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BACKGROUND
injury site.
Regulation of inflammation during the wound healing process reduces scar formation at the
OBJECTIVE To evaluate the effect of intralesional injection of low-dose steroid with pulsed dye laser on
healing of early postoperative thyroidectomy scars.
MATERIALS AND METHODS Twenty Korean women with thyroidectomy scars were enrolled. All were
treated with an intralesional injection of low-dose steroid (2 mg/mL) and 595-nm pulsed dye laser starting
within 4 weeks of suture removal. The Vancouver Scar Scale (VSS), Global Assessment Score (GAS), and
Patient Satisfaction Score were used in this evaluation.
RESULTS Average VSS scores were significantly lower after treatment. The GAS also indicated better
cosmetic outcomes after steroid injection in the laser treatment group than after laser treatment only.
CONCLUSION Early postoperative intralesional injection of low-dose steroid and pulsed dye laser treatment
is effective and safe.
The authors have indicated no significant interest with commercial supporters.
*Department of Dermatology, School of Medicine, Keimyung University, Daegu, South Korea; Department of General
Surgery, School of Medicine, Keimyung University, Daegu, South Korea
2014 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.
ISSN: 1076-0512 Dermatol Surg 2014;40:562568 DOI: 10.1111/dsu.12472
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RYU ET AL
Methods
Participants
The Institutional Review of Board of Dongsan
Hospital approved this clinical study. Twenty
patients (20 women; mean age 41.9, range 2461;
Fitzpatrick skin type IV) were enrolled in this
prospective study at the Department of Dermatology, Keimyung University School of Medicine. All
participants provided written informed consent
before inclusion in the study. Patients were excluded
if they had recently received systemic steroid treatment or had previously been treated with any other
modalities. Patients began treatment 4 weeks after
suture removal and were followed for 6 months.
Treatment
Each patient was treated with two sessions of pulsed
dye laser (595 nm, Perfecta, Candela, Wayland,
MA) with a 10-ms pulse duration, a 7-mm spot size
of, and energy fluency or 5.25 to 5.75 mJ/cm2. The
treatment area on the neck was cleansed with 70%
alcohol, and a topical eutectic mixture of 2.5%
lidocaine hydrochloric acid and 2.5% prilocaine
(EMLA, AstraZeneca, S
odert
alje, Sweden) was
applied to the neck under occlusion 30 minutes
before therapy. Immediately after the laser treatment, low-dose intralesional triamcinolone acetate
(2 mg/mL, 0.02 mL/point) was injected along the
suture line at 0.5-cm intervals. The treatment was
repeated at 2- to 3-week intervals. After two sessions
of the pulsed dye laser with an intralesional steroid
injection, patients were treated twice at 1-month
intervals using a fractional carbon dioxide (CO2)
laser (CICU2, ilooda, Suwon, South Korea) with an
energy setting of 4.5 to 7.0 mJ/cm2, width of
0.8 mm, and density of 100 spots/cm2. Photographs
were taken using identical camera settings, lighting,
and patient positioning at baseline and 6 months
after the last treatment.
Objective and Subjective Evaluations
Two dermatologists performed objective clinical
assessments in a blinded fashion by comparing
Results
Patients were treated with a pulsed dye laser and an
intralesional injection of low-dose steroid starting
within 4 weeks after suture removal. After two
treatments, a fractional CO2 laser was used twice at
1-month intervals.
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563
Figure 1. Schematic data presented as the Vancouver Scar Scale (VSS), physician Global Assessment Scores (GAS), and
Patient Satisfaction Score (PSS). Note a serial decrease in the VSS at the initial, 1-month, 6-month, and final assessment
after treatment (p < .005).
(A)
(B)
Figure 2. Clinical results of the grade 4 sequential treatment. Prescars were observed on the neck on suture removal day
(before, A, B), 1 month after two sessions of pulsed dye laser treatment and an intralesional steroid injection every 2 weeks,
and 6 months after an additional three sessions of fractional carbon dioxide laser resurfacing. Note the decreased erythema,
irregular texture, and prevention of a hypertrophic scar.
