Scar therapy consists of a wide variety of possible treatments from injections, lasers and light devices and surgical excision. There is no one type of scar treatment which is uniformly effective for all scars. There are simply too many types of scars and differing skin types and body locations for any uniform approach to improving the appearance of scars.
While scar revision by excision still remains a mainstay for many scar patients that I see, it is not effective for scars that involve large surface areas. Broad hypertrophic scars, particularly from burns and other forms of trauma, pose unique challenges for improvement. While in some cases complete excision and skin grafting may be useful, patients may either not want that approach or want to try non-surgical methods first.
One non-excisional treatment approach, and the only that I find effective for established scars, is that of combined laser resurfacing and topical steroids. When referring to laser resurfacing, I am not talking about a uniform ablative approach but specifically that of fractional CO2 ablation. This ablative CO2 laser creates channels from 400 to 600 microns or more deep into the dermis/scar. Such channels provide many points of entry for topical agents such as steroids. The early introduction of intradermal steroids helps to control the inflammation that the laser causes as well as suppresses collagen synthesis to reduce scar thickness
This scar treatment approach can be done under either topical or local anesthetic. Usually topical is better because wide hypertrophic scars are typically hard to inject under and get good pain relief. Numerous topical anesthetic creams are available but ones that contain a combination of benzocaine, lidocaine and tetracaine penetrate and work the best. Once adequately anesthetized, the broad scar is treated by the fractional CO2 laser to create intradermal pores. Thereafter, the steroid triamcinolone acetonide suspension (kenalog) is applied over the laser-treated area. Different concentrations of the steroid can be used from prepared concentrates of 10, 20 and 40mg/cc. In some cases, intralesional steroid injections may be given as well if the scar is very thick. The topical steroid suspension is held into place over the scar treated area by a clear adhesive dressing for 24 hours.
Few wide hypertrophic scars respond well to a single treatment and a series of fractional laser resurfacing and topical steroids is needed to get the best result. Typically it requires three or four sessions spaced four to six weeks apart.
This combined laser and steroid treatment is fairly novel but makes biologic sense with its multimodality approach. The synergism of these two treatments strives to create a flatter scar that is more supple, not necessarily complete scar removal. Breaking down existing scar tissue, without creating a lot more, is the only realistic goal for this type of hypertrophic scar.
Dr. Barry Eppley
Indianapolis, Indiana