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. 2022 Sep 26;9(9):CD011642.
doi: 10.1002/14651858.CD011642.pub2.

Laser therapy for treating hypertrophic and keloid scars

Rafael Leszczynski  1 , Carolina Ap da Silva  2 , Ana Carolina Pereira Nunes Pinto  2   3   4 , Uliana Kuczynski  5 , Edina Mk da Silva  6
Affiliations

Laser therapy for treating hypertrophic and keloid scars

Rafael Leszczynski et al. Cochrane Database Syst Rev. .

Abstract

Background: Hypertrophic and keloid scars are common skin conditions resulting from abnormal wound healing. They can cause itching, pain and have a negative physical and psychological impact on patients' lives. Different approaches are used aiming to improve these scars, including intralesional corticosteroids, surgery and more recently, laser therapy. Since laser therapy is expensive and may have adverse effects, it is critical to evaluate the potential benefits and harms of this therapy for treating hypertrophic and keloid scars.

Objectives: To assess the effects of laser therapy for treating hypertrophic and keloid scars.

Search methods: In March 2021 we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL EBSCO Plus and LILACS. To identify additional studies, we also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports. There were no restrictions with respect to language, date of publication, or study setting.

Selection criteria: We included randomised controlled trials (RCTs) for treating hypertrophic or keloid scars (or both), comparing laser therapy with placebo, no intervention or another intervention.

Data collection and analysis: Two review authors independently selected studies, extracted the data, assessed the risk of bias of included studies and carried out GRADE assessments to assess the certainty of evidence. A third review author arbitrated if there were disagreements.

Main results: We included 15 RCTs, involving 604 participants (children and adults) with study sample sizes ranging from 10 to 120 participants (mean 40.27). Where studies randomised different parts of the same scar, each scar segment was the unit of analysis (906 scar segments). The length of participant follow-up varied from 12 weeks to 12 months. All included trials had a high risk of bias for at least one domain: all studies were deemed at high risk of bias due to lack of blinding of participants and personnel. The variability of intervention types, controls, follow-up periods and limitations with report data meant we pooled data for one comparison (and only two outcomes within this). Several review secondary outcomes - cosmesis, tolerance, preference for different modes of treatment, adherence, and change in quality of life - were not reported in any of the included studies. Laser versus no treatment: We found low-certainty evidence suggesting there may be more hypertrophic and keloid scar improvement (that is scars are less severe) in 585-nm pulsed-dye laser (PDL) -treated scars compared with no treatment (risk ratio (RR) 1.96; 95% confidence interval (CI): 1.11 to 3.45; two studies, 60 scar segments). It is unclear whether non-ablative fractional laser (NAFL) impacts on hypertrophic scar severity when compared with no treatment (very low-certainty evidence). It is unclear whether fractional carbon dioxide (CO2) laser impacts on hypertrophic and keloid scar severity compared with no treatment (very low-certainty evidence). Eight studies reported treatment-related adverse effects but did not provide enough data for further analyses. Laser versus other treatments: We are uncertain whether treatment with 585-nm PDL impacts on hypertrophic and keloid scar severity compared with intralesional corticosteroid triamcinolone acetonide (TAC), intralesional Fluorouracil (5-FU) or combined use of TAC plus 5-FU (very low-certainty evidence). It is also uncertain whether erbium laser impacts on hypertrophic scar severity when compared with TAC (very low-certainty evidence). Other comparisons included 585-nm PDL versus silicone gel sheeting, fractional CO2 laser versus TAC and fractional CO2 laser versus verapamil. However, the authors did not report enough data regarding the severity of scars to compare the interventions. As only very low-certainty evidence is available on treatment-related adverse effects, including pain, charring (skin burning so that the surface becomes blackened), telangiectasia (a condition in which tiny blood vessels cause thread-like red lines on the skin), skin atrophy (skin thinning), purpuric discolorations, hypopigmentation (skin colour becomes lighter), and erosion (loss of part of the top layer of skin, leaving a denuded surface) secondary to blistering, we are not able to draw conclusions as to how these treatments compare. Laser plus other treatment versus other treatment: It is unclear whether 585-nm PDL plus TAC plus 5-FU leads to a higher percentage of good to excellent improvement in hypertrophic and keloid scar severity compared with TAC plus 5-FU, as the certainty of evidence has been assessed as very low. Due to very low-certainty evidence, it is also uncertain whether CO2 laser plus TAC impacts on keloid scar severity compared with cryosurgery plus TAC. The evidence is also very uncertain about the effect of neodymium-doped yttrium aluminium garnet (Nd:YAG) laser plus intralesional corticosteroid diprospan plus 5-FU on scar severity compared with diprospan plus 5-FU and about the effect of helium-neon (He-Ne) laser plus decamethyltetrasiloxane, polydimethylsiloxane and cyclopentasiloxane cream on scar severity compared with decamethyltetrasiloxane, polydimethylsiloxane and cyclopentasiloxane cream. Only very low-certainty evidence is available on treatment-related adverse effects, including pain, atrophy, erythema, telangiectasia, hypopigmentation, regrowth, hyperpigmentation (skin colour becomes darker), and depigmentation (loss of colour from the skin). Therefore, we are not able to draw conclusions as to how these treatments compare. AUTHORS' CONCLUSIONS: There is insufficient evidence to support or refute the effectiveness of laser therapy for treating hypertrophic and keloid scars. The available information is also insufficient to perform a more accurate analysis on treatment-related adverse effects related to laser therapy. Due to the heterogeneity of the studies, conflicting results, study design issues and small sample sizes, further high-quality trials, with validated scales and core outcome sets should be developed. These trials should take into consideration the consumers' opinion and values, the need for long-term follow-up and the necessity of reporting the rate of recurrence of scars to determine whether lasers may achieve superior results when compared with other therapies for treating hypertrophic and keloid scars.

