HAND/PERIPHERAL NERVE

Hypertrophic Scars of the Hand: The Role of

Electrophotobiomodulation Theory as a Recent
Line of Treatment
Nader Gomaa Elmelegy, MD

Background: A more enduring strategy for the treatment of hypertrophic scars

Tanta, Egypt of the hand is still a challenge facing restorative dermatologists and plastic sur-
geons. Nonetheless, with the use of nonablative devices, intense pulsed light
and different types of lasers have started to yield promising outcomes and are
close to becoming an effective and dependable technique. The advances in
radiofrequency energy have brought new life to optical-based frameworks.
Radiofrequency current delivers an unadulterated heat effect according to the
electrical response characteristics of each tissue. The purpose of this study was
to assess the patient satisfaction, safety, and clinical efficacy of the use of elec-
trophotobiomodulation (combined intense pulsed light and radiofrequency
energy) in the treatment of postburn hypertrophic scars of the hand.
Methods: This was a prospective clinical study that was performed on 56 patients
who presented with postburn hypertrophic scars on the hands between March
of 2013 and January of 2020.
Results: The clinical appraisal showed excellent results in 33 patients (58.9%),
good results in 18 patients (32.2%), fair results in five patients (8.9%), and no
poor results.
Conclusion: The use of radiofrequency energy combined with intense pulsed
light was effective for the treatment of hand scars on people with various skin
tones.   (Plast. Reconstr. Surg. 151: 375, 2023.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

E
lectrophotobiomodulation is the use of a date, an ideal treatment strategy has not been
combination of intense pulsed light (IPL) achieved.3
and radiofrequency (RF) to modulate body A more enduring technique for the treat-
tissues so that the body can repair itself, to reduce ment of hypertrophic scars of the hand with con-
inflammation, and to assist in wound healing.1 vincing results across all skin types is the essential
Hypertrophic scar of the hand is a serious prob- test today facing restorative dermatologists or
lem for burn survivors and can result in a wide plastic surgeons. However, with the advent of
range of life-restricting issues. These include psy- nonablative devices, such as IPL and various
chologic problems, itching, pain, solidness, and types of lasers, which have been successfully used
contractures.2 Various strategies and treatment to treat hypertrophic scars, promising results
modalities have been applied for the treatment are set to transform into an ensured trustworthy
of hypertrophic scars of the hand, including sur- procedure.4–6
gical excision with or without grafting, pressure The advances in RF energy brought new life
treatment, intralesional interferon, corticoste- to optical-based frameworks, as this energy meth-
roids or bleomycin, laser treatment, silicone gel odology is not sensitive to the melanin concen-
sheeting, onion extract gel, and RF; however, to tration in the epidermis. RF current delivers an

From the Department of Plastic Surgery, Faculty of Medicine,

Tanta University.
Received for publication July 29, 2021; accepted April 18, Disclosure: The author has no financial interest to
2022. declare in relation to the content of this article. No
Copyright © 2022 by the American Society of Plastic Surgeons funding was received for this work.
DOI: 10.1097/PRS.0000000000009962

