Abstract
Background
Fractional picosecond lasers (FPL) are reported to be effective and safe for atrophic acne scars and post‐acne erythema. However, there is no evidence regarding the effectiveness and safety of FPL treatment for non‐acne atrophic scars and scar erythema among Chinese patients.
Methods
In this retrospective study, 12 Chinese patients with non‐acne atrophic scars, including nine with scar erythema, were treated with one to three sessions of 1064 nm FPL treatment. Clinical improvement was objectively assessed through blinded evaluations by external physicians. A modified Manchester Scar Scale (mMSS) and the Clinician Erythema Assessment Scale (CEAS) were individually used to evaluate atrophic scars and scar erythema based on photographs. Physician‐assessed and subject‐assessed Global Aesthetic Improvement Scale (GAIS) were used to assess changes before and after FPL treatment. Patient satisfaction and adverse events were also documented.
Results
Total mMSS scores, as well as three parameters (color, distortion, and texture), were significantly decreased after FPL treatment, with a mean reduction of 3.18 ± 1.60 in total scores (p < 0.05). The CEAS scores were significantly reduced from 2.41 ± 0.98 before treatment to 0.41 ± 0.40 at the final visit (p < 0.05). Based on physician‐assessed and subject‐assessed GAIS scores, 11 (91.7%) patients were improved after FPL treatment. 33.3% of patients were very satisfied, and 41.7% were satisfied. No serious, prolonged (> 3 weeks) adverse events were observed.
Conclusion
Our study suggests that 1064 nm FPL treatment may be a promising option for non‐acne atrophic scars, especially with scar erythema. Further studies are needed to confirm our results.
Keywords: atrophic scar, erythema, fractional laser, picosecond laser
1. INTRODUCTION
Scars are the consequence of an abnormal wound‐healing process, usually associated with erythema and hyperpigmentation. 1 , 2 According to their morphology, scars may be categorized into atrophic scars, flat scars, hypertrophic scars, and keloids. 3 Atrophic scars result from the loss of dermal collagen and/or adipose tissue after injury, from inversion of the wound edge during wound healing, or from adhesion of the dermis with the underlying tissue after surgery. 4 The common causes of atrophic scars may be trauma, surgery, burns, chemical injury, acne, and varicella. 5 In addition to physical disfigurement, atrophic scars can also lead to psychological morbidities and social difficulties. 3 , 6 Furthermore, persistent scar erythema may worsen the disfiguring appearance in addition to atrophic scars, which motivates patients to seek treatment as soon as possible. 2
There are a variety of treatment approaches for atrophic scars, including dermabrasion, chemical peeling, fractional lasers (FL), microneedling, radiofrequency, subcision, and dermal fillers. 5 , 7 Ablative fractional laser (AFL) and nonablative fractional laser (NAFL) are widely used to treat atrophic scars. 8 , 9 According to the fractional photothermal theory, fractional lasers stimulate the regeneration of neocollagen and the remodeling of the dermis by acting on the microscopic treatment area of the epidermis and dermis (AFL) or the dermis (NAFL). 10 Although AFLs, such as CO2FL and Er:YAG FL, can effectively treat atrophic scars, they are prone to post‐inflammatory hyperpigmentation (PIH) in darker skin, and there is a lengthy recovery period due to exudation, swelling, and persistent erythema. 9 , 11 There is some evidence that NAFL treatment can improve both atrophic scars and scar erythema, but it is still associated with the risk of PIH and evident pain. 9 , 12
In contrast to traditional nanosecond Q‐switched lasers, picosecond lasers provide a more pronounced photoacoustic effect and less photothermal damage due to their shorter pulse duration. 13 Fractional picosecond lasers (FPL) generate a fractional array of focused, high‐fluence microspots surrounded by a low‐fluence background. Histologically, FPL creates laser‐induced cavitation (LIC) in the dermis or epidermis via laser‐induced optical breakdown (LIOB). This photomechanical stress transmits into the dermis and induces skin remodeling. 10 More and more evidence demonstrates that FPL treatment is effective for both atrophic acne scars and post‐acne erythema. 13 , 14 , 15 There is, however, limited evidence regarding the effectiveness of FPL treatment for non‐acne atrophic scars. 1 , 4 , 16 , 17 , 18 , 19
As far as we know, it is unknown whether FPL treatment is effective and safe for Chinese patients with non‐acne atrophic scars. Furthermore, there is little evidence regarding the effectiveness of FPL treatment for scar erythema associated with non‐acne atrophic scars. We reported the effectiveness and safety of 12 Chinese patients with non‐acne atrophic scars treated with 1064 nm FPL.
