Tratamento a laser de cicatrizes hipertróficas e queloides: revisão sistemática

• Ano de defesa: 2018
• Autor(a) principal: Leszczynski, Rafael [UNIFESP]
• Tipo de documento: Tese
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Universidade Federal de São Paulo (UNIFESP)
• Palavras-chave em Português: Keloid; Hypertrophic scar; Laser therapy; Systematic review; Queloide; Cicatriz hipertrófica; Terapia a Laser; Revisão sistemática
• Link de acesso: https://sucupira.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=6907107; https://repositorio.unifesp.br/handle/11600/52499

Background: Keloids and hypertrophic scars are common conditions resulting from an abnormal cutaneous healing process that can affect any skin area subjected to trauma or infection, especially regions of higher stretching tension. They appear as firm elevated scars, often with erythematous or hyperchromic coloring. In addition to being unsightly, the scars may present pruritus and pain, in some cases leading to negative physical and psychological impact on patients’ lives. Unlike hypertrophic scars, which remain confined within the boundaries of the original injury, keloid tissue extends beyond the limits the original scar. Despite the many therapeutic alternatives, treatment of these scars still presents challenges, and there is no gold standard therapy. Among proposed treatments, laser therapy is one of the most recent. Objective: To evaluate the effectiveness of laser therapy for treating hypertrophic and keloid scars. Methods: systematic review of randomized clinical trials evaluating the use of lasers for the treatment of hypertrophic and keloid scars. A search of the following electronic databases was conducted up to May 2018: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, EBSCO CINAHL Plus, LILACS, WHO International Clinical Trials Registry Platform eclinicaltrials.gov. A manual search of the list of references from relevant studies and from the annals of conferences was also performed; specialists in the area were contacted to locate studies. Two independent reviewers selected studies, assessed methodological quality, and extracted data considered relevant. Results: Eleven studies met the inclusion criteria and were added to this systematic review, with a total of 466 participants (children and adults of both sexes) and 733 scar segments (analysis units) evaluated. The duration of the studies ranged from 12 weeks to 24 months. The quality of the available evidence was considered low or very low, and the heterogeneity of interventions, control and evaluation parameters made it difficult to perform metaanalyses. The keloid and hypertrophic scar segments treated with a 585nm pulsed dye laser (PDL) showed greater improvement in severity, according to evaluation of nonblinded participants, compared to the untreated segments, (RR 1.95, 95% CI: 1.10 to 3.46, 2 studies, 60 scar segments, P = 0.02, I2 = 0%). The fractional CO2 laser, according to the Vancouver burn scale (VBS), showed an improvement in keloid severity when compared to no treatment (MD 1.90, 95% CI: 3.02 to 0.78, one study, 36 scar segments, P <0.001), however the same did not occur with hypertrophic scars (MD 1.30, 95% CI: 4.32 to 1.71, 2 studies, 104 scar segments, P = 0.40, I2 = 84%). For nonablative fractional lasers, the available studies showed conflicting results, regarding the improvement of the scars, when evaluated by blinded observers and unblinded participants, and it was not possible to prove their superiority over no treatment. There are data supporting that the 585nm PDL and the Erbium laser can have superior results to intralesional trancinolone acetonide (TAC) in the treatment of hypertrophic scars (MD: 2.50, 95% CI: 3.20 to 1, 80, 1 study, 80 participants, 80 scars for PDL versus TAC and MD: 2.10; 95% CI: 2.87, 1.33 1 study, 80 participants, 80 scars for the Erbium laser versus TAC), according to evaluations of blinded observers. Comparing laser plus another treatment versus another treatment (585 nm PDL + TAC + 5fluorouracil versus TAC + 5FU, CO2 laser + TAC versus Cryosurgery + TAC, and 1064nm Nd:YAG laser + betamethasone preparation + 5FU versus betamethasone preparation + 5FU) analysis of available data did not show significant difference in scar improvement, between areas treated or not with laser. The reported side effects in the laser treated areas were erythema, purpura, edema, pain, blisters, erosions and crusts. No permanent sequelae were reported. Conclusion: There is insufficient evidence to support or refute the effictiveness of laser therapy for treating hypertrophic and keloid scars, since the quality of the available evidence is low or very low. Due to the lack of blinding, heterogeneity, small number of studies and the small sample sizes, more trials are needed to determine the effects of lasers in the treatment of hypertrophic and keloid scars.