over the course of 17 months. Treatment settings are detailed in Table 1. Additionally, he received LADD of topical TAC 0.1% ointment (Perrigo Company plc, Bronx, NY) to the area immediately post-treatment.Seventeen months following the first treatment, our patient’s keloid demonstrated significant reduction in thickness, improvement in texture, and overall aesthetic appearance, resulting in high patient satisfaction (Figure 1B). He reported subjective “flattening of the scar” and was “happy” with results. This clinical improvement was sustained at 22 months post-initial treatment with no complications or adverse events.Search StrategyA review of the published literature was performed on July 28, 2016 searching medical bibliographic databases PubMed, EMBASE, Cochrane, and Web of Science. The search terms were: “keloid”, “carbon dioxide”, and “laser”. Clinical studies in patients with keloids using fractionated CO2 lasers were included. Non-English articles and conference posters/abstracts were excluded.
The search returned 269 articles. After removal of duplicates, 194 articles were screened. Five articles on fractionated CO2 laser treatment of keloids were identified. Three studies utilized single Jagdeotreatment modality with fractionated CO2 laser and reported mixed clinical improvement.8-10 Two case series reported clinical improvement following a minimum of six sessions with fractionated CO2 laser in Italian patients (Fitzpatrick II-IV) with no recurrence at 12-month follow-up.9,10 An open-label, split-scar study reported no significant improvement following seven sessions of fractionated CO2 laser in patients (Fitzpatrick II-IV) with keloids and hypertrophic scars, however, histopathology showed marked decrease in collagen density and a change from haphazard to a more aligned horizontal arrangement of collagen fibers.8A 15-patient (Fitzpatrick II-V) case series utilized combination therapy of fractionated CO2 laser immediately followed by TAC suspension applied topically and achieved good cosmesis after 3 to 5 sessions and no recurrence observed at 6-month follow-up.11 Martin and Collawn reported successful treatment of refractory keloids in a Caucasian patient (Fitzpatrick type not specified) following seven sessions of combination therapy of fractionated CO2 laser, pulsed-dye laser (PDL), and TAC without recurrence at 6 months post-initial treatment.12 TAC solution (0.5 ml, 40 mg/ml) was administered intralesionally immediately before laser treatment during sessions 1-5.12 No adverse events were reported in all reviewed studies.8-12
DISCUSSION AND FUTURE DIRECTIONS
Keloids may have a significant negative psychosocial impact on patients due to their aesthetically displeasing appearance and associated functional impairment, resulting in decreased patient quality-of-life.2
Early published studies of keloid treatment using non-fractionated CO2 laser dated back to the 1980s.13-17
These studies achieved good clinical outcomes initially, however, almost all patients had keloid recurrence at 6-24 months post-treatment.13-17
Published evidence suggests that non-fractionated CO2 laser is not optimal for treatment of keloid due to high risk of keloid recurrence.3
Fractionated CO2 laser is widely employed by dermatologists and other physicians today and has significant advantages compared