2. METHOD
2.1. Patients
The study analyzed a retrospective case series of 12 out of 15 Chinese patients with non‐acne atrophic scars treated with at least one session of 1064 nm FPL in our Department of Dermatology between December 2021 and January 2024. Atrophic scar patients with comprehensive clinical and follow‐up records were included in our study. The exclusion criteria were as follows: (1) atrophic scars due to acne; (2) previous history of keloid; (3) a history of connective tissue disease, blood coagulopathy, skin infections, pregnancy, lactation, or any other conditions that would affect wound healing, (4) previous treatments with systemic retinoids, immunosuppressive or cytotoxic drugs within the past 6 months, (5) treatments with dermabrasion, chemical peeling, microneedling, subcision, dermal fillers, other types of energy‐based devices or topical anti‐scarring medications on skin lesions from 6 months before treatment to the final visit. (6) photosensitivity or current use of photosensitive drugs. Based on electronic medical documents, demographic data, medical history, clinical evaluation findings, treatment records, and adverse events were collected for all patients involved in our study. This study was approved by the Ethics Committee of Beijing Jishuitan Hospital (No. K2024‐027‐00). Written informed consent was obtained from the patients or their family members before treatment.
2.2. Fractional picosecond laser treatment
In preparation for laser treatment, scar areas were cleaned and disinfected without topical anesthesia. Patients were required to wear protective eye masks during all treatments. All patients were treated with a dual‐wavelength fractional picosecond neodymium‐doped yttrium aluminum garnet (Nd: YAG) laser system (Picoway, Candela Corporation, Wayland, USA). By incorporating the holographic beam‐splitting optic into the picosecond laser, the system delivers a 10 × 10 array of 150 µm‐diameter microbeams arranged in a 6 mm × 6 mm square treatment area. For 1064 nm FPL (Resolve 1064 handpiece), the pulse duration of 450 ps, the energy of 1.1–2.1 mJ/microbeam, frequency of 4–5 Hz, and 2–3 passes were adopted in the study. Pinpoint petechiae or marked erythema are the desired endpoint.
