HAND/PERIPHERAL NERVE

Hypertrophic Scars of the Hand: The Role of

Electrophotobiomodulation Theory as a Recent
Line of Treatment
Nader Gomaa Elmelegy, MD

Background: A more enduring strategy for the treatment of hypertrophic scars

Tanta, Egypt of the hand is still a challenge facing restorative dermatologists and plastic sur-
geons. Nonetheless, with the use of nonablative devices, intense pulsed light
and different types of lasers have started to yield promising outcomes and are
close to becoming an effective and dependable technique. The advances in
radiofrequency energy have brought new life to optical-based frameworks.
Radiofrequency current delivers an unadulterated heat effect according to the
electrical response characteristics of each tissue. The purpose of this study was
to assess the patient satisfaction, safety, and clinical efficacy of the use of elec-
trophotobiomodulation (combined intense pulsed light and radiofrequency
energy) in the treatment of postburn hypertrophic scars of the hand.
Methods: This was a prospective clinical study that was performed on 56 patients
who presented with postburn hypertrophic scars on the hands between March
of 2013 and January of 2020.
Results: The clinical appraisal showed excellent results in 33 patients (58.9%),
good results in 18 patients (32.2%), fair results in five patients (8.9%), and no
poor results.
Conclusion: The use of radiofrequency energy combined with intense pulsed
light was effective for the treatment of hand scars on people with various skin
tones.   (Plast. Reconstr. Surg. 151: 375, 2023.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

E
lectrophotobiomodulation is the use of a
combination of intense pulsed light (IPL)
and radiofrequency (RF) to modulate body
tissues so that the body can repair itself, to reduce
inflammation, and to assist in wound healing.1
Hypertrophic scar of the hand is a serious prob-
lem for burn survivors and can result in a wide
range of life-restricting issues. These include psy-
chologic problems, itching, pain, solidness, and
contractures.2 Various strategies and treatment
modalities have been applied for the treatment
of hypertrophic scars of the hand, including sur-
gical excision with or without grafting, pressure
treatment, intralesional interferon, corticoste-
roids or bleomycin, laser treatment, silicone gel
sheeting, onion extract gel, and RF; however, to
date, an ideal treatment strategy has not been
achieved.3
A more enduring technique for the treat-
ment of hypertrophic scars of the hand with con-
vincing results across all skin types is the essential
test today facing restorative dermatologists or
plastic surgeons. However, with the advent of
nonablative devices, such as IPL and various
types of lasers, which have been successfully used
to treat hypertrophic scars, promising results
are set to transform into an ensured trustworthy
procedure.4–6
The advances in RF energy brought new life
to optical-based frameworks, as this energy meth-
odology is not sensitive to the melanin concen-
tration in the epidermis. RF current delivers an

From the Department of Plastic Surgery, Faculty of Medicine,

Tanta University.
Received for publication July 29, 2021; accepted April 18, Disclosure: The author has no financial interest to
2022. declare in relation to the content of this article. No
Copyright © 2022 by the American Society of Plastic Surgeons funding was received for this work.
DOI: 10.1097/PRS.0000000000009962

