Performing Fractional CO2 Laser treatment prior to injection acts as a mechanical "pre-drilling" technique for dense tissue. By creating a network of vertical microscopic channels in the hardened keloid, the laser significantly reduces the internal tissue pressure. This allows viscous medications, such as corticosteroids, to permeate the lesion with minimal resistance, ensuring the drug is distributed evenly rather than pooling in a single area.
The Core Mechanism Hard-textured keloids act as a physical barrier to liquid medication, causing injections to be painful and inefficient. The primary goal of using a laser first is Laser-Assisted Drug Delivery (LADD): transforming the dense scar into a permeable structure that allows therapeutic agents to penetrate deeply and uniformly.
Overcoming the Mechanical Barrier
The Challenge of Hard Keloids
Keloids with an extremely hard texture present a significant physical challenge. The dense collagen bundles create high internal pressure.
When a clinician attempts to inject fluid into this environment, the resistance is immense. This often results in poor drug diffusion, where the medication stays localized to the needle tip, and causes intense pain for the patient due to tissue expansion.
Creating Vertical Micropores
The Fractional CO2 Laser utilizes a specific wavelength to create large numbers of "micropores" or Microscopic Ablative Zones (MAZs) on the skin surface.
These are essentially tiny, vertical tunnels drilled into the scar tissue. Mechanically, this turns a solid, impermeable mass into a "sieve-like" structure.
Reducing Injection Resistance
Once these micropores are established, the physical tension within the keloid drops.
When the needle is subsequently inserted, the medication encounters far less resistance. The suspension can flow through the laser-created channels, significantly reducing the force required to inject and alleviating patient discomfort.
Enhancing Therapeutic Efficacy
Laser-Assisted Drug Delivery (LADD)
The combination of laser followed by injection is technically referred to as Laser-Assisted Drug Delivery.
Rather than relying on the pressure of the syringe to force medication through cells, the drug passively and actively flows down the microscopic thermal channels. This breaks through the dense tissue barriers that usually block topical or injected drugs.
Uniform Distribution
In a standard injection, the drug often creates a "bolus" (a lump of fluid) that affects only the immediate area.
With pre-treatment laser ablation, the medication disperses throughout the network of micropores. This ensures that the steroid or chemotherapeutic agent reaches a wider volume of the pathological tissue, enhancing the biological suppression of the keloid.
Synergistic Remodeling
Beyond drug delivery, the laser injury itself triggers a healing response. The creation of Microscopic Thermal Zones (MTZs) induces collagen reorganization.
By combining this remodeling effect with the chemical inhibition of the injected steroid, clinicians can attack the keloid on two fronts: physical remodeling and chemical suppression of fibroblast proliferation.
Understanding the Trade-offs
The Necessity of Combination
It is critical to note that standalone laser ablation often has a high recurrence rate (exceeding 70%) and can induce severe inflammatory responses if used in isolation.
The laser creates the pathway, but the injection provides the necessary chemical suppression to prevent the scar from growing back more aggressively.
Thermal Injury Management
While Fractional CO2 is safer than full-field ablation, it still causes thermal damage.
The "bridges" of untreated tissue left between the micro-beams are essential for rapid healing and preventing infection. Aggressive laser treatment without leaving these healthy bridges can lead to delayed healing or secondary scarring.
Making the Right Choice for Your Goal
When planning a treatment protocol for recalcitrant keloids, consider the following biological objectives:
- If your primary focus is Drug Absorption: Use the laser to break the physical barrier of the stratum corneum and dermis, maximizing the penetration depth of viscous suspensions.
- If your primary focus is Patient Comfort: utilize the laser to decompress the tissue tension, reducing the sharp pain associated with high-pressure injections in dense scars.
- If your primary focus is Reducing Recurrence: Ensure the laser treatment is always followed by the injection or topical application, as the laser alone may trigger an inflammatory rebound.
Ultimately, the laser prepares the terrain, allowing the injection to do its work effectively without fighting the density of the scar.
Summary Table:
| Feature | Injection Alone | Fractional CO2 + Injection (LADD) |
|---|---|---|
| Drug Distribution | Localized bolus (uneven) | Uniform distribution via micropores |
| Tissue Resistance | High (difficult to inject) | Low (sieve-like permeable structure) |
| Patient Pain | High (due to tissue expansion) | Significantly reduced |
| Recurrence Risk | Moderate | Lower (synergistic remodeling) |
| Mechanism | Chemical suppression only | Physical remodeling + Chemical suppression |
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References
- Young Gue Koh, Sun Young Choi. Treatment of an ear keloid refractory to intralesional triamcinolone injection monotherapy with fractional CO<sub>2</sub> laser and triamcinolone combination therapy: a case report. DOI: 10.25289/ml.23.024
This article is also based on technical information from Belislaser Knowledge Base .
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