www.PRSJournal.com 375
 Plastic and Reconstructive Surgery • February 2023

unadulterated heat effect according to the electri- signed by each patient in this study, including the
cal response characteristics of each tissue.7,8 The risk of complications, agreement to undergo clini-
purpose of this study was to assess patient satisfac- cal photography, and the possibility of using their
tion, safety, and clinical efficacy of the use of elec- data in medical publications.
trophotobiomodulation (combined IPL and RF)
for the treatment of postburn hypertrophic scars
of the hand. Technique
The E-light machine (Beijing Oriental Wison
PATIENTS AND METHODS Mechanical & Electronic Co. Ltd .; Beijing,
People’s Republic of China) with a handle that
All of the procedures performed in this study was used in this study contained both IPL and RF.
followed the requirements of the institutional Special eye goggles were used by the treating doc-
and national research committees and the 1964 tor and the patients to protect their eyes. EMLA
Declaration of Helsinki and its later amend- 5% (AstraZeneca, Cambridge, United Kingdom)
ments or comparable ethical standards. The rules anesthetic cream was applied over the affected
and principles of ethical and professional con- hands half an hour before the start of the pro-
duct were followed in this study. This article was cedure. All patients underwent sessions at 2- to
approved by Tanta University’s ethical committee 4-week intervals. The author evaluated the hyper-
(December 14, 2012). This is a prospective clini- trophic scar and proposed the number of sessions,
cal study that has been performed on 43 patients but this could be increased or decreased accord-
who presented with postburn hypertrophic scars ing to the response of treatment. The decision to
on the hands (34 patients were one-sided and nine stop the treatment was made by both the treating
were bilateral), in the period between March of doctor and the patient according to the response
2013 and January of 2020. The age of the patients and satisfaction.
ranged between 18 and 52 years, with a mean age Different filters—530, 560, and 580 nm—
of 27 years. were used according to the skin color to
Written consent for performing the punch avoid complications. The IPL fluence varied
biopsy specimen was obtained from all patients. between 18 and 25 J, and the RF fluences var-
The punch biopsy specimens were taken from all ied between 5 and 7 J. The spot diameter was
patients under completely sterilized conditions 8 × 32 mm. Pulse durations of 2 to 4 msec and
using 10% povidone-iodine and under local infil- pulse delays of 15 to 30 msec were used for all
trative anesthesia (2% lidocaine). A sequence of patients. Cold compression was applied imme-
three punch biopsies (6-mm skin punch) were diately after each session for 10 minutes; then,
performed. The first was taken from the most anti-inflammatory cream, which contained pan-
prominent area of the hypertrophic scar, before thenol, calendula extract, and triclosan, was
the treatment. The second was taken from the applied until the inflammation subsided. The
same area at week 8 of the treatment. The third sessions were stopped once there was an overt
was also taken from the same area at week 12 after decrease in scar firmness, redness, and itching,
the completion of treatment. All specimens were and a marked improvement in the pigmentary
stained with hematoxylin and eosin as a routine disorders of the affected area. The number of
histologic examination. sessions for each patient was reported. Patients
were followed up after 2 weeks, 1 month, 3
Inclusion Criteria months, 6 months, and 1 year or more. No
All patients older than 18 years with postburn posttreatment advice was given (ie, massage or
hypertrophic scarring of the hand who presented local treatment). Aesthetic outcome data were
to the Burn Casualty Unit of Tanta University recorded after at least 6 months.
Hospital and the author’s private practice were The photography session during the last
included in this study. follow-up visit was considered to be the postop-
erative photographic outcome, provided that
Exclusion Criteria it was performed 6 months or more after the
Patients with systemic diseases (eg, diabetes final treatment. The preoperative and postop-
mellitus, immunity disorders, photosensitivity) or erative photographic outcomes were compared.
who had received any other treatment for their Patient satisfaction was assessed according to
hand scars before the start of our treatment proto- the patient-reported outcome measures, which
col were excluded. Written informed consent was were specific questionnaires that described the

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Volume 151, Number 2 • Treatment of Hand Hypertrophic Scars

