Burn Scar Treatment Called ‘Work in Progress’

PHOENIX — Burn scars rank as one of the most difficult dermatologic conditions to treat, Dr. Jill S. Waibel said at the annual meeting of the American Society for Laser Medicine and Surgery.

"Burn scars are the worst we see in clinical medicine," said Dr. Waibel, a dermatologist with a laser practice in Miami. "I believe that if we can treat a burn scar, we can treat any scar."

Under normal circumstances, wounded skin re-epithelizes from hair follicles and dermal glands, but because burn scars are often partially or completely deprived of their epidermal appendages, "healing is severely affected," she noted.

Thanks to surgical advances in the past decade, survival of burn patients has risen from about 30% to 95%. The types of scars they present with include hypertrophic, keloid, contracture, and atrophic.

Current efforts to treat burn scars fall into one of two camps: prevention of scar formation and late reconstruction of mature scars.

"We do have a model for a scarless wound," Dr. Waibel said. "A fetus in utero does not scar. We don't understand that process. There are also a number of topical applications to prevent scars at the time of the wound. Over 200 cytokines are involved in wound healing."

Research efforts are also under way on laser-assisted skin healing with a diode laser, she said, which alters the wound-healing process by thermal stress.

Current treatment for late reconstruction of mature scars includes surgery, followed by laser combination therapy. "I think fractional therapy is the … standard, but I really don't think we understand the mechanism of action in laser and scar reduction," Dr. Waibel commented. "I think we break it down into two areas: either fractional versus thermal, or probably it's fractional and thermal. The thermal effects are the most interesting. How much heat is required for the most constructive healing versus too much thermal injury? We need to look more at what that [ideal] temperature is."

She tells her burn scar patients to consider their treatment as a "work in progress" and asks them to give her a year before they start to assess efficacy. In 2005, her first burn patient underwent five treatments with a 1550-nm, nonablative, erbium-fiber fractional laser; intralesional Kenalog (triamcinolone); and a shave biopsy.

"We see functional improvement as well as cosmetic, especially with contracture scars, and we're working on some range-of-motion studies right now," Dr. Waibel said.

In a study presented at the society's 2009 meeting, Dr. Waibel and her associates presented results from a proof-of-concept study of 10 patients who had burn scars that were treated with a 1550-nm, nonablative, erbium-fiber fractional laser.

Objective scoring by blinded investigators of photos taken pretreatment and at 3 months posttreatment indicated that 78% of patients had excellent to moderate results.

Dr. Waibel acknowledged certain limitations in current efforts to improve treatment for patients with burn scars, including the need for surgery for anatomical fixes and the lack of understanding of the processes of scar formation and the laser effects on scars. "We need better technology, and we need to maximize treatment modalities," she said. "We really need to develop a scar laser. All of the lasers that we use for scars right now were invented for wrinkles."

Dr. Waibel has conducted research for Solta Medical and Sciton, and she has received honoraria from Lumenis for lectures.

PHOENIX — Burn scars rank as one of the most difficult dermatologic conditions to treat, Dr. Jill S. Waibel said at the annual meeting of the American Society for Laser Medicine and Surgery.

"Burn scars are the worst we see in clinical medicine," said Dr. Waibel, a dermatologist with a laser practice in Miami. "I believe that if we can treat a burn scar, we can treat any scar."

Under normal circumstances, wounded skin re-epithelizes from hair follicles and dermal glands, but because burn scars are often partially or completely deprived of their epidermal appendages, "healing is severely affected," she noted.

Thanks to surgical advances in the past decade, survival of burn patients has risen from about 30% to 95%. The types of scars they present with include hypertrophic, keloid, contracture, and atrophic.

Current efforts to treat burn scars fall into one of two camps: prevention of scar formation and late reconstruction of mature scars.

"We do have a model for a scarless wound," Dr. Waibel said. "A fetus in utero does not scar. We don't understand that process. There are also a number of topical applications to prevent scars at the time of the wound. Over 200 cytokines are involved in wound healing."

Research efforts are also under way on laser-assisted skin healing with a diode laser, she said, which alters the wound-healing process by thermal stress.

Current treatment for late reconstruction of mature scars includes surgery, followed by laser combination therapy. "I think fractional therapy is the … standard, but I really don't think we understand the mechanism of action in laser and scar reduction," Dr. Waibel commented. "I think we break it down into two areas: either fractional versus thermal, or probably it's fractional and thermal. The thermal effects are the most interesting. How much heat is required for the most constructive healing versus too much thermal injury? We need to look more at what that [ideal] temperature is."

