TBD Meeting (3715-15)

COPENHAGEN – The fractional CO₂ laser at 10,600 nm has emerged as the premier tool for improving the texture and elasticity of hypertrophic burn scars, Dr. Gerd G. Gauglitz asserted at the annual congress of the European Academy of Dermatology and Venereology.

“When it comes to improving the smoothness and the little elevations that are so bothersome to the burn patient, and especially when it comes to the stiffness of the scar, I think the fractional CO₂ laser is the approach that has no competition. There might be other devices to come in the future, but I think the results we now see with the fractional CO₂ laser are amazing,” said Dr. Gauglitz of Ludwig-Maximilian University, Munich.

Bruce Jancin/Frontline Medical News

It’s an opinion shared by other experts, he noted. For example, last year a panel of eight prominent American academic and military dermatologists and plastic surgeons with extensive experience in laser therapy of traumatic scars – including Dr. R. Rox Anderson of the Wellman Center for Photomedicine in Boston – published a consensus report that concluded “laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars” (JAMA Dermatol. 2014 Feb;150[2]:187-93).

Moreover, an international expert panel that issued updated clinical recommendations on scar management in 2014 declared that broader application of laser therapy constitutes “one of the most significant advances in scar management over the last 10 years.” The panel, which included Dr. Gauglitz, noted that “positive data for fractional lasers support their use for burn scar treatment” (Dermatol Surg. 2014 Aug;40[8]:817-24).

That being said, the current level of evidence supporting the use of fractional CO₂ laser therapy for hypertrophic burn scars is poor, Dr. Gauglitz pointed out. No clear data-driven recommendations exist as to the optimal number of laser sessions, between-treatment intervals, or device settings. This was the impetus for his ongoing prospective, controlled study, evaluating a specific treatment protocol in 20 patients with severe, mature hypertrophic burn scars of an average 12.7 years duration.

For purposes of the study, as well as in his own clinical practice, Dr. Gauglitz utilizes the UltraPulse fractional CO₂ laser to improve hypertrophic burn scars. He believes it offers compelling advantages over the alternative SuperPulse and continuous wave fractional CO₂ laser technologies. The UltraPulse features the narrowest zone of thermal damage, meaning greater precision, less pain and down time; and a favorable safety profile. Most importantly, it has greater penetration capacity, causing microscopic thermal wounds to a depth of 4 mm below the skin surface, which is important for purposes of collagen remodeling, he explained.

When using CO₂ lasers for burn scars, “clinically, we see completed reepithelialization after the procedure and then an ongoing collagen-remodeling phase lasting for up to 9 months. We see improvements in dermal architecture and creation of a collagen subtype profile that’s closer to nonwounded healthy skin,” according to the dermatologist.

Because other studies have relied heavily upon nonstandardized before and after photos and the Vancouver Scar Scale, with relatively short-term follow-up, Dr. Gauglitz and coinvestigators sought to advance the field by incorporating a variety of more objective measures, including the PRIMOS (Phaseshift Rapid in Vivo Measurement of the Skin) three-dimensional device widely utilized for wrinkle measurement, as well as the Cutometer, which evaluates skin elasticity. The investigators are also formally measuring the quality of life impact of their laser regimen.

The study consists of two parts. At the EADV congress, Dr. Gauglitz presented the results of the first part, which involved a single treatment of a 12-by-8 cm² area, with a comparable untreated control area, and a 6-month follow-up. In the ongoing second part of the study, the same patients are undergoing three treatment sessions on a larger scarred area, with 3-month intervals between sessions. Again, a comparable untreated area of the body serves as the control.

Each treatment session involves three passes with the UltraPulse laser. The first is done at the most intense setting, known by the proprietary name of SCAAR FX (Synergistic Coagulation and Ablation for Advanced Resurfacing). This is aimed at inducing the collagen-remodeling process. The setting is 70-140 mJ/cm², 250 Hz, with a density of 1%. The second pass utilizes the small-spot ACTIVE FX setting, designed to provide superficial ablative therapy to remove fine elevated scars. This involves 40-90 mJ/cm₂ at high density and 300 Hz. The final pass is set at large-spot Active FX and employs 125 mJ/cm² at low density and 125 Hz; the purpose is to smooth the scar and make the skin surface more homogeneous.

The most interesting aspect about the results, Dr. Gauglitz observed, is that 1 month after treatment, across-the-board improvements were documented, but then continued to grow in magnitude through the final 6-month follow-up – despite no further treatment. This was presumably the consequence of the collagen-remodeling process.

For example, scores on the Vancouver Scar Scale – still the most widely used scoring tool in the burn field – improved from roughly 7 at baseline to 2 at 6 months, compared with no change in the control area. Similarly, scores on the POSAS (Patient and Observer Scar Assessment Scale) showed highly significant and steadily growing improvement over 6 months of follow-up in most domains, including scar pigmentation, thickness, surface area, and flexibility.