After treatment, cooling packs were used to minimize heat and pain. Patients were instructed to apply recombinant bovine basic fibroblast growth factor gel (Zhuhai Yisheng Biological Bio‐Pharmaceutical Co Ltd, Zhuhai, China) once daily (dosage 300 IU/cm2) to the scar area for 1 week in patients with sensitive skin. In addition, patients were advised not to expose the treated area to sunlight for 1 month. The same dermatologist conducted all laser treatments. In all cases, one to three sessions were administered at intervals of 4–9 weeks. All patients were followed up every month after each session and 2 to 6 months after the last treatment. High‐resolution digital photographs of the scars were taken by the skin image analyzer (ISOMECO, Shanghai May Skin Information Technology Co Ltd, Shanghai, China) and the same digital camera before every treatment session and during the final visit. 20
2.3. Clinical assessment
Clinical improvement was objectively assessed in atrophic scars and scar erythema by three blinded physicians, who analyzed high‐resolution digital photographs at the baseline and final visit. Discordances were resolved by a fourth senior dermatologist. A modified Manchester scar scale (mMSS) was used to evaluate atrophic scars and the effect of FPL treatment on them. 3 , 21 The mMSS consists of three parameters: color, distortion/skin surface appearance, and texture (Table A1). For those patients with scar erythema, the Clinician Erythema Assessment Scale (CEAS) was used to evaluate erythema and response to FPL treatment based on the photographs (Table A2). 13 , 15 The Global Aesthetic Improvement Scale (GAIS), which was completed by both the physician (PGAIS) and subjects enrolled (SGAIS), was also used to compare baseline and final visit photographs and assess changes after FPL treatment (Table A3). 15 , 17
In addition to SGAIS, patient satisfaction, and adverse events were recorded. Patient satisfaction was documented at each visit using a 5‐point Likert satisfaction scale (1: very dissatisfied; 2: dissatisfied; 3: slightly satisfied; 4: satisfied; and 5: very satisfied). 22 Pain scores were assessed immediately after treatment with a 0–10 visual analog scale (VAS). 0 indicated no discomfort, and 10 indicated intolerable pain. 13 Other adverse effects, such as pinpoint bleeding, erythema, edema, crusting, hyperpigmentation, hypopigmentation, sensitivity, blisters, pruritus, and scars, were noted during each follow‐up at the clinic or by telephone.
2.4. Statistical analysis
Statistical analyses were performed with SPSS 22.0 (IBM). Categorical variables were expressed as numbers and proportions (%). Normally distributed continuous variables were presented as mean and standard deviation (SD), and a paired t‐test was conducted to compare the paired variables before and after treatment. Skewed distributed continuous variables were described as medians and ranges, and the Wilcoxon signed‐rank test was used to test the paired variables before and after treatment. p < 0.05 was considered statistically significant.
3. RESULTS
3.1. Patient demographics
This study retrospectively analyzed 15 patients with non‐acne atrophic scars who agreed and received FPL treatment. Three patients were excluded from the study because they received other anti‐scar treatments 3 months before FPL treatment. We enrolled 12 patients (7 males and 5 females) who met the eligibility criteria (Table 1). The age of the patients ranged from 7 to 55 years, with an average of 33.67 ± 15.08 years. Among these patients, half had Fitzpatrick skin type III, and the other half had type IV. Seven patients were injured by sharp trauma, two by operation, two by burns, and one by chemical exposure. There were one to several scars on each patient. Atrophic scars on eleven patients were distributed on the face and one on the hand. Nine (75%) patients were associated with scar erythema. All patients received one to three sessions of FPL treatment at an average interval of 6 ± 1.76 weeks.
TABLE 1.
Characteristics of 12 patients with atrophic scars.
|
Patient no. |
Sex |
Age (year) |
Skin type |
Scar course |
