Scar Treatment Combinations

This is part 2 of a 2-part series.

Part 1: Innovations in Scar Treatment

Scars are multimodal problems and need customized solutions, Dr. Waibel emphasizes, which are determined by color, size, and location.

“Is it red, brown, or white? For red scars you need to pick a vascular laser first,” she says.

A pulsed dye laser is her device of choice for smaller treatment areas. For larger areas, it’s the IPL because it can cover a larger area in a shorter amount of time.

“Then I'll follow up with the ablative fractional CO2 or erbium in the same day of treatment, and then a topical application of Kenalog,” says Dr. Waibel.

Notably, she always performs the nonablative laser treatments first.

Dr. Waibel approaches brown scars, which are more frequently seen in skin of color patients, with the 1927 nm laser, calling it “magical” for hyperpigmentation. She follows that up with the ablative fractional laser followed by laser-assisted drug or molecule delivery.

“Hypopigmentation is the toughest,” she says. “I just published an article on this.1 Sometimes laser alone can repigment [the skin]. If you don't get laser repigmentation alone with laser, you can add laser-assisted delivery of bimatoprost. And you drip this in immediately postoperative laser and then the patient takes it home and does it twice a day, anywhere from 10 to 14 days.”

After color, the next big consideration for determining scar treatment is collagen: atrophic vs. hypertrophic scars.

“My favorite treatment for atrophic acne scars is doing the ablative fractional,” says Dr. Waibel.

To treat a specific acne scar patient, she describes using punch biopsies, fractional ablative laser, Z-plasty, and fractional ablative laser again to achieve around 80% improvement.

For surgical scars that are thick and hypertrophic, she says she uses the pulse dye and ablative fractional laser. However, for scars that are less than three months old, she’ll use the pulse dye and fractional non-ablative.

For keloids on the ears, Dr. Waibel says she performs a shave biopsy, leaving just 1 mm of the scar, which she then lasers and treats with Kenalog.

“If they haven't had surgery, this can be a permanent improvement. [However,] I always tell patients, keloids can recur,” she says.

For catastrophic scars that result from trauma, Dr. Waibel recommends performing scar treatment in the operating room to avoid the possibility of having the smell make a patient’s posttraumatic stress worse.

Beyond appearance, scar treatments can offer improved range of motion and reduce scar- related discomfort.

“We see lots of patients [for] range of motion, especially in the digital webs, the feet, and neck. But not only can we help range of motion, we can help our patients walk again after treatment,” she says.

Some scar patients have a significant amount of itching, especially in the first year posttrauma. Sometimes it’s the itching, not the scars, that cause the problems.

“And then one of the greatest honors of my career was treating Kim Phuc, the napalm girl…,” says Dr. Waibel, who performed a series of eight treatments with the pulse dye, IPL, thulium, nonablative fractional, laser hair removal, and Botox.

According to Dr. Waibel, this combination treatment brought her pain down from a 10/10 to a 3/10.

“Dermatologists have entered the trauma center,” says Dr. Waibel. “Treating scars really changes lives and if you're in front of someone who is suffering and you have the tools at your disposal to alleviate suffering, you act.”

Reference:

1. Seago M, Shumaker PR, Spring LK, et al. Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations. Lasers Surg Med. 2020;52(2):96-116.