Skin elasticity as measured by the Cutometer improved steadily by 28% at the 6-month mark. Likewise, evaluation with the PRIMOS device showed a steadily smoother scar surface over time.

Final results on the Dermatology Life Quality Index (DLQI) are still being tabulated, but there clearly is a strong improvement on this score – much of it attributed to the improved function resulting from greater flexibility.

“The results of fractional CO₂ laser therapy are actually difficult to visualize, but patients are incredibly happy. For us, it might not be a big difference, but if you smoothen the scar surface and the patient is suddenly able to apply makeup without making the scar too visible, for those patients it’s a big thing,” Dr. Gauglitz said.

It’s clear from the ongoing multitreatment stage of the study that a single laser session is not optimal. “I think it’s going to be three, at least, for maximum benefit,” the dermatologist commented.

Asked if he thinks the fractional CO₂ laser is the most effective tool for all aspects of scar treatment, Dr. Gauglitz was quick to say no.

“It depends, really, on the indication you want to treat. When it comes to erythema, a pulsed dye laser is much more effective than a fractional CO₂ laser. For hyperpigmentation, a Q-switched ruby laser or the new picosecond laser might be a more interesting approach,” he replied.

Dr. Gauglitz reported serving on advisory boards and speakers’ bureaus for laser manufacturers Lumenis and Candela as well as for Merz Pharmaceuticals and Sinclair Pharma.

bjancin@frontlinemedcom.com

COPENHAGEN – The fractional CO₂ laser at 10,600 nm has emerged as the premier tool for improving the texture and elasticity of hypertrophic burn scars, Dr. Gerd G. Gauglitz asserted at the annual congress of the European Academy of Dermatology and Venereology.

“When it comes to improving the smoothness and the little elevations that are so bothersome to the burn patient, and especially when it comes to the stiffness of the scar, I think the fractional CO₂ laser is the approach that has no competition. There might be other devices to come in the future, but I think the results we now see with the fractional CO₂ laser are amazing,” said Dr. Gauglitz of Ludwig-Maximilian University, Munich.

Bruce Jancin/Frontline Medical News

It’s an opinion shared by other experts, he noted. For example, last year a panel of eight prominent American academic and military dermatologists and plastic surgeons with extensive experience in laser therapy of traumatic scars – including Dr. R. Rox Anderson of the Wellman Center for Photomedicine in Boston – published a consensus report that concluded “laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars” (JAMA Dermatol. 2014 Feb;150[2]:187-93).

Moreover, an international expert panel that issued updated clinical recommendations on scar management in 2014 declared that broader application of laser therapy constitutes “one of the most significant advances in scar management over the last 10 years.” The panel, which included Dr. Gauglitz, noted that “positive data for fractional lasers support their use for burn scar treatment” (Dermatol Surg. 2014 Aug;40[8]:817-24).

That being said, the current level of evidence supporting the use of fractional CO₂ laser therapy for hypertrophic burn scars is poor, Dr. Gauglitz pointed out. No clear data-driven recommendations exist as to the optimal number of laser sessions, between-treatment intervals, or device settings. This was the impetus for his ongoing prospective, controlled study, evaluating a specific treatment protocol in 20 patients with severe, mature hypertrophic burn scars of an average 12.7 years duration.

For purposes of the study, as well as in his own clinical practice, Dr. Gauglitz utilizes the UltraPulse fractional CO₂ laser to improve hypertrophic burn scars. He believes it offers compelling advantages over the alternative SuperPulse and continuous wave fractional CO₂ laser technologies. The UltraPulse features the narrowest zone of thermal damage, meaning greater precision, less pain and down time; and a favorable safety profile. Most importantly, it has greater penetration capacity, causing microscopic thermal wounds to a depth of 4 mm below the skin surface, which is important for purposes of collagen remodeling, he explained.

When using CO₂ lasers for burn scars, “clinically, we see completed reepithelialization after the procedure and then an ongoing collagen-remodeling phase lasting for up to 9 months. We see improvements in dermal architecture and creation of a collagen subtype profile that’s closer to nonwounded healthy skin,” according to the dermatologist.

Because other studies have relied heavily upon nonstandardized before and after photos and the Vancouver Scar Scale, with relatively short-term follow-up, Dr. Gauglitz and coinvestigators sought to advance the field by incorporating a variety of more objective measures, including the PRIMOS (Phaseshift Rapid in Vivo Measurement of the Skin) three-dimensional device widely utilized for wrinkle measurement, as well as the Cutometer, which evaluates skin elasticity. The investigators are also formally measuring the quality of life impact of their laser regimen.

