Introduction: A deep burn ulcer, especially in areas with sensory-motor dysfunction, is hard to cure.Case Report: The patient was a 20-year-old paraplegic girl with a grade 3 necrotic burn ulcer for 3 weeks. We used a fractional Co2 laser along with chemical debridement with trichloroacetic acid (TCA 80%) and low-level laser therapy (LLLT) with a 808 nm infrared laser, 6 J/cm2 for the necrotic area, and a 650 nm red laser, 2 J/cm2 for the open wound area. Complete healing occurred after 25 sessions without surgery.Conclusion: Laser debridement along with LLLT and TCA administration may be useful to treat necrotic ulcers without surgery

Dahmardehei, Mostafa

Hashemi pour, Saeed

Kazemi khoo, Nooshafarin

Mokmeli, Soheila

Nilforoushzadeh, Mohammad Ali

English

Journals Portal, Shahid Beheshti University of Medical Sciences

Please cite this article as follows: Kazemikhoo N, Hashemi Pour S, Nilforoushzadeh MA, Mokmeli S, Dahmardehei M. The efficacy of carbone dioxide laser debridement along with low-level laser therapy in treatment of a grade 3 necrotic burn ulcer in a paraplegic patient (a case report). J Lasers Med Sci. 2019;10(4):338-341. doi:10.15171/jlms.2019.54. Case Reportdoi 10.15171/jlms.2019.54The Efficacy of Carbone Dioxide Laser Debridement Along With Low-Level Laser Therapy in Treatment of a Grade 3 Necrotic Burn Ulcer in a Paraplegic Patient (A Case Report)    Nooshafarin Kazemikhoo1,2, Saeed Hashemi Pour3, Mohammad Ali Nilforoushzadeh1*, Soheila Mokmeli4, Mostafa Dahmardehei51Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran 2Department of Dermatology, St. George Hospital. UNSW. Sydney. Australia3Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran4Laser Therapist and Instructor, Canadian Optic and Laser Center, BC, Canada5Burn Research center, Department of Plastic and Reconstructive Surgery, Iran University of Medical Sciences, Tehran, Iran AbstractIntroduction: A deep burn ulcer, especially in areas with sensory-motor dysfunction, is hard to cure. Case Report: The patient was a 20-year-old paraplegic girl with a grade 3 necrotic burn ulcer for 3 weeks. We used a fractional Co2 laser along with chemical debridement with trichloroacetic acid (TCA 80%) and low-level laser therapy (LLLT) with a 808 nm infrared laser, 6 J/cm2 for the necrotic area, and a 650 nm red laser, 2 J/cm2 for the open wound area. Complete healing occurred after 25 sessions without surgery. Conclusion: Laser debridement along with LLLT and TCA administration may be useful to treat necrotic ulcers without surgery. Keywords: Co2 Laser debridement; Trichloroacetic Acid; Low-level laser Therapy; Wound healing. *Correspondence toMohammad Ali Nilforoushzadeh,Professor, Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran. Email: dr_nilforoush@yahoo.comPublished online October 1, 2019 Journal ofLasersin Medical SciencesJ Lasers Med Sci 2019 Autumn;10(4):338-341http://journals.sbmu.ac.ir/jlmsIntroductionDamaged necrotic skin in third-degree burns is highly susceptible to infection and must be removed by debridement. Debridement can be done surgically, chemically or by lasers. The carbon dioxide laser (Co2) has great potentials for surgical purposes. It can incise almost all tissues. Resulting heat automatically coagulates small vessels and induces hemostasis.1 Early animal studies showed that the Co2 laser could vaporize skin, crusts, dried blood, and pus in grade 3 burns without difficulty and with complete wound healing.2,3 The material can be removed layer by layer until it can reach normal tissue. The Co2 laser is a safe instrument in proper hands.4 The standard treatment after debridement for deep necrotic burns is the autologous split-thickness skin graft or rotation flap closure.2 Autografts are highly successful immediately after laser debridement.1,5 Trichloroacetic acid (TCA) is used as a chemical peeling agent in dermatology. It penetrates the mid dermis and destroys the epidermal lesions. Acute post-inflammatory reaction stimulates cellular regeneration.6 This agent has been used for non-surgical debridement and accelerating the healing process in necrotic diabetic ulcers.7 In paralyzed patients, because of neurological and vascularization impairment, the healing process is complicated and using therapeutic methods like low-level laser therapy (LLLT) can accelerate the healing process. LLLT is an effective, safe, and non-invasive method for the treatment of complicated ulcers, including