Practical Dermatology
Laser Treatment of Burn Scars
Tratamiento láser de cicatrices por quemaduras
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Primera parte. Referente a la sífilis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Martín de Santa-Olalla y Llanes, R.M. Díaz-Díaz" "autores" => array:2 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Martín de Santa-Olalla y Llanes" ] 1 => array:2 [ "nombre" => "R.M." 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Altemir, P. Boixeda" "autores" => array:2 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Altemir" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Boixeda" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022006822?idApp=UINPBA000044" "url" => "/00017310/0000011300000010/v1_202211300529/S0001731022006822/v1_202211300529/es/main.assets" ] "asociados" => array:1 [ 0 => array:19 [ "pii" => "S0001731022006822" "issn" => "00017310" "doi" => "10.1016/j.ad.2022.06.018" "estado" => "S300" "fechaPublicacion" => "2022-11-01" "aid" => "3171" "copyright" => "AEDV" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Actas Dermosifiliogr. 2022;113:938-44" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Dermatología Práctica</span>" "titulo" => "Tratamiento láser de cicatrices por quemaduras" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "938" "paginaFinal" => "944" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Laser Treatment of Burn Scars" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 629 "Ancho" => 1005 "Tamanyo" => 102311 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ejemplo de tratamiento con láser de colorante pulsado 595<span class="elsevierStyleHsp" style=""></span>nm (8 sesiones), láser CO<span class="elsevierStyleInf">2</span> fraccionado (7 sesiones) y Alejandrita 755<span class="elsevierStyleHsp" style=""></span>nm (3 sesiones), antes (izquierda) y después (derecha).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Altemir, P. Boixeda" "autores" => array:2 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Altemir" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Boixeda" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022006822?idApp=UINPBA000044" "url" => "/00017310/0000011300000010/v1_202211300529/S0001731022006822/v1_202211300529/es/main.assets" ] ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Practical Dermatology</span>" "titulo" => " Laser Treatment of Burn Scars" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "T938" "paginaFinal" => "T944" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Altemir, P. Boixeda" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Altemir" "email" => array:1 [ 0 => "arcadi.altemir@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Boixeda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Sagrat Cor, Grupo Hospitalario Quirónsalud, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Ramon y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento láser de cicatrices por quemaduras" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 659 "Ancho" => 1005 "Tamanyo" => 126064 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Example of treatment with a 595-nm pulsed dye laser (2 sessions), fractional carbon dioxide laser (1 session), and 755-nm alexandrite laser (2 sessions), before (left) and after (right).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Laser devices have proven very useful for the treatment of scars.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">1</span></a> Lasers have been widely studied in specific types of scar, such as those resulting from acne, surgery, and injury, as well as keloids.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">1,2</span></a> However, laser treatment for the sequelae of burns has received less attention, and the option is not available in most hospitals.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2017, the worldwide prevalence of burn injuries exceeded 1000 per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants. Most burns affected <20% of the body surface and mainly involved the skin, thus highlighting the role of the dermatologist.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Complications resulting from burn scars can have a considerable effect on patient quality of life.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">4</span></a> Contractures and disfigurement have a huge impact on function, reduce mobility, and cause pain and itching. Moreover, the strong emotional component associated with this type of lesion can be stigmatizing, especially in lesions affecting the face and neck, and lead to anxiety, depression, and low self-esteem.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A variety of conservative treatments have traditionally been administered to manage burn scars, including silicone gel, corticosteroid injections, pressure therapy, and therapeutic massages.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">6</span></a> These approaches must often be combined with surgery, which can range from resection of the scar with closure of the wound to transverse incision, Z-plasty, flaps, and skin grafting.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Lasers</span><p id="par0025" class="elsevierStylePara elsevierViewall">In recent years, lasers have proven effective in the treatment of burn injuries. They are minimally invasive, carry a low risk of adverse effects, and are associated with rapid recovery. Therefore, they are included in some treatment protocols alongside modestly successful conservative approaches and surgical interventions, which may be very effective but are associated with high morbidity.