What are scars?

Scars are a common complication of acne, burns, surgeries, and traumatic injuries affecting millions of individuals consistently. The presence of scars can be exceedingly disturbing to patients both physically and psychologically. Numerous treatment options and modalities have been utilized for the reduction and prevention of scar formation, including topical steroids, intralesional steroids, cryosurgery, interferon, 5flurouracil, silicone gel, radiation, and surgeries. There is no broad consensus in the literature concerning what is the optimal treatment. The evolution of lasers and microneedling over the most recent couple of decades has demonstrated clinical and cosmetic benefits for patients and are great treatment option for some types of scars.

What are available treatments?

Laser Treatment

Laser Treatment of Scars was introduced in the 1970s and Lasers were first utilized as a part of the treatment of scars in 1978. The first laser that was used to treat hypertrophic scars and keloids was the continuous wave argon. Despite encouraging early reports, subsequent studies indicated limited efficacy and high incidence of side impacts. At that point, the neodymium: yttrium-aluminum-garnet (Nd:YAG, 1064 nm) laser and continuous wave CO2 laser (10,600 nm) were described in the mid-1980s as an alternative to argon by selectively inhibiting collagen production. However, results indicated a failure to inhibit keloid formation and repeat of lesions one year after treatment. The theory of selective photothermolysis, which was introduced in the mid-1980s, has brought about the invention of pulsed lasers that provided target selectivity, reducing the thermal damage and scarring. More recently, the idea of fractional photothermolysis (FP) was introduced in 2003 as an option for low risk, effective resurfacing techniques. Fractionated lasers work by thermally altering a “fraction” of the skin, leaving up to 95 % of skin untouched, which repopulates the removed columns of tissue permitting rapid epidermal repair. FP induces little three-dimensional zones of thermal damage known as microscopic treatment zones (MTZs). Water is the target chromophore for all available fractional devices on the market as of now. For FP, as the energy of the treatment is increased, the profundity of penetration increases, and as the treatment level is increased, the density of the spots is increased. Densities can be accounted for as either percentage of coverage or number of MTZs per square centimeter. Fractionated lasers are divided into ablative and non-ablative fractional resurfacing given the wavelength affinity for water. Ablative fractional resurfacing (AFR) lasers have a high affinity for water and these include the fractionated CO2 10,600 nm, erbium: yttrium aluminum garnet (Er:YAG 2990 nm) and Fraxel lasers. Those with minimal affinity for water are classified as non-ablative fractionated lasers and include the following wavelengths: 1410 nm, 1440 nm, 1540 nm, and 1550 nm. Hypertrophic scars are firm, red or pink raised scars enclosed within the margins of the original injury. They are typically most prevalent within the first month after injury and may relapse over time. Interestingly, keloids are raised, reddish-purple, nodular scars, firmer than hypertrophic scars, and keloids reach out past the margins of the original wound and don’t relapse over time.

Various lasers have been tried in the treatment of hypertrophic scars and keloids with variable efficacy. The most common laser utilized as a part of the treatment of hypertrophic scar and keloids has been the pulsed dye laser (PDL 585595 nm), which is considered the laser of choice in treating pigmented and hypertrophic scars. The no doubt mechanism by which PDL works is through selective photothermolysis in which energy is consumed by oxyhemoglobin leading to coagulation necrosis. It has additionally been demonstrated that PDL treatments increase MMP-13 activity and reduce TGF-beta expression, fibroblast proliferation, collagen type III, and controls the degree of angiogenesis within the wound and assists in minimizing scarring.

Furthermore, PDL has been recently appeared to up-regulate P53 expression, which captures the fibroblast proliferation cell cycle. While treating hypertrophic scars and keloids, PDL is utilized primarily to reduce erythema yet has additionally been appeared to reduce scar volume and improve scar texture and also reduce pain and pruritus. When comparing results of the two different PDL wavelengths, it has been looked in a systematic review by Vrijman et al. that PDL 585 nm has a low efficacy for the treatment of hypertrophic scars when compared to PDL 595 nm, which has direct efficacy. Keloids do indicate minimum improvement with PDL yet appear to demonstrate upgraded clinical results when combined with intralesional corticosteroids or 5-fluorouracil injections. The parameter utilized for hypertrophic scars and keloids are non-overlapping pulses ranging from 6 to 7.5 J/cm2 (7 spot) or 4.5 to 5.5 J/cm2 (10 mm spot), which ought to be applied over the entire surface of the scar. Reducing pulse duration from 40 ms to 0.45 ms has been appeared to be more efficacious in reducing scar volume and improving pliability, however, demonstrated no difference in scar erythema. Energy density ought to be diminished by 10 % in darker-pigmented patients or while treating scars in sensitive zones, for example, the anterior chest and neck. The most common post-PDL treatment side impacts are purpura that can last up to 3 to 7 days, blistering can happen, and additionally pigment alteration, which is more common in the darkly pigmented skin. Treatments are typically done at 6-to 8-week intervals to allow for satisfactory healing time. However, longer intervals might be required for darker pigmented patients and patients with sensitive territory scars.