www.PRSJournal.com 375
 Plastic and Reconstructive Surgery • February 2023
unadulterated heat effect according to the electri-
cal response characteristics of each tissue.7,8 The
purpose of this study was to assess patient satisfac-
tion, safety, and clinical efficacy of the use of elec-
trophotobiomodulation (combined IPL and RF)
for the treatment of postburn hypertrophic scars
of the hand.
PATIENTS AND METHODS
All of the procedures performed in this study
followed the requirements of the institutional
and national research committees and the 1964
Declaration of Helsinki and its later amend-
ments or comparable ethical standards. The rules
and principles of ethical and professional con-
duct were followed in this study. This article was
approved by Tanta University’s ethical committee
(December 14, 2012). This is a prospective clini-
cal study that has been performed on 43 patients
who presented with postburn hypertrophic scars
on the hands (34 patients were one-sided and nine
were bilateral), in the period between March of
2013 and January of 2020. The age of the patients
ranged between 18 and 52 years, with a mean age
of 27 years.
Written consent for performing the punch
biopsy specimen was obtained from all patients.
The punch biopsy specimens were taken from all
patients under completely sterilized conditions
using 10% povidone-iodine and under local infil-
trative anesthesia (2% lidocaine). A sequence of
three punch biopsies (6-mm skin punch) were
performed. The first was taken from the most
prominent area of the hypertrophic scar, before
the treatment. The second was taken from the
same area at week 8 of the treatment. The third
was also taken from the same area at week 12 after
the completion of treatment. All specimens were
stained with hematoxylin and eosin as a routine
histologic examination.
Inclusion Criteria
All patients older than 18 years with postburn
hypertrophic scarring of the hand who presented
to the Burn Casualty Unit of Tanta University
Hospital and the author’s private practice were
included in this study.
Exclusion Criteria
Patients with systemic diseases (eg, diabetes
mellitus, immunity disorders, photosensitivity) or
who had received any other treatment for their
hand scars before the start of our treatment proto-
col were excluded. Written informed consent was
376
signed by each patient in this study, including the
risk of complications, agreement to undergo clini-
cal photography, and the possibility of using their
data in medical publications.
Technique
The E-light machine (Beijing Oriental Wison
Mechanical & Electronic Co. Ltd .; Beijing,
People’s Republic of China) with a handle that
was used in this study contained both IPL and RF.
Special eye goggles were used by the treating doc-
tor and the patients to protect their eyes. EMLA
5% (AstraZeneca, Cambridge, United Kingdom)
anesthetic cream was applied over the affected
hands half an hour before the start of the pro-
cedure. All patients underwent sessions at 2- to
4-week intervals. The author evaluated the hyper-
trophic scar and proposed the number of sessions,
but this could be increased or decreased accord-
ing to the response of treatment. The decision to
stop the treatment was made by both the treating
doctor and the patient according to the response
and satisfaction.
Different filters—530, 560, and 580 nm—
were used according to the skin color to
avoid complications. The IPL fluence varied
between 18 and 25 J, and the RF fluences var-
ied between 5 and 7 J. The spot diameter was
8 × 32 mm. Pulse durations of 2 to 4 msec and
pulse delays of 15 to 30 msec were used for all
patients. Cold compression was applied imme-
diately after each session for 10 minutes; then,
anti-inflammatory cream, which contained pan-
thenol, calendula extract, and triclosan, was
applied until the inflammation subsided. The
sessions were stopped once there was an overt
decrease in scar firmness, redness, and itching,
and a marked improvement in the pigmentary
disorders of the affected area. The number of
sessions for each patient was reported. Patients
were followed up after 2 weeks, 1 month, 3
months, 6 months, and 1 year or more. No
posttreatment advice was given (ie, massage or
local treatment). Aesthetic outcome data were
recorded after at least 6 months.
The photography session during the last
follow-up visit was considered to be the postop-
erative photographic outcome, provided that
it was performed 6 months or more after the
final treatment. The preoperative and postop-
erative photographic outcomes were compared.
Patient satisfaction was assessed according to
the patient-reported outcome measures, which
were specific questionnaires that described the
Volume 151, Number 2 • Treatment of Hand Hypertrophic Scars
patient’s views of satisfaction about the follow-