Etiology |
Scar number |
Scar Site |
Scar erythema |
Sessions |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Male | 46 | III | 1 m | Sharp trauma | 1 | Periorbital region | Yes | 1 |
| 2 | Male | 27 | III | 1 m | Operation | 1 | Periorbital region | Yes | 1 |
| 3 | Female | 42 | IV | 2 m | Sharp trauma | 12 | Cheek and forehead | Yes | 3 |
| 4 | Male | 51 | IV | 2 m | Chemical injury | 4 | Cheek and tempus | Yes | 3 |
| 5 | Female | 33 | III | 1.5 m | Burn injury | 49 | Cheek | Yes | 2 |
| 6 | Male | 23 | IV | 16 m | Burn injury | 2 | Hand | Yes | 2 |
| 7 | Male | 55 | IV | 4 m | Operation | 1 | Forehead | Yes | 3 |
| 8 | Female | 30 | III | 14 y | Sharp trauma | 1 | Cheek | No | 2 |
| 9 | Male | 7 | III | 2 m | Sharp trauma | 3 | Cheek and periorbital region | Yes | 1 |
| 10 | Female | 26 | III | 8 m | Sharp trauma | 1 | Periorbital region | Yes | 2 |
| 11 | Male | 15 | IV | 13 y | Sharp trauma | 1 | Cheek | No | 2 |
| 12 | Female | 49 | IV | 46 y | Sharp trauma | 1 | Nose | No | 3 |
3.2. Clinical efficacy
According to the mMSS scores, the total scores as well as three parameters (color, distortion and texture) were significantly reduced after FPL treatment (p < 0.05). The mean reduction of total mMSS scores from pretreatment to posttreatment was 3.18 ± 1.60 (Table 2). The CEAS scores of nine patients with scar erythema were significantly reduced from 2.41 ± 0.98 before treatment to 0.41 ± 0.40 at the final visit (p < 0.05). Figures 1, 2, 3, 4 show representative photographs of different scar causes before and after FPL treatment. Based on PGAIS and SGAIS scores, 11 (91.7%) patients had improved at the final visit after FPL treatment. All patients whose PGAIS or SGAIS scores were rated as “much improved” or “very much improved” had atrophic scars on the face associated with scar erythema, and the duration of these scars was less than 1 year (Table 3). Moreover, patient satisfaction evaluation revealed that four (33.3%) patients were very satisfied, five (41.7%) were satisfied, and two (16.7%) were slightly satisfied (Table 4).
TABLE 2.
Scar assessment using the mMSS.
| mMSS scores | Color | Distortion | Texture | Total |
|---|---|---|---|---|
| Pre‐treatment (Mean ± SD.) | 3.17 ± 0.69 | 2.30 ± 0.28 | 2.28 ± 0.40 | 7.76 ± 1.01 |
| Post‐treatment (Mean ± SD.) | 1.67 ± 0.52 | 1.39 ± 0.41 | 1.52 ± 0.50 | 4.60 ± 1.26 |
| Change (Mean ± SD.) | ↓1.51 ± 0.82 | ↓0.93 ± 0.50 | ↓0.75 ± 0.45 | ↓3.18 ± 1.60 |
| t | 6.293 | 6.161 | 5.733 | 6.880 |
| p‐value | <0.001 | <0.001 | <0.001 | <0.001 |
Abbreviation: mMMS, modified Manchester Scar Scale.
FIGURE 1.
Photographs of a 33‐year‐old woman with atrophic scars and scar erythema on the cheek caused by burn injury. (A) and (C): Before treatment. (B) and (D) Five months after two sessions of FPL treatment. FPL, Fractional picosecond lasers.
FIGURE 2.
Photographs of a 42‐year‐old woman with atrophic scars and scar erythema on the forehead and cheek caused by sharp trauma. (A) and (C): Before treatment. (B) and (D) 6 months after three sessions of FPL treatment. FPL, Fractional picosecond lasers.
FIGURE 3.
Photographs of a 51‐year‐old man with atrophic scars and scar erythema on the cheek and tempus caused by chemical injury. (A) and (C): Before treatment. (B) and (D) 6 months after three sessions of FPL treatment. FPL, Fractional picosecond lasers.
FIGURE 4.
Photographs of a 27‐year‐old man with atrophic scars and scar erythema on the periorbital region caused by the operation. (A) and (C): Before treatment. (B) and (D) Two months after one session of FPL treatment. The scar erythema and atrophic scar improved after FPL treatment except for the scar on the eyelid margin untreated. FPL, Fractional picosecond lasers.
TABLE 3.
GAIS scores assessed by physicians and subjects.
| GAIS | PGAIS, N (%) | SGAIS, N (%) |
|---|---|---|
| Very much improved | 4 (33.3%) | 2 (16.7%) |
| Much improved | 2 (16.7%) | 3 (25%) |
| Improved | 5 (41.7%) | 6 (50%) |
| Unaltered | 1 (8.3%) | 1 (8.3%) |
| Worsened | 0 (0%) | 0 (0%) |
Abbreviations: GAIS, Global Aesthetic Improvement Scale; N, number; PGAIS, Physician‐assessed GAIS; SGAIS: Subject‐assessed GAIS.