patient’s views of satisfaction about the follow- study, using a four-point scale. There were excel-
ing parameters: aesthetic shape, functional lent results in 23 patients (53.5%), good results
outcome, comments of relatives, lifestyle, and in 15 patients (34.9%), fair results in five patients
general satisfaction degree. The collected data (11.6%), and no poor results.
were organized and tabulated. The patients Patient satisfaction was assessed through
were asked to rate their degree of satisfaction patient-reported outcome measures. A four-point
on a four-point scale as follows: 4, excellent; 3, scale was used. It showed excellent results in 31
good; 2, fair; and 1, poor. This was used for eval- patients (72.1%), good results in nine patients
uating each parameter. Clinical satisfaction was (20.9%), fair results in three patients (7%), and
assessed by three plastic surgeons not actively no poor results.
involved in the study. Through a general score The histologic evaluation was performed
from 1 to 4, the preoperative and last subse- by the economic division at the pathology aca-
quent photographs were surveyed and the treat- demic department of the faculty of medicine.
ment effect was rated as excellent, good, fair, or The analysis of all histologic samples had shown
poor. that collagen bundles are interlaced and thick
in all dermis, and that there is perivascular cel-
lular infiltration in the pretreatment (RF and
RESULTS IPL) biopsy specimens. It had also shown that the
This study was carried out on 43 patients (34 collagen bundles become more parallelized and
patients were one-sided and nine were bilateral), thinner; there is also end-arteritis obliterans and
32 men and 11 women. Their age ranged between perivascular lymphocytic infiltration at week 8 of
18 and 52 years, with a mean of 27 years. The mean the treatment. The last biopsy specimen was taken
follow-up period was 1 year after the last session. at week 12 after completing the treatment, and
According to the Fitzpatrick skin type classifica- it showed that all collagen bundles became more
tion, four patients were type II, 15 patients were parallelized to the epidermal surface and thinner,
type III, 19 patients were type IV, and five patients so there were fewer identified as bundles in the
were type V. papillary dermis, and the blood vessels are fewer
The postprocedure downtime was a few (Fig. 1). The results are reported in Tables 1 and
hours, and the patient could resume normal 2 and Figures 1 through 5.
daily life thereafter. All adverse effects, such as
erythema and edema, were transient and cleared
completely within a few hours. In all patients, DISCUSSION
electrophotobiomodulation using a combina- A variety of modalities have been used for
tion of IPL and RF was performed. The mean the treatment of hypertrophic or keloid scars.
fluence used for the IPL treatment was 21 J/cm2 Silicone gel sheeting has been widely used in
(range, 18 to 25 J/cm2), and the mean RF power clinical practice since the early 1980s.9 However,
was 6 J/cm2 (range, 5 to 7 J/cm2). Different unsatisfactory patient compliance with the use
E-light filters were used according to Fitzpatrick of silicone gel sheets, difficulty in application,
skin type: 530  nm in seven patients, 580 nm in persistent pruritus, skin breakdown, skin rash,
23 patients, and 630 nm in 13 patients. The use the disappointment of the sheet’s inability to
of filters helped in the treatment of various skin improve the hydration of dry scars, and the vis-
types. ibility of the treatment for scars situated in vis-
According to the modified Vancouver Scar ible regions (eg, the face or the hand) have been
Scale, there was an improvement of scar hyper- reported as serious limitations.10 In our study,
pigmentation in 92.6%, hypopigmentation in we were not confronted with such undesirable
63.6% (the response was greater in the darker side effects, as we did not apply any type of skin
skin types), and in mixed cases, 78.5%. Also, there coverage.
was an affect on scar vascularity in 83.3% to 100%, Heparin and onion extract affect scar devel-
scar pliability in 42.8% to 100%, and scar height opment by means of their inhibitory effects on
in 82.6% to 88.9%. All symptoms such as pain and inflammatory processes, fibroblast proliferation,
pruritus improved from one meeting to the other and the synthesizing capacity of fibroblasts.11
until they were completely relieved without the However, Chanprapaph et al.12 observed that
need for any medication. there was no statistically significant difference in
The clinical appraisal was performed by three the scars’ redness, pliability, or overall cosmetic
plastic specialists not actively involved in the appearance among patients who used a topical

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 Plastic and Reconstructive Surgery • February 2023

Fig. 1. (Above, left) Collagen bundles are interlaced and thick in all dermis. There is perivascular cellular infiltration before (RF and
IPL) (hematoxylin and eosin; original magnification, × 100). (Above, right) The collagen bundles become more parallelized and
thinner, at week 8 of treatment (hematoxylin and eosin; original magnification, × 100). (Below, left) There is end-arteritis obliter-
ans and perivascular lymphocytic infiltration at week 8 of the treatment (hematoxylin and eosin; original magnification, × 200).
(Below, right) All collagen bundles are parallelized to the epidermal surface and thinner so that fewer are identified as bundles in
the papillary dermis; there are fewer blood vessels at week 12 after completing the treatment (hematoxylin and eosin; original
magnification, × 100).