ing parameters: aesthetic shape, functional
outcome, comments of relatives, lifestyle, and
general satisfaction degree. The collected data
were organized and tabulated. The patients
were asked to rate their degree of satisfaction
on a four-point scale as follows: 4, excellent; 3,
good; 2, fair; and 1, poor. This was used for eval-
uating each parameter. Clinical satisfaction was
assessed by three plastic surgeons not actively
involved in the study. Through a general score
from 1 to 4, the preoperative and last subse-
quent photographs were surveyed and the treat-
ment effect was rated as excellent, good, fair, or
poor.
RESULTS
This study was carried out on 43 patients (34
patients were one-sided and nine were bilateral),
32 men and 11 women. Their age ranged between
18 and 52 years, with a mean of 27 years. The mean
follow-up period was 1 year after the last session.
According to the Fitzpatrick skin type classifica-
tion, four patients were type II, 15 patients were
type III, 19 patients were type IV, and five patients
were type V.
The postprocedure downtime was a few
hours, and the patient could resume normal
daily life thereafter. All adverse effects, such as
erythema and edema, were transient and cleared
completely within a few hours. In all patients,
electrophotobiomodulation using a combina-
tion of IPL and RF was performed. The mean
fluence used for the IPL treatment was 21 J/cm2
(range, 18 to 25 J/cm2), and the mean RF power
was 6 J/cm2 (range, 5 to 7 J/cm2). Different
E-light filters were used according to Fitzpatrick
skin type: 530  nm in seven patients, 580 nm in
23 patients, and 630 nm in 13 patients. The use
of filters helped in the treatment of various skin
types.
According to the modified Vancouver Scar
Scale, there was an improvement of scar hyper-
pigmentation in 92.6%, hypopigmentation in
63.6% (the response was greater in the darker
skin types), and in mixed cases, 78.5%. Also, there
was an affect on scar vascularity in 83.3% to 100%,
scar pliability in 42.8% to 100%, and scar height
in 82.6% to 88.9%. All symptoms such as pain and
pruritus improved from one meeting to the other
until they were completely relieved without the
need for any medication.
The clinical appraisal was performed by three
plastic specialists not actively involved in the
study, using a four-point scale. There were excel-
lent results in 23 patients (53.5%), good results
in 15 patients (34.9%), fair results in five patients
(11.6%), and no poor results.
Patient satisfaction was assessed through
patient-reported outcome measures. A four-point
scale was used. It showed excellent results in 31
patients (72.1%), good results in nine patients
(20.9%), fair results in three patients (7%), and
no poor results.
The histologic evaluation was performed
by the economic division at the pathology aca-
demic department of the faculty of medicine.
The analysis of all histologic samples had shown
that collagen bundles are interlaced and thick
in all dermis, and that there is perivascular cel-
lular infiltration in the pretreatment (RF and
IPL) biopsy specimens. It had also shown that the
collagen bundles become more parallelized and
thinner; there is also end-arteritis obliterans and
perivascular lymphocytic infiltration at week 8 of
the treatment. The last biopsy specimen was taken
at week 12 after completing the treatment, and
it showed that all collagen bundles became more
parallelized to the epidermal surface and thinner,
so there were fewer identified as bundles in the
papillary dermis, and the blood vessels are fewer
(Fig. 1). The results are reported in Tables 1 and
2 and Figures 1 through 5.
DISCUSSION
A variety of modalities have been used for
the treatment of hypertrophic or keloid scars.
Silicone gel sheeting has been widely used in
clinical practice since the early 1980s.9 However,
unsatisfactory patient compliance with the use
of silicone gel sheets, difficulty in application,
persistent pruritus, skin breakdown, skin rash,
the disappointment of the sheet’s inability to
improve the hydration of dry scars, and the vis-
ibility of the treatment for scars situated in vis-
ible regions (eg, the face or the hand) have been
reported as serious limitations.10 In our study,
we were not confronted with such undesirable
side effects, as we did not apply any type of skin
coverage.
Heparin and onion extract affect scar devel-
opment by means of their inhibitory effects on
inflammatory processes, fibroblast proliferation,
and the synthesizing capacity of fibroblasts.11
However, Chanprapaph et al.12 observed that
there was no statistically significant difference in
the scars’ redness, pliability, or overall cosmetic
appearance among patients who used a topical
377
 Plastic and Reconstructive Surgery • February 2023

