burns 43 (2017) 1379 –1389

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Review

Laser in the management of burn scars

Brooke M. Willows a , Muneeb Ilyas b, * , Amit Sharma b

a
School of Medicine, University of Arizona, Phoenix,AZ, United States
b
Department of Dermatology, Mayo Clinic Arizona, 13400 E. Shea Blvd. Scottsdale, AZ 85259, United States

article info abstract

Article history: Background and objective: Burn scars are associated with significant morbidity ranging from
Accepted 5 July 2017 contractures, pruritus, and disfigurement to psychosocial impairment. Traditional therapies
include silicone gel, compression garments, corticosteroid injections, massage therapy, and
surgical procedures, however, newer and advanced therapies for the treatment of burn scars
have been developed. Lasers, specifically ablative fractional lasers, show potential for the
Keywords: treatment of burn scars.
Burn scars Methods: Both MeSH and keyword searches of the PubMed, Medline and Embase databases
Laser treatment were performed and relevant articles were read in full for the compilation of this review.
Ablative laser Results: Fifty-one relevant observational studies, clinical trials, and systematic reviews
Non-ablative laser published in English from 2006 to 2016 were reviewed and summarized.
Hypertrophic scars Conclusion: Laser therapy is effective for the treatment of burn scar appearance, including
Contracture measures such as pigmentation, vascularity, pliability, and thickness. Ablative fractional
laser therapy, in particular, shows significant potential for the release of contractures
allowing for improved range of motion of affected joints. Patients may benefit from the use of
lasers in the treatment of burn scars, and the safety profile of lasers allows the benefits of
treatment to outweigh the risks. Laser therapy should be included in burn scar treatment
protocols as an adjuvant therapy to traditional interventions.
© 2017 Elsevier Ltd and ISBI. All rights reserved.

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1380
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1381
3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1382
3.1. Laser selection . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1382
3.2. Introduction to fractional lasers . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1382
3.3. Mechanisms of fractional lasers . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1383
3.4. Ablative fractional lasers . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1383
3.5. Non-ablative fractional lasers . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1384
3.6. Settings for ablative fractional lasers . .... .... .... .... .... .... ... .... .... .... .... .... ... .... .... 1385

Abbreviations: VSS, Vancouver Scar Scale; POSAS, Patient and Observer Scar Assessment Scale; TGF, Transforming growth factor; CO2,
Carbon dioxide; Er:YAG, erbium:yttrium-aluminum-garnet; HSP, Heat shock protein; SOFT, Selective objective fractional technique.
* Corresponding author.
E-mail address: Milyas92@midwestern.edu (M. Ilyas).
http://dx.doi.org/10.1016/j.burns.2017.07.001
0305-4179/© 2017 Elsevier Ltd and ISBI. All rights reserved.
1380 burns 43 (2017) 1379 –1389

3.7. Other lasers and light devices . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... .. 1385
3.8. Radiofrequency devices . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... .. 1385
3.9. Use of lasers in pediatrics . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... .. 1385
3.10. Adverse effects of laser treatment for burn scars .... .... .... .... .... .... ... .... .... .... .... .... .. 1387
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... .. 1387
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... .. 1387
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... .. 1387
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... .... .... .... .... ... .... .... .... .... .... .. 1387