preparation containing onion extract, heparin, the scar.16 The use of interferon-alpha, interferon-
and allantoin gel. In our study, marked improve- beta, and interferon-gamma increases collagen
ments in redness (84.2% to 100%) and pliability lysis. Nonetheless, interferon application is excru-
(33% to 100%) were documented. An overall ciating and is very expensive.17 In contrast, in our
improved cosmetic appearance was noticed, and study, we found improvement in hypopigmenta-
the level of scar improvement increased with an tion in 61.5% of our patients. No cases with skin
increase in the number of sessions. atrophy, telangiectasia, or rebound were reported
The use of corticosteroids to treat unusual during long-term follow-up.
scar arrangements has been generally success- Surgical removal of hypertrophic scars with
ful for most patients. Koc et al.13 reported that no adjuvant treatment ought to be avoided
the response rates to intralesional corticosteroid because of the extraordinarily high recurrence
injections varied from 50% to 100%, with a recur- rates (45% to 100%). Intramarginal excision of
rence rate of 9% to 50%. Nevertheless, up to 63% the hypertrophic scar has a recurrence rate of
of patients experience certain incidental effects, 100%, whereas extramarginal excision of the
including skin hypopigmentation, subcutaneous hypertrophic scar has a recurrence rate of 33%.
fat decay, telangiectasias, and ineffectiveness.14 Thus, adjuvant treatments, including triamcino-
The use of intralesional bleomycin has lone injection, radiation therapy, silicone sheet
been applied to the treatment of keloids and application, and pressure therapy, have been
hypertrophic scars, with promising outcomes.15 proposed to prevent a recurrence. In any case,
Concerning the side effects of intralesional bleo- none of these therapies have become successful
mycin, hyperpigmentation and dermal atrophy treatment methods.18–21 In our study, we used
can be induced in the sound skin surrounding electrophotobiomodulation only, without any

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Volume 151, Number 2 • Treatment of Hand Hypertrophic Scars

Table 1. Descriptive Analytic Data, Using the Modified Vancouver Scar Scale of Different Variabilities in
Pigmentation, Vascularity, Pliability, Height, Fitzpatrick Skin Type, and Filter Type in 52 Affected Hand
Scar Character Score No. of Affected Hands (%) Improvement (%)
Pigmentation 0–2
 Normal 0 — —
 Hypopigmentation 1 11 (21.2) 7 (63.6)
 Hyperpigmentation 2 27 (51.9) 25 (92.6)
 Mixed 3 14 (26.9) 11 (78.5)
Vascularity 0–3
 Normal 0 — —
 Pink 1 17 (32.7) 17 (100)
 Red 2 23 (44.2) 21 (91.3)
 Purple 3 12 (23.1) 10 (83.3)
Pliability 0–5
 Normal 0 — —
 Supple 1 7 (13.5) 7 (100)
 Yielding 2 8 (15.3) 7 (87.5)
 Firm 3 21 (40.4) 19 (90.5)
 Banding 4 9 (17.3) 7 (77.8)
 Contracture 5 7 (13.5) 3 (42.8)
Height 0–3
 Normal (flat) 0 — —
 0–2 mm 1 9 (17.3) 8 (88.9)
 2–5 mm 2 20 (38.5) 17 (85)
 >5 mm 3 23 (44.2) 19 (82.6)
Fitzpatrick skin type
 I 0 (0) 0 (0)
 II 4 (9.3) 4 (100)
 III 15 (34.9) 13 (86.6)
 IV 19 (44.2) 14 (73.6)
 V 5 (11.6) 3 (600)
Filter type
 530 nm 7 (20.9) 7 (100)
 580 nm 23 (62.8) 19 (82.6)
 630 nm 13 (16.3) 8 (61.5)

