0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Case Report/Case Series |

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

Tania J. Phillips, MD, FRCPC1,2; Laurel M. Morton, MD2; Nathan S. Uebelhoer, DO3,4; Jeffrey S. Dover, MD, FRCPC2,5,6,7
[+] Author Affiliations
1Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
2Department of Dermatology, SkinCare Physicians, Chestnut Hill, Massachusetts
3Department of Dermatology, Naval Medical Center San Diego, San Diego, California
4The Aroostook Medical Center, Presque Isle, Maine
5Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
6Department of Dermatology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
7Department of Dermatology, Brown Medical School, Providence, Rhode Island
JAMA Dermatol. 2015;151(8):868-871. doi:10.1001/jamadermatol.2015.0645.
Text Size: A A A
Published online

ABSTRACT

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 accelerate healing in each of these posttraumatic wounds. It may be a helpful adjunct in nonhealing posttraumatic wounds.

Figures in this Article

INTRODUCTION

Treating posttraumatic lower-extremity wounds can be challenging, especially in elderly patients. Recently, the use of the fractional carbon dioxide laser has been shown to improve wound healing in scar-related wounds.1 We tested this treatment modality in posttraumatic wounds that were slow to heal in 3 elderly patients. Because of the observational nature of this report, it was not submitted for institutional review board approval. Both oral and written patient consent was obtained for the laser treatment.

REPORT OF CASES

Case 1

A woman in her 70s had a traumatic injury to the dorsum of the left foot following a degloving injury after a motor vehicle crash. The wound was sutured, but dehisced, and the patient was left with an open wound on the dorsum of the foot that had been present for 3 months when we first examined her. Despite frequent leg elevation, multilayer compression bandages, and nonadherent dressings applied to the wounds daily, there had been no significant decrease in wound size.

The patient reported mild ankle swelling and numbness in the foot following the accident. She had quit smoking 30 years previously and had well-controlled hypertension. On examination, there was a 3.0 × 1.7-cm (5.78 cm2) ulcer on the left dorsal foot (Figure 1A). She had mild pitting edema, bounding pulses, a warm foot, and mild neuropathy affecting the left sole. She was treated with a hydrocolloid dressing and a multilayer compression wrap (elastic bandage with overlying self-adherent wrap) for a further 2 weeks. Because of the slow healing process with compression and moisture-retentive dressings, she was treated with the Deep FX fractional carbon dioxide laser (Lumenis Ltd). Before fractional carbon dioxide laser treatment, 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. One month after treatment, it measured 7 × 3 mm, and it was completely healed 6 weeks after treatment (Figure 1B).

Place holder to copy figure label and caption
Figure 1.
Chronic Lower-Extremity Wound Resulting From a Degloving Injury Before and After Treatment With the Fractional Carbon Dioxide Laser

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.

Graphic Jump Location
Case 2

A man in his 70s had a history of multiple nonmelanoma skin cancers and well-controlled type 2 diabetes mellitus. He had undergone Mohs surgery for a basal cell carcinoma on the right shin. The surgical site was treated with a hydrocolloid dressing and a multilayer compression wrap. However, the wound was slow to heal and 6 weeks after surgery measured 1.5 × 1.5 cm (2.25 cm2). Eleven weeks after surgery, there was minimal change in the wound’s size (Figure 2A). The patient received treatment with the Deep FX fractional carbon dioxide laser. Three weeks after treatment, the wound had completely healed (Figure 2B).

Place holder to copy figure label and caption
Figure 2.
Nonhealing Wound on the Shin Resulting From Mohs Surgery and Treated With the Fractional Carbon Dioxide Laser

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.

Graphic Jump Location
Case 3

A healthy woman in her 90s walked 1.6 km per day. Following Mohs surgery for a squamous cell carcinoma on the right shin, she had a nonhealing wound measuring 2.2 × 2.2 cm (4.84 cm2). Following surgery, she developed a wound infection and was treated with oral cephalexin, 500 mg, 4 times per day for 10 days. However, the wound was slow to heal despite being treated with multilayer compression wraps and hydrofiber silver dressings. The dressings were changed by the visiting nurses every 2 to 3 days. Six weeks later, the wound had only minimally decreased in size, measuring 2.2 × 1.7 cm (Figure 3A). Seven weeks after Mohs surgery, the wound was treated with the Deep FX fractional carbon dioxide laser. One week later, the wound measured 1.8 × 1.6 cm. At 3 weeks, the wound measured 1.2 × 7 mm; 3 weeks later, the wound was completely healed (Figure 3B).

