Ablative Fractional Carbon Dioxide Laser in the Treatment of Chronic, Posttraumatic, Lower-Extremity Ulcers in Elderly Patients

Research

Case Report/Case Series Ablative Fractional Carbon Dioxide Laser in the Treatment of Chronic, Posttraumatic, Lower-Extremity Ulcers in Elderly Patients

Tania J. Phillips, MD, FRCPC; Laurel M. Morton, MD; Nathan S. Uebelhoer, DO; Jeffrey S. Dover, MD, FRCPC

Viewpoint page 815 IMPORTANCE Treating posttraumatic lower extremity wounds can be challenging, especially in elderly patients. Recently, the use of fractional carbon dioxide laser has been shown to improve wound healing in scar-related wounds. We used this treatment modality in posttraumatic wounds that were slow to heal in 3 elderly patients.

OBSERVATIONS Each wound underwent one fractional carbon dioxide laser treatment. The wound base was treated at 30 mJ and 5% density. The entire wound edge and 1 to 2 cm into the normal surrounding skin were treated at 50 mJ and 5% density. One pass was completed at 150 Hz per treatment. Treatments were well tolerated with only mild discomfort. Each wound healed by 60% or greater within 3 weeks. No adverse events were reported aside from mild and transient erythema at site of treatment.

CONCLUSIONS AND RELEVANCE Fractional carbon dioxide laser treatment appeared to Author Affiliations: Author accelerate healing in each of these posttraumatic wounds. It may be a helpful adjunct in affiliations are listed at the end of this nonhealing posttraumatic wounds. article. Corresponding Author: Tania J. Phillips, MD, FRCPC, Department of JAMA Dermatol. 2015;151(8):868-871. doi:10.1001/jamadermatol.2015.0645 Dermatology, Boston University Published online May 6, 2015. School of Medicine, 609 Albany St, Boston, MA 02118 ([email protected]).

reating posttraumatic lower-extremity wounds can be dorsal foot (Figure 1A). She had mild pitting edema, bounding challenging, especially in elderly patients. Recently, the pulses, a warm foot, and mild neuropathy affecting the left sole. T use of the fractional carbon dioxide laser has been shown She was treated with a hydrocolloid dressing and a multilayer to improve wound healing in scar-related wounds.1 We tested compression wrap (elastic bandage with overlying self- this treatment modality in posttraumatic wounds that were adherent wrap) for a further 2 weeks. Because of the slow heal- slow to heal in 3 elderly patients. Because of the observa- ing process with compression and moisture-retentive dress- tional nature of this report, it was not submitted for institu- ings, she was treated with the Deep FX fractional carbon dioxide tional review board approval. Both oral and written patient con- laser (Lumenis Ltd). Before fractional carbon dioxide laser treat- sent was obtained for the laser treatment. ment, the wound measured 3.0 × 1.7 cm. One week later, the wound appeared to be epithelializing and measured 3.0 × 1.0 cm. After another 2½ weeks, the ulcer measured 2.0 × 1.0 cm. Report of Cases One month after treatment, it measured7×3mm,anditwas completely healed 6 weeks after treatment (Figure 1B). Case 1 A woman in her 70s had a traumatic injury to the dorsum of Case 2 the left foot following a degloving injury after a motor vehicle A man in his 70s had a history of multiple nonmelanoma skin crash. The wound was sutured, but dehisced, and the patient cancers and well-controlled type 2 diabetes mellitus. He had un- was left with an open wound on the dorsum of the foot that dergone Mohs surgery for a basal cell carcinoma on the right had been present for 3 months when we first examined her. shin. The surgical site was treated with a hydrocolloid dress- Despite frequent leg elevation, multilayer compression ban- ing and a multilayer compression wrap. However, the wound dages, and nonadherent dressings applied to the wounds daily, was slow to heal and 6 weeks after surgery measured 1.5 × 1.5 there had been no significant decrease in wound size. cm (2.25 cm2). Eleven weeks after surgery, there was minimal The patient reported mild ankle swelling and numbness change in the wound’s size (Figure 2A). The patient received in the foot following the accident. She had quit smoking 30 treatment with the Deep FX fractional carbon dioxide laser. years previously and had well-controlled hypertension. On ex- Three weeks after treatment, the wound had completely healed amination, there was a 3.0 × 1.7-cm (5.78 cm2) ulcer on the left (Figure 2B).

