Scar treatment protocol creates synergism between fractional lasers, corticosteroids: Part 1

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Same-session therapy that incorporates topical/intralesional corticosteroid and multiple-wavelength laser treatment, including the fractional CO₂ ablative laser, shows promise as a safe and effective protocol for providing aesthetic and functional improvement for patients with challenging cutaneous scars, says Jill Waibel, M.D. 

A patient before (left) and after three treatments with fractional ablative laser and injected Kenalog 20 mg/cc. (Photos credit: Jill Waibel, M.D.)

Dr. Waibel reports results from a retrospective study including 15 patients treated for hypertrophic or keloidal scars secondary to third-degree burns or surgical or traumatic injuries. First, a nonablative laser was used to treat any vascular and pigmented components of the lesion. Then a fractional CO₂ ablative laser (UltraPulse TotalFX, Lumenis) was used to achieve scar resurfacing and to improve bioavailability of triamcinolone acetonide suspension (Kenalog) that was applied immediately after the laser procedure. 

All scars were treated for a total of three sessions at one-month intervals. Results were graded six months after the last treatment by three blinded observers who used a 0 to 3 quartile scale to rate improvement in four areas: overall, dyschromia, hypertrophy and texture. The mean score for overall improvement was 2.73; all scars received a score of 2 or higher for improvement in texture, and 14 (93 percent) were rated with a score of 2 or higher for improvement in hypertrophy. 

A patient before (left) and after three treatments with fractional ablative laser and topical Kenalog 10 mg/cc.

While dyschromia showed the least improvement among the three characteristics rated, all scars were judged to have some improvement in color, and the change was rated with a score of 2 or higher for 60 percent of the scars, says Dr. Waibel, Miami Dermatology & Laser Institute, Miami, and clinical voluntary professor, department of dermatology and cutaneous surgery, University of Miami Miller School of Medicine. 

"We have come a long way in treating severe cutaneous scars in the past few years, and in my opinion, the fractional ablative laser has emerged not just as the new gold standard for scar resurfacing, but the platinum," Dr. Waibel says. "However, cutaneous scars can present a complex problem, and in that situation, the treatment approach should also be complex.
"Use of a multimodal protocol combining various laser wavelengths and corticosteroid treatment is based on that principle, because it addresses multiple features of the scar while also taking advantage of the variable depth ablation zones created by the fractional ablative laser to assist drug delivery," she adds. "These channels, which reach 500 to 800 microns into the dermis, allow for synergistic efficacy by enabling dermal penetration of the corticosteroid deeper than can be achieved even with intralesional injection, and thereby optimize its efficacy in breaking down scar tissue." 

The combination laser and corticosteroid treatment is performed under topical anesthesia using a compounded cream containing benzocaine 20 percent, lidocaine 8 percent and tetracaine 4 percent. The triamcinolone acetonide is applied or injected immediately after the fractional ablative laser treatment is finished with the chosen concentration (10 mg/cc, 20 mg/cc or 40 mg/cc) and method of administration (topical and/or intralesional), based on scar severity and thickness, Dr. Waibel says. 

"We know the inflammatory cascade initiated by the laser treatment begins within just two minutes, and by delivering intralesional steroid we can decrease inflammation and simultaneously diminish collagen synthesis. Application of the corticosteroid immediately after the laser treatment aims to maximize inhibition of this process," Dr. Waibel says.