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Scars and Keloids: Laser Therapy

Jill Waibel, MD, gave a presentation at the Skin of Color Update, which was held virtually on September 10-12, about lasers and their applications for scar and keloid removal. Medical director and owner of Miami Dermatology and Laser Institute, subsection chief of dermatology at Baptist Hospital, medical director of Multidisciplinary Skin Cancer Clinic at Miami Cancer Institute (all in Miami Florida), and member of the Dermatology Times® editorial board are just a few of Waibel's many accomplishments.

She went on to explain that the level of wound trauma, personal genetics, and the location of the scar all play a role in the formation of scars. Keloids tend to form in the same location over and over again as a result of tension; however, Waibel believes that the problem may be more complicated than it appears.

Despite the fact that it is typically used for wrinkles, the ablative fraction laser (AFL) was, according to Waibel, the laser that changed the world of scar treatment forever. She explains that when choosing an approach, combination treatment is required, but the scar type determines which combination therapies should be used in which situations.

When it comes to treating scars and keloid patients, Waibel says one thing he does almost every time is use laser assisted drug delivery. "It's the one thing that I almost always do," he says. She went on to say that when using a fractional ablative laser, columns of holes appear on the skin, and these holes remain open for approximately 48 hours after the procedure. According to her, the majority of research indicates that physicians can inject FDA-approved medication into a scar. Before, when treating triplets, Waibel injected one of the triplets, resulting in that patient healing 60% better than her other two sisters, according to her.

Waibel treats hyperpigmentation with a 1927 nm laser and AFL, which are both FDA approved. She says she can use a variety of solutions to treat hypopigmentation, which she describes as difficult to treat. These include non-AFL (NAFL), AFL, AFL and bimatoprost, as well as CelluTome (KCI). Her treatment for glaucoma involves injecting bimatoprost, which is FDA-approved for this purpose, immediately after the laser treatment and then twice per day for one week, which helps to repigment the skin.

Atrophic scars are characterized by dermal depressions that develop as a result of the loss of dermal collagen and can pose a difficult reconstruction challenge. An alternative treatment recommended by Waibel is AFL combined with an after topical treatment of poly-L-lactic acid (PLLA) for both deep and thin skin atrophic scars. She reminds her patients that collagen remodeling can take anywhere from 3 to 6 months to complete.

For post-inflammatory erythema (PIE) and post-inflammatory hyperpigmentation (PIH), which she claims are caused by acne and must be treated first, she recommends a topical steroid cream. She used a pulse dye laser to treat a patient, and while some inflammation remained, it was able to stop the spread of the disease.

When it comes to excessive scarring, such as that caused by surgery, the etiologies include the location of the scar, hormones, genetics, chronic inflammation (acne), tension wound borders, and delayed epithelization, among other things. Waibel believes that if a scar is less than 6 months old, it can be avoided. Scars must be treated gently, and she prefers to use NAFL, which is effective on all skin types.

To treat keloids, Waibel explained that because the knowledge of how to treat them is still developing, she never tells a patient that the condition will not return after treatment. Rather than suturing keloids, she shaves them off first and then uses a laser to remove the remaining keloid. She has found that suturing causes the keloid to reappear worse than before. If the patient has never had surgery in that area before, she uses a fractional laser and triamcinolone acetonide 10 mg to treat the area. According to Waibel, higher doses are not used because they increase the risk of hyperpigmentation.

She has the ability to use multiple lasers to treat burn and trauma scars. After treating a burn patient with a 1550 nm laser and a 1927 nm NAFL, Waibel noticed that the scarring appeared more even after only two sessions. When performing these procedures, she collaborates closely with reconstructive surgeons so that they can come up with the best treatment for the patient.

According to Waibel, not only can cosmetic improvements be made, but also motion improvements can be made, and it is important to remember that symptoms are sometimes what brings a patient into the office. She also discovered that scars may be deeper than she had anticipated, and that scars may be of varying depths on different levels.

According to Waibel, the sooner scars are treated – and this is true of all scars – the more quickly they fade away. She stated that laser treatments play an important role in trauma rehabilitation because they give physicians the ability to heal patients and help them to feel better.

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