The study consists of two parts. At the EADV congress, Dr. Gauglitz presented the results of the first part, which involved a single treatment of a 12-by-8 cm² area, with a comparable untreated control area, and a 6-month follow-up. In the ongoing second part of the study, the same patients are undergoing three treatment sessions on a larger scarred area, with 3-month intervals between sessions. Again, a comparable untreated area of the body serves as the control.

Each treatment session involves three passes with the UltraPulse laser. The first is done at the most intense setting, known by the proprietary name of SCAAR FX (Synergistic Coagulation and Ablation for Advanced Resurfacing). This is aimed at inducing the collagen-remodeling process. The setting is 70-140 mJ/cm², 250 Hz, with a density of 1%. The second pass utilizes the small-spot ACTIVE FX setting, designed to provide superficial ablative therapy to remove fine elevated scars. This involves 40-90 mJ/cm₂ at high density and 300 Hz. The final pass is set at large-spot Active FX and employs 125 mJ/cm² at low density and 125 Hz; the purpose is to smooth the scar and make the skin surface more homogeneous.

The most interesting aspect about the results, Dr. Gauglitz observed, is that 1 month after treatment, across-the-board improvements were documented, but then continued to grow in magnitude through the final 6-month follow-up – despite no further treatment. This was presumably the consequence of the collagen-remodeling process.

For example, scores on the Vancouver Scar Scale – still the most widely used scoring tool in the burn field – improved from roughly 7 at baseline to 2 at 6 months, compared with no change in the control area. Similarly, scores on the POSAS (Patient and Observer Scar Assessment Scale) showed highly significant and steadily growing improvement over 6 months of follow-up in most domains, including scar pigmentation, thickness, surface area, and flexibility.

Skin elasticity as measured by the Cutometer improved steadily by 28% at the 6-month mark. Likewise, evaluation with the PRIMOS device showed a steadily smoother scar surface over time.

Final results on the Dermatology Life Quality Index (DLQI) are still being tabulated, but there clearly is a strong improvement on this score – much of it attributed to the improved function resulting from greater flexibility.

“The results of fractional CO₂ laser therapy are actually difficult to visualize, but patients are incredibly happy. For us, it might not be a big difference, but if you smoothen the scar surface and the patient is suddenly able to apply makeup without making the scar too visible, for those patients it’s a big thing,” Dr. Gauglitz said.

It’s clear from the ongoing multitreatment stage of the study that a single laser session is not optimal. “I think it’s going to be three, at least, for maximum benefit,” the dermatologist commented.

Asked if he thinks the fractional CO₂ laser is the most effective tool for all aspects of scar treatment, Dr. Gauglitz was quick to say no.

“It depends, really, on the indication you want to treat. When it comes to erythema, a pulsed dye laser is much more effective than a fractional CO₂ laser. For hyperpigmentation, a Q-switched ruby laser or the new picosecond laser might be a more interesting approach,” he replied.

Dr. Gauglitz reported serving on advisory boards and speakers’ bureaus for laser manufacturers Lumenis and Candela as well as for Merz Pharmaceuticals and Sinclair Pharma.

bjancin@frontlinemedcom.com

COPENHAGEN – The fractional CO₂ laser at 10,600 nm has emerged as the premier tool for improving the texture and elasticity of hypertrophic burn scars, Dr. Gerd G. Gauglitz asserted at the annual congress of the European Academy of Dermatology and Venereology.

“When it comes to improving the smoothness and the little elevations that are so bothersome to the burn patient, and especially when it comes to the stiffness of the scar, I think the fractional CO₂ laser is the approach that has no competition. There might be other devices to come in the future, but I think the results we now see with the fractional CO₂ laser are amazing,” said Dr. Gauglitz of Ludwig-Maximilian University, Munich.

Bruce Jancin/Frontline Medical News

It’s an opinion shared by other experts, he noted. For example, last year a panel of eight prominent American academic and military dermatologists and plastic surgeons with extensive experience in laser therapy of traumatic scars – including Dr. R. Rox Anderson of the Wellman Center for Photomedicine in Boston – published a consensus report that concluded “laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars” (JAMA Dermatol. 2014 Feb;150[2]:187-93).

Moreover, an international expert panel that issued updated clinical recommendations on scar management in 2014 declared that broader application of laser therapy constitutes “one of the most significant advances in scar management over the last 10 years.” The panel, which included Dr. Gauglitz, noted that “positive data for fractional lasers support their use for burn scar treatment” (Dermatol Surg. 2014 Aug;40[8]:817-24).

