“For burn patients, traditional scar therapies, such as silicone sheeting and compression garments, are highly reliant on patient compliance and have not demonstrated satisfactory efficacy,” explains Justin Gillenwater, MD, MS, FACS. “However, fractional CO2 laser treatment for burn scar treatment has shown significant improvement in burn scar profiles with high patient satisfaction and very few adverse effects in prior research.”

A Systematic Review & Meta-Analysis

For a paper published in Burns, Dr. Gillenwater and colleagues conducted a systematic review and meta-analysis to determine the efficacy of fractional CO2 lasers in treating patients with burn scars. Their objective was to do so using validated and subjective measurements, as well as to determine if laser therapy results in higher patient satisfaction and cost-effectiveness.

The comprehensive literature search resulted in 157 articles, published from 2012 to 2019, of which 15—three randomized controlled trials (RCTs) and 12 observational studies—were included in the analysis, with a total of 778 patients. Sample sizes ranged from 10 to 320, with a median of 22. Gender was reported in 93% (n = 14) of studies, with a higher proportion of females (52%, n = 235) than males (48% n = 213). The median reported age was 22.

Significant Improvement in Burn Scars With Laser Therapy

“Laser therapy alone demonstrated statistically significant improvement in hypertrophic scar profiles,” says Dr. Gillenwater. “For burn patients, quality of life can be greatly diminished due to pain, scarring, stiffness, contracture, and the psychological burden of disfigurement. Pathologic scar formation can also impair a patient’s ability to return to normal functionality.”

For dermatologists, plastic surgeons, and other physicians who work with burn patients, the use of fractional CO2 lasers has an increasing body of evidence that yields beneficial results in the treatment of hypertrophic scars, according to Dr. Gillenwater. “Fractional CO2 laser therapy is an efficacious procedure that can be used to improve burn scars in an outpatient setting,” he says. “It offers a relatively low side effect profile and is very well tolerated by patients. Traditional burn scare management treatments can be labor and time intensive and, in some cases, has not demonstrated positive outcomes.”

Two main observer description measures—the Vancouver scar scale (VSS) and patient/observer subjective assessment scale (POSAS; Table)—were commonly used to measure response to therapy. “All studies that used the POSAS (58%) demonstrated significant improvement in vascularization, pigmentation, thickness, relief, pliability, pain, and pruritis when comparing patients before and after treatment,” explains Dr. Gillenwater.

Fractional CO2 Laster Treatment Proves Cost-Effective

In addition to significantly and rapidly improving burn scars, fractional CO2 laser treatment is cost-effective, according to Dr. Gillenwater. The study team notes that fractional CO2 laser therapy can be performed as an outpatient procedure under local anesthesia, avoiding the need for surgical scar excision, which comes with higher costs, longer hospital stays, and morbidity, without a guarantee of superior outcomes.

Dr. Gillenwater would like to see burn management practitioners utilize laser therapy before attempting more invasive scar treatments. “I would also like to see physicians consider the use fractional CO2 laser therapy for treatment of all hypertrophic scarring, not just that due to burn injuries,” he says. Future research focusing on burn scar treatment, he adds, should examine the distinction between different types of CO2 lasers, as well as compare CO2 lasers to other types of scar management lasers. “Researchers should also evaluate the outcome of different CO2 laser settings,” he continues. “Optimal laser settings differ in the treatment of different types of hypertrophic scars.”

Dr. Gillenwater and colleagues also note the need for future studies focused on the cost-effectiveness of fractional CO2 laser treatment for burn scars. “Considering the total costs for burn treatment in the United States in 2010 was $1.5 billion, with another $5 billion lost due to inability to work, future research should be geared toward large-scale RCTs and determining the cost-effectiveness of fractional CO2 lasers over traditional burn scar management,” they write.