inflammatory factors as well as increased densities of

1. Introduction
substance P positive nerve fibers [8]. In addition to changes
at the site of injury, generalized anxiety, depression, and social
In 2016, there will be 486,000 burn injuries in the United States anxiety are associated with burn scars [9]. Patients with burn
requiring medical treatment with 40,000 of those patients scars report avoiding public places where scars would be
requiring hospitalization [1]. With current treatment proto- visible, such as swimming pools, feeling unattractive and
cols, 97% of the patients admitted to burn centers will survive sexually undesirable because of the scars, and hiding scars
[1]. However, non-fatal burns are an important cause of even from people in close relationships [10].
morbidity, with burn scars causing contractures, pruritus, and There are several interventions traditionally used in the
disfigurement with associated psychosocial impairments. management of burn scars. Silicone gel sheeting increases the
Burn scars can be classified by their pigmentation, elasticity of burn scar tissue with studies also suggesting a
espessura
erythema, texture, and thickness [2]. Scars can be either reduction in pruritus, erythema, and scar thickness [11,12].
hyper- or hypo-pigmented compared to the patient’s unaf- Similarly, compression garments result in decreased erythe-
fected skin, and many burn scars are erythematous. Also, ma, thickness, and hardness of burn scars [11,12], and this
irregularities in scar texture are common among patients change is likely due to inhibition of transforming growth factor
suffering from burns with the meshing of skin grafts being a (TGF) b1 release and ultimately decreased fibroblast activity
common culprit for these irregularities [3]. Up to 91% of burn [13]. Due to discomfort, appearance, interference with move-
scars are hypertrophic, and this hypertrophy is caused by ment, and social stigma, patient compliance can be low [13].
excessive and disorganized fibroblast deposition of type III, Burn scar corticosteroid injections are another commonly
mostly, and type I collagen in dermis [4]. Hypertrophic scars used intervention and inhibit inflammatory processes in the
form within weeks to months of the burn insult [4] and peak in dermis such as cell migration and fibroblast proliferation,
posteriormente
thickness at 6–12 months. Thereafter, scar thickness de- which ultimately contribute to scar regression [14]. However,
creases, and at 24-months post-burn injury, less than 30% of topical steroids often do not produce similar effects due to a
scars are hypertrophic [5]. This hypertrophic tissue, along with lack of penetration of scar tissue [14]. As for massage therapy, a
altered pigmentation, erythema, and irregular texture, is a decrease in pain and pruritus can be reported immediately
target of interventions. after the first session with improvements in the Vancouver
To help quantify changes in the characteristics of burn Scar Scale, scar thickness, hyperpigmentation, and erythema
scars, there are 2 commonly used scar scales. One is the after longer treatment regimens [11,15]. Overall, silicone gel
Vancouver Scar Scale (VSS) [6], which quantifies pigmentation, sheeting, compression garments, corticosteroid injections,
vascularity, pliability, and scar height. The other is the Patient and massage therapy are often combined as part of a
and Observer Scar Assessment Scale (POSAS) [7], which is treatment protocol specific to each institution.
divided into a patient assessed portion and a physician In addition to the traditional standard of care for the
assessed portion. The patient component quantifies pain, treatment of burn scars, several surgical interventions are
itchiness, color, stiffness, thickness, and irregularity of the also available [2]. A common surgical intervention involves
burn scars, while the investigator component quantifies the step-wise resection of the burn scar with incremental
vascularity, pigmentation, thickness, relief, and pliability of approximation of unaffected skin. Alternatively, the burn
the burn scars. scar can be resected with placement of a new skin graft,
In addition to cosmetic effects of burn scars, there are although this new graft is at risk of developing similar
several other morbidities associated with these scars. One undesirable characteristics in the future. Diffuse contrac-
important, and unfortunately common, morbidity of burn tures are typically released with a transverse incision and
scars is contractures whereby the location of scar tissue limits subsequently grafted or covered with an advancement,
the movement of nearby joints. Contractures can be classified rotation, or transposition flap from adjacent unaffected
as diffuse or linear, with linear contractures being comprised tissue while variations of a z-plasty are used to release linear
of prominent, well-defined bands and diffuse contractures contractures. Often these surgical interventions are com-
spanning larger areas without discrete bands. Another major bined with non-surgical interventions as a comprehensive
morbidity associated with burn scars is pruritus. Up to 87% of management of burn scars.
patients with burns report pruritus, specifically with hyper- Lasers are now playing an important role in burn scar
trophic burn scars, and symptoms disrupt sleep and daily management. A recently published treatment algorithm
activities [8]. Studies have shown this might be mediated by recommends all adult and pediatric patients begin a series
 burns 43 (2017) 1379 –1389 1381