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Figure 1. Chronic Lower-Extremity Wound Resulting From a Degloving Injury Before and After Treatment With the Fractional Carbon Dioxide Laser

A Before treatment B After treatment

Case 1. A, View of the presenting 1.7 × 3.0-cm (5.78 cm2) dorsal foot wound. B, View of the healed wound 47 days after fractional carbon dioxide laser treatment.

Figure 2. Nonhealing Wound on the Shin Resulting From Mohs Surgery and Treated With the Fractional Carbon Dioxide Laser

A Before treatment B After treatment

Case 2. A, View of the presenting 1.5 × 1.5-cm (2.25 cm2) shin wound. B, View of the healed wound 21 days after fractional carbon dioxide laser treatment.

Case 3 30%, was applied for 30 minutes and removed before treat- A healthy woman in her 90s walked 1.6 km per day. Following ment. Each wound underwent 1 fractional carbon dioxide la- Mohs surgery for a squamous cell carcinoma on the right shin, ser treatment (Deep FX). The wound base was treated at 30 mJ she had a nonhealing wound measuring 2.2 × 2.2 cm (4.84 cm2). and 5% density. The entire wound edge and 1 to 2 cm of the Following surgery, she developed a wound infection and was normal surrounding skin were treated at 50 mJ and 5% den- treated with oral cephalexin, 500 mg, 4 times per day for 10 sity. One pass was completed at 150 Hz per treatment. Imme- days. However, the wound was slow to heal despite being diately following treatment, the entire treatment site (wound treated with multilayer compression wraps and hydrofiber sil- base and 1-2 cm of the wound edge) was dressed with a ver dressings. The dressings were changed by the visiting thick layer of a commercially available healing ointment nurses every 2 to 3 days. Six weeks later, the wound had only (Aquaphor [petrolatum, 41%]; Eucerin), a nonstick gauze dress- minimally decreased in size, measuring 2.2 × 1.7 cm (Figure 3A). ing, and a compression wrap. Following fractional carbon di- Seven weeks after Mohs surgery, the wound was treated with oxide laser treatment, no adverse events were reported ex- the Deep FX fractional carbon dioxide laser. One week later, cept for mild and transient erythema at the site of treatment. the wound measured 1.8 × 1.6 cm. At 3 weeks, the wound mea- Treatments were well tolerated, with only mild discomfort. sured 1.2 × 7 mm; 3 weeks later, the wound was completely healed (Figure 3B). Discussion Treatment Methods Before intervention, the wounds were measured, photo- Before treatment, each of the patients in this series had wounds graphs were taken, and topical lidocaine hydrochloride gel, that failed to heal despite adequate wound care for 6 to 8 weeks.

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Figure 3. Nonhealing Wound on the Shin Following Mohs Surgery and Treated With the Fractional Carbon Dioxide Laser

A Before treatment B After treatment

Case 3. A, View of the presenting 2.2 × 2.2-cm (4.84 cm2) shin wound. B, View of the healed wound 42 days after fractional carbon dioxide laser treatment.

