, there is no treatment for radiation dermatitis. Here, we report a case series using the combination of laser treatment, including pulsed-dye laser, fractional CO2 laser, and epidermal grafting to improve the appearance and function of the radiation scars in these young patients. We hope that by improving the appearance and function of these scars, we can improve the quality of life for these young patients and potentially open up a new avenue of treatment for cancer patients affected with chronic radiation dermatitis, potentially improving their range of motion, cosmesis, and reducing their risk of secondary skin malignancies. Semin Cutan Med Surg 34:42-47 © 2015 Frontline Medical Communications

Letter of Apology and Notice of Retraction

Pedram Yazdan

The paper I authored and published 3 years ago in Seminars in Cutaneous Medicine and Surgery1 contains significant portions of wording and sections from this other article.2 This was highly negligent on my behalf and I deeply apologize for my actions. As a trainee at the time I submitted my paper, I had limited experience in publishing manuscripts. Without any malicious intent, due to ignorance and poor judgment, I plagiarized the words of another author in my paper and without proper citation. I apologize to Dr Leona Yip, Dr Nick Rufaut and Dr Rod Sinclair, the authors whose knowledge and words I appropriated. I also apologize to Dr Stephen Shumack and Dr H. Peter Soyer from the Australian Journal of Dermatology for breaching the copyright of their Journal. I apologize to the editors of the Seminars in Cutaneous Medicine and Surgery for using their trust and submitting an original contribution that fell short of originality. Most of all, I apologize to the national and international research community for presenting a part of another authors’ work as my own. I respectfully ask that the article “Yazdan P. Update on the genetics of androgenetic alopecia, female pattern hair loss, and alopecia areata: implications for molecular diagnostic testing. Semin Cutan Med Surg. 2012 Dec;31(4):258-266.” be retracted.