Burn Scars

  • Best Results9-24 months
  • Treatment Recovery3-12 days
  • Procedure Time30-120 minutes
  • Skin SpecialistDavin Lim
  • Duration of ResultsPermanent
  • AnaestheticBlocks, numbing, sedation
  • Back to Work0-8 days
  • Cost$- $$ Medicare

Burn Scars

Lasers can be useful as adjunctive therapy to burn scars. Lasers provided controlled thermal energy. This stimulates collagen cells to remodel established scar tissue. This improves scar thickness & reduces symptoms. The laser of choice is the Lumenis Ultrapulse carbon dioxide or CO2 laser.

FactsFacts on treating burns scars

  • Lasers are not a substitute for surgery, silicone, & compression
  • They can be a useful adjunct to the above
  • A short pulse duration CO2 is the Gold Standard for burn scarring
  • Lasers can reduce symptoms such as itch, pain, & tightness
  • Laser resurfacing can improve mobility, contraction & improve range of motion
  • CO2 & thulium lasers can also potentiate absorption of topicals

What is the concept of burn scar revision?

Logically scars are textural, contour changes, & colour changes or a mixture of three. For burns scars the aim of treatment is to –

  1. Improve skin texture & pliability.
  2. Normalise pigment within the scar (re-pigment white areas).
  3. Reduce scar thickness.
  4. Reduce symptoms such as itch or pain
  5. Improve range of movement & function
  6. Restore normal contours

How should one approach burn scars?

Burns scars are unique because the normal components of skin including pigment cells, hair follicles, & sweat glands are either damaged or markedly attenuated. Additionally, scar tissue can give rise to thickened areas with abnormal collagen. Thick areas of scar tissue may lead to scar contractures with reduced function & sensitivity.

Treatment is aimed at reducing thickness & improving function, as well as decreasing scar contractures. I need to work with a plastic surgeon, physiotherapists & an occupational therapist for the best results. Lasers are not a substitute for surgical procedures, compression, silicone & mobility exercises. Fractional lasers are adjunctive therapy.

What is the logic of using lasers for burns?

I get it, it sounds counterintuitive to cause thermal damage (burn) for tissue that has experienced a thermal burn. The fundamental differences of lasers for burn scarring are the generation of low density but deep controlled thermal damage. It works by-

  1. Modifying cytokine & growth factor release. This results in scar remodelling. As it normalises the ratio of type 1 to 3 collagen within the burn scar.
  2. Allows for anti-inflammatory penetration of corticosteroids. This improves the pliability & softens scar tissue.
  3. Reduces redness through inflammatory modulation.
  4. Stimulates pigmentation in some scars, providing there are viable melanocytes present.

What lasers do I use?

I use the gold stand of CO2 lasers for burns – the Lumenis Ultrapulse SCAAR FX. Look it up. This laser is ancient, however with a recent software update it can produce a lot of power. In the context of deep scars, I can go down to 4,000 microns or 4 mm. This does not sound that deep, but in reality, it is 30 to 40 times the thickness of epidermis.

The concept of treating burn scars is easy to understand– if I push up the power, I reduce the density of CO 2 laser. Hence for 4mm depth penetration, my density level is 1-2. For more superficial scars, my density level is 3-6. In some cases, I use a Lutronic laser as it has an even shorter pulse duration (fire a Lumenis side by side with the same depth of penetration to compare & you will understand the PD).

Lasers also help with dermal drug delivery. In this context I may use a combination of deep CO2, with low density, & superficial thulium 1927 lasers. The drug of choice is triamcinolone as this can improve scar pliability. I also deliver other drugs such as PG analogues, tacrolimus & others to stimulate pigment production.

Is the treatment painful?

Treatments are comfortable. I use a mixture of numbing gel, injections & in some cases sedation. Post laser, there is no pain.

How many laser sessions are required?

It really depends on the extent of scarring, both in surface area & thickness. Typically, 3-12 sessions are required over a course of 6 to 24 months.

Progress is marked in the first few sessions. Patients will receive a noticeable improvement in texture, as well as range of movement. Most patients will also experience reduced symptoms such as itch. 

Davin’s Viewpoint on treating burn scars

Lasers are useful as adjunctive treatment for surgical, traumatic, & burn scarring. In the context of burns, the traditional approaches of surgical revision with grafts, Z-pasties, tissue expanders, & contracture release all applies. Laser is not a substitute for surgical management. Additionally, the use of silicone sheeting & compression garments still forms the foundation of treatment. Occupational & physiotherapy plays a vital role in rehabilitation as it aids mobility & range of movement.

The role of fractional lasers for burn scarring is relatively new, pioneered by dermatologists & plastic surgeons in the United States & in Italy. There have been many papers over the past 5-10 years demonstrating efficacy & safety. My goal is to improve-

  1. Symptoms, including itch & pain. Lasers can modify the inflammatory response, including histamine release & mast cells, thereby reducing itch & pain.
  2. Improve range of motion. This occurs as a result of scar remodelling as the ratio of type 1 & 3 collagen changes with CO2 lasers.
  3. Contour changes can be improved with collagen remodelling. Scars are less thick.
  4. Color changes are harder to correct with lasers. Fractional CO2, coupled with topicals may induce hyperpigmentation if there are viable pigment cells/melanocytes.

Inflammation & trauma (scratch, accident, burn) can reduce melanocyte numbers. If this happens, I need to transfer pigment cells from one area to another. This is surgical. There is no other way to reliably replace melanocytes.

Hypopigmented scars take time to heal & re-pigment, especially with lasers, microneedling & topicals. Melanocyte transfer is faster, I often get re-pigmentation within 3-8 weeks of surgery. The scar-recipient site looks somewhat patchy for many months before evening up at 12 months. You are in it for the long haul. Unlike pigment transfer for vitiligo, melanocyte transfer is more stable in scar tissue. In the context of burn scars, this transfer is more complex. The primary reason is that I cannot aggressively dermabrade or resurface the scar. This is due to the lack of pilosebaceous units. In 2022 I am researching the viability of FUE (follicular unit extraction & translation) for burns. This will increase melanin production as I transfer viable hair follicles in the burn scar itself. This has to be performed when scar thickness normalizes as this will give the highest survival rate for follicles.

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