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a> While lasers do not necessarily replace surgery, they can reduce the area to be treated, thus leading to fewer postsurgical complications.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Lasers are classified according to their mechanism of action as ablative/nonablative and fractional/nonfractional.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">10</span></a> The main devices used in the treatment of burn scars are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">This article covers the parameters most commonly applied for the treatment of burn scars and could prove useful for guidance only. Importantly, these parameters differ widely owing to the heterogeneous nature of the scars themselves and the wide variety of devices available (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Evaluation of the Scar</span><p id="par0040" class="elsevierStylePara elsevierViewall">Burn scars generally result in abnormal healing of the skin in more than 70% of cases owing to abnormalities in thickness, texture, erythema, and pigmentation.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">11</span></a> Such is the case of burns affecting the deep layers of the dermis, for example, second- or third-degree burns, which may require laser treatment. Superficial burns that do not reach the reticular dermis rarely lead to abnormal scarring and do not generally cause complications.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In terms of thickness, the scars can be classified as keloids, hypertrophic and atrophic scars; in terms of pigmentation, they can be classified as hypopigmented and hyperpigmented regarding adjacent healthy skin. Furthermore, erythema is common, especially in active and recent scars.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The severity of the scar should be assessed before initiating and monitoring therapy. The most common approach is the Vancouver Scar Scale,<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">13</span></a> which evaluates vascularization, thickness, flexibility, and pigmentation. However, the Patient and Observer Scar Assessment Scale (POSAS) is considered the most complete, since it also includes subjective symptoms, such as pain and itching.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">14</span></a> Appropiate evaluation allows selecting the most suitable laser for treatment. Moreover, in order to choose the right type of device and parameters, we must take into account both the characteristics of the patient (e.g., skin phototype, comorbidities) and the location of the scar (e.g., head, neck, limb).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Vascular Lasers</span><p id="par0055" class="elsevierStylePara elsevierViewall">Pulsed dye lasers (PDLs) are nonablative vascular lasers with wavelengths of 585 and 595<span class="elsevierStyleHsp" style=""></span>nm.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">15</span></a> Using selective photothermolysis, they cause coagulation and necrosis of the blood vessels, with oxyhemoglobin as the target molecule (chromophore).<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">16</span></a> PDLs are considered the laser of choice for treating the vascular component of burn scars and carry a low risk of adverse effects.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Multiple studies have shown PDLs to be effective for the treatment of scar erythema, which is caused by excess neovascularization during the scarring process.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">17</span></a> It has also proven effective for the treatment of hypertrophic scars through destruction of collagen secondary to tissue hypoxia caused by coagulation of the vessels.<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">18</span></a> Allison et al.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">19</span></a> also recorded an improvement in itching after treating the vascular component. While not fully defined, this mechanism is thought to be associated with a change in cytokines, neuropeptides, and histamine resulting from hypoxia and local heat after laser treatment.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Fluence is generally low, 4–8<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>, with a beam diameter (spot size) of 7–10<span class="elsevierStyleHsp" style=""></span>mm and short pulse duration (0.5–2<span class="elsevierStyleHsp" style=""></span>ms).<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a> The endpoint, or immediate desired effect, is mild purpura, since overtreatment can lead to pigmentation abnormalities. Patients with skin phototypes I-III are the best candidates for PDL because they have less melanin, which competes with hemoglobin for the absorption of energy. Treatment is usually administered in sessions separated by a 6- to 8-week interval until the desired therapeutic effect is achieved. A mean of 4 sessions is normal.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The fact that the laser penetrates approximately 1.2<span class="elsevierStyleHsp" style=""></span>mm into the skin means that its use in thick hypertrophic scars is limited. Therefore, it is frequently combined with ablative fractional lasers (AFLs) in thick scars to generate a potentially synergic effect.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">15</span></a> We have found that pediatric patients generally have poor tolerance to AFL treatment and that PDL in monotherapy has very good results, especially in the early phases of scarring (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In a clinical trial, Al-Mohamady et al.