TABLE 4.
Patient satisfaction.
| Patient satisfaction | N (%) |
|---|---|
| Very satisfied | 4 (33.3%) |
| Satisfied | 5 (41.7%) |
| Slightly satisfied | 2 (16.7%) |
| Dissatisfied | 1 (8.3%) |
| Very dissatisfied | 0 (0%) |
Abbreviation: N, Number.
3.3. Safety
None of the patients had received topical anesthetics before receiving treatment. The mean of pain VAS scores is 2.83 ± 2.33. Six patients experienced transient hyperpigmentation that faded away within 2 weeks. Pinpoint bleeding was observed in five patients and resolved within 3 days. The median duration of erythema is 3 days (range between 1 and 21). Two patients complained of edema that disappeared within 5 days. One patient experienced crusting and skin sensitivity, which were individually relieved within 1 week and 2 weeks. There was no hypopigmentation, hypertrophic scar, blister, or pruritus.
4. DISCUSSION
Atrophic scars are dermal depressions caused by trauma, surgery, burns, chemical injury, acne, or varicella. 3 , 5 Permanent scar erythema may exacerbate aesthetic distress and magnify psychological disorders, prompting patients to seek medical assistance. 2 , 6
Atrophic scars can be treated with several modalities, among which AFL and NAFL are widely utilized. 3 , 5 , 7 , 8 , 9 Both treatments carry the risk of PIH and obvious pain, and AFL has a longer recovery period. 9 , 11 , 12 . Management of atrophic scars remains challenging for clinicians. The development of FPL has offered a new way of treating scars compared to nanosecond laser therapy. FPL generates LIC in the dermis or epidermis and photomechanical pressure, which are caused by LIOB through a fractional array of intensified high‐energy microspots, and then induces dermal remodeling and skin regeneration. 23 There are rising reports that FPL treatment is effective for atrophic scars, and most of them have explored FPL efficacy for atrophic acne scars. There is still limited evidence of the effectiveness of FPL treatments for non‐acne atrophic scars. Three recent studies have presented the effectiveness and safety of 1064 nm FPL treatment for posttraumatic and postsurgical atrophic scars in Italy and Thailand. 4 , 16 , 17 Lee et al. reported that 755 nm FPL treatment was effective and safe for linear atrophic scars caused by trauma in Korea. 18
In this retrospective case series, we provided the first report on the effectiveness and safety of FPL treatment for non‐acne atrophic scars in Chinese patients. In addition to sharp trauma and operation, the causes of these scars included burns and chemical exposure. According to PGAIS and SGAIS, 91.7% of patients were rated as “improved” to “very much improved”. This result is consistent with the previous study, which found that 91.7% of patients with atrophic traumatic and surgical scars obtained mild to excellent improvement in 1064 nm FPL treated side assessed by blinded dermatologists in Thailand. 4 Due to the lack of a 3‐dimensional camera and reflectance confocal microscopy, it is unfortunate that this study cannot provide accurate data on volume changes in atrophic scars. However, based on mMSS scores, the total score and scores of three parameters (color, distortion, and texture) have statistically significant reductions after FPL treatment. As for the patient satisfaction rate, our results are generally consistent with previous studies. 16 , 17
Erythema accompanied by atrophic scars makes them more visible and amplifies their disfiguring effects. 2 The mechanisms of scar erythema include inflammation, vascularization, and epidermal thinning. Erythema also reflects scar remodeling. 24 Many vascular‐specific lasers and light devices have been widely used in treating erythematous scars owing to their efficacy in hemoglobin absorption. 24 Pulsed dye laser (PDL) is the mainstay of vascular‐specific lasers, and its common adverse event is postoperative purpura. Dark‐skinned patients still face hypopigmentation risks after PDL treatment. 25 Regarding erythema accompanied by atrophic scars, the results of different studies on the effectiveness of FPL treatment are controversial. A randomized split‐face investigator‐blinded study demonstrated that 755 nm FPL treatment is effective in treating post‐acne erythema and atrophic acne scars. 13 Lee et al. presented the data that vascularity scores of linear atrophic scars were decreased after 755 nm FPL treatment. 18
