Clinical effects of sequential laser treatments on early stage hypertrophic burn scars
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摘要: 目的 观察脉冲染料激光(PDL)+剥脱性点阵二氧化碳激光序贯治疗对早期增生性烧伤瘢痕的临床效果。 方法 2016年1月—2017年12月,到笔者单位就诊的221例烧伤患者创面愈合6个月以内全身各部位增生性瘢痕228个符合入选标准纳入本前瞻性研究,先采用PDL治疗,每个月治疗1次,至瘢痕充血程度评分降至2分以下时,改行剥脱性点阵二氧化碳激光治疗,每3个月治疗1次。记录治疗开始时间、次数及随访时间。首次治疗开始前(以下称治疗前)、末次随访(以下称治疗后),采用自制瘢痕评定量表评定瘢痕充血程度、厚度及柔韧度,对观察时间为创面愈合后6~18个月的患者,按年龄、瘢痕部位、治疗开始时间及治疗次数分组比较瘢痕评分;采用激光散斑血流成像仪测定瘢痕血流值;以瘙痒语言评分量表评估瘢痕瘙痒情况。治疗后调查医患双方疗效满意度参照李克特量表评分,记录治疗全程的治疗反应或不良反应。对数据行配对
t 检验、Mann-WhitneyU 检验、Wilcoxon符号秩和检验、Kruskal-WallisH 检验及Spearman秩相关分析。 结果 (1)本组患者于创面愈合后(64±36)d开始治疗,行PDL治疗(2.5±1.3)次,行剥脱性点阵二氧化碳激光治疗(2.2±1.2)次,随访时间(331±189)d。(2)本组患者治疗后瘢痕的充血程度、厚度、柔韧度及总分分别为(1.4±0.9)、(2.0±0.8)、(1.7±0.8)、(5.0±2.1)分,明显低于治疗前的(4.1±0.7)、(3.1±0.8)、(3.0±0.9)、(10.2±2.0)分(t =43.332、24.968、28.063、46.394,P <0.01)。(3)本组患者中观察时间为创面愈合后6~18个月的有120例共123个瘢痕。治疗后,不同年龄段患者瘢痕充血程度、厚度、柔韧度评分及总分总体比较差异均无统计学意义(χ 2=4.339、1.826、1.375、2.879,P >0.05);不同部位瘢痕仅柔韧度评分总体比较差异有统计学意义(χ 2=13.530,P <0.05);不同治疗开始时间瘢痕充血程度、厚度、柔韧度评分及总分总体比较差异均有统计学意义(χ 2=30.725、25.233、25.119、35.798,P <0.01),治疗开始时间与瘢痕充血程度、厚度、柔韧度评分及总分呈明显正相关(r =0.492、0.442、0.446、0.532,P <0.01);不同治疗次数瘢痕充血程度、柔韧度评分及总分总体比较差异均有统计学意义(Z =4.883、4.910、5.049,P <0.05),治疗次数与瘢痕充血程度、厚度、柔韧度评分及总分呈明显负相关(r =-0.176、-0.131、-0.191、-0.201,P <0.05)。(4)18例患者18个瘢痕测定了瘢痕血流值,结果显示,治疗后瘢痕血流值较治疗前明显降低(t =7.230,P <0.01)。(5)本组患者治疗后瘢痕瘙痒评分较治疗前明显降低(Z =12.818,P <0.01)。(6)治疗后医患双方疗效满意度有明显差异(t =12.130,P <0.01)。(7)PDL治疗后11例(5.0%)患者起水疱,全部患者均伴不同程度水肿及紫癜反应。剥脱性点阵二氧化碳激光治疗后4例(1.8%)患者起水疱,5例(2.3%)患者出现炎症反应及糜烂,9例(4.1%)患者出现色素沉着。 结论 PDL+剥脱性点阵二氧化碳激光序贯治疗可使早期增生性烧伤瘢痕的评分明显改善,开始治疗越早、治疗次数越多,改善越明显;治疗可使瘢痕血流值下降、瘙痒症状减轻,医患双方满意度较高。Abstract: Objective To observe the clinical effects of sequential treatments of pulsed dye laser (PDL) and ablative fractional carbon dioxide laser on early stage hypertrophic burn scars. Methods From January 2016 to December 2017, 221 patients with 228 hypertrophic scars in all parts of body within 6 months post healing, conforming to the study criteria and treated in our department, were included in this prospective study. They were first treated by PDL, repeated at an interval of one month until the vascularity score of scar fell below 2 points, and then treated by ablative fractional carbon dioxide laser, repeated at an interval of 3 months. Their start time and numbers of treatment and follow-up time were recorded. Before the first treatment (hereinafter referred to as before treatment) and at the last follow-up (hereinafter referred to as after treatment), the vascularity, thickness, and pliability of scars were scored by a self-made scar rating scale. The scores of patients with the observation time between 6 to18 months post healing were compared among scars of patients grouped by age, body site of scar, starting time of treatment and numbers of treatment. The laser speckle contrast imaging technique was used to measure the blood flow value of scars. The itching symptom of the scars was evaluated by the Verbal Rating Scale. The satisfaction to the final effects of the doctors and patients was investigated and scored separately by Likert scale after treatment. The therapeutic or adverse reactions were recorded during the treatment. Data were processed with pairedt test, Mann-WhitneyU