Main Issue June 2011

Laser Update

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What are some of the most common scars that pediatricians may see and what are some of the first-line laser therapies?

In general, lasers offer an assortment of benefits for general scarring. “The benefit of the laser is precision,” says Dr. Ross. “Oftentimes, scars are wide but not deep, and these types of scars can be amenable to laser therapy, particularly to improve color, tone, and texture.” They can also be used effectively in combination with topical retinoids, particularly in long-term scar improvement, observes Dr. Ross.

The typical scars that pediatricians see would be traumatic scars, notes Dr. Ross. “These scars often times occur after swimming pool accidents or falling down on bicycles, and these types of scars often times will recover on their own. Some of these scars certainly will be sewn up in an emergency room if they are open wounds,” says Dr. Ross. “Once these wounds heal and sutures have been taken out, oftentimes a pulsed dye laser may be helpful to reduce the redness and improve the tone and texture.” Other common procedures for general scarring include using a Q-switched 1064nm laser for tattoos that have black asphalt or other materials in them, observes Dr. Ross.

Are there specific devices and procedures recommended for particular conditions?

The type of scar ultimately determines the proper type of treatment and whether laser treatment should be rendered or not, according to Dr. Ross. “In general, red scars respond well to visible light technologies in the green-yellow spectrum, whether that be an IPL device or pulsed dye laser. In my opinion, the pulsed dye laser or IPL with purpuric settings works better than at nonpurpuric settings,” says Dr. Ross. “Oftentimes, I employ the least prupuric settings that are available with the device.”

Scars that are more white or older typically respond best to fractional abalative and nonablative technologies, says Dr. Ross. “I usually use a nonablative technology first because there is no downtime. The patients and parents typically respond to these with more acceptance,” Dr. Ross notes. He also points out that a resolving hemangioma often responds particularly well to ablative or nonablative fractional lasers.

But lasers are not for all types of scarring. “Old, burned-out, thick keloidal scars are very challenging to treat with any type of laser,” says Dr. Ross. “I have used fractional ablative technologies to improve the penetration of topical steroids after treatment. However, my results have been modest and unpredictable.”

For acne scarring, however, lasers are very effective. “Oftentimes the patient presents first with what we call macular erythematous scars. These usually respond well to visible light technologies, such as a short pulsed dye laser or short-pulsed IPL,” he continues. “As a first-line therapy for most kids, a nonablative technology is nice because they can return to school very quickly and the treatments are atraumatic for the parents and child alike, as far as downtime. There is no open wound,” says Dr. Ross. “For more severe scarring, certainly ablative fractional technologies and even nonablative fractional ablative technologies may be helpful, but they have to be done within the context of downtime and acceptance of the patient.”

What would be the typical duration of treatment and how many treatments are required?

“Most of the time we start treating scars as early as two to three months after the injury, and oftentimes we will do treatments every one to two months, and as many as eight to 10 treatments over a year to a year and a half may be necessary,” says Dr. Ross. Typically there is incremental improvement in the scar and sometimes a scar will improve minimally over the first three or four treatments, but then have dramatic improvement over later treatments, he says. Oftentimes, there is an infection point in a scar where the scar really ramps up, as far as improvement. “The skeptic might say these scars will improve with time anyway. Certainly that is the case for many scars, but studies have shown that those treated with pulsed dye laser or fractional laser, for example, have fared better than those who did not receive laser treatment,” observes Dr. Ross.

What recommendations do you have for pain management?

In general, patients seem to take to laser treatment well. However, Dr. Ross points out that pain is an issue with laser therapy. “For small scars typically we just use a topical anesthetic. If there are larger scars, a general anesthetic might be necessary, just because of the length of the procedure,” says Dr. Ross. “Additionally, if the scar is near the eye and internal eye shields are necessary, typically a general anesthetic would be necessary.”

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