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DERMATOLOGIC SURGERY
RYU ET AL
Figure 3. Clinical results of grade 3 sequential treatment. Prescars were observed on the neck on suture removal day
(before), 1 month after two sessions of pulsed dye laser treatment and an intralesional steroid injection every 2 weeks, and
6 months after an additional two sessions of fractional carbon dioxide laser resurfacing. Note the decreased erythema and
irregular texture but still irregular surface with erythema at the midline.
(A)
(C)
(B)
(D)
(E)
Figure 4. Clinical results without an intralesional steroid injection. Photographs on day of suture removal (A) and 3 months
after steroid injection and pulsed dye laser with fractional carbon dioxide (CO2) treatment on the right side and without
steroid injection with the same laser treatment on the left side. Hypertrophic scar and erythema are observed clearly on the
left side of neck (B). Photographs on day of suture removal (C) and 1 month (D) after two sessions of pulsed dye laser
treatment without intralesional steroid injections. Six months (E) after an additional three sessions of pulsed dye laser with
fractional CO2 laser treatment. Note the hypertrophic scar with erythema formation. (TRID, triamcinolone acetate
intradermal injection).
Discussion
Wound healing consists of several steps, including
an inflammatory phase, a tissue formation phase,
and a tissue remodeling phase.12 Scar formation
after wound healing is a consequence of a repair
mechanism that replaces the missing normal tissue
with extracellular matrix, but skin wounds on
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565
TABLE 1. Baseline Patient Characteristics and Clinical Outcomes after Laser Treatment
Patient
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Age
Initiation of
Treatment,
Weeks
Vancouver Scar
Scale
Initial
Final
Global
Assessment
Score
Patient
Satisfaction
Score
53
41
43
31
40
61
57
57
37
28
50
26
24
41
36
45
31
48
38
52
2
3
2
3
3
2
3
3
4
4
2
2
2
3
2
3
2
4
2
3
8
6
7
9
8
10
10
5
8
8
7
9
9
7
8
6
6
7
8
7
4
4
4
3
4
3
4
4
3
4
3
4
4
3
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
3
4
4
4
4
4
3
4
4
4
3
2
1
4
4
4
4
4
3
3
6
4
3
5
0
2
2
2
3
3
Adverse
Effects
PIH
PIH
Pruritus
(A)
(B)
(C)
Figure 5. Histology of the skin lesions from a mouse surgical scar. Unlike normal skin (A), surgical scar shows acanthosis
with marked inflammatory cell infiltration and fibrosis in the dermis (B). Inflammatory cell infiltration and fibrosis were
reduced after intralesional steroid injection (C). ((A) hematoxylin and eosin [H&E] 940; (B, C) H&E 9100).
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dehiscence. Therefore, fractional CO2 laser treatment is suitable as a late treatment method for
managing scar texture. We used the fractional CO2
laser as a final step to improve prescar textural
irregularities. We prevented hypertrophic scar formation in approximately 80% of cases using pulsed
dye laser and an intralesional injection of low-dose
steroid into the thyroid scar without fractional CO2
laser treatment. Although the pulsed dye laser with
intralesional injection of low-dose steroid nearly
completely prevented hypertrophic scar formation,
scar texture remained rough. Thus, we added
fractional CO2 laser treatment at the late stage.
Fractional CO2 laser treatment during late treatment
stages played an important role in improving texture
and preventing hypertrophic scar formation. A new
strategy should be developed in which a sequential
dye laser treatment and steroid injection is used first,
followed by a fractional CO2 laser as a final step for
prescar management.
Early postoperative intralesional injections of lowdose steroid and pulsed dye laser treatment markedly prevented the development of hypertrophic
scars after a thyroidectomy.
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