Scar Treatment In the Laser Age
Appropriate Education and Expectations Are Essential
The number of treatments available to treat scars is growing. Depending on scar type and severity, as well as the patient's preferences and expectations, nurse practitioners can recommend a variety of appropriate treatment plans. A treatment mode suitable for one patient may be inappropriate for another. Only a personal consultation and examination can determine the best course of action. In most cases, treatments will diminish the appearance of a scar but not eliminate it altogether.
Types of Scars
Scars appear as brown, red or white areas of skin. They may be raised or flat, depending on the type and extent of skin damage. Keloid and hypertrophic scars are caused by an excessive amount of collagen and fibrous tissue that forms during healing. Both types of scars are raised above skin level and reveal increased fibrous activity. The propensity for keloids is often hereditary, particularly in dark-skinned patients.
Keloids often occur after insect bites or ear piercing and tend to invade the undamaged surrounding tissue. Hypertrophic scars are common after a surgical procedure or a severe burn. These types of scars do not invade surrounding tissue; rather, they tend to remain localized within the initial injury.1
Scarring can be a lasting complication of acne that causes emotional and psychological stress for many patients. Acne scars occur as a result of injury to the skin. In response, the body produces collagen, a fibrous protein that acts like a bridge to reconnect the broken tissue and create new skin. Sometimes, the fibrous material produces a scar at the site of injury. In the case of acne, scarring typically appears as a red, raised area or an indentation. To successfully treat this type of scar, the epidermis must be repaired, and new collagen production must be stimulated to improve the skin's overall tone and texture.2
Overview of Treatments
Lasers can be used to treat various color abnormalities associated with scars and can greatly improve appearance. Other scar treatments include abrasion, steroid injections, dermal filler injections, micropigmentation and tattooing. In addition, a tattoo gun technique performed without any pigment can encourage the return of normal pigment into white scars.
Clinical studies of over-the-counter scar treatment options, such as scar hydration with vitamin E and other herbal products, are limited compared with those that have examined provider-directed therapies. A majority of these studies demonstrate no improvement of scars with OTC products.
Available research about laser therapies, on the other hand, strongly suggests that these procedures are effective in improving scar appearance.
This article outlines laser treatment options for scars.
The treatment of scars is a complex and intricate process. The gold standard has traditionally been ablative procedures such as CO2or erbium YAG resurfacing, and punch excisions for acne scars.3But ablative procedures typically prompt patient complaints of pain and prolonged downtime (up to 4 weeks), and the risk for an adverse event is high. The risks posed by resurfacing with ablative procedures include hyperpigmentation and hypopigmentation, as well as erythematic, keloid or atrophic scars, acne flareups, pruritus, wound infection and milia.4
Treating deeply pigmented skin with ablative procedures carries even greater risk. Refer patients with darker skin tones to an experienced dermatologic surgeon or plastic surgeon.
A variety of nonablative procedures are available to reduce the appearance of scars. The following sections describe the most commonly used selections.
One of the newest technologies is called fractional photothermolysis (Fraxel by Reliant Technologies), and it is effective in treating acne and surgical scars. Fractional photothermolysis produces thousands of tiny but deep columns of microthermal wounds into the dermal region of the skin, where scar tissue resides. This treatment is precise and spares the top layer of the skin so that redness and irritation are short lived.
Studies have demonstrated that patients who have both atrophic acne and surgical scars experience improved skin smoothness and noticeably diminished scarring with fractional photothermolysis. In one study, histologic biopsies performed after four fractional photothermolysis procedures identified an abundance of healthy new skin cells producing collagen.3Another study confirmed that the 1550-nm erbium fiber Fraxel is a safe and reliable tool for reducing the appearance of acne scars.8Both light-skinned and dark-skinned patients with facial acne scars experienced clinical improvement ranging between 51% and 75% after receiving three fractional photothermolysis treatments with a 1550-nm erbium-doped fiber laser. No permanent scarring or pigmentation occurred in this study.
The Fraxel laser is more effective for the treatment of scars than many of the other nonablative lasers on the market because it is a 1550-nm laser with higher energy and therefore allows for more aggressive treatment. The benefit of this procedure is a more than moderate improvement in scars, with a minimal downtime of about 24 to 48 hours. During this time, the skin is pink and swollen. Adverse events are rare because the laser does not damage the stratum corneum, the protective top layer of the skin. Therefore, there is minimal risk of infection and rarely any pigmentation problems.
Lisa Williams, MS, RN, ANP-C
Ultra Smooth Skin at Canyon Falls
14891 N. Northsight Blvd
Scottsdale, AZ 85260