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">20</span></a> demonstrated that the long-pulse, low-fluence 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser was effective for the treatment of hypertrophic scars, observing no significant differences with respect to PDL.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Finally, intense pulsed light lasers emit a broad-spectrum polychromatic light beam (500–1200<span class="elsevierStyleHsp" style=""></span>nm) that can be delimited using filters and act on various types of chromophores by means of selective photothermolysis.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">21</span></a> These devices can also prove useful for the treatment of the vascular component, pigmentation, and hypertrophy in various types of scar, such as burn scars, and can be a good alternative. However, evidence for their use in the treatment of burn scars is limited.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ablative Fractional Lasers</span><p id="par0085" class="elsevierStylePara elsevierViewall">AFLs are the cornerstone of burn scar treatment. The most common are the 10<span class="elsevierStyleHsp" style=""></span>600-nm carbon dioxide laser and the 2940-nm erbium-doped yttrium aluminum garnet (Er:YAG) laser, which use water as a chromophore. They act by generating columns of thermal damage in the epidermis and dermis. These columns favor collagen remodeling, thus improving the thickness, flexibility, and color of the scars. They vary in depth from 0.2 to 4<span class="elsevierStyleHsp" style=""></span>mm. Furthermore, the healthy tissue between the columns serves as a reservoir for rapid posttreatment recovery.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">23</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Carbon dioxide lasers have less affinity for water than Er:YAG lasers and generate more thermal coagulation in peripheral tissue. Given that this mechanism facilitates collagen repair, the carbon dioxide laser is considered the more effective and is more widely used. In addition, carbon dioxide lasers deposit energy at a greater depth, up to 4<span class="elsevierStyleHsp" style=""></span>mm, and their role in vessel coagulation prevents some bleeding during treatment.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Recent meta-analyses show that the use of fractional carbon dioxide lasers significantly improves the thickness, flexibility, vascularization, and pigmentation of burn scars, and even associated pain and itching.<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">24,25</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Depending on the characteristics of the scar, the laser can be applied superficially to smoothen the skin and deep to reduce tension and favor remodeling of abnormal collagen. It can even be used in combination<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">26</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The parameters applied in AFLs vary considerably and are adjusted to the characteristics of the scar and the patient's skin phototype. For example, more hypertrophic scars tend to be treated at higher energy levels in order to act at greater depths, albeit with lower densities to compensate for excessive thermal damage. The most common parameters used are intermediate-high powers (15–30<span class="elsevierStyleHsp" style=""></span>W) and low densities (5%–15%). Darker skin phototypes require more conservative approaches in order to prevent hyperpigmentation. Treatment is usually administered in a mean of 3–5 sessions over 4–12 weeks.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">27</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The carbon dioxide laser has been used in its continuous nonfractional mode (traditional mode) to reduce tension and increase mobility in hypertrophic scars associated with contractures, mainly around joints. This procedure consists of incisions made perpendicular to the most prominent part of the contracture or in the form of the Mercedes Benz car logo in cases of extensive scarring, leaving the wound to heal by secondary intention.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">AFLs can also be used in atrophic scars resulting from reduced dermal collagen in order to stimulate new collagen production.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Treatment with AFLs is generally well tolerated, with few adverse effects, which, when they do occur, are usually mild. Reported complications, in order of frequency, include hypopigmentation, pain and inflammation, prolonged erythema, vesicles, paradoxical growth of scar tissue, and infections.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Nonablative Fractional Lasers</span><p id="par0125" class="elsevierStylePara elsevierViewall">Nonablative fractional lasers (NAFLs) cause heat damage in the dermis in the form of columns of coagulation without ablation, leaving the epidermis intact.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">10</span></a> This mechanism makes it possible to reduce surface damage and the degree of heat applied to the skin; therefore, recovery time is shorter.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">26</span></a> The most commonly used type is the 1540-nm or 1550-nm Er:glass laser.