of 4 ablative fractional laser treatments at 9 months post-

2. Methods
injury [16]. Similarly, a treatment algorithm for mature burn
scars published as a consensus statement recommends using
fractional and vascular lasers when appropriate [17]. These The authors performed a comprehensive search of the current
treatment algorithms are based on exciting new research that literature on the following databases: PubMed, Medline and
has shown over the past 10 years the beneficial effects of laser Embase. MeSH terms were used on PubMed and keyword
treatments on mature burn scars. This article presents a search was used on all the databases (Table 1). Publications
comprehensive literature review on the utility of laser therapy between 2006 and 2016 were included in the literature search.
in burn scar management and the mechanisms behind the Searches were performed by two authors (BW and AS) and full
effects of the lasers. This review informs care providers of burn text articles were retrieved when possible. Systematic reviews,
scar patients with current information regarding newer, randomized controlled trials, observational studies and
advanced therapy options for managing burn scars. The use studies of equal level of evidence were summarized. When
of ablative and non-ablative fractional lasers, pulsed dye these were unavailable, case series were included. Non-
lasers, radiofrequency devices, and adverse effects associated English articles were excluded. A total of 51 studies were
with laser therapy are discussed. referenced for this review as outlined in Fig. 1.

Table 1 – PubMed MeSH and keyword searches.

PubMed MeSH search Laser therapy [MeSH] AND burns [MeSH] AND cicatrix [MeSH] AND last
10 years [PDat] AND humans [MeSH] AND English [lang]
Lasers [MeSH] AND burns [MeSH] AND cicatrix [MeSH] AND last 10 years
[PDat] AND humans [MeSH] AND English [lang]
PubMed keyword search Laser therapy AND burn scars
Lasers AND burn scars
Laser AND burn AND scar
Filters: published in last 10 years, humans, English

Fig. 1 – A flowchart outlining the selection of the studies included in this review.
1382 burns 43 (2017) 1379 –1389

3.2. Introduction to fractional lasers

3. Discussion
Fractional lasers generate thermal energy that is deposited in
3.1. Laser selection columns through the epidermis and into the dermis [18]. The
uniformemente
columns are evenly spaced throughout the treatment area
The past 20 years have provided a wealth of novel laser and creating microscopic treatment zones, and the pulse energy of
profundidade
light devices that can be used for both medical and cosmetic the lasers determines both the depth and diameter of the
purposes. In selecting a laser to treat a burn scar, the burn columns. Depths of the microscopic columns range from 0.2 to
physician must begin by evaluating the characteristics of the 4.0mm. They are appropriately named fractional lasers
hipertrófica, plana ou atrófica
scar. Scar type (hypertrophic, flat or atrophic) and scar because the treatment density determines the number of
dyschromia (i.e. erythema) are the main factors that drive thermal columns within each area of skin being treated, and all
laser device selection. Body location and patient character- intervening areas are composed of untreated viable skin. Most
istics (normal skin color and comorbid conditions) help fractional laser treatments use lower treatment densities to
determine the settings of the selected laser device. Fig. 2 avoid undesired cutaneous injury from excessive thermal
provides an adapted algorithm to guide laser selection [17]. deposition, although there are reports using higher densities
The followingsections detail the evidence for the use of each [19]. A consensus of expert opinions recommends performing
laser device type. more treatments using lower treatment densities to lessen the

Fig. 2 – An algorithm for managing burn scars using laser treatment. AFL—Ablative fractional laser; NAFL—Non-ablative
fractional laser; PDL—Pulsed dye laser.
Adapted from “Laser Treament of Traumatic Scars With an Emphasis on Ablative Fractional Laser Resurfacing Consensus
Report” by Anderson et al.
 burns 43 (2017) 1379 –1389 1383