bedsores8,9 and diabetic and venous ulcers.10-12 These lasers have no thermal effects and stimulate the healing process by improving microcirculation, fibroblast proliferation, collagen synthesis, granulation tissue formation, regenerative capacity, and cellular metabolic processes of injured tissues and by modulating the immune system.13,14In this case report, for the first time, we used the Co2 laser, TCA and LLLT for healing the ulcer without the skin graft in a paralyzed patient.Case ReportThe patient was a 20-year-old paraplegic girl due to meningomyelocele since her childhood. She had had a grade 3 burn ulcer due to hot water bag usage on the sacral area for 3 weeks ago. She was dressed in mupirocin Journal of Lasers in Medical Sciences  Volume 10, Number 4, Autumn 2019 339                                                   Efficacy of CO2 Laser With LLLT in Grade 3 Necrotic Burn Ulcerand mafenide ointments and the necrotic surface was scratched with a scalpel during this period in Motahari burn center, but as there was no improvement, she was a candidate for surgical debridement and a skin graft by a plastic surgeon. She did not accept surgery and was referred to a laser clinic. Photography was done and calculated with Pictzar software which was 52 cm2. Three protocols were used to treat this ulcer: 1- Co2 laser debridement, 2- Chemical debridement with TCA, and 3- LLLT. Protocol 1- Co2 laser debridement: We used the Unixel Co2 laser (Union medical Co., South Korea), 10.60 nm. As removing all the necrotic skin in one session would induce an open ulcer which needed a skin graft and patient did not agree with the surgical procedure, we used a fractional mode, 6 W (Level = 20), point of shot: 4, pulse width: 1250 µs, with medium micro thermal zone (MTZ), pitch: 0.8, which produces 169 micro-cavities (300 micron is the diameter of each micro-cavity) in 20 × 20 mm spot size for debridement. Protocol 2- Chemical debridement: After Co2 laser debridement, TCA 80% was applied over the necrotic area by a cotton applicator. Laser-induced micro-cavities would increase TCA penetration. Protocol 3- LLLT: We used an 808 nm, 200 mW laser with 1 cm2 radiation area, 6 J/cm2, contact, continuous mode (a portable 3L laser, Iran), over the necrotic area and the surrounding healthy skin. After each session dressing was done by using mupirocin ointment, mafenide ointments, and sterile wet gauze. Protocol 2 and 3 were applied every other day for 25 sessions. The necrotic layer gradually began to separate from the sidelines. To irradiate these fresh ulcers, the portable laser probe (PLP), 650 nm, 150 mW, radiation area: 0.25 cm2, power density: 0.6 W/cm2, contact, continuous mode, 2 J/cm2, (Canadian Optic Laser Center, COL laser, Canada) was used. This is a suggested protocol for wound treatment in most studies.10,15,16After 10 sessions of TCA and laser therapy, the necrotic layer was separated (Figure 1D) and after 25 sessions (2 months), complete healing occurred. The Patient had no side effects or discomfort during this period and one-year follow-up.DiscussionIn this study, for the first time we used Co2 laser debridement along with chemical debridement with TCA and LLLT for treatment of a deep necrotic ulcer without surgery. The Co2 laser created tinny holes on the necritic surface for TCA to penetrate deeper and the combination of these two helped to remove the thick necrotic tissue without surgery as patient wished and LLLT induced wound healing by increasing perfusion, stimulation of fibroblasts, and epithelial cells.11,12,17 Our results showed this method might be useful therapeutically, even in complicated situations, including paraplegic patients without any side effects. Although surgical debridement followed by an autologous skin graft is the gold standard treatment in deep necrotic ulcers, this method has several complications, including the need to hospitalization, the risk of anaesthesia, and surgery. In this study, instead of surgical debridement of a large area which needed a skin graft, we gradually removed the layer by a fractional laser and chemical debridement and used LLLT for healing the ulcer. The patient’s ulcer healed completely during 2 months.Our previous finding showed that LLLT has significant effects on growth factors involved in wound healing, including EGF, FGF, and PDGF,17 on wound healing, neuropathy, and metabonomics of diabetic patients.10,18,19 Moreover, its positive effects have