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Conflict of interest statement

Rafael Leszczynski: works as a health professional. Carolina da Silva: works as a health professional. Ana Carolina Pereira Nunes Pinto: none known. Uliana Kuczynski: none known. Edina MK da Silva: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: 585‐nm Pulsed‐Dye Laser (PDL) versus no treatment, Outcome 1: Severity of scar: Patient self‐assessment (32 weeks)
1.2
1.2. Analysis
Comparison 1: 585‐nm Pulsed‐Dye Laser (PDL) versus no treatment, Outcome 2: Incidence and severity of treatment‐related adverse effects (32 weeks)
2.1
2.1. Analysis
Comparison 2: Non‐ablative Fractional Laser (NAFL) versus no treatment, Outcome 1: Severity of scar: Health Professional Global Assessment (3 months)
2.2
2.2. Analysis
Comparison 2: Non‐ablative Fractional Laser (NAFL) versus no treatment, Outcome 2: Incidence and severity of treatment‐related adverse effects (3 months)
2.3
2.3. Analysis
Comparison 2: Non‐ablative Fractional Laser (NAFL) versus no treatment, Outcome 3: Scar size, colour, height, length, width, pliability, skin surface texture, pruritus and pain (3 months)
3.1
3.1. Analysis
Comparison 3: Fractional carbon dioxide (CO2) versus no treatment, Outcome 1: Severity of scar: Vancouver Burn Scar (VBS) scale (up to 6 months)
3.2
3.2. Analysis
Comparison 3: Fractional carbon dioxide (CO2) versus no treatment, Outcome 2: Severity of scar: Patient and Observer Scar Assessment Scale (POSAS) (at least one month)
3.3
3.3. Analysis
Comparison 3: Fractional carbon dioxide (CO2) versus no treatment, Outcome 3: Scar size, colour, height, length, width, pliability, skin surface texture, pruritus and pain (12 to 18 weeks)
4.1
4.1. Analysis
Comparison 4: 585‐nm Pulsed‐Dye Laser (PDL) versus Triamcinolone acetonide (TAC), Outcome 1: Severity of scars: Vancouver Burn Scar (VBS) scale (up to 12 months)
4.2
4.2. Analysis
Comparison 4: 585‐nm Pulsed‐Dye Laser (PDL) versus Triamcinolone acetonide (TAC), Outcome 2: Severity of scars: Patient self‐assessment (up to 12 months)
4.3
4.3. Analysis
Comparison 4: 585‐nm Pulsed‐Dye Laser (PDL) versus Triamcinolone acetonide (TAC), Outcome 3: Incidence and severity of treatment‐related adverse effects (up to 12 months)
5.1
5.1. Analysis
Comparison 5: 585‐nm Pulsed‐Dye Laser (PDL) versus 5‐Fluorouracil (5‐FU), Outcome 1: Severity of scars: Patient self‐assessment (32 weeks)
5.2
5.2. Analysis
Comparison 5: 585‐nm Pulsed‐Dye Laser (PDL) versus 5‐Fluorouracil (5‐FU), Outcome 2: Incidence and severity of treatment‐related adverse effects (32 weeks)
6.1
6.1. Analysis
Comparison 6: 585‐nm Pulsed‐Dye Laser (PDL) versus Triamcinolone acetonide (TAC) plus 5‐Fluorouracil (5‐FU), Outcome 1: Severity of scars: Patient self‐assessment (32 weeks)
6.2
6.2. Analysis
Comparison 6: 585‐nm Pulsed‐Dye Laser (PDL) versus Triamcinolone acetonide (TAC) plus 5‐Fluorouracil (5‐FU), Outcome 2: Incidence and severity of treatment‐related adverse effects (32 weeks)
7.1
7.1. Analysis
Comparison 7: 585‐nm Pulsed‐Dye Laser (PDL) versus Silicone Gel Sheeting, Outcome 1: Incidence and severity of treatment‐related adverse effects (24 weeks)
8.1
8.1. Analysis
Comparison 8: Erbium laser versus Triamcinolone acetonide (TAC), Outcome 1: Severity of scars: Vancouver Burn Scar (VBS) scale (up to 12 months)
8.2
8.2. Analysis
Comparison 8: Erbium laser versus Triamcinolone acetonide (TAC), Outcome 2: Severity of scars: Patient self‐assessment (up to 12 months)
9.1
9.1. Analysis
Comparison 9: Fractional carbon dioxide (CO2) laser versus intralesional Triamcinolone acetonide (TAC), Outcome 1: Incidence of treatment‐related adverse effects (24 weeks)
9.2
9.2. Analysis
Comparison 9: Fractional carbon dioxide (CO2) laser versus intralesional Triamcinolone acetonide (TAC), Outcome 2: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain (12 weeks)
9.3
9.3. Analysis
Comparison 9: Fractional carbon dioxide (CO2) laser versus intralesional Triamcinolone acetonide (TAC), Outcome 3: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain (24 weeks)
10.1
10.1. Analysis
Comparison 10: Fractional carbon dioxide (CO2) laser versus Intralesional Verapamil, Outcome 1: Incidence of treatment‐related adverse effects (24 weeks)
10.2
10.2. Analysis
Comparison 10: Fractional carbon dioxide (CO2) laser versus Intralesional Verapamil, Outcome 2: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain (12 weeks)
10.3
10.3. Analysis
Comparison 10: Fractional carbon dioxide (CO2) laser versus Intralesional Verapamil, Outcome 3: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain (24 weeks)
11.1
11.1. Analysis
Comparison 11: 585‐nm Pulsed‐Dye Laser (PDL) plus Triamcinolone acetonide (TAC) plus 5‐Fluorouracil (5‐FU) versus TAC plus 5‐FU, Outcome 1: Severity of scars (12 weeks)
12.1
12.1. Analysis
Comparison 12: Carbon dioxide (CO2) Laser plus Triamcinolone acetonide (TAC) versus Cryosurgery plus TAC, Outcome 1: Severity of scars (12 months)
12.2
12.2. Analysis
Comparison 12: Carbon dioxide (CO2) Laser plus Triamcinolone acetonide (TAC) versus Cryosurgery plus TAC, Outcome 2: Incidence and severity of treatment‐related adverse effects (12 months)
12.3
12.3. Analysis
Comparison 12: Carbon dioxide (CO2) Laser plus Triamcinolone acetonide (TAC) versus Cryosurgery plus TAC, Outcome 3: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain(12 months)
12.4
12.4. Analysis
Comparison 12: Carbon dioxide (CO2) Laser plus Triamcinolone acetonide (TAC) versus Cryosurgery plus TAC, Outcome 4: Recurrence of the condition (12 months)
13.1
13.1. Analysis
Comparison 13: Neodymium‐doped yttrium aluminum garnet (Nd:YAG) laser plus intralesional corticosteroid diprospan plus 5‐Fluorouracil (5‐FU) versus Intralesional corticosteroid diprospan plus 5‐FU, Outcome 1: Severity of scars (3 months)
14.1
14.1. Analysis
Comparison 14: Helium–neon (He‐Ne) laser plus Decamethyltetrasiloxane, Polydimethylsiloxane and Cyclopentasiloxane cream versus Decamethyltetrasiloxane, Polydimethylsiloxane and Cyclopentasiloxane cream, Outcome 1: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain (12 weeks)
15.1
15.1. Analysis
Comparison 15: 595‐nm Pulsed‐Dye Laser (PDL) plus intralesional verapamil versus intralesional verapamil, Outcome 1: Incidence of treatment‐related adverse effects (24 weeks)
15.2
15.2. Analysis
Comparison 15: 595‐nm Pulsed‐Dye Laser (PDL) plus intralesional verapamil versus intralesional verapamil, Outcome 2: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain (change from baseline) (12 weeks)
15.3
15.3. Analysis
Comparison 15: 595‐nm Pulsed‐Dye Laser (PDL) plus intralesional verapamil versus intralesional verapamil, Outcome 3: Scar size, colour, height, length, width and pliability, skin surface texture, pruritus and pain (change from baseline) (24 weeks)
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Update of