likelihood of adverse events [17]. Many lasers include cooling untreated dermis and epidermis [23]. Three months post
devices to prevent unwanted thermal damage to the nearby ablation, the dermal-epidermal junction is located at the
untreated skin, and post-procedural ice packs are often used to appropriate depth, hsp-72 trends toward normal levels, and
supplement the cooling process [17]. hsp-47 is further diffusely elevated [23].
Overall, ablative fractional lasers tend to deposit thermal
3.3. Mechanisms of fractional lasers energy at greater depths than non-ablative fractional lasers,
and because of this, thicker scars may be better targeted with
Fractional lasers can be divided into non-ablative and ablative. ablative fractional lasers [17]. Selective objective fractional
Non-ablative lasers produce columns of coagulated tissue technique (SOFT) can help determine the full penetration of
composed of denatured collagen while leaving the epidermal the scar with ablative laser columns [25]. The depth of the scar,
layer intact. On the other hand, ablative lasers create columns and thereby the energy required to fully penetrate the scar, is
of vaporized tissue with surrounding eschar and coagulated determined in each region of the scar by increasing the energy
tissue. An example of a non-ablative fractional laser is the of the laser until pinpoint bleeding is observed [25]. This
erbium: glass laser, using a wavelength of 1550nm. Ablative pinpoint bleeding is a sign that the full thickness has been
fractionated lasers include carbon dioxide (CO2) lasers, using a penetrated by the laser columns [25].
wavelength of 10,600nm, and erbium: yttrium-aluminum-
garnet (Er:YAG) lasers, using a wavelength of 2940nm. 3.4. Ablative fractional lasers
On histologic examination, burn scars treated with frac-
tional lasers show near-normalized rete ridges, decreased Ablative fractional lasers have been found to improve multiple
inflammation, increased vascularity, and an interwoven characteristics of burn scars. Two young women with 15 and
collagen structure with an overall increased similarity to 17-year-old burn scars reported decreased scar thickness,
normal unaffected skin six months post-treatment [20]. increased smoothness, and color more consistent with normal
Specifically, decreases in type I collagen and increases in type skin after ablative fractional laser therapy [26]. One middle-
III collagen are found when compared to baseline specimens, aged woman with burn scars was treated with an ablative
however, elastin content remains unchanged [21]. Surprising- fractional laser with resulting noticeable improvement of the
ly, laser treatment can also induce an increase in vascularity of texture (Fig. 3) [27]. Similarly, a young man with a predomi-
the papillary dermis [22]. nantly hypo-pigmented atrophic burn scar with segments of
More specific to ablative fractional lasers, 48-h post- hypertrophic contractures had improvements in the color and
ablation, epidermal cells fill the vaporized columns with texture of the scar and high patient satisfaction [28]. These
complete continuity of the surface epithelium, and heat shock noticeable changes in scar appearance are encouraging, but
protein (hsp) 72 is increased in epidermal cells [23]. Type I and quantifiable measurements of scar characteristics were
type III procollagen mRNA levels, two isoforms of TGF-b, as absent in these reports.
well as basic fibroblast growth factor are significantly down- When able to quantify changes in burn scar characteristics,
regulated while matrix metalloproteinase 1 is significantly up- statistically significant improvements are seen after treat-
regulated [24]. Seven days post-ablation, the basement ment with ablative fractional lasers. A retrospective chart
membrane of the epidermis is completely repaired, spindle review [16] used the VSS before and after treatment with an
cell numbers are increased in the dermis, and hsp-72 continues ablative fractional laser, and a significant decrease in score
to be increased in the epidermis [23]. One month post-ablation, was found post-treatment. Lee et al. [29] found more than
the majority of the epidermal invagination is replaced by new three-quarters of their patients had a 50% or greater
collagen formation, spindle cells are more prominent, and improvement in burn scar appearance after laser-cision
both hsp-72 and hsp-47 are elevated in both treated and release of contractures plus ablative fractional laser therapy.