She tells her burn scar patients to consider their treatment as a "work in progress" and asks them to give her a year before they start to assess efficacy. In 2005, her first burn patient underwent five treatments with a 1550-nm, nonablative, erbium-fiber fractional laser; intralesional Kenalog (triamcinolone); and a shave biopsy.

"We see functional improvement as well as cosmetic, especially with contracture scars, and we're working on some range-of-motion studies right now," Dr. Waibel said.

In a study presented at the society's 2009 meeting, Dr. Waibel and her associates presented results from a proof-of-concept study of 10 patients who had burn scars that were treated with a 1550-nm, nonablative, erbium-fiber fractional laser.

Objective scoring by blinded investigators of photos taken pretreatment and at 3 months posttreatment indicated that 78% of patients had excellent to moderate results.

Dr. Waibel acknowledged certain limitations in current efforts to improve treatment for patients with burn scars, including the need for surgery for anatomical fixes and the lack of understanding of the processes of scar formation and the laser effects on scars. "We need better technology, and we need to maximize treatment modalities," she said. "We really need to develop a scar laser. All of the lasers that we use for scars right now were invented for wrinkles."

Dr. Waibel has conducted research for Solta Medical and Sciton, and she has received honoraria from Lumenis for lectures.

PHOENIX — Burn scars rank as one of the most difficult dermatologic conditions to treat, Dr. Jill S. Waibel said at the annual meeting of the American Society for Laser Medicine and Surgery.

"Burn scars are the worst we see in clinical medicine," said Dr. Waibel, a dermatologist with a laser practice in Miami. "I believe that if we can treat a burn scar, we can treat any scar."

Under normal circumstances, wounded skin re-epithelizes from hair follicles and dermal glands, but because burn scars are often partially or completely deprived of their epidermal appendages, "healing is severely affected," she noted.

Thanks to surgical advances in the past decade, survival of burn patients has risen from about 30% to 95%. The types of scars they present with include hypertrophic, keloid, contracture, and atrophic.

Current efforts to treat burn scars fall into one of two camps: prevention of scar formation and late reconstruction of mature scars.

"We do have a model for a scarless wound," Dr. Waibel said. "A fetus in utero does not scar. We don't understand that process. There are also a number of topical applications to prevent scars at the time of the wound. Over 200 cytokines are involved in wound healing."

Research efforts are also under way on laser-assisted skin healing with a diode laser, she said, which alters the wound-healing process by thermal stress.

Current treatment for late reconstruction of mature scars includes surgery, followed by laser combination therapy. "I think fractional therapy is the … standard, but I really don't think we understand the mechanism of action in laser and scar reduction," Dr. Waibel commented. "I think we break it down into two areas: either fractional versus thermal, or probably it's fractional and thermal. The thermal effects are the most interesting. How much heat is required for the most constructive healing versus too much thermal injury? We need to look more at what that [ideal] temperature is."

She tells her burn scar patients to consider their treatment as a "work in progress" and asks them to give her a year before they start to assess efficacy. In 2005, her first burn patient underwent five treatments with a 1550-nm, nonablative, erbium-fiber fractional laser; intralesional Kenalog (triamcinolone); and a shave biopsy.

"We see functional improvement as well as cosmetic, especially with contracture scars, and we're working on some range-of-motion studies right now," Dr. Waibel said.

In a study presented at the society's 2009 meeting, Dr. Waibel and her associates presented results from a proof-of-concept study of 10 patients who had burn scars that were treated with a 1550-nm, nonablative, erbium-fiber fractional laser.

Objective scoring by blinded investigators of photos taken pretreatment and at 3 months posttreatment indicated that 78% of patients had excellent to moderate results.

Dr. Waibel acknowledged certain limitations in current efforts to improve treatment for patients with burn scars, including the need for surgery for anatomical fixes and the lack of understanding of the processes of scar formation and the laser effects on scars. "We need better technology, and we need to maximize treatment modalities," she said. "We really need to develop a scar laser. All of the lasers that we use for scars right now were invented for wrinkles."

Dr. Waibel has conducted research for Solta Medical and Sciton, and she has received honoraria from Lumenis for lectures.