Medical Laser Application 26 (2011) 10–15

www.elsevier.de/mla

Treatment of keloids and hypertrophic scars with the triple-mode Er:YAG

laser: A pilot study
Justinus A. Wagner, Uwe Paasch, Marc O. Bodendorf, Jan C. Simon, Sonja Grunewald∗
Department of Dermatology, Venerology and Allergology, University of Leipzig, Philipp-Rosenthal-Str. 23, 04103 Leipzig, Germany

Received 13 August 2010; accepted 28 October 2010

Abstract
Introduction: Hypertrophic scars and keloid formation are common problems which are not only the result of surgical
procedures. Many treatment protocols exist without standardization. The aim of our study was to compare various treatment
protocols using a 2940 nm Er:YAG laser with and without additional silicone gel application.
Patients and methods: Twenty-one patients suffering from keloids or hypertrophic scars were treated in four groups with
the Burane XL Er:YAG laser (Quantel Derma GmbH; Erlangen, Germany) either in thermal or combined thermoablative mode
with or without additional silicone gel application under non-blinded conditions. The appearance of the scars (redness, hardness
and elevation) before therapy, and 12 months after therapy was evaluated by therapists based on a scaling system from 0 to 3
(0 = minimum, 3 = maximum).
Results: The patient group was made up of 21 people, 16 females and five males, ranging in age from 16 to 79 years. All
patients had a mean reduction of redness, hardness and scar elevation by 51.3% (p = 0.0012), 48.9% (p = 0.0015) and 50.0%
(p = 0.0015), respectively. There was no significant difference between groups with or without additional silicone gel application
(p > 0.05).
Conclusion: Our pilot study proved the effectiveness of Er:YAG laser treatments (thermal and combined thermoablative
mode) for the reduction of hypertrophic scars and keloids. However, the additional application of silicone gel was not as effective
as postulated. Larger randomized double-blinded studies are needed to further evaluate treatment protocols for hypertrophic
scars and keloids.
© 2010 Published by Elsevier GmbH.