been observed in treatment of pressure ulcer,8 after skin graft surgery,20,21     Figure 1. A: the Grade 3 burn ulcer for 3 weeks, B: surface measurement by software, C: Co2 laser debridement, D: After 10 sessions of a low-level laser and TCA therapy, the necrotic layer was separated completely. E: After 25 sessions of a low-level laser and TCA therapy, F: 1 month after complete healing.Kazemikhoo et al Journal of Lasers in Medical Sciences  Volume 10, Number 4, Autumn 2019340and post-cesarean surgery.22 Several reviews and meta-analyses introduce LLLT as an effective therapeutic modality for wound healing.11,12 Lucas et al evaluated the effect of LLLT for treatment of a stage 3 decubitus ulcer in a randomized clinical trial.9 Several reviews and clinical trials indicate the efficacy of LLLT for wound healing,12,23 but these studies are mainly focused on diabetic, venous and pressure ulcers and we did not find any clinical trials which evaluate the effect of LLLT in burned patients except our previous study in which we used LLLT for treating a grade 3 burn ulcer in diabetic patients who were a candidate for amputation.20 Levin et al compared laser debridement and surgical debridement in pigs with 10%-15% body surface area burns. Their results showed that blood loss was significantly reduced in the laser group and the applied autografts to the lased area took better than the surgery group. Then they used this technique on a patient with a symmetrical third-degree burn ulcer. Again, they reported blood loss reduction in the laser debrided side compared with the scalpel excised side, but the healing of the skin graft in both sides was comparable.1 Domankevitz et al used the CO2 laser for debridement of burn ulcers before skin grafting. They reported that this method is useful for cutaneous surgery and debridement of burn wounds before skin grafting.3 Stellar et al used laser debridement for a decubitus ulcer.5 Nilforoushzade et al used TCA along with autologous fibroblast suspension to treat a diabetic foot ulcer7 and the scar of leshmaniasis.24 Cho et al reported that a high concentration of TCA (65%-100%) can stimulate dermal fibroblasts and increase the collagen content.25 ConclusionLaser debridement along with LLLT and TCA administration may be useful to treat necrotic ulcers without surgery.Ethical ConsiderationsAn informed consent was obtained from the patient for publication of this report.Conflict of InterestsThe authors declare no conflict of interest.References1. Levine N, Ger R, Stellar S, Levenson SM. Use of a carbon dioxide laser for the debridement of third degree burns. Ann Surg. 1974;179(2):246-52. doi: 10.1097/00000658-197402000-00024. 2. Graham JS, Schomacker KT, Glatter RD, Briscoe CM, Braue EH, Squibb KS. Efficacy of laser debridement with autologous split-thickness skin grafting in promoting improved healing of deep cutaneous sulfur mustard burns. Burns. 2002;28(8):719-30. doi:10.1016/S0305-4179(02)00198-5.3. Domankevitz Y, Nishioka NS. Effects of a rapidly scanned carbon dioxide laser on porcine dermis. J Burn Care Res. 1997;18(3):206-9. doi.org/10.1097/00004630-199705000-000054. Stellar S. Applications of the Carbon Dioxide Laser to Neurosurgical and other Surgical Problems. In: Fusek I, Kunc Z, editors. Present limits of neurosurgery. Proceedings of the IV European Congress of Neurosurgery Present Limits of Neurosurgery; June 28-July 2, 1971; Prague-Czechoslovakia. Prague: Amsterdam Excerpta Medica;19715. Stellar S, Meijer R, Walia S, Mamoun S. Carbon dioxide laser debridement of decubitus ulcers: followed by immediate rotation flap or skin graft closure. Ann Surg. 1974;179(2):230-7. doi: 10.1097/00000658-197402000-00022. 6. Coleman WP. Dermal peels. Dermatol clin. 2001;19(3):405-11. doi:10.1016/S0733-8635(05)70281-37. Nilforoushzadeh MA, Jaffary F, Siavash M, Ansari N, Siadat AH, Heidari A. Autologous fibroblast suspension for the treatment of refractory diabetic foot ulcer. Indian J Dermatol Venereol Leprol. 2016;82(1):105-6. doi:10.4103/0378-6323.1729058. Kazemi Khoo N, Rahbar MR, Akrami SM. Low-Level Laser Therapy Along With Intravascular Laser in Deep Pressure Ulcer Resistant to Conventional Therapies. J Skin Stem Cell. 2015 ;2(4):e30686. doi:10.17795/jssc30686.   