Fig. 3 – (a) Deep dermal burns on forehead and face. (b) After 3 months of ablative laser treatment. (c) After 6 months of ablative
testa
laser treatment.
Reprinted with permission. “Laser in the treatment of hypertrophic burn scars,” by Kawecki M., Bernad-Wis niewska T., Sakiel
S., Nowak M. and Andriessen A, 2008, International Wound Journal, 5(1), p. 91. Copyright 2008 Wiley Periodicals, Inc.
1384 burns 43 (2017) 1379 –1389

Two similar prospective studies [21,24] used an ablative future nail growth to normalize. Waibel et al. [35] applied
fractional laser on hypertrophic burn scars and found both topical triamcinolone suspension directly to ablative laser
the VSS and POSAS had statistically significant improvements microcolumns within 2min of laser treatments to improve
when compared to baseline scores. In a large study by Kawecki delivery of the topical medication to deeper tissue. This form of
et al. [30], using the VSS as an objective measure, 31% of laser-assisted delivery system might improve the beneficial
patients had resolution of erythema with resulting normal effects of corticosteroids in hypertrophic burn scars by
skin tone, 61% had conversion of hypertrophic scars to normal allowing better targeting of affected tissues.
thickness tissue, and 40% had complete softening of their scars
after ablative laser therapy. 3.5. Non-ablative fractional lasers
Burn scar contractures can be improved with ablative
fractional laser therapy. An older woman with an old burn scar Recent reports have found non-ablative fractional lasers
of her face had decreased distortion of her smile after a beneficial in the treatment of dyschromic burn scars. One
combination of ablative fractional laser therapy and a micro- young woman with a hyper-pigmented burn scar refractory to
needle roller [31]. A contracture limiting range of motion of the traditional interventions had significant reduction in pigmen-
elbow was released with ablative laser therapy in a young tation after treatment with a non-ablative fractional laser [36].
woman [26]. A middle-age woman with a burn contracture of Another woman with a mixed hypo- and hyper-pigmented
her hand had increased range of motion after treatment with atrophic contracted burn scar had visual improvement in both
an ablative fractional laser [32]. A similar case report of a color and texture of the scar [37].
patient with disabling bilateral hand contractures had 100% A prospective study [38] showed the cumulative effect of a
flexion of her left hand and 95% flexion of her right hand after series of non-ablative fractional laser treatments on burn scars
treatment with an ablative fractional laser [25]. In addition, an and how psychosocial elements can be affected by laser
observation made during a retrospective chart review [16] of therapy. Overall improvement in scar appearance and texture
patients treated with an ablative fractional laser found that was evident in 90% of patients, while improvement in color
several patients suffering from burn scars near joints reported and thickness was seen in 80%. In addition, self-esteem was
subjective increased mobility in their joints after treatment. significantly increased at 3 months post-laser treatment.
As an interesting aside, ablative laser therapy has the Controlled studies show the beneficial changes seen post-
potential to impact sensation and nail dystrophy in burn fractional laser therapy are not simply attributable to inevita-
patients or be used as a delivery method for topical corticoste- ble changes in the natural history of burn scar remodeling. A
roids. A case report [33] of a man with burn scars over his randomized controlled trial [39] using a non-ablative fractional
palmar surface showed improvement in sensation after laser showed significant improvement in texture at both 4 and
treatment with an ablative fractional laser. The authors 12 weeks post treatment when compared to the untreated
postulated this increased sensation could be due to laser- controls, and half of the patients reported moderate to
triggered molecular stimulation of nerve regeneration or significant improvement in appearance of their scars at the
thinning of scar tissue and subsequent increased transmission completion of the treatment series (Fig. 4). Also noted was
of stimuli to pre-existing nerves. Krakowski et al. [34] used an thinner scars responded better to non-ablative fractional laser
ablative fractional laser on the nail bed of a patient with therapy than did hypertrophic scars. Another randomized
extensive burn scaring of the hands with resultant nail controlled trial [20] using a non-ablative fractional laser on
dystrophy. Laser release of the scarred eponychium allowed normotrophic, hypertrophic, and atrophic burn scars showed