Keywords: Keloid; Hypertrophic scar; Er:YAG; Laser; Silicone gel sheeting

Introduction repair with scarring [2]. Hypertrophic scars are confined to

Pathological hypertrophic scars and keloid formation have
a considerable effect on the functional and esthetic results of
wound healing after accidents and surgical interventions. The
underlying pathology of this complication is still unknown
[1]. Generally, wound healing of the skin results in defect
∗ Corresponding author. Tel.: +49 341 9718650; fax: +49 341 9718619.
E-mail address: sonja.grunewald@medizin.uni-leipzig.de
(S. Grunewald).
1615-1615/$ – see front matter © 2010 Published by Elsevier GmbH.
doi:10.1016/j.mla.2010.10.001
the original wound site, whereas keloids are characterized by
an overgrowth of scar tissue exceeding the borders of the orig-
inal wound area [3]. Several treatment modalities, such as top-
ical silicone gel sheeting, intralesional injections of various
agents (e.g. corticosteroids, ␣ or ␥ interferon, 5-fluorouracil),
positive pressure dressings, cryotherapy, surgical removal,
and laser therapy are in use but are not all completely suc-
cessful [4–6]. Our experience revealed that a combination of
these therapies may be the key to an effective outcome.
Scar laser treatments were first published in the 1980s
with the continuous wave carbon dioxide (CO2 ), argon
 J.A. Wagner et al. / Medical Laser Application 26 (2011) 10–15
and neodymium-doped yttrium aluminum garnet (Nd:YAG)
laser. These therapies led to a recurrence or a worsen-
ing of the scarring. In the 1990s, high-energy pulsed CO2
and erbium:YAG (Er:YAG) lasers improved the therapeutic
options by causing less side effects with a wide range of indi-
cations [7,8]. The short-pulsed Er:YAG laser was designed as
a less aggressive alternative to CO2 lasers. The Er:YAG laser
emits a wavelength of 2940 nm. This wavelength relates to the
peak absorption coefficient of water and is absorbed 12–18
times more efficiently by cutaneous tissue than the CO2 laser
(10,600 nm) [9]. With a pulse duration of 250 ␮s, the short-
pulsed Er:YAG laser removes 10–20 ␮m of tissue per pass at
a fluence of 5 J/cm2 , resulting in a residual zone of thermal
injury not exceeding 15 ␮m [10,11]. To overcome the limi-
tations of short-pulsed Er:YAG lasers, long-pulsed systems
(so-called “modulated”, “dual-mode” or novel “triple-mode”
Er:YAG lasers) have been developed which combine ablative
and coagulative pulses to produce deeper tissue vaporization,
greater contraction of collagen, and improved hemostasis
[11].
With subablative pulses of up to 500 ␮s, Er:YAG-laser
systems can produce larger zones of residual thermal
injury reaching the dermal compartment of the skin
[12]. Supraphysiologic temperatures induce a heat shock
response (HSR) that results in temporary changes in cellu-
lar metabolism. The result of this HSR is the production of
proteins known as heat shock proteins (HSP). HSP 70 is pro-
duced following laser application and plays an important role
of coordination of growth-factor expression such as trans-
forming growth factor beta (TGF-␤). TGF-␤ is prominent in
the inflammatory response and fibrogenic process [13]. Com-
bined treatment with CO2 and Er:YAG lasers suppresses the
production of TGF-␤1 in keloid-producing fibroblasts [14].
Nd:YAG-laser radiation decreases collagen production with-
out affecting cell proliferation [15]. The thermal modus of
Er:YAG laser systems induce collagen neogenesis and der-
mal collagen formation by thermal injury. Histologically,
these new collagens replace the elastotic collagen of con-
nective tissues, leading to a decrease in the clumping of
collagen bundles and an increase of thin collagen fibers
with regular orientation in the upper dermis. A rise of pro-
collagen expression in dermal fibroblasts to a depth of about
320 ␮m is found by immunohistochemistry [16]. Despite
these findings, the complete mechanism is not yet fully
understood.
Silicone-based products are widely used in the treatment of
hypertrophic scars and keloids; this management is described
in numerous evidence-based publications as being effec-
tive for the prevention and treatment of hypertrophic scars
[6,17–21].
The present study was a clinical pilot trial with four groups
of patients (n = 21) with keloids and hypertrophic scars who
received treatments with Er:YAG laser (thermal mode versus
combined thermoablative mode), with or without additional
silicone sheeting. The purpose of this clinical study was to
evaluate the efficacy of these treatment variations.
11
Materials and methods
Patients
Twenty-one patients with keloids and hypertrophic scars
were treated with a 2940 nm Er:YAG laser (Burane XL;
Quantel Derma GmbH, Erlangen, Germany) and silicone
gel sheeting (Dermatix, now sold as Kelo-cote® ; ABT
Deutschland GmbH, Arnsberg, Germany) under non-blinded
conditions after informed consent. The patient group was
made up of 16 females and 5 males, ranging in age from
16 to 79 years old. All scars had existed more than one year;
there had been no previous laser treatment. The scars were
located at different locations on the face and body.
The patient pool was split into four treatment groups as
follows.
• Group #1: thermal mode without silicone gel application
• Group #2: thermal mode with silicone gel application once
daily
• Group #3: combined thermoablative mode without silicone
gel application
• Group #4: combined thermoablative mode with silicone
gel application once daily
Patients were allocated to the four groups in the order that
they appeared in our outpatient department.
Laser
The used Burane XL laser is a so-called “triple-mode”
Er:YAG laser which can be operated in an (1) ablative, (2)
thermal or (3) combined thermoablative mode. The Er:YAG
laser with 2940 nm achieves the highest absorption in water.
Consequently, the laser energy causes immediate vaporiza-
tion of the tissue water in the upper skin layers and therefore
ablates thin layers. The thermal load on the tissue beneath
this layer is very low, leading to the term “cold ablation”
(ablative mode). When the triple-mode Er:YAG laser is run
in the thermal mode, a sequence of subablative pulses brings
thermal energy to the skin allowing thermal stimulation of
the dermis. The “combination mode” is characterized by a
cold superficial ablation followed by subablative pulses.
Procedure
All patients were treated with a 5-mm spot using a 30%
overlap technique. Every patient received about six laser
sessions with a four-week interval. The following thermal
energy fluences were chosen: 3.0 J/cm2 (first treatment ses-
sion), 3.3 J/cm2 (second treatment session), 3.5 J/cm2 (third
treatment session), 4.0 J/cm2 (fourth, fifth and sixth treatment
session). For patients treated with the combined mode, addi-
tional ablative energy was chosen at 1.0–3.0 J/cm2 depending
on the thickness of the scar.
12 J.A. Wagner et al. / Medical Laser Application 26 (2011) 10–15

Table 1. Definition of scar scoring for the parameters of redness, elevation compared to groups #2 and #4 (Table 3). However,
hardness and elevation. in all four groups a reduction in redness, scar elevation and
hardness was achieved (Table 3).
Parameter Score
During the treatment most patients felt a slight pain
0 1 2 3 with the erbium laser. Common post-treatment side effects
included redness, turgor and scabs. We did not observe any
Redness None Rose Red Intense red
severe side effects.
Elevation (mm) 0 1–4 4–8 >8
Hardness Soft Slightly hard Hard Very hard