Place holder to copy figure label and caption
Figure 3.
Nonhealing Wound on the Shin Following Mohs Surgery and Treated With the Fractional Carbon Dioxide Laser

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.

Graphic Jump Location
Treatment Methods

Before intervention, the wounds were measured, photographs were taken, and topical lidocaine hydrochloride gel, 30%, was applied for 30 minutes and removed before treatment. Each wound underwent 1 fractional carbon dioxide laser treatment (Deep FX). The wound base was treated at 30 mJ and 5% density. The entire wound edge and 1 to 2 cm of the normal surrounding skin were treated at 50 mJ and 5% density. One pass was completed at 150 Hz per treatment. Immediately following treatment, the entire treatment site (wound base and 1-2 cm of the wound edge) was dressed with a thick layer of a commercially available healing ointment (Aquaphor [petrolatum, 41%]; Eucerin), a nonstick gauze dressing, and a compression wrap. Following fractional carbon dioxide laser treatment, no adverse events were reported except for mild and transient erythema at the site of treatment. Treatments were well tolerated, with only mild discomfort.

DISCUSSION

Before treatment, each of the patients in this series had wounds that failed to heal despite adequate wound care for 6 to 8 weeks. Following a standard protocol treatment with a fractional carbon dioxide laser, each wound healed by 60% or more within 3 weeks. The advent of ablative fractional photothermolysis in the past decade and its application to the treatment of traumatic scars represents a breakthrough in the restoration of function and cosmetic appearance for injured patients, but the procedure is not yet widely used.

Recently, Shumaker and colleagues1 reported rapid healing of scar-associated ulcers in young patients following fractional carbon dioxide treatment. These patients had multiple traumatic scars following blast injuries as well as chronic focal ulcerations in the scars that had failed to heal despite good wound care. After ablative fractional resurfacing to treat the scars, there was incidental rapid healing of the wounds within 2 weeks of laser treatment. Our findings suggest that the ablative fractional carbon dioxide laser is also helpful in nonhealing posttraumatic nonscarred wounds in elderly patients.

The ablative fractional carbon dioxide laser creates a unique pattern of injury. The primary mechanism of improved healing appears to be related to the ablative laser fenestration of the relatively contracted skin at the periphery of 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, encouraging more rapid healing. In our experience, using high-energy, low-density ablative fractional carbon dioxide lasers on both the peripheral skin and wound bed yields a substantially shorter healing time than treating the peripheral skin alone. This finding suggests that other nonmechanical mechanisms may be involved and likely have a synergistic effect on healing. None of the wounds were surgically debrided before laser treatment. It is possible that the laser causes microdebridement of the wound bed, creating acute injury cytokines that may stimulate the healing process. Laser treatment may also disrupt the bacterial biofilm that is commonly present in wounds and that may impede wound healing.2,3

Laser treatment may stimulate collagen remodeling. Ozog and colleagues4 demonstrated that fractional carbon dioxide ablation of hypertrophic scars leads to increased type III collagen and decreased type I collagen, favoring a ratio more typical for normal wound healing. These changes appear to occur in concert with increased expression of microRNA from the 17-92 cluster that is involved in the transforming growth factor β signaling pathway, while transforming growth factor β3 is significantly reduced.5 Lasers can also change the gene expression of many matrix metalloproteinases, including 1, 3, 9, 10, 11, and 13, which are all upregulated following fractional carbon dioxide laser treatment and play an important role in collagen degradation and reorganization.6 The fractional laser may also remove necrotic and senescent cells that inhibit wound healing.2,3 These alternate pathways are currently under investigation and may support the model of a unique injury and repair pathway.

CONCLUSIONS

It should be emphasized that our patients were in good health, without significant comorbidities, and that their wounds were posttraumatic. These results cannot be extrapolated to patients with significant venous, arterial, or chronic diabetic ulcers. Controlled studies should be conducted to further validate this modality as a second-line treatment for difficult-to-heal lower-extremity wounds.