Table 2. Descriptive Analytic Data of Different decades. Carbon dioxide laser and an argon laser
Variabilities in Age, Sex, Number of Sessions, Clinical have been used for the treatment of hypertrophic
Satisfaction, and Patient Satisfaction in 43 Patients scars but were found to be ineffective, with a high
Variable No. of Patients (%) rate of recurrence. Choi et al.22 studied the clini-
Age cal outcome of 1064-nm picosecond neodymium-
 18–20 years 7 (16.3) doped yttrium aluminum garnet laser for the
 21–30 years 27 (62.8) treatment of hypertrophic scars and reported
 >30 years 9 (20.9)
Sex that patient satisfaction was moderate. Lei et al.23
 Male 32 (74.4) contemplated the clinical adequacy of using ultra
 Female 11 (25.6)
No. of sessions pulse carbon dioxide combined with a fractional
 6 9 (20.9) carbon dioxide laser for the treatment of hyper-
 8 27 (62.8) trophic scars in Asian patients, and they found
 10 7 (16.3)
Clinical satisfaction that the overall satisfaction rate was 92%. No long-
 Excellent 23 (53.5) term complications occurred in their clinical trial.
 Good 15 (34.9)
 Fair 5 (11.6) The most encouraging results have been
 Poor 0 (0) demonstrated with the use of a 585-nm pulsed
Patient satisfaction according to dye laser.24 According to Alster and Handrick,25
PROMs
 Excellent 31 (72.1) two to six treatment sessions are necessary to
 Good 9 (20.9) successfully improve the scar color, height, pli-
 Fair 3 (7) ability, and texture. However, these findings
 Poor —
PROMs, patient-reported outcome measures.
could not be reproduced in several subsequent
studies.26 Longer persisting hyperpigmentation
adjuvant treatment, and we had no recurrence particularly occurs in darker skin types, but
during the long-term follow-up. this is less frequent with the use of wavelengths
Various types of lasers have been evaluated of 595  nm than with 585  nm.27 In our work,
for the treatment of hypertrophic scars in recent there were improvements in scar color, height,

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 Plastic and Reconstructive Surgery • February 2023

Fig. 2. (Left) A 47-year-old man presented with a postburn hypertrophic scar, hyperpigmentation, and hypopigmentation affect-
ing the right hand (above) and left hand (below). (Right) Images obtained after application of eight sessions of IPL and RF, with
excellent results (6 months from the first session).

pliability, texture, and hyperpigmentation in melanin absorption of light energy, which is the
all patients with Fitzpatrick skin types II, III, IV, main cause of complications that occurred with
and V. the use of the IPL alone. These lower energy
Hultman et al.28 reported that the treat- prerequisites make E-light (IPL and RF) safer,
ment of postburn hypertrophic scars using IPL and they can be used to treat a more extensive
provides a minimal improvement, a variable assortment of patients by being appropriate for
efficacy, a high cost for patients, and prob- various skin types.
able recurrence of the hyperpigmentation fol- In our study, the use of RF with IPL helped
lowing ultraviolet light exposure. Dermal RF diminish the IPL force, which guarded against
has been used as another therapeutic option the unwanted side effects of using the IPL
for the treatment of hypertrophic scars. The alone. The clinical assessment showed excellent
mechanism of action of this treatment is based results in 33 patients (58.9%), good results in
on a slight increase in the skin temperature, 18 patients (32.2%), fair results in five patients
increasing its extensibility, and reducing the (8.9%), and no poor results. Patient satisfaction
density of collagen; nevertheless, the results showed excellent results in 38 patients (67.9%),
are unsatisfactory.29 good results in 15 patients (26.8%), fair results
Elmelegy et al.1 used a combination of IPL in three patients (5.3%), and no poor results.
and RF for the treatment of postburn hypertro- Hyperpigmentation was improved in 29 patients
phic scars of the face in pediatric patients. This (93.6%) and hypopigmentation was improved in
combination permitted the use of lower levels eight patients (61.5%). Improvement was seen
of IPL energy for treatment, thus diminishing in 19 mixed cases (89.7%).

