Ablative fractional CO2 laser surgery improving sleep quality, pain and pruritus in adult hypertrophic scar patients: a prospective cohort study

Abstract

Background: Poor sleep quality is associated with a decrease in quality of life in patients with major burn scars, combined with pruritus and pain. Few interventions have been reported to improve the sleep quality of patients with scars. In the current prospective cohort study, we investigated the efficacy of CO₂-ablative fractional laser (AFL) surgery vs conventional surgery in post-burn patients with hypertrophic scars with sleep quality as the primary study outcome.

Methods: In total 68 consecutive patients undergoing scar surgical treatment were recruited, including a CO₂-AFL surgery cohort (n = 35) and a conventional surgery cohort (n = 33). A subgroup from the AFL cohort was selected. Sleep quality, pain and pruritus were evaluated. Multiple linear regression analyses were performed to reveal the effect of CO₂-AFL surgery.

Results: The CO₂-AFL surgery cohort had significantly lower Pittsburgh sleep quality index (PSQI) global scores than the conventional surgery cohort after the last surgical treatment. In the subgroup of patients receiving hardware sleep monitoring, CO₂-AFL markedly increased deep sleep time, deep sleep efficiency and reduced initial sleep latency. Compared to the conventional surgery cohort, the CO₂-AFL cohort presented significantly lower pain and pruritus scores. Correlation analysis showed pain and pruritus were significantly associated with PSQI scores, and there were also significant correlations between pain and pruritus scores. Multiple linear regression analysis showed that surgery method was negatively linearly correlated with visual analog scale (VAS) pain score, brief pain inventory (BPI) total, VAS pruritus score, 5-D itch scale total, four-item itch questionnaire (FIIQ) total and PSQI total.

Conclusions: CO₂-AFL surgery significantly improved sleep quality and reduced pain and pruritus of hypertrophic scar patients. The alleviation of sleep disorder was associated with improvement of deep sleep quality including deep sleep time and deep sleep deficiency.

Trial registration: The Chinese Clinical Trial Registry (ChiCTR200035268) approved retrospectively registration on 5 May 2020.

Keywords: Ablative CO2 fractional laser; Burn scar; Cardiopulmonary coupling; Pain; Pruritus; Sleep quality.

Figure 1.

Pain scores of patients receiving CO₂-AFL surgery, conventional surgery and the subgroup who underwent sleep monitoring by cardiopulmonary coupling before and after CO₂-AFL surgery. (a) VAS scores of patients receiving CO₂-AFL surgery (n = 35) vs patients undergoing conventional surgery (n = 33), (b) BPI scores of patients receiving CO₂-AFL surgery (n = 35) vs patients undergoing conventional surgery (n = 33), (c) VAS scores of subgroup patients (n = 14), (d) BPI scores of subgroup patients (n = 14). ^*p < 0.05, ^**p < 0.01, ^***p < 0.001. AFL ablative fractional laser, VAS visual analogue scale, BPI brief pain inventory

Figure 2.

Case presentation of a burn patient with large area scar. (a and c) 20-year-old male after a 95% TBSA flame burn in a fire accident. There were severe congestive hypertrophic scars all over the whole body when the wound healing was finished. He suffered from severe scar pruritus every day and night which kept him awake and he scratched the new body surface every 2–3 h at night. Silicone gel/silicone gel sheeting, pressure therapy and rehabilitation therapy were routinely performed which did not improve the sleep quality and paresthetic symptoms, and the symptoms got worse even 7 months after the burn. Then he was transferred to the department of burns, Changhai Hospital for further treatment. (b and d) The patient received four sessions of whole-body AFL surgery under general anesthesia and two sessions of local AFL surgery under local anesthesia in 7 months. The laser treatments accelerated the maturation of the scar and significantly improved the sleep quality and scar pruritus right after the second session of AFL surgery. The congestive scars appearance of the whole body was normalized, and his contracture of neck was improved significantly. No scar tissue was ever excised and no surgical surgery was performed during the 7 months. AFL ablative fractional laser, TBSA total body surface area