9. Lucas C, Van Gemert M, De Haan R. Efficacy of low-level laser therapy in the management of stage III decubitus ulcers: a prospective, observer-blinded multicentre randomised clinical trial. Lasers Med Sci. 2003;18(2):72-7. doi:10.1007/s10103-003-0259-510. Kazemi Khoo N. Successful treatment of diabetic foot ulcers with low-level laser therapy. Foot. 2006;16(4):184-7. doi:10.1016/j.foot.2006.05.00411. Woodruff LD, Bounkeo JM, Brannon WM, Dawes KS, Barham CD, Waddell DL, et al. The efficacy of laser therapy in wound repair: a meta-analysis of the literature. Photomed Laser Surg. 2004;22(3):241-7. doi:10.1089/154954104143862312. Schindl A, Schindl M, Pernerstorfer-Schön H, Schindl L. Low-intensity laser therapy: a review. J Investig Med. 2000;48(5):312-26.13. Bihari I. The biostimulative effect of low level laser therapy of long-standing crural ulcers using helium neon laser, helium neon plus infrared lasers, and noncoherent light. Laser Ther. 1989;1(2):97-8.14. Almeida‐Lopes L, Rigau J, Amaro Zângaro R, Guidugli‐Neto J, Marques Jaeger MM. Comparison of the low level laser therapy effects on cultured human gingival fibroblasts proliferation using different irradiance and same fluence. Lasers Surg Med. 2001;29(2):179-84. doi:10.1002/lsm.110715. Nilforoushzadeh MA, Jaffary F, Ansari N, Siadat AH, Heidari A, Adibi N. Treatment of recalcitrant diabetic ulcers using trichloroacetic acid. J Res Med Sci. 2012 03;17(5):1-5.16. Al-Watban FA, Zhang XY, Andres BL, Al-Anize A. Visible lasers were better than invisible lasers in accelerating burn healing on diabetic rats. Photomed Laser Surg. 2009;27(2):269-72.doi:10.1089/pho.2008.231017. Kazemi Khoo N, Shokrgozar MA, Kashani IR, Amanzadeh A, Mostafavi E, Sanati H, et al. In vitro therapeutic effects Journal of Lasers in Medical Sciences  Volume 10, Number 4, Autumn 2019 341                                                   Efficacy of CO2 Laser With LLLT in Grade 3 Necrotic Burn Ulcerof low level laser at mRNA level on the release of skin growth factors from fibroblasts in diabetic mice. Avicenna J Med Biotechnol. 2014;6(2):113.18. Khamseh ME, Kazemikho N, Aghili R, Forough B, Lajevardi M, Dabaghian FH, et al. Diabetic distal symmetric polyneuropathy: effect of low-intensity laser therapy. Lasers Med Sci. 2011;26(6):831-5. doi: 10.1007/s10103-011-0977-z.19. Kazemi Khoo N, Iravani A, Arjmand M, Vahabi F, Lajevardi M, Akrami S, et al. A metabolomic study on the effect of intravascular laser blood irradiation on type 2 diabetic patients. Lasers Med Sci. 2013;28(6):1527-32. doi: 10.1007/s10103-012-1247-4. 20. Dahmardehei M, Kazemikhoo N, Vaghardoost R, Mokmeli S, Momeni M, Nilforoushzadeh MA, et al. Effects of low level laser therapy on the prognosis of split-thickness skin graft in type 3 burn of diabetic patients: a case series. Lasers Med Sci. 2016;31(3):497-502. doi: 10.1007/s10103-016-1896-921. Vaghardoost R, Momeni M, Kazemikhoo N, Mokmeli S, Dahmardehei M, Ansari F, et al. Effect of low-level laser therapy on the healing process of donor site in patients with grade 3 burn ulcer after skin graft surgery (a randomized clinical trial). Lasers Med Sci. 2018 Apr;33(3):603-7. doi: 10.1007/s10103-017-2430-4.22. Mokmeli S, Khazemikho N, Niromanesh S, Vatankhah Z. The application of low-level laser therapy after cesarean section does not compromise blood prolactin levels and lactation status. Photomed Laser Surg. 2009 Jun;27(3):509-12. doi: 10.1089/pho.2008.2314.23. Enwemeka CS, Parker JC, Dowdy DS, Harkness EE, Harkness LE, Woodruff LD. The efficacy of low-power lasers in tissue repair and pain control: a meta-analysis study. Photomedicine and Laser Therapy. Photomed Laser Surg. 2004;22(4):323-9. doi:10.1089/pho.2004.22.32324. Nilfroushzadeh M, Jaffary F, Reiszadeh M. Comparative effect of topical trichloroacetic acid and intralesional meglumine antimoniate in the treatment of acute cutaneous leishmaniasis. Int J Pharmacol. 2006;2(6):633-6. doi:10.3923/ijp.2006.633.63625. Cho SB, Park CO, Chung WG, Lee KH, Lee JB, Chung KY. Histometric and histochemical analysis of the effect of trichloroacetic acid concentration in the chemical reconstruction of skin scars method. Dermatol Surg. 2006 ;32(10):1231-6. doi:10.1111/j.1524-4725.2006.32281.x

Efficacy of Carbone Dioxide laser Debridement along with Low level laser Therapy in Treatment of Grade 3 Necrotic Burn Ulcer in a Paraplegic Patient (A Case Report)

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Efficacy of Carbone Dioxide laser Debridement along with Low level laser Therapy in Treatment of Grade 3 Necrotic Burn Ulcer in a Paraplegic Patient (A Case Report)

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