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Volume 151, Number 2 • Treatment of Hand Hypertrophic Scars

Fig. 3. (Left) A 31-year-old man who presented with a postburn hypertrophic scar, hyperpigmentation, and hypopigmentation
affecting the right hand. (Right) Images obtained after application of six sessions of IPL and RF, with good results (5 months from
the first session).

Fig. 4. (Left) A 19-year-old man who presented with severe postburn hypertrophic scars, and hyperpigmentation, affecting both
the left and right hands. (Right) Images obtained after application of 10 sessions of IPL and RF, with fair results (9 months from the
first session).

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 Plastic and Reconstructive Surgery • February 2023

ACKNOWLEDGMENTS
The author acknowledges colleagues Amr Magdy,
MD (Ain Shams University), Raafat Anany, MD
(Zagazig University), Tarek Elbanoby, MD (Al-Azhar
University), Ahmed Elshahat, MD (Ain Shams
University), and the nursing staff at Tanta University
Hospital for their help during all steps of this work.

REFERENCES
1. Elmelegy NG, Hegazy AM, Sadaka MS, Abdeldaim DE.
Electrophotobiomodulation in the treatment of facial hyper-
trophic scars in pediatric patients. Ann Burns Fire Disasters
2018;31:127–132.
2. Jonathan S, Scott H. Hypertrophic burn scar management:
what does the evidence show? A systematic review of random-
ized controlled trials. Ann Plast Surg. 2014;72:S198–S201.
3. Wolfram D, Tzankov A, Pülzl P, Piza-Katzer H. Hypertrophic
scars and keloids: a review of their pathophysiology, risk factors,
and therapeutic management. Dermatol Surg. 2009;35:171–181.
4. Han G. Basics of lasers in dermatology. Cutis 2014;94:E23–E25.
5. Haedersdal M, Beerwerth F, Nash JF. Laser and intense
pulsed light hair removal technologies: from professional to
home use. Br J Dermatol. 2011;165(Suppl 3):31–36.
6. Nistico SP, Del Duca E, Farnetani F, et al. Removal of
unwanted hair: efficacy, tolerability, and safety of long-
pulsed 755-nm alexandrite laser equipped with a sapphire
handpiece. Lasers Med Sci. 2018;33:1479–1483.
7. el-Domyati M, el-Ammawi TS, Medhat W, et al.
Radiofrequency facial rejuvenation: evidence-based effect. J
Am Acad Dermatol. 2011;64:524–535.
8. Sadick N, Rothaus KO. Aesthetic applications of radiofre-
quency devices. Clin Plast Surg. 2016;43:557–565.
9. Signorini M, Clementoni MT. Clinical evaluation of a new
self-drying silicone gel in the treatment of scars: a prelimi-
nary report. Aesthetic Plast Surg. 2007;31:183–187.
10. Karagoz H, Yuksel F, Ulkur E, Evinc R. Comparison of effi-
cacy of silicone gel, silicone gel sheeting, and topical onion
extract including heparin and allantoin for the treatment of
Fig. 5. (Above) A 34-year-old man presented with a postburn postburn hypertrophic scars. Burns 2009;35:1097–1103.
hypertrophic scar, hyperpigmentation, and hypopigmen- 11. Ho WS, Ying SY, Chan PC, Chan HH. Use of onion extract,
heparin, allantoin gel in prevention of scarring in Chinese
tation affecting the left hand. (Center and below) Images
patients having laser removal of tattoos: a prospective ran-
obtained after application of six sessions of IPL and RF, with domized controlled trial. Dermatol Surg. 2006;32:891–896.
excellent results (4 months from the first session). 12. Chanprapaph K, Tanrattanakorn S, Wattanakrai P,
Wongkitisophon P, Vachiramon V. Effectiveness of onion
extract gel on surgical scars in Asians. Dermatol Res Pract.
CONCLUSIONS 2012;2012:212945.
The use of RF combined with intense light 13. Koc E, Arca E, Surucu B, Kurumlu Z. An open, random-
for the treatment of hypertrophic scars has been ized, controlled, comparative study of the combined effect
demonstrated to be a compelling technique for of intralesional triamcinolone acetonide and onion extract
gel and intralesional triamcinolone acetonide alone in the
people of various skin tones. Additional longer- treatment of hypertrophic scars and keloids. Dermatol Surg.
term studies and correlation analyses are expected 2008;34:1507–1514.
to support the combined use of RF and optical 14. Roques C. Téot L. The use of corticoids to treat keloids: a
energy for the treatment of hypertrophic scars. review. Int J Low Extrem Wounds 2008;7:137–145.
15. España A, Solano T, Quintanilla E. Bleomycin in the treat-
Nader Gomaa Elmelegy, MD ment of keloids and hypertrophic scars by multiple needle
Department of Plastic Surgery punctures. Dermatol Surg. 2001;27:23–27.
Tanta University 16. Saray Y, Güleç AT. Treatment of keloids and hypertrophic
Station Square scars with dermojet injections of bleomycin: a preliminary
Tanta, ZC 31511, Egypt study. Int J Dermatol. 2005;44:777–784.
[email protected] 17. Shridharani SM, Magarakis M, Manson PN, Singh NK,
Facebook: https://web.facebook.com/?_rdc=1&_rdr Basdag B, Rosson GD. The emerging role of antineoplastic

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agents in the treatment of keloids and hypertrophic scars: a the treatment of hypertrophic scars in Asians: a prospective
review. Ann Plast Surg. 2010;64:355–361. clinical evaluation. J Cosmet Dermatol. 2017;16:210–216.
18. Ogawa R. Surgery for scar revision and reduction: from pri- 24. Oosterhoff TCH, Beekman VK, van der List JP, Niessen FB.
mary closure to flap surgery. Burns Trauma 2019;7:7. Laser treatment of specific scar characteristics in hypertro-
19. Mustoe TA, Cooter RD, Gold MH, et al.; International phic scars and keloid: a systematic review. J Plast Reconstr
Advisory Panel on Scar Management. International clinical Aesthet Surg. 2021;74:48–64.
recommendations on scar management. Plast Reconstr Surg. 25. Alster TS, Handrick C. Laser treatment of hypertrophic scars,
2002;110:560–571. keloids, and striae. Semin Cutan Med Surg. 2000;19:287–292.
20. Al-Attar A, Mess S, Thomassen JM, Kauffman CL, Davison 26. Gauglitz GG. Management of keloids and hypertrophic
SP. Keloid pathogenesis and treatment. Plast Reconstr Surg. scars: current and emerging options. Clin Cosmet Investig
2006;117:286–300. Dermatol. 2013;6:103–114.
21. Slemp AE, Kirschner RE. Keloids and scars: a review of 27. de las Alas JM, Siripunvarapon AH, Dofitas BL. Pulsed dye
keloids and scars, their pathogenesis, risk factors, and man- laser for the treatment of keloid and hypertrophic scars: a
agement. Curr Opin Pediatr. 2006;18:396–402. systematic review. Expert Rev Med Devices 2012;9:641–650.
22. Choi YJ, Kim JY, Nam JH, Lee GY, Kim WS. Clinical outcome 28. Hultman CS, Friedstat JS, Edkins RE. Efficacy of intense
of 1064-nm picosecond neodymium-doped yttrium alumin- pulsed light for the treatment of burn scar dyschromias: a
ium garnet laser for the treatment of hypertrophic scars. J pilot study to assess patient satisfaction, safety, and willing-
Cosmet Laser Ther. 2019;21:91–98. ness to pay. Ann Plast Surg. 2015;74(Suppl 4):S204–S208.
23. Lei Y, Li SF, Yu YL, Tan J, Gold MH. Clinical efficacy of utiliz- 29. Rabello FB, Souza CD, Farina Júnior JA. Update on hyper-
ing ultrapulse CO2 combined with fractional CO2 laser for trophic scar treatment. Clinics (Sao Paulo) 2014;69:565–573.

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