Following a standard protocol treatment with a fractional car- bridement of the wound bed, creating acute injury cytokines bon dioxide laser, each wound healed by 60% or more within that may stimulate the healing process. Laser treatment may 3 weeks. The advent of ablative fractional photothermolysis also disrupt the bacterial biofilm that is commonly present in in the past decade and its application to the treatment of trau- wounds and that may impede wound healing.2,3 matic scars represents a breakthrough in the restoration of Laser treatment may stimulate collagen remodeling. Ozog function and cosmetic appearance for injured patients, but the and colleagues4 demonstrated that fractional carbon dioxide procedure is not yet widely used. ablation of hypertrophic scars leads to increased type III col- Recently, Shumaker and colleagues1 reported rapid heal- lagen and decreased type I collagen, favoring a ratio more typi- ing of scar-associated ulcers in young patients following frac- cal for normal wound healing. These changes appear to occur tional carbon dioxide treatment. These patients had multiple in concert with increased expression of microRNA from the traumatic scars following blast injuries as well as chronic focal 17-92 cluster that is involved in the transforming growth fac- ulcerations in the scars that had failed to heal despite good tor β signaling pathway, while transforming growth factor β3 wound care. After ablative fractional resurfacing to treat the is significantly reduced.5 Lasers can also change the gene ex- scars, there was incidental rapid healing of the wounds within pression of many matrix metalloproteinases, including 1, 3, 9, 2 weeks of laser treatment. Our findings suggest that the abla- 10, 11, and 13, which are all upregulated following fractional tive fractional carbon dioxide laser is also helpful in nonheal- carbon dioxide laser treatment and play an important role in ing posttraumatic nonscarred wounds in elderly patients. collagen degradation and reorganization.6 The fractional la- The ablative fractional carbon dioxide laser creates a ser may also remove necrotic and senescent cells that inhibit unique pattern of injury. The primary mechanism of im- wound healing.2,3 These alternate pathways are currently un- proved healing appears to be related to the ablative laser fen- der investigation and may support the model of a unique in- estration of the relatively contracted skin at the periphery of jury and repair pathway. the wound.1 Presumptively, by improving the pliability of the tissue at the wound edge and adjacent skin, there is, at least, an increase in oxygen and circulation to the wound, encour- Conclusions aging more rapid healing. In our experience, using high- energy, low-density ablative fractional carbon dioxide lasers It should be emphasized that our patients were in good health, on both the peripheral skin and wound bed yields a substan- without significant comorbidities, and that their wounds were tially shorter healing time than treating the peripheral skin posttraumatic. These results cannot be extrapolated to pa- alone. This finding suggests that other nonmechanical mecha- tients with significant venous, arterial, or chronic diabetic nisms may be involved and likely have a synergistic effect on ulcers. Controlled studies should be conducted to further healing. None of the wounds were surgically debrided before validate this modality as a second-line treatment for difficult- laser treatment. It is possible that the laser causes microde- to-heal lower-extremity wounds.

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ARTICLE INFORMATION Study concept and design: All authors. 3. Leaper DJ, Schultz G, Carville K, Fletcher J, Accepted for Publication: February 26, 2015. Acquisition, analysis, or interpretation of data: All Swanson T, Drake R. Extending the TIME concept: authors. what have we learned in the past 10 years? Int Published Online: May 6, 2015. Drafting of the manuscript: Phillips, Morton, Dover. Wound J. 2012;9(suppl 2):1-19. doi:10.1001/jamadermatol.2015.0645. Critical revision of the manuscript for important 4. Ozog DM, Liu A, Chaffins ML, et al. Evaluation of Author Affiliations: Department of Dermatology, intellectual content: All authors. clinical results, histological architecture, and Boston University School of Medicine, Boston, Statistical analysis: Morton. collagen expression following treatment of mature Massachusetts (Phillips); Department of Administrative, technical, or material support: burn scars with a fractional carbon dioxide laser. Dermatology, SkinCare Physicians, Chestnut Hill, Morton, Dover. JAMA Dermatol. 2013;149(1):50-57. Massachusetts (Phillips, Morton, Dover); Study supervision: Phillips, Dover. Department of Dermatology, Naval Medical Center 5. Qu L, Liu A, Zhou L, et al. Clinical and molecular Conflict of Interest Disclosures: Dr Dover reports effects on mature burn scars after treatment with a San Diego, San Diego, California (Uebelhoer); The serving on the medical advisory board of Lumenis. fractional CO2 laser. Lasers Surg Med. 2012;44(7): Aroostook Medical Center, Presque Isle, Maine No other disclosures were reported. (Uebelhoer); Department of Dermatology, Yale 517-524. University School of Medicine, New Haven, REFERENCES 6. Reilly MJ, Cohen M, Hokugo A, Keller GS. Connecticut (Dover); Department of Dermatology, Molecular effects of fractional carbon dioxide laser Geisel School of Medicine at Dartmouth, Hanover, 1. Shumaker PR, Kwan JM, Badiavas EV, Waibel J, resurfacing on photodamaged human skin. Arch New Hampshire (Dover); Department of Davis S, Uebelhoer NS. Rapid healing of Facial Plast Surg. 2010;12(5):321-325. scar-associated chronic wounds after ablative Dermatology, Brown Medical School, Providence, 7. Anderson RR, Donelan MB, Hivnor C, et al. Laser Rhode Island (Dover). fractional resurfacing. Arch Dermatol. 2012;148(11): 1289-1293. treatment of traumatic scars with an emphasis on Author Contributions: Drs Phillips and Dover had ablative fractional laser resurfacing: consensus full access to all the data in the study and take 2. Steed DL. Debridement. Am J Surg. 2004;187(5A): report. JAMA Dermatol. 2014;150(2):187-193. responsibility for the integrity of the data and the 71S-74S. accuracy of the data analysis.