References

References to studies included in this review

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References to studies excluded from this review

Alster 2003a {published data only}
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Blome‐Eberwein 2018 {published data only}
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Chan 2004 {published data only}
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Freitas 2013 {published data only}
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Gaida 2004 {published data only}
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Ghalambor 2006 {published data only}
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Ouyang 2018 {published data only}
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References to studies awaiting assessment

Maari 2017 {published data only}
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References to ongoing studies

ACTRN12619001317189 {published data only}
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ACTRN12621000288820 {published data only}
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ChiCTR1900027249 {published data only}
    1. ChiCTR1900027249. The efficacy and safety of low energy carbon dioxide fractional in the treatment of pediatric hypertrophic scar: a perspective, randomized, self-controlled study. www.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR1900027249 2019.
ChiCTR‐ONH‐17012350 {published data only}
    1. ChiCTR-ONH-17012350. A randomized, parallel controlled study: the treatment of hypertrophic scars by combining fractional CO2 laser with narrow-spectrum intense pulsed light. www.chictr.org.cn/showproj.aspx?proj=20887 2017.
CTRI/2015/01/005400 {published data only}
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CTRI/2019/08/020883 {published data only}
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IRCT2016052318210N7 {published data only}
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NCT02996097 {published data only}
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NCT03240718 {published data only}
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NCT04769089 {published data only}
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PACTR202004808998657 {published data only}
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References to other published versions of this review

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