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COPYRIGHT 2008 JOURNAL OF DRUGS IN DERMATOLOGY

CASE REPORTS: FRACTIONAL LASER RESURFACING FOR THERMAL BURNS

Jill Waibel MD, Kenneth Beer MD
West Palm Beach, FL and Jupiter, FL

Abstract
Fractional resurfacing may be an effective treatment for burn scars because of its unique healing properties and depth of penetration. This case report shows the successful use of fractional resurfacing to treat burn scars. Although more extensive clinical trials are needed, fractional resurfacing could prove to be a therapeutic option for the extensive cutaneous scarring in burn patients.

Introduction
The American Burn Association (ABA) estimates that more than 1 million burn injuries occur annually in the United States. Treating burns poses a great clinical challenge in that the scars formed following thermal or chemical injury are some of the worst scars seen in clinical practice. If a patient survives a burn injury, there can be both physical and psychologically devastating effects. There have been many approaches to the treatment of burn scars with only moderate success. Fractional photothermolysis has successfully treated a wide variety of dermatologic conditions including rhytids, pigmented lesions, melasma, acne scars, surgical scars, and actinic keratoses. Other benefits of fractional resurfacing include the safe treatment of all skin types and anatomical areas.
Figure 1. Facial scars following thermal burns.

Case Report
A 37-year-old woman who had been burned in a grease fire presented for an evaluation of options for the treatment of her scars. The patient had been treated in a burn unit for burns that covered more than 30% of her body. Treatments for the burns included debridement and skin grafting. Following the grafting of her hands, she had scar contractures of the left hand interdigital spaces. Upon presentation, the patient examination (Figure 1) revealed scattered hypertrophic scars on her face that severely disfigured her appearance. She also had keloidal scarring of her hands with pigment irregularities (Figure 2). The facial scars were initially treated with a series of 3 intralesional cortisone injections, 5 mg/mL of triamcinolone acetonide (Kenalog, Bristol Myers Squibb). Although this treatment improved appearance, the scars did not resolve to a degree that was cosmetically acceptable. Following the intralesional injections, additional treatment options were considered including excision of the scars, pulsed dye laser treatments, and fractional resurfacing. Excision of the scars was thought to be impractical since the extent of the scarring spanned several cosmetic units and the patients skin had formed hypertrophic scarring from the initial injury. Pulsed dye lasers presented an opportunity to shrink the scars but they would not adequately restore the surface of the skin. After a discussion of the relative risks and benefits of each of these procedures, it was decided to proceed with a course of fractional laser treatments.
Figure 2. Hand scars following thermal burns.

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JOURNAL OF DRUGS IN DERMATOLOGY JANUARY 2008 VOLUME 7 ISSUE 1

FRACTIONAL LASER RESURFACING FOR THERMAL BURNS

Treatments were begun approximately 20 months after the injury using the Reliant Fraxel SR laser (Reliant Technology) with a wavelength of 1550 nm. A Zimmer cooler (Zimmer MedizinSystems) was utilized to enhance the patients comfort during the fractional resurfacing sessions. A total of 5 fractional laser treatments were performed, each approximately 1 month apart. Treatment parameters utilized 40-45 mJ on the face and 30-35 mJ on the hands. Following the 5 treatments, the appearance of the skin on her face had significantly improved and treatments were stopped (Figure 3). In addition, the skin of her hands was markedly improved (Figure 4). The patient was extremely pleased with her appearance and noted improvement of the contractures on her hands.

of fractional resurfacing stimulates collagen formation in the dermis and causes remodeling at this level. Whereas fractional laser resurfacing has largely been used to resurface skin for aesthetic indications including photodamage, its use for the treatment of atrophic and surgical scars suggests that it may be highly useful in other types of scarring.3,4 There is a great deal of experience with fractional resurfacing of the skin and the histological data documents the type and depth of injuries caused when fractional resurfacing lasers are used to treat atrophic scars. Whereas traditional ablative resurfacing is able to treat scars, the prolonged recovery time and frequent complications limits their usage.5 Clinical trials on the use of fractional resurfacing for the treatment of burns are needed to determine the optimal parameters for treatments including energy settings, time intervals between treatments, number of treatments, wavelength, and spot size. Although there are numerous burn injuries that may benefit from this treatment within the civilian community, its use in military medicine may unleash its full potential. It is interesting to speculate on why fractional resurfacing provided such an outstanding result in this patient. Perhaps the fact that islands of viable skin remain to repair the microthermal damage which results in remodeling of the collagen fibers and promotes normal collagen formation rather than keloid formation. Alternatively, the results may have to do with the unique nature of a fractional laser wound that causes the increased expression of heat shock proteins and/or activates epidermal stem cells to replace damaged epidermal and dermal tissue.

Discussion
Scarring from thermal injuries occurs from a variety of sources including electrical burns, thermal burns from scalding water, grease, and direct burns from fires. Unfortunately, these burns frequently involve the face where they can have significant morbidity. These burns also tend to involve children or young adults who frequently suffer the sequelae for the duration of their lives. Lasers have been utilized to treat scars for several years and the utility for this indication has been well documented.1 Fractional lasers utilize light energy in the 1550 nm range to remove microthermal zones of skin, leaving island of skin intact and able to protect and replenish the skin.2 The process
Figure 3. Facial scars following treatment with Fraxel; near total resolution.

Conclusion
We report a case treated with the Reliant Fraxel device and the significant improvement achieved. Whether other types of fractional resurfacing devices, including carbon dioxide fractional resurfacing, may be superior to the system we utilized should be determined in a clinical trial. The mechanism of action for scar correction using fractional laser resurfacing may provide insights into future treatments for scars and aging skin. Clinical trials to determine optimal parameters for treatment and to define the mechanism of action should be pursued.
Figure 4. Hand scars following treatment with Fraxel; near total resolution.

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JOURNAL OF DRUGS IN DERMATOLOGY JANUARY 2008 VOLUME 7 ISSUE 1

FRACTIONAL LASER RESURFACING FOR THERMAL BURNS

Disclosure
Drs. Beer and Waibel report that they are speakers as well as investigators for Reliant.

References
1. Alster T, Zaulyanov L. Laser Scar Revision: A Review. Dermatol Surg. 2007;33:131-140. 2. Alster T, Tanzi E, Lazarus M. The use of fractional laser photothermolysis for the treatment of atrophic scars. Dermatol Surg. 2007;33:295-299. 3. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatment of facial and nonfacial cutaneous photodamage with a 1,550-nm erbium-doped fiber laser. Dermatol Surg. 2007;33:23-28. 4. Behroozan DS, Goldberg LH, Dai T, et al. Fractional photothermolysis for the treatment of surgical scars: a case report. J Cosmet Laser Ther. 2006; 8:35-8. 5. Tanzi E, Alster T. Comparison of a 1450-nm diode laser and a 1320nm Nd:YAG laser in the treatment of atrophic facial scars: a prospective clinical and histologic study. Dermatol Surg. 2004;30: 152-157.

ADDRESS FOR CORRESPONDENCE Kenneth Beer MD 1500 N. Dixie Highway West Palm Beach, FL 33401