</p><p id="par0130" class="elsevierStylePara elsevierViewall">NAFLs heat the skin to a lower temperature (50–70<span class="elsevierStyleHsp" style=""></span>°C) and reach lower depths (approximately 1.8<span class="elsevierStyleHsp" style=""></span>mm) than AFLs.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a> Despite the paucity of studies comparing the 2 lasers for treatment of scars, NAFLs cause less thermal damage and are therefore less effective and require more sessions.<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">26,30</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In a clinical trial, Taudorf et al.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">31</span></a> found an improvement in the thickness, flexibility, and roughness of burn scars, as well as normalization of collagen in histology, albeit at the expense of reduced effectiveness in hypertrophic scars.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pigment Lasers</span><p id="par0140" class="elsevierStylePara elsevierViewall">The main pigment lasers are the 694-nm ruby laser, the 755-nm alexandrite laser, and the 1064-nm and 523-nm potassium-titanyl-phosphate (KTP) lasers in Q-switched mode (nanoseconds or picoseconds).<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">32</span></a> Although these are widely used to treat dyschromia in several types of scar,<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">33</span></a> we found no studies specifically assessing their use in burn scars. Management of pigment abnormalities is generally complex, and recurrences are frequent.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Ablative lasers that use water as a chromophore (e.g., carbon dioxide lasers) are commonly applied to treat textural abnormalities, although they can also be used to nonselectively eliminate hyperpigmentation through vaporization of melanin in the epidermis. Lasers that use melanin as a chromophore, however, are more specific, since they selectively destroy melanosomes in keratinocytes and melanocytes, thus limiting collateral thermal damage in peripheral tissue.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">32</span></a> Furthermore, topical depigmenting treatments combined with rigorous photoprotection are essential for management of postinflammatory hyperpigmentation.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">32</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In our experience, pigment lasers such as the short-pulsed 755-nm alexandrite laser provide good results (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). We propose low fluence values (1–3<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>) to improve tolerance at pulses measured in nanoseconds or picoseconds with a spot size of 3–5<span class="elsevierStyleHsp" style=""></span>mm.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Finally, AFLs and NAFLs have led to some improvement in hypopigmentation, possibly owing to migration of normal melanocytes from peripheral tissue.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Combination Laser Therapy</span><p id="par0160" class="elsevierStylePara elsevierViewall">Given that burn scars are frequently characterized by abnormalities in thickness, texture, erythema, and pigmentation, combining several lasers makes for more complete and specific therapy. Clinical trials have shown more favorable outcomes with the combination of treatments, especially PDL and carbon dioxide laser.<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">35,36</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Anderson et al.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a> propose a therapy plan including initial application of PDL for treatment of erythema and inflammation, followed by combination with AFL to improve thickness and texture. In our experience, scars with abnormal pigmentation or hypertrichosis can also be treated by combining lasers whose chromophore is melanin, such as the 755-nm alexandrite laser and the 1064-nm Nd:YAG laser. We propose a therapeutic algorithm for the management of burn scars based on a review of the literature and our professional experience (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Combination With Other Treatments</span><p id="par0170" class="elsevierStylePara elsevierViewall">Applying adjuvant treatment to laser treatment can generate a synergistic effect in the management of burn scars. An improvement in hypertrophic scars has been observed when PDL is combined with intralesional corticosteroids, mainly triamcinolone, and 5-fluorouracil.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">37</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Laser-assisted delivery of corticosteroids is an increasingly used and promising modality. This approach is based mainly on fractional Er:YAG laser and carbon dioxide laser. The underlying mechanism involves delivery of the drug via the columns generated in the epidermis, thus increasing its ability to act.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">38</span></a> The main advantage of this modality is that the topical treatment delivered is better tolerated than intralesional corticosteroids. The drug usually administered is triamcinolone at 10–40<span class="elsevierStyleHsp" style=""></span>mg/mL. This modality generally requires low laser densities (<5%) and energies that vary depending on the thickness of the scar.