In addition to non‐acne atrophic scars, our case series also focused on the effectiveness of 1064 nm FPL treatment for scar erythema. According to the CEAS scores, the scar erythema of nine patients was statistically improved after FPL treatment (Figures 1, 2, 3, 4 C, D). Our results confirmed the previous finding that the hemoglobin levels of surgical scars decreased after 1064 nm FPL treatment. 17 Likewise, our results were verified by the recent finding that 1064 nm FPL treatment was effective and safe for post‐acne erythema in Chinese patients. 15 The possible mechanisms of FPL treatment for scar erythema were as follows: according to the previous histopathological study, the vascular disruption during FPL treatment was most likely due to hemoglobin absorption of high‐focused FPL energy, despite melanin being the first target chromophore to absorb FPL energy. 26 Furthermore, large numbers of LIOBs and LICs, which occur in superficial vessels after hemoglobin absorption of FPL energy, could lead to randomly repeated damage to cutaneous vessels. 15 However, more superficial and larger intraepidermal vacuoles were observed in individuals with more melanin after FPL treatment. 10 In light of these pathological findings, it is understandable why no significant difference in hemoglobin average levels was found before and after 1064 nm FPL treatment on flat hyperpigmented postburn scars. 19 The discrepancy among different studies on scar erythema may be due to scar color, skin type, and laser fluence. 10 A further randomized controlled trial is needed to verify our result.
In our case series, no serious, prolonged (> 3 weeks) adverse events were identified by the physicians or complained about by the patients. Despite the absence of topical anesthetics before treatment, the mean of pain VAS scores is 2.83. This finding was consistent with the previous result that FPL treatment on acne scars has lower pain scores than other FLs. 14 FPL treatment may be more appropriate for scars in pain‐sensitive areas or patients. The purpura after 1064 nm FPL treatment was pinpoint and transient. No hypopigmentation was found. The low incidence of adverse events is because FPL produces a fractional array of focused high‐fluence microspots surrounded by a low‐fluence background, which produces nonthermal, photomechanical changes with little adjacent damage. 10
This study has some limitations, including the small sample size, lack of controls, the retrospective design, and the absence of 3‐dimensional photographs. However, this is the first study to report the effectiveness and safety of FPL treatment on non‐acne atrophic scars and scar erythema in Chinese patients. The scars in our case series had different causes and durations. To the best of our knowledge, this is also the first report involving the effectiveness of FPL treatment on scars caused by chemical injury and immature atrophic scars lasting less than 6 months. Considering the possibility that scar erythema may fade over time, further randomized split‐lesion‐controlled trials are needed to verify our results.
5. CONCLUSION
Our study suggests that 1064 nm FPL treatment may be a promising option for non‐acne atrophic scars, especially with scar erythema. Further well‐designed randomized controlled trials are warranted to confirm our findings.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
This study was approved by the Ethics Committee of Beijing Jishuitan Hospital (No. K2024‐027‐00) in February 2024. Written informed consent and permission to publish medical images were obtained from the patients or their family members.
Supporting information
Supporting Information
Supporting Information
Supporting Information
ACKNOWLEDGMENTS
We thank Professor Wu Shanshan for helping us settle the disagreement over applying statistical methods.
Li J, Duan F, Kuang J, et al. Fractional picosecond laser treatment of non‐acne atrophic scars and scar erythema in Chinese patients. Skin Res Technol. 2024;30:e13856. 10.1111/srt.13856
DATA AVAILABILITY STATEMENT
Data are available on request from the authors.
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Associated Data
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Supplementary Materials
Supporting Information
Supporting Information
Supporting Information
Data Availability Statement
Data are available on request from the authors.