ARTICLE INFORMATION

Accepted for Publication: February 26, 2015.

Corresponding Author: Tania J. Phillips, MD, FRCPC, Department of Dermatology, Boston University School of Medicine, 609 Albany St, Boston, MA 02118 (tphill@bu.edu).

Published Online: May 6, 2015. doi:10.1001/jamadermatol.2015.0645.

Author Contributions: Drs Phillips and Dover had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Phillips, Morton, Dover.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Morton.

Administrative, technical, or material support: Morton, Dover.

Study supervision: Phillips, Dover.

Conflict of Interest Disclosures: Dr Dover reports serving on the medical advisory board of Lumenis. No other disclosures were reported.

REFERENCES

Shumaker  PR, Kwan  JM, Badiavas  EV, Waibel  J, Davis  S, Uebelhoer  NS.  Rapid healing of scar-associated chronic wounds after ablative fractional resurfacing. Arch Dermatol. 2012;148(11):1289-1293.
PubMed   |  Link to Article
Steed  DL.  Debridement. Am J Surg. 2004;187(5A):71S-74S.
PubMed   |  Link to Article
Leaper  DJ, Schultz  G, Carville  K, Fletcher  J, Swanson  T, Drake  R.  Extending the TIME concept: what have we learned in the past 10 years?. Int Wound J. 2012;9(suppl 2):1-19.
PubMed   |  Link to Article
Ozog  DM, Liu  A, Chaffins  ML,  et al.  Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser. JAMA Dermatol. 2013;149(1):50-57.
PubMed   |  Link to Article
Qu  L, Liu  A, Zhou  L,  et al.  Clinical and molecular effects on mature burn scars after treatment with a fractional CO2 laser. Lasers Surg Med. 2012;44(7):517-524.
PubMed   |  Link to Article
Reilly  MJ, Cohen  M, Hokugo  A, Keller  GS.  Molecular effects of fractional carbon dioxide laser resurfacing on photodamaged human skin. Arch Facial Plast Surg. 2010;12(5):321-325.
PubMed   |  Link to Article
Anderson  RR, Donelan  MB, Hivnor  C,  et al.  Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report. JAMA Dermatol. 2014;150(2):187-193.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Chronic Lower-Extremity Wound Resulting From a Degloving Injury Before and After Treatment With the Fractional Carbon Dioxide Laser

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.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Nonhealing Wound on the Shin Resulting From Mohs Surgery and Treated With the Fractional Carbon Dioxide Laser

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.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Nonhealing Wound on the Shin Following Mohs Surgery and Treated With the Fractional Carbon Dioxide Laser

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.

Graphic Jump Location

Tables

References

Shumaker  PR, Kwan  JM, Badiavas  EV, Waibel  J, Davis  S, Uebelhoer  NS.  Rapid healing of scar-associated chronic wounds after ablative fractional resurfacing. Arch Dermatol. 2012;148(11):1289-1293.
PubMed   |  Link to Article
Steed  DL.  Debridement. Am J Surg. 2004;187(5A):71S-74S.
PubMed   |  Link to Article
Leaper  DJ, Schultz  G, Carville  K, Fletcher  J, Swanson  T, Drake  R.  Extending the TIME concept: what have we learned in the past 10 years?. Int Wound J. 2012;9(suppl 2):1-19.
PubMed   |  Link to Article
Ozog  DM, Liu  A, Chaffins  ML,  et al.  Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser. JAMA Dermatol. 2013;149(1):50-57.
PubMed   |  Link to Article
Qu  L, Liu  A, Zhou  L,  et al.  Clinical and molecular effects on mature burn scars after treatment with a fractional CO2 laser. Lasers Surg Med. 2012;44(7):517-524.
PubMed   |  Link to Article
Reilly  MJ, Cohen  M, Hokugo  A, Keller  GS.  Molecular effects of fractional carbon dioxide laser resurfacing on photodamaged human skin. Arch Facial Plast Surg. 2010;12(5):321-325.
PubMed   |  Link to Article
Anderson  RR, Donelan  MB, Hivnor  C,  et al.  Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report. JAMA Dermatol. 2014;150(2):187-193.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

888 Views
1 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Diabetes, Foot Ulcer

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Original Article: Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?