Dermatology Online Journal

595 nm long pulsed dye laser with a hydrocolloid dressing for the treatment of hypergranulation tissue on the scalp in postsurgical defects
Megan N Moody MD MPH¹, Jennifer M Landau BS¹, Leonard H Goldberg MD^{1, 2, 3}, Denise Marquez PA-C¹, Irene J Vergilis-Kalner MD^{1, 2}
Dermatology Online Journal 17 (7): 2

1. DermSurgery Associates, Houston, Texas
2. Departments of Dermatology, Weill Cornell Medical College, Methodist Hospital, Houston, Texas
3. Departments of Dermatology, University of Texas at Houston, Houston, Texas

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Abstract

The formation of hypergranulation tissue is an aberrant process that interferes with normal wound healing. Excessive granulation tissue results in the persistence of open wounds. It is resistant to currently available treatment modalities. We report a case series of patients with hypergranulation tissue on the scalp who were successfully treated with a 595 nm pulsed dye laser and hydrocolloid dressing.

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Introduction

We previously reported the use of the 595 nm pulsed dye laser (PDL) in conjunction with a topical corticosteroid, fluocinonide 0.05 percent, for treatment of excessive granulation tