الفهرس 
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Abstract
Hypertrophic scars and keloids are pathological scars which are problematic in treatment. Many treatment modalities have been described including pressure therapy, surgical revision, laser therapy, silicone garments, and intralesional drug treatments.
The aim of this study was evaluating the efficacy of the combination therapy of fractional carbon dioxide laser with topically applied verapamil hydrochloride or 5-flurouracil (5-FU) in the treatment of hypertrophic scars and keloids.
This was a randomized comparative single blinded prospective study that included 30 patients with HTSs or keloids with no history of treatment 6 months prior to the study. Patients were randomized into three study groups, group I (CO2 laser followed by topical verapamil application), group II (CO2 laser followed by topical 5-flurouracil application), and group III (CO2 laser only).
All patients received a course of four treatment sessions of laser therapy at one-month intervals. Photography, clinical improvement assessment by Vancouver scar scale (VSS), patients′ symptoms and satisfaction assessment by Patient Scar Assessment Scale were done for each patient before and one month after the last session. Skin biopsies were taken from some patients before and one month after the 4th session. The biopsies were assessed histopathologically and by immunohistochemical staining with TGF-β1.
The results of our study were as follow:
Compared to baseline, there was a significant reduction in the VSS one month after the last treatment session in all groups (P <0.05). VSS showed 50% reduction in group I, 58% reduction in group II and 25% reduction in group III.
Pigmentation showed the least improvement while pliability, vascularity and height showed the most significant improvement.
In this study, combined therapy showed more improvement than laser monotherapy in all scar characteristics except for pigmentation which showed very poor improvement in all groups
Laser-assisted 5-flurouracil delivery tended to show a higher extent of improvement in scar characteristics than laser-assisted verapamil hydrochloride delivery without reaching a statistical significance.
In the current study, despite the significant DROP in the VSS in the control group, patients were poorly satisfied (mean patient satisfaction was less than 50%).
In contrary, combined treatment sessions also showed significant improvement in VSS, pain and pruritus and better patient satisfaction (more than 70%) than that achieved with laser monotherapy.
No significant side effects were reported in all patients groups.
In this study, there was no correlation between the improvement in VSS parameters and the age of patients or the size of the scars.
In this study there was a negative correlation between improvement in Vancouver scale parameters and the duration of lesions.
Histopathological examination of skin biopsies after treatment showed thinning in stratum corneum, replacement of the irregular collagen bands with organized new collagen fibrils.
Immunohistochemical staining showed decrease in TGF-β1 expression after laser sessions. These changes were more remarkable after combined treatment protocols than after laser monotherapy.
In conclusion:
• Laser assisted 5-FU or Verapamil hydrochloride delivery offers a safe and cost-effective combination therapy for hypertrophic scars and keloids that significantly outperforms fractional CO2 laser modality alone.
• Laser assisted 5-FU delivery tended to show higher extent of improvement in all scar characteristics than laser assisted verapamil hydrochloride, although the difference is not statistically significant.
• Scars with shorter duration showed better improvement.
• Neither fractional CO2 laser, verapamil hydrochloride nor 5-FU improve pigmentation in hyperpigmented scars.
• TGF-β1 has an important role in pathogenesis of hypertrophic scars and keloids, and is decreased with treatment.