Fig. 4 – Clinical photo comparing the treatment area (A) versus the untreated control area (B) after 12 weeks of 1540nm non-
ablative laser treatment.
Reprinted with permission. “Fractional nonablative 1540nm laser resurfacing for thermal burn scars: a randomized controlled
trial,” by Hædersdal M., Moreau K.E.R., Beyer D.M., Nymann P. and Alsbjørn B., 2009, Laser in Surgery and Medicine, 41(3), p. 192.
Copyright 2009 Wiley Periodicals, Inc.
 burns 43 (2017) 1379 –1389 1385

the overall appearance, thickness, and pliability to be thereby causing coagulation and ultimately decreased inflam-
significantly improved at 6-months while the control areas mation and edema, effective at treating erythematous scars.
did not change over this same time period. Hypertrophic scars Q-switched Nd:YAG lasers, which generate thermal energy
showed less improvement than normotrophic and atrophic using a wavelength of 1064nm in very short pulses, have
scars. This decreased effectiveness of non-ablative fractional potential to treat hyper-pigmented and other dyschromic burn
laser therapy in hypertrophic scars, when compared to scars.
atrophic and normotrophic scars, suggests the limited depth Intense pulsed light devices use of different filters to allow
of penetration of non-ablative fractional lasers may prevent passage of specific wavelengths within the visible light
adequate treatment of hypertrophic burn scars. spectrum can be helpful in treating dyschromia of burn scars.
Hultman et al. [42] used intense pulsed light to treat burn scars
3.6. Settings for ablative fractional lasers and found 80% of patients reported improvement in the
coloration of scar tissue. More than half of the patients
To determine the density of micro-columns that works best reported they would repeat the procedure if given the
when treating burn scars, Haedersdal [19] treated a middle-age opportunity and slightly more patients would recommend
man with an ablative fractional laser, separating the scar into the procedure to others with dyschromia. In spite of this, the
3 zones with similar characteristics. One zone was treated with authors concluded intense pulsed light should not be used in
a high density (20%) of ablative micro-columns, one zone was the treatment of burn scars due to variable efficacy that might
treated with a medium density (13%) of ablative micro- not exceed that expected from less invasive interventions.
columns, and one zone was the untreated control. Significant A cohort study [43] used a combination of lasers for the
improvement in color and texture was seen when comparing treatment of hypertrophic burn scars. A pulsed dye laser was
the high density section with the control, while a slight used for erythema and edema, intense pulsed light for
improvement was seen when comparing the medium density dyschromia, and an ablative fractional laser for hypertrophy
and the control. and contractures. There was significant improvement in both
Setting the energy levels of the lasers such that the micro- the VSS and the North Carolina 4P Scar Scale with the most
columns penetrate the full thickness of the burn scars was pronounced improvement after the first treatment, and this
addressed in a report and a retrospective chart review. Bowen improvement in the VSS continued 2 years later. This suggests
[25] treated a woman with burn scars using an ablative either long-term effects of the initial combined treatments or
fractional laser with energies sufficient to create pinpoint benefits of continuing combination laser treatments over
bleeding within each of the ablative columns signifying the full longer terms [44].
thickness of the scar was being treated. When the patient
returned 6 weeks later for a second treatment, lower depths 3.8. Radiofrequency devices
were required to penetrate the full thickness of her scars
showing the thickness of her scar was significantly reduced Radiofrequency devices use the energy from radiofrequencies
after just one laser treatment. A similar retrospective chart to excite nitrogen gas into a high-energy state called plasma.
review of ablative fractional laser treatments using energy Plasma forms a grid that is then applied to the skin surface
settings so that at least 50% of the columns developed pinpoint which causes partial ablation of the epidermis with columns of
bleeding found decreased pain, tightness, and pruritus post- energy extending into the dermis. In so doing, collagen is
laser treatment, and overall, a 97% patient satisfaction [40]. remodeled and the surface is re-epithelialized with complete
Laser treatment is safe to commence within months of repair of the epithelium in about 7 days [45].
injury. Shumaker et al. [41] used an ablative fractional laser on Radiofrequency devices are beneficial in the treatment of
patients within 2–5 months of their burns or final surgeries. burn scar hyperpigmentation. A prospective study [45] treated
One patient with a contracture over the dorsum of his hand post-burn hyperpigmentation using a microplasma radio-
regained complete range of motion of his hand while another frequency device. Investigators classified 37% of patients as
with a burn contracture over his knee joint reported a restored having excellent improvement in their hyperpigmentation
ability to walk and resolution of a chronic erosion. The third and 54% of patients having good improvement, while accord-
patient, who had burn scars around his knee amputation, ing to patients’ self-assessments, 11% had excellent improve-
reported improved wound healing and tolerance of his ment and 77% had good improvement.
prosthesis, and the last patient with a burn contracture over
his abdomen had improved mobility and range of motion. In 3.9. Use of lasers in pediatrics
addition, all patients reported improved overall appearance,
texture, and color of their burn scars with further improve- According to a national survey of pediatric burn units in the
ment after additional treatments. United Kingdom [46], traditional therapies are the mainstay in
the treatment of burn scars while the use of laser therapies is
3.7. Other lasers and light devices less common. All pediatric burn units recommend the use of
moisturizers and massage, while 95% recommend silicone
Although the majority of research on the use of lasers in the products and pressure therapy. Only 5% of the burn units used
treatment of burn scars has concentrated on fractional lasers, laser therapy in the treatment of burn scars.
other lasers have the potential to be useful in burn scar Lasers are safe and effective in the treatment of pediatric
interventions. Pulsed dye lasers generate thermal energy patients with respect to burn scars. A retrospective chart
using wavelengths around 595-nm that target micro-vessels review [16] showed adult and pediatric patients with burn
1386 burns 43 (2017) 1379 –1389