NOTABLE NOTES

Buzzwords in Dermatology Opening a Can of Worms

Rashi Minocha, MBBS; Deshan F. Sebaratnam, MBBS; James Young Joon Choi, MBBS, FRACP, FACD

Like moths to a flame, the phylum Arthropoda has attracted the atten- Histologically,thetermcaterpillarbodieshasbeenusedtodescribethe tion of dermatologists with several classical dermatological descrip- linear bodies in the roofs of bullae of porphyria cutanea tarda, resembling tions drawn from insects. the larvae of butterflies.3 In alopecia areata, the peribulbar aggregation of It is well known that the malar rash in acute lupus erythematosus lymphocytes around anagen follicles has been said to resemble a “swarm resembles the morphologic appearance of a butterfly, with wings of bees,”and the fragmentation of neutrophil debris in leukocytoclasis has spanning across the cheeks, and is hence more commonly referred to been compared with the segmented bodies of countless ants. as a “butterfly rash.”1 Bees have inspired a number of terms, such the The insect world is one of the most diverse biologically, and accord- characteristic transgradiens palmoplantar keratoderma of Vohwinkel ingly it follows that dermatologists have made a beeline for this realm syndrome, which is described as having the appearance of honey- when constructing memorable descriptors. comb, as well as the colloquial “hives” of urticarial pathologic Author Affiliations: Department of Dermatology, Royal Prince Alfred Hospital, abnormalities.2 Camperdown, New South Wales, Australia (Minocha); Department of The formication of delusional parasitosis draws its name from the Dermatology, Westmead Hospital Australia, New South Wales, Australia formic acid contained in ant bites. Worms are not forgotten, with the (Sebaratnam, Choi). dermatosis of atrophoderma vermiculata presenting as “worm-eaten” Corresponding Author: Rashi Minocha, MBBS, Department of Dermatology, reticular atrophy of the skin over the cheeks, periauricular regions, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, Australia 2050 ([email protected]). and temples, and the superficial erosions in the oral mucosa of 1. Tay CH. Cutaneous manifestation of systemic lupus erythematosus: a clinical pyostomatitis vegetans have been likened to snail trails. From the study from Singapore. Australas J Dermatol. 1970;11(1):30-41. Arachnida class, spider naevi are so termed such because the telangi- 2. Burgdorf WH, Hoenig LJ. Favorite animal names in dermatology. JAMA ectasia that arises from a central arteriole resemble the legs and Dermatol. 2013;149(8):997. abdomen of a spider. In addition, patients with Marfan syndrome are 3. Egbert BM, LeBoit PE, McCalmont T, Hu CH, Austin C. Caterpillar bodies: described as having arachnodactyly—a descriptive term for long, distinctive, basement membrane-containing structures in blisters of porphyria. slender fingers. Am J Dermatopathol. 1993;15(3):199-202.

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