<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">39,40</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Administration of prostaglandins such as latanoprost and bimatoprost after fractional laser treatment recently led to significant improvements in hypopigmentation. This phenomenon is probably due to the increased transfer of melanosomes in melanocytes to basal keratinocytes. Adjuvant topical retinoids, which have traditionally been used to treat postinflammatory hyperpigmentation, have also been used to restore pigment through modulation of tyrosinase activity.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">41</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Platelet-rich plasma,<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">42</span></a> autologous fat grafting,<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">43</span></a> and radiofrequency<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">36</span></a> may also prove useful.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">When to Treat</span><p id="par0190" class="elsevierStylePara elsevierViewall">Once the burn injury has completely healed, early intervention on the scar makes it possible to alleviate symptoms, prevent contractures, and improve the recovery process.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a> While the ideal time to start treatment of burn scars has not been defined, PDL, AFL, and NAFL applied to surgical scars on the day the sutures are removed have proven safe and effective.<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">44,45</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Erythematous and hypertrophic scars are common, especially during the first year of healing. Therefore, early treatment with vascular lasers plays a major role and can even prevent complications.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">46</span></a> In some patients, especially those with low skin phototypes (I–II), erythema can become chronic. PDL has also proven successful in the treatment of lesions that have progressed over several years.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">47</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">Burn scars are generally associated with considerable morbidity. Lasers, especially PDLs and carbon dioxide lasers, have proven effective for improving erythema, hypertrophy, pigmentation, flexibility, and itching, with a low risk of adverse effects and rapid recovery time. We believe that implementing laser treatment in the management of these lesions would go a long way to improving patients’ quality of life.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that no funding was received for the present article.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of Interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:18 [ 0 => array:3 [ "identificador" => "xres1808949" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1580721" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1808948" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1580720" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Lasers" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Evaluation of the Scar" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Vascular Lasers" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Ablative Fractional Lasers" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Nonablative Fractional Lasers" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Pigment Lasers" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Combination Laser Therapy" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Combination With Other Treatments" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "When to Treat" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 15 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 16 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of Interest" ] 17 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-03-05" "fechaAceptado" => "2022-06-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1580721" "palabras" => array:5 [ 0 => "Burns" 1 => "Scars" 2 => "Hypertrophic scar" 3 => "CO<span class="elsevierStyleInf">2</span> laser" 4 => "Pulsed dye laser" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1580720" "palabras" => array:5 [ 0 => "Quemaduras" 1 => "Cicatrices" 2 => "Cicatrices hipertróficas" 3 => "Láser CO<span class="elsevierStyleInf">2</span>" 4 => "Láser colorante pulsado" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Burn scars cause high morbidity in the form of contractures, body disfigurement, and itching, as well as a high emotional impact that adversely affects patient quality of life. Laser therapy has proven effective in this setting. It is superior to topical treatments and can be used in conjunction with surgery, helping to reduce morbidity. The use of lasers in hospital dermatology departments, however, is still limited. Carbon dioxide laser is the most widely used device for reducing scar thickness, improving textural abnormalities, and treating associated contractures, which may restore the mobility of these patients when it is altered. Pulsed dye laser treatments are particularly useful for reducing erythema in recent burn scars and preventing subsequent hypertrophy. Pigment laser treatments with short pulse durations (nanoseconds or picoseconds) can improve hyperpigmentation. In this article, we review the evidence for the use of laser therapy for burn scars and propose a treatment algorithm.