Fig. 5 – (a) Partial-thickness facial burn an 11-year-old girl after 35 days. (b) Same patient after 6 laser treatments and 2 z-plasty
procedures, forty-two months later.
Reprinted with permission. “Pulsed dye laser therapy and z-plasty for facial burn scars: the alternative to excision,” by Donelan,
Matthias B., Parrett, Brian M. and Sheridan, Robert L, 2008, Annals of Plastic Surgery, 60(5), p. 483. Copyright 2008 Lippincott
Williams & Wilkins.

scars treated with an ablative fractional laser have a significant contracture of his hand showed increased finger extension,
improvement in VSS scores post-treatment. Additionally, improved grip strength, and decreased pruritus 5 months after
several patients suffering from burn scars near joints reported ablative fractional laser treatment. A randomized controlled
subjective increased mobility in their joints after treatment. A study [48] of pediatric patients treated split-thickness grafts
cohort study [44], in which 43% of the patients were under the with pulsed dye laser therapy. Vascularity, pigmentation, and
age of 18, made comparisons between adult patients and scar height were significantly reduced while elasticity was
pediatric patients, finding no differences in VSS scores at significantly increased when compared to compression alone.
baseline, after treatment, or at long-term follow-up between These studies support the beneficial effects of using ablative
the groups. fractional lasers and pulsed dye lasers in the treatment of burn
To address pediatric patients directly, two case reports and scars in the pediatric population (Fig. 5).
1 randomized controlled trial looked solely at the pediatric Pulsed dye lasers have been successfully used to treat facial
population when addressing the effects of lasers on burn scars. burn scars in pediatric patients and younger adults. Donelan
Krakowski et al. [47] used ablative fractional laser therapy on a et al. [49] used a pulsed dye laser, in combination with z-
2-year-old girl with a contracture burn of her hand, and she plasties in 60% of patients, to decrease hypertrophic facial burn
showed improved active range of motion 1 month after her scars in mostly pediatric patients. All patients had decreased
laser treatment. Similarly, an 18 year old boy with a burn scar erythema and scar thickness after laser treatment (Fig. 6). One-

Fig. 6 – (a) Deep partial-thickness scald injury that led to hypertrophic scarring on the posterior neck of a 5-year-old girl. (b) Same
site after 4 pulsed-dye laser treatments showing dramatic improvement.
Reprinted with permission. “Prospective, before-after cohort study to assess the efficacy of laser therapy on hypertrophic burn
scars,” by Hultman C., Edkins R.E., Wu C., Catherine T. and Cairns B.A, 2013. Annals of Plastic Surgery, 70(5), p. 523. Copyright
2013 Lippincott Williams & Wilkins.
 burns 43 (2017) 1379 –1389 1387

fifth of the patients were less than 1 year from burn, with the still common enough to deserve attention, and severe adverse
goal of laser therapy to prevent the formation of hypertrophic effects have been described in the literature.
scars, while two-fifths were more than 5 years from injury,
showing how laser therapy can be helpful at multiple points in
the natural history of burn scars. 4. Conclusion