The silicone gel was applied once daily by the patients in
groups #2 and #4. The application started eight weeks before
laser sessions and was performed until the end of the study.
The appearance of the scars (redness, hardness and eleva-
tion) before and 12 months after the therapy was evaluated
by therapists based on a scaling system from 0 to 3
(0 = minimum, 3 = maximum) according to the Vancouver
Scar Scale (VSS) [22]. The detailed scar score is explained
in Table 1.
Statistics
The Wilcoxon test for dependent samples was used to cal-
culate the difference between the scar scores of all patients
before and after the laser treatment. All tests were 2-tailed,
and significance was indicated by p < 0.05. The statistical
analysis was performed using Statistica 6.0 software (Stat-
Soft; Tulsa, United States).
Results
All 21 patients completed the study. No worsening of the
scars was observed within any of the study groups. Table 2
gives an overview of the scar reduction using the 2940 nm
Er:YAG laser in thermal or combined thermoablative mode.
Overall significant reduction of redness (−51.3%, p < 0.01),
hardness (−48.9%, p < 0.01) and scar elevation (−50.0%,
p < 0.01) was found, indicating effective treatment of the scars
(Fig. 1).
Although the patients were randomly divided into four
treatment groups, due to the limited number of patients the
initial values of the four groups varied. The scars in groups #1
and #3 tended to have lower levels of hardness, redness and
Discussion
The Er:YAG laser with a wavelength of 2940 nm is optimal
because of its peak absorption coefficient of water. Enhance-
ment with long-pulsed, subablative laser systems allows the
therapist to release coagulative pulses for deeper reactions
such as thermal tissue irritation. The thermal mode has an
interesting mechanism besides the ablation mode. Whereas
the short-pulse mode vaporizes the upper layer of the water
intense cutis with immediate effect, the thermal mode mod-
ulates the deeper layers of skin by transferring energy in the
form of heat.
The intention of this pilot study was to select the best treat-
ment protocol using a 2940 nm Er:YAG laser in thermal or
combined thermoablative mode, with or without additional
silicone gel therapy.
Generally, the study showed a reduction in the redness,
hardness and elevation of the treated scars in all groups
(Table 2). Such an improvement is in full agreement with
previous studies using the 2940 nm Er:YAG laser in thermal
mode [23].
However, there were no significant differences in the scar
reduction between the thermal and the combined thermoabla-
tive mode of the Er:YAG laser. The ablative modus vaporizes
the epidermis at a depth of about 10–20 ␮m per pass [9].
This additional superficial ablation did not result in measur-
able scar reduction after six treatment sessions. One can only
speculate on the effect of a complete ablation. Earlier inves-
tigations proved that simple ablation of hypertrophic scars
and resurfacing of depressed scars using only ablative pulses
of an Er:YAG laser led to an improvement of 75% of hyper-
trophic and 85% of depressed scars [24]. However, several
authors observed wound healing problems following abla-
tion of hypertrophic scars [24,25]. In our study a complete
ablation was not investigated to avoid such prolonged wound
healing and any worsening, particularly of the keloidal scars.

Table 2. Overview of scar reduction in all patient groups.

Parameter n Scar score Reduction by

Before laser therapy (mean ± SD) After laser therapy (mean ± SD) Difference Δ (%)

Redness 21 1.86 ± 0.19 0.90 ± 0.19a 0.95 51.3

Elevation 21 1.52 ± 0.18 0.76 ± 0.17a 0.76 50.0
Hardness 20b 1.86 ± 0.17 0.95 ± 0.18a 0.91 48.9
a p < 0.01.
b Hardness could not be evaluated for one patient.
 J.A. Wagner et al. / Medical Laser Application 26 (2011) 10–15 13

Fig. 1. (a) Keloid of an 18-year-old male patient before treatment. The keloid resulted from minor surgery five years ago; it was treated
previously with cryotherapy and intralesional injections of corticosteroids without success. After two years without therapy, the patient was
affiliated to study group #4. (b) The same patient after six sessions of combined thermoablative Er:YAG laser therapy. The patient also applied
the silicone gel once daily.

Table 3. Detailed results of scar reduction in the various patient groups.

Parameter n Scar score Reduction by

Before laser therapy (mean ± SD) After laser therapy (mean ± SD) Difference Δ (%)

Group #1: thermal mode without silicone gel application

Redness 5 1.60 ± 0.24 0.40 ± 0.24 1.20 75.0
Elevation 5 1.20 ± 0.20 0.20 ± 0.20 1.00 83.3
Hardness 5 1.60 ± 0.24 0.60 ± 0.24 1.00 62.5
Group #2: thermal mode with silicone gel application once daily
Redness 3 2.33 ± 0.33 1.33 ± 0.67 1.00 42.9
Elevation 3 1.67 ± 0.33 1.00 ± 0.58 0.67 40.0
Hardness 3 2.33 ± 0.33 1.33 ± 0.67 1.00 42.9
Group #3: combined thermoablative mode without silicone gel application
Redness 5 1.40 ± 0.60 0.40 ± 0.24 1.00 71.4
Elevation 5 1.40 ± 0.51 0.60 ± 0.24 0.80 57.1
Hardness 4a 1.80 ± 0.37 1.25 ± 0.63 0.55 30.6
Group #4: combined thermoablative mode with silicone gel application once daily
Redness 8 2.13 ± 0.23 1.38 ± 0.32 0.75 35.3
Elevation 8 1.75 ± 0.31 1.13 ± 0.30 0.63 35.7
Hardness 8 1.88 ± 0.35 0.88 ± 0.23 1.00 53.3
a Hardness could not be evaluated for one patient.