test, Wilcoxon signed rank sum test, Kruskal-WallisH test, and Spearman rank correlation analysis. Results (1) The patients were treated on (64±36) d post healing, by PDL for (2.5±1.3) times and by ablative fractional carbon dioxide laser for (2.2±1.2) times. The follow-up time was (331±189) d. (2) The vascularity, thickness, pliability scores and total scores of scars were (1.4±0.9), (2.0±0.8), (1.7±0.8), and (5.0±2.1) points respectively after treatment, which were significantly lower than those before treatment [(4.1±0.7), (3.1±0.8), (3.0±0.9), and (10.2±2.0) points respectively,t =43.332, 24.968, 28.063, 46.394,P <0.01]. (3) Among the 123 scars from 120 patients with observation time between 6 to 18 months post healing, there were no statistically significant differences in the vascularity, thickness, pliability scores and total scores of scars among patients with different ages after treatment (χ 2=4.339, 1.826, 1.375, 2.879,P >0.05). There was only significant difference in the pliability scores of scars among different body sites (χ 2=13.530,P <0.05). There were statistically significant differences in the vascularity, thickness, pliability scores and total scores of scars with different starting time of treatment (χ 2=30.725, 25.233, 25.119, 35.798,P <0.01). There were significantly positive correlation between starting time of treatment and the vascularity, thickness, pliability scores and total scores of scars (r =0.492, 0.442, 0.446, 0.532,P <0.01). There were statistically significant differences in the vascularity, pliability scores and total scores of scars with different numbers of treatment (Z =4.883, 4.910, 5.049,P <0.05). There were significantly negative correlation between number of treatment and the vascularity, thickness, pliability scores and total scores of scars (r =-0.176, -0.131, -0.191, -0.201,P <0.05). (4) The blood flow values were determined in 18 scars of 18 patients. The results showed that the blood flow values of scars after treatment were significantly decreased compared with those before treatment (t =7.230,P <0.01). (5) The pruritus scores of scars of patients after treatment were significantly decreased compared with those before treatment (Z =12.818,P <0.01). (6) There were significant differences between the satisfaction scores of doctors and the scores of patients after treatment (t =12.130,P <0.01). (7) After PDL treatment, there were some edema and purpura reactions for all the patients, and 11 (5.0%) patients had blisters. After ablative fractional carbon dioxide laser treatment, 4 (1.8%) patients had blisters, 5 (2.3%) patients suffered inflammatory reaction and erosion, and 9 (4.1%) patients suffered pigmentation. Conclusions The scores of hypertrophic burn scars can be obviously improved by sequential treatments of PDL and ablative fractional carbon dioxide laser. The effects can be more obvious with the earlier starting time and more numbers of treatment. The laser treatments can also decrease the blood flow values and alleviate the pruritus of scars, with high satisfaction of both patients and doctors.-
Key words:
- Burns /
- Cicatrix /
- Laser therapy /
- Pulsed dye laser /
- Carbon dioxide laser
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