3.10. Adverse effects of laser treatment for burn scars Laser therapy is effective for the treatment of burn scars.
Observational studies and clinical trials have found that lasers
The adverse effects of laser treatments can be divided into improve burn scar appearance, pigmentation, vascularity,
flexibilidade espessura
three groups: minor, moderate, and severe [50]. Minor adverse pliability, and thickness, after laser treatment. Furthermore,
effects range from pain, erythema, and edema to infection, laser therapy is both safe and effective in treating burn scars in
ecchymoses, and blistering. Moderate complications include all age groups.
hyper- and hypo-pigmentation, while a severe adverse effect Different types of lasers and light sources can be used in the
would be new scar formation. The incidence of these adverse treatment of burn scars, with specific treatment modalities
events is not affected by the age of the scar at the time of dependent on scar type and thickness. Intense pulsed light has
treatment or the total body surface area burned and treated been used for dyschromia in burn scars and pulsed dye lasers
[51]. for scar erythema. For treating hypertrophic scars, non-
Reports of minor adverse effects are common and ablative fractional lasers are less effective than ablative
sometimes affect patients over long durations. A retrospec- fractional lasers, suggesting that the limited depth of
tive chart review [40] of ablative fractional laser treatments penetration of non-ablative fractional lasers may prevent
on burn scars reported the most common adverse effect of adequate treatment. Similarly, fewer treatment sessions are
laser treatment was post-procedural blistering, which required to achieve the same result when using ablative
occurred in 23% of patients; these blisters lasted an average fractional lasers compared to non-ablative fractional lasers.
of 1.5 days. Similarly, patients treated with a combination of Laser therapy in the treatment of burn scars has a good
lasers had blistering as one of the most common complica- safety profile. Minor adverse events, including pain, erythema,
tions [43]. Another retrospective study [51] using mostly edema, infection, ecchymoses, and blistering, are to be
pulsed dye and CO2 lasers showed pain was the most expected. Moderate complications, such as hyper- and
commonly reported side effect accounting for 37% of the hypo-pigmentation, are less common, while severe adverse
documented adverse effects, while mild blistering accounted effects, such as new scar formation, are rare. The majority of
for 27% of events, rashes/erythema 7%, and infection 2%. A adverse events resulting from laser treatment are minor and
randomized controlled study [39] using a non-ablative often transient. However, it is important to note that burn scar
fractional laser on burn scars found the majority of patients therapy is multimodal. Traditional therapies including com-
reported pain immediately after treatments, nearly 100% pression therapy, corticosteroid injections, physiotherapy and
reported erythema, more than half reported edema, and one- ultimately, surgery, all reduce burn scar associated morbidity.
sixth reported bullae and or crusts. Another study [20] using Given the significant benefits afforded and minimal risk, we
a non-ablative fractional laser, reported 100% of patients had recommend that laser therapies be included in current burn
erythema, about half had dryness, one-third had edema, and scar treatment paradigms.
one-fifth had temperature sensitivity at 24-h post-treatment;
at 6 months following completion laser treatments, about
half still had erythema. Funding
Moderate adverse effects are less common than minor
effects, but still relatively common. A retrospective study [51] This research did not receive any specific grant from funding
found hypopigmentation accounted for 12% of adverse effects agencies in the public, commercial, or not-for-profit sectors.
and hyperpigmentation accounted for 2%. With combined
laser treatments, both hypopigmentation and post-inflamma-
tory hyperpigmentation were the most common complica- Conflicts of interest
tions [43]. At a 6 month follow up after treatment with a non-
ablative fractional laser, one-third of patients continued to None.
have hyperpigmentation [20].
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