Innovative Treatments for Scars from Burns and Other Trauma

Published in Physician Update Winter 2020

Over the last decade, there have been dramatic advancements for patients with problematic scars from burns or other trauma, says surgeon Scott Hultman, director of the Johns Hopkins Burn Center. “With laser therapies, especially, there are now more treatment options available, and those options are more affordable and convenient than one might think.”

Where problems such as pain and restricted mobility caused by scarring are involved, the treatments are quite likely to be covered by insurance. “That’s still a holdup in too many cases,” Hultman says. “Word is still getting out to physicians that most insurance companies are now on board with reimbursing laser treatments that help patients make functional improvements.”

Traumatic scarring is quite common, with the number of victims worldwide estimated in the tens of millions. Every year, more than 1 million people in the United States seek treatment for problematic scars. Between 400 and 500 such patients visit the Burn Center annually, suffering from problems caused by all manner of trauma, not just burns.

The approaches that Johns Hopkins physicians take with these patients are a mix-and-match array of traditional therapies — massages, moisturizing, silicone sheeting and surgical excision among them — with the newer laser treatments that have been available at the Burn Center since 2015.

“What we’re trying to do with these laser treatments is take tension off of the scar and increase the pliability of the tissue,” says Burn Center surgeon Julie Ann Caffrey. “Within a few treatments, most patients get to experience quite a bit of relief from the pain and itchiness they were suffering.”

Two types of laser treatments are employed by center physicians. Pulsed dye lasers reduce inflammation by cauterizing the small blood vessels that cause the body to build up new, excess scar tissue. Fractional carbon dioxide laser resurfacing targets areas of tissue where excess water buildup leads to stiff, thick scars.

While putting together a journal article with Burn Center colleagues Kevin Klifto and Mohammed Asif, Hultman conducted a review of the scientific literature on laser therapy that was published earlier this year in Burns & Trauma. That study found both types of laser treatment winning high marks in patient satisfaction surveys, as well as in clinical research projects employing objective measures of improvement in the pigmentation, pliability, texture, and bulk of scar tissue.

Laser therapies are outpatient affairs done under anesthesia. A single treatment suffices in some cases, but most necessitate a run of multiple procedures. Patients are usually back to work and other normal activities in a single day or two at the most. While lasers eliminate the need for surgery in many cases, they are employed in others as a “prehabilitation” strategy that reduces the scope of scars in advance of operations that then become less invasive and less risky.

Success stories abound among Burn Center patients. One teenage patient cited by Hultman suffered from scar-related itching so intense that an opioid was prescribed. After laser therapy, that patient scaled down to the occasional dose of ibuprofen. Caffrey used laser therapies to help another patient make a full recovery from one-year-old, post-burn scars that left her unable to turn her head or even wear a t-shirt without experiencing intense pain.

“This is really a win-win-win situation with laser therapies,” Hultman says. “We’re looking at really strong outcomes for patients that come with reduced hospitalizations, reduced costs and reduced risks.”

A Life-Saving Burn Surgery

Pediatric plastic surgeon Rick Redett is able to achieve good outcomes because most burn patients have plenty of unburned skin on their body that can be used for skin grafts. But what if a child has severe burns over his entire body, leaving no healthy skin? “The biggest challenge in treating severe burns is replacing like tissue with like tissue,” says Redett. “We don’t have easy solutions for big burns.” Redett was recently faced with such a challenge in treating a Baltimore 3-year-old with burns over 92 percent of her body. Cadaveric skin alone could close her wounds and protect her body, but only temporarily as the body usually rejects cadaveric skin within 14 days. And without a skin covering, burn patients are extremely vulnerable to life-threatening inflammation, infections, bleeding and drops in temperature.

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Evaluating Burns Consistently

How staff members at local hospitals assess burns in children can affect the quality of care of patients transferred to pediatric burn centers.

Leticia Ryan, M.D.