Fraxel dual has shown impressive results with scar and wrinkle removal with short downtime; the recovery time can be enhanced by apply plasma directly after the treatment


On the other hand, Microneedling, otherwise called percutaneous collagen induction therapy, is a relatively new treatment option in dermatology. Although laser skin resurfacing has for quite some time been considered the treatment of choice for photoaged and scarred skin, microneedling has recently been touted for an expansive scope of applications including skin rejuvenation, acne scarring, wrinkles, surgical scars, dyschromia, melasma, enlarged pores, and transdermal drug delivery. The detailed high efficacy, safety, and minimal post-treatment recovery rates associated with microneedling have increased patient satisfaction and clinician awareness of this prevalent strategy.

According to the American Society of Plastic Surgery, minimally invasive, nonsurgical procedures represented approximately 89% of every cosmetic strategy directed in 2015. This significant increase in minimally invasive procedures suggests that microneedling may possess a specific niche for patients who desire treatments with little to no recovery, while still attaining measurable results. For treatment of superficial wrinkles, microneedling is believed to work similarly, relying heavily on the production of new collagen to fill in and elevate the existing furrow. The creation of bottomless micro wounds directly stimulates the arrival of various growth factors that assume a direct part of collagen and elastin synthesis and deposition within the dermis. More specifically, the creation of microchannel induces a controlled skin injury with minimal epidermal damage and stimulates the dermal wound-healing cascade (inflammation, proliferation, and remodeling) to occur. This prompts the arrival of platelet-derived growth factor, fibroblast growth factor(FGF), and transforming growth factor alpha and beta (TGF-an and TGF-b). Neovascularization and neocollagenesis happen secondary to fibroblast proliferation and migration. After the cutaneous injury, a fibronectin network is made, providing a matrix for collagen type III deposition, which is in the end supplanted by Type I collagen. This transition can happen over weeks two dermatologic-surgery to months, resulting in clinical skin tightening and wrinkles reduction. There are numerous microneedling devices on the market, every one of which makes various epidermal and dermal micro wounds to stimulate collagen production. A scope of fixed needle rollers and electric-powered pen devices with disposable sterile needle tips are available. These devices differ given the needle length, quantity, diameter, configuration, and material. Manual rollers and electric-powered pens are operated by gliding perpendicularly over the skin surface until miniture pinpoint bleeding is achieved. Electric pens offer a few points of interest over roller drum devices including the ability to easily change their operating speeds and penetration depths along these lines permitting treatment of large surface regions efficiently and at varying needle depths as important. The disposable needle tips limit the risk of infection and furthermore permit treatment of little focal lesions, for example, traumatic scars or upper lip wrinkles which would be difficult to do to accomplish with a roller drum. Optimal clinical results are achieved when needle depths are changed in accordance with the specific skin location (and thickness). For instance, a thick sebaceous skin will require deeper needle penetration in comparison with thin periocular skin.

Summarily, Scars can come about as a component of the typical healing procedure after a burn or other trauma, for example, surgery or injury. However, there is a scope of scarring from ‘great’ to ‘awful’ depending on various features of the scars. Some can be can be knotty and raised (hypertrophic and keloid scars), have changes in pigmentation (increased or diminished coloration) or have specific features identified with the reason (for instance acne scars, burns scars).

Microneedling is a safe, minimally invasive, and effective esthetic treatment for a few different dermatological conditions including acne and different scars, wrinkles, and striae. Given its expedient post-treatment recovery, limited side impacts profile, and significant clinical results, microneedling is a worthful alternative to more invasive procedures such as deep chemical peeling.

There are many laser systems in circulation that permit successful treatment of different types of scars. The 585-nm PDL remains the gold standard for laser treatment of hypertrophic scars and keloids. Although atrophic scars may best be treated with ablative CO2 and Er:YAG lasers, the intense interest in procedures with reduced morbidity profiles have increased the popularity of nonablative laser procedures. Laser scar revision is optimized when an individual patient and scar characteristics are thoroughly evaluated to determine the best course of treatment and, more essentially, to determine whether the patient and physician share realistic outlook and treatment goals. As lasers and microneedling evolve and the mechanics of wound healing continue to be elucidated, new uses for the technology will be identified, resulting in improved management of a wide range of wounds and scars.



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