Fig. 1. (Above, left) Collagen bundles are interlaced and thick in all dermis. There is perivascular cellular infiltration before (RF and
IPL) (hematoxylin and eosin; original magnification, × 100). (Above, right) The collagen bundles become more parallelized and
thinner, at week 8 of treatment (hematoxylin and eosin; original magnification, × 100). (Below, left) There is end-arteritis obliter-
ans and perivascular lymphocytic infiltration at week 8 of the treatment (hematoxylin and eosin; original magnification, × 200).
(Below, right) All collagen bundles are parallelized to the epidermal surface and thinner so that fewer are identified as bundles in
the papillary dermis; there are fewer blood vessels at week 12 after completing the treatment (hematoxylin and eosin; original
magnification, × 100).

preparation containing onion extract, heparin,
and allantoin gel. In our study, marked improve-
ments in redness (84.2% to 100%) and pliability
(33% to 100%) were documented. An overall
improved cosmetic appearance was noticed, and
the level of scar improvement increased with an
increase in the number of sessions.
The use of corticosteroids to treat unusual
scar arrangements has been generally success-
ful for most patients. Koc et al.13 reported that
the response rates to intralesional corticosteroid
injections varied from 50% to 100%, with a recur-
rence rate of 9% to 50%. Nevertheless, up to 63%
of patients experience certain incidental effects,
including skin hypopigmentation, subcutaneous
fat decay, telangiectasias, and ineffectiveness.14
The use of intralesional bleomycin has
been applied to the treatment of keloids and
hypertrophic scars, with promising outcomes.15
Concerning the side effects of intralesional bleo-
mycin, hyperpigmentation and dermal atrophy
can be induced in the sound skin surrounding
the scar.16 The use of interferon-alpha, interferon-
beta, and interferon-gamma increases collagen
lysis. Nonetheless, interferon application is excru-
ciating and is very expensive.17 In contrast, in our
study, we found improvement in hypopigmenta-
tion in 61.5% of our patients. No cases with skin
atrophy, telangiectasia, or rebound were reported
during long-term follow-up.
Surgical removal of hypertrophic scars with
no adjuvant treatment ought to be avoided
because of the extraordinarily high recurrence
rates (45% to 100%). Intramarginal excision of
the hypertrophic scar has a recurrence rate of
100%, whereas extramarginal excision of the
hypertrophic scar has a recurrence rate of 33%.
Thus, adjuvant treatments, including triamcino-
lone injection, radiation therapy, silicone sheet
application, and pressure therapy, have been
proposed to prevent a recurrence. In any case,
none of these therapies have become successful
treatment methods.18–21 In our study, we used
electrophotobiomodulation only, without any

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Volume 151, Number 2 • Treatment of Hand Hypertrophic Scars

Table 1. Descriptive Analytic Data, Using the Modified Vancouver Scar Scale of Different Variabilities in
Pigmentation, Vascularity, Pliability, Height, Fitzpatrick Skin Type, and Filter Type in 52 Affected Hand
Scar Character Score No. of Affected Hands (%) Improvement (%)
Pigmentation 0–2
 Normal 0 — —
 Hypopigmentation 1 11 (21.2) 7 (63.6)
 Hyperpigmentation 2 27 (51.9) 25 (92.6)
 Mixed 3 14 (26.9) 11 (78.5)
Vascularity 0–3
 Normal 0 — —
 Pink 1 17 (32.7) 17 (100)
 Red 2 23 (44.2) 21 (91.3)
 Purple 3 12 (23.1) 10 (83.3)
Pliability 0–5
 Normal 0 — —
 Supple 1 7 (13.5) 7 (100)
 Yielding 2 8 (15.3) 7 (87.5)
 Firm 3 21 (40.4) 19 (90.5)
 Banding 4 9 (17.3) 7 (77.8)
 Contracture 5 7 (13.5) 3 (42.8)
Height 0–3
 Normal (flat) 0 — —
 0–2 mm 1 9 (17.3) 8 (88.9)
 2–5 mm 2 20 (38.5) 17 (85)
 >5 mm 3 23 (44.2) 19 (82.6)
Fitzpatrick skin type
 I 0 (0) 0 (0)
 II 4 (9.3) 4 (100)
 III 15 (34.9) 13 (86.6)
 IV 19 (44.2) 14 (73.6)
 V 5 (11.6) 3 (600)
Filter type
 530 nm 7 (20.9) 7 (100)
 580 nm 23 (62.8) 19 (82.6)
 630 nm 13 (16.3) 8 (61.5)