Moreover, the daily application of silicone gel did not
appear to further improve the effect of laser scar therapy.
Silicone gels and sheeting have been used successfully for
more than 20 years in the treatment of scars and various
publications have presented benefits using silicone products
[6,17–21]. In the present study no group was treated with
silicone gel alone, so perhaps the combination with a laser
treatment, as was the case in our study, may have covered
up the positive effects of silicone gel application on scars.
Another survey has reported controversial findings stating
that using silicone was ineffective and that the scars worsened
after treatment [26]. Nevertheless, the exact mode of action
of this therapy has not been completely determined. It is sug-
gested that the effect derives from occlusion and hydration of
the stratum corneum with subsequent cytokine-mediated sig-
naling from keratinocytes to dermal fibroblasts [27]. The skin
surface temperature with silicone therapy of hypertrophic
burn scars increases up to 1.7 ◦ C [28]. The increasing tem-
perature significantly improves the activity of collagenase
leading to reduced scarring [29]. Our pilot study could not
demonstrate a significant difference between the groups with
or without additional silicone gel application. This may have
been due to the difference in the severity of the scars in the
various groups.
The sample size will need to be increased in order to
improve the significance of the results of study. As every
scar is unique both in this study and every other study, it can
be said that the representative scars in the four groups were
14 J.A. Wagner et al. / Medical Laser Application 26 (2011) 10–15
individual in their redness, hardness and elevation. Perhaps
the most interesting mechanism of reduction of scarring is
the thermal assumption, both for the silicone sheeting and
for the thermal mode using the Er:YAG lasers.
Conclusion
In conclusion, the treatment of scars with Er:YAG laser,
in the combined thermoablative mode and especially in the
thermal mode, significantly reduces hardness, redness and
elevation of hypertrophic scars and keloids. The addition
of silicone sheets was not as effective as postulated. Fur-
ther studies are needed to establish the efficacy of diverse
treatment variations.
Zusammenfassung
Behandlung von Keloiden und hypertrophen Narben
mittels “Triple-Mode” Er:YAG-Laser: Eine Pilotstudie
Einleitung: Hypertrophe Narben und Keloide sind nicht
nur nach chirurgischen Eingriffen ein häufiges Problem. Es
existieren zahlreiche Behandlungsoptionen, jedoch fehlt eine
Standardisierung. Ziel dieser Studie war es, die Effektivität
verschiedener Behandlungsprotokolle eines “Triple-Mode”
Er:YAG-Lasers mit oder ohne begleitende Silikongel-
Anwendung zur Narbenreduktion zu evaluieren.
Patienten und Methoden: 21 Patienten (16 weiblich, 5
männlich) mit Keloiden bzw. hypertrophen Narben nah-
men an der unverblindeten Studie teil. Je ein Viertel des
Patientenkollektives wurde thermisch bzw. kombiniert ther-
moablativ sowie mit bzw. ohne supportive Anwendung
eines Silikongels behandelt. Die Behandlungen erfolgten mit
einem 2940 nm Er:YAG-Laser (Burane XL, Quantel Derma
GmbH; Erlangen, Germany).
Ergebnisse: Alle Patienten (Altersspanne: 16–79) zeigten
nach der Behandlung eine Reduktion der Rötung, der
Härte bzw. der Narbenhöhe von 51,3% (p = 0,0012),
48,9% (p = 0,0015) und 50,0% (p = 0,0015). Ein Vergleich
der Gruppen mit und ohne Silikongel-Applikation zeigte
überraschenderweise keinen zusätzlichen Effekt zur Laser-
therapie (p > 0,05).
Schlussfolgerung: Unsere Pilotstudie konnte die Effektivi-
tät des Er:YAG-Lasers zur Behandlung von hypertrophen
Narben und Keloiden sowohl im thermischen als auch im
kombiniert thermoablativen Modus aufzeigen. Die zusätz-
liche Applikation von Silikongel erbrachte in diesem
Zusammenhang nicht den erwarteten Effekt. Weitere ran-
domisierte und doppelt verblindete Studien sind nötig, um
ein standardisiertes Prozedere zur Behandlung von über-
schießenden Narben zu evaluieren.
Schlüsselwörter: Keloid; Hypertrophe Narbe; Er:YAG; Laser;
Silikongel
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