That being said, the current level of evidence supporting the use of fractional CO₂ laser therapy for hypertrophic burn scars is poor, Dr. Gauglitz pointed out. No clear data-driven recommendations exist as to the optimal number of laser sessions, between-treatment intervals, or device settings. This was the impetus for his ongoing prospective, controlled study, evaluating a specific treatment protocol in 20 patients with severe, mature hypertrophic burn scars of an average 12.7 years duration.

For purposes of the study, as well as in his own clinical practice, Dr. Gauglitz utilizes the UltraPulse fractional CO₂ laser to improve hypertrophic burn scars. He believes it offers compelling advantages over the alternative SuperPulse and continuous wave fractional CO₂ laser technologies. The UltraPulse features the narrowest zone of thermal damage, meaning greater precision, less pain and down time; and a favorable safety profile. Most importantly, it has greater penetration capacity, causing microscopic thermal wounds to a depth of 4 mm below the skin surface, which is important for purposes of collagen remodeling, he explained.

When using CO₂ lasers for burn scars, “clinically, we see completed reepithelialization after the procedure and then an ongoing collagen-remodeling phase lasting for up to 9 months. We see improvements in dermal architecture and creation of a collagen subtype profile that’s closer to nonwounded healthy skin,” according to the dermatologist.

Because other studies have relied heavily upon nonstandardized before and after photos and the Vancouver Scar Scale, with relatively short-term follow-up, Dr. Gauglitz and coinvestigators sought to advance the field by incorporating a variety of more objective measures, including the PRIMOS (Phaseshift Rapid in Vivo Measurement of the Skin) three-dimensional device widely utilized for wrinkle measurement, as well as the Cutometer, which evaluates skin elasticity. The investigators are also formally measuring the quality of life impact of their laser regimen.

The study consists of two parts. At the EADV congress, Dr. Gauglitz presented the results of the first part, which involved a single treatment of a 12-by-8 cm² area, with a comparable untreated control area, and a 6-month follow-up. In the ongoing second part of the study, the same patients are undergoing three treatment sessions on a larger scarred area, with 3-month intervals between sessions. Again, a comparable untreated area of the body serves as the control.

Each treatment session involves three passes with the UltraPulse laser. The first is done at the most intense setting, known by the proprietary name of SCAAR FX (Synergistic Coagulation and Ablation for Advanced Resurfacing). This is aimed at inducing the collagen-remodeling process. The setting is 70-140 mJ/cm², 250 Hz, with a density of 1%. The second pass utilizes the small-spot ACTIVE FX setting, designed to provide superficial ablative therapy to remove fine elevated scars. This involves 40-90 mJ/cm₂ at high density and 300 Hz. The final pass is set at large-spot Active FX and employs 125 mJ/cm² at low density and 125 Hz; the purpose is to smooth the scar and make the skin surface more homogeneous.

The most interesting aspect about the results, Dr. Gauglitz observed, is that 1 month after treatment, across-the-board improvements were documented, but then continued to grow in magnitude through the final 6-month follow-up – despite no further treatment. This was presumably the consequence of the collagen-remodeling process.

For example, scores on the Vancouver Scar Scale – still the most widely used scoring tool in the burn field – improved from roughly 7 at baseline to 2 at 6 months, compared with no change in the control area. Similarly, scores on the POSAS (Patient and Observer Scar Assessment Scale) showed highly significant and steadily growing improvement over 6 months of follow-up in most domains, including scar pigmentation, thickness, surface area, and flexibility.

Skin elasticity as measured by the Cutometer improved steadily by 28% at the 6-month mark. Likewise, evaluation with the PRIMOS device showed a steadily smoother scar surface over time.

Final results on the Dermatology Life Quality Index (DLQI) are still being tabulated, but there clearly is a strong improvement on this score – much of it attributed to the improved function resulting from greater flexibility.

“The results of fractional CO₂ laser therapy are actually difficult to visualize, but patients are incredibly happy. For us, it might not be a big difference, but if you smoothen the scar surface and the patient is suddenly able to apply makeup without making the scar too visible, for those patients it’s a big thing,” Dr. Gauglitz said.

It’s clear from the ongoing multitreatment stage of the study that a single laser session is not optimal. “I think it’s going to be three, at least, for maximum benefit,” the dermatologist commented.

Asked if he thinks the fractional CO₂ laser is the most effective tool for all aspects of scar treatment, Dr. Gauglitz was quick to say no.

“It depends, really, on the indication you want to treat. When it comes to erythema, a pulsed dye laser is much more effective than a fractional CO₂ laser. For hyperpigmentation, a Q-switched ruby laser or the new picosecond laser might be a more interesting approach,” he replied.

Dr. Gauglitz reported serving on advisory boards and speakers’ bureaus for laser manufacturers Lumenis and Candela as well as for Merz Pharmaceuticals and Sinclair Pharma.

bjancin@frontlinemedcom.com