Table 2. Descriptive Analytic Data of Different decades. Carbon dioxide laser and an argon laser
Variabilities in Age, Sex, Number of Sessions, Clinical have been used for the treatment of hypertrophic
Satisfaction, and Patient Satisfaction in 43 Patients scars but were found to be ineffective, with a high
Variable No. of Patients (%) rate of recurrence. Choi et al.22 studied the clini-
Age cal outcome of 1064-nm picosecond neodymium-
 18–20 years 7 (16.3) doped yttrium aluminum garnet laser for the
 21–30 years 27 (62.8) treatment of hypertrophic scars and reported
 >30 years 9 (20.9)
Sex that patient satisfaction was moderate. Lei et al.23
 Male 32 (74.4) contemplated the clinical adequacy of using ultra
 Female 11 (25.6)
No. of sessions pulse carbon dioxide combined with a fractional
 6 9 (20.9) carbon dioxide laser for the treatment of hyper-
 8 27 (62.8) trophic scars in Asian patients, and they found
 10 7 (16.3)
Clinical satisfaction that the overall satisfaction rate was 92%. No long-
 Excellent 23 (53.5) term complications occurred in their clinical trial.
 Good 15 (34.9)
 Fair 5 (11.6) The most encouraging results have been
 Poor 0 (0) demonstrated with the use of a 585-nm pulsed
Patient satisfaction according to dye laser.24 According to Alster and Handrick,25
PROMs
 Excellent 31 (72.1) two to six treatment sessions are necessary to
 Good 9 (20.9) successfully improve the scar color, height, pli-
 Fair 3 (7) ability, and texture. However, these findings
 Poor —
PROMs, patient-reported outcome measures.
could not be reproduced in several subsequent
studies.26 Longer persisting hyperpigmentation
adjuvant treatment, and we had no recurrence particularly occurs in darker skin types, but
during the long-term follow-up. this is less frequent with the use of wavelengths
Various types of lasers have been evaluated of 595  nm than with 585  nm.27 In our work,
for the treatment of hypertrophic scars in recent there were improvements in scar color, height,

379
 Plastic and Reconstructive Surgery • February 2023

Fig. 2. (Left) A 47-year-old man presented with a postburn hypertrophic scar, hyperpigmentation, and hypopigmentation affect-
ing the right hand (above) and left hand (below). (Right) Images obtained after application of eight sessions of IPL and RF, with
excellent results (6 months from the first session).

pliability, texture, and hyperpigmentation in
all patients with Fitzpatrick skin types II, III, IV,
and V.
Hultman et al.28 reported that the treat-
ment of postburn hypertrophic scars using IPL
provides a minimal improvement, a variable
efficacy, a high cost for patients, and prob-
able recurrence of the hyperpigmentation fol-
lowing ultraviolet light exposure. Dermal RF
has been used as another therapeutic option
for the treatment of hypertrophic scars. The
mechanism of action of this treatment is based
on a slight increase in the skin temperature,
increasing its extensibility, and reducing the
density of collagen; nevertheless, the results
are unsatisfactory.29
Elmelegy et al.1 used a combination of IPL
and RF for the treatment of postburn hypertro-
phic scars of the face in pediatric patients. This
combination permitted the use of lower levels
of IPL energy for treatment, thus diminishing
melanin absorption of light energy, which is the
main cause of complications that occurred with
the use of the IPL alone. These lower energy
prerequisites make E-light (IPL and RF) safer,
and they can be used to treat a more extensive
assortment of patients by being appropriate for
various skin types.
In our study, the use of RF with IPL helped
diminish the IPL force, which guarded against
the unwanted side effects of using the IPL
alone. The clinical assessment showed excellent
results in 33 patients (58.9%), good results in
18 patients (32.2%), fair results in five patients
(8.9%), and no poor results. Patient satisfaction
showed excellent results in 38 patients (67.9%),
good results in 15 patients (26.8%), fair results
in three patients (5.3%), and no poor results.
Hyperpigmentation was improved in 29 patients
(93.6%) and hypopigmentation was improved in
eight patients (61.5%). Improvement was seen
in 19 mixed cases (89.7%).

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Volume 151, Number 2 • Treatment of Hand Hypertrophic Scars

Fig. 3. (Left) A 31-year-old man who presented with a postburn hypertrophic scar, hyperpigmentation, and hypopigmentation
affecting the right hand. (Right) Images obtained after application of six sessions of IPL and RF, with good results (5 months from
the first session).

Fig. 4. (Left) A 19-year-old man who presented with severe postburn hypertrophic scars, and hyperpigmentation, affecting both
the left and right hands. (Right) Images obtained after application of 10 sessions of IPL and RF, with fair results (9 months from the
first session).

381
 Plastic and Reconstructive Surgery • February 2023

ACKNOWLEDGMENTS
The author acknowledges colleagues Amr Magdy,
MD (Ain Shams University), Raafat Anany, MD
(Zagazig University), Tarek Elbanoby, MD (Al-Azhar
University), Ahmed Elshahat, MD (Ain Shams
University), and the nursing staff at Tanta University
Hospital for their help during all steps of this work.

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