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las cicatrices por quemadura suponen una elevada morbilidad en forma de contracturas, desfiguración corporal y prurito, así como un elevado impacto emocional que disminuye la calidad de vida de estos pacientes. Los dispositivos láser se han mostrado eficaces para su tratamiento, por encima de los tratamientos tópicos y complementarios a la cirugía, sin generar tanta morbilidad. Sin embargo, su uso en los departamentos de dermatología hospitalarios todavía está poco extendido. El láser más utilizado es el láser CO<span class="elsevierStyleInf">2</span> para tratar el grosor de la cicatriz, alteraciones texturales, y la posible contractura asociada, restaurando la movilidad de estos pacientes cuando se encuentra alterada. El láser de colorante pulsado es especialmente útil ante las cicatrices de quemaduras recientes con componente eritematoso y para prevenir el desarrollo de cicatrices hipertróficas posteriores. La hiperpigmentación puede mejorar con láseres de pigmento en modalidades de pulso corto (nano- y picosegundos). Revisamos la evidencia de estos dispositivos para el tratamiento de las cicatrices por quemaduras y aportamos una propuesta de algoritmo terapéutico.</p></span>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 437 "Ancho" => 1005 "Tamanyo" => 78192 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Example of treatment with 595-nm pulsed dye laser (4 sessions), before (left) and after (right).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 629 "Ancho" => 1005 "Tamanyo" => 102311 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Example of treatment with a 595-nm pulsed dye laser (8 sessions), fractional carbon dioxide laser (7 sessions), and a 755-nm alexandrite laser (3 sessions), before (left) and after (right).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 659 "Ancho" => 1005 "Tamanyo" => 126064 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Example of treatment with a 595-nm pulsed dye laser (2 sessions), fractional carbon dioxide laser (1 session), and 755-nm alexandrite laser (2 sessions), before (left) and after (right).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2589 "Ancho" => 2917 "Tamanyo" => 393630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the treatment of burn scars. *Laser of choice. IPL indicates intense pulse light; PDL, pulsed dye laser; Nd:YAG, neodymium-doped yttrium aluminum garnet; KTP, potassium-titanyl-phosphate; AFL, ablative fractional laser; NAFL, nonablative fractional laser; QS, Q-switched (nanoseconds or picoseconds); LADD, laser-assisted drug delivery.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: AFL, ablative fractional laser; IPL, intense pulsed light; KTP, potassium-titanyl-phosphate; LADD, laser-assisted drug delivery; ms, milliseconds (long pulse); NAFL, nonablative fractional lasers; Nd:YAG, neomydium: yttrium-aluminum-garnet; PDL, pulsed dye laser; QS, Q-switched (nanoseconds/picoseconds, short pulse).</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Abnormality \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laser \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Erythema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">585- and 595-nm PDL, 500- to 1200-nm IPL, 1064-nm Nd:YAG (ms), 532-nm KTP (ms) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thickness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AFL10<span class="elsevierStyleHsp" style=""></span>600-nm carbon dioxide2940-nm Er:YAGNAFL1540- and 1550-nm Er:glass \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flexibility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10<span class="elsevierStyleHsp" style=""></span>600-nm carbon dioxide \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pigmentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AFL, NAFL, QS 755-nm alexandrite, QS 1064-nm Nd:YAG, QS 694-nm ruby, QS 532-nm KTP \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Main Scar Abnormalities and Lasers Available for Treatment.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: Er, erbium; PDL, pulsed dye laser.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Laser \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade of recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Level of evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10<span class="elsevierStyleHsp" style=""></span>600-nm carbon dioxide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">585- and 595-nm PDL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1540- and 1550-nm Er:glass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">755-nm alexandrite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Main Lasers for the Treatment of Burn Scars: Grade of Recommendation and Level of Evidence.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:47 [ 0 => array:3 [ "identificador" => "bib0240" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early laser intervention to reduce scar formation – a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 5 | 20 |
| 2024 October | 338 | 133 | 471 |
| 2024 September | 331 | 99 | 430 |
| 2024 August | 313 | 136 | 449 |
| 2024 July | 296 | 1804 | 2100 |
| 2024 June | 264 | 112 | 376 |
| 2024 May | 278 | 75 | 353 |
| 2024 April | 235 | 82 | 317 |
| 2024 March | 241 | 81 | 322 |
| 2024 February | 294 | 87 | 381 |
| 2024 January | 312 | 77 | 389 |
| 2023 December | 283 | 62 | 345 |
| 2023 November | 433 | 97 | 530 |
| 2023 October | 432 | 91 | 523 |
| 2023 September | 399 | 75 | 474 |
| 2023 August | 362 | 65 | 427 |
| 2023 July | 338 | 90 | 428 |
| 2023 June | 278 | 80 | 358 |
| 2023 May | 394 | 110 | 504 |
| 2023 April | 319 | 58 | 377 |
| 2023 March | 365 | 67 | 432 |
| 2023 February | 296 | 52 | 348 |
| 2023 January | 216 | 84 | 300 |
| 2022 December | 257 | 96 | 353 |
| 2022 November | 224 | 51 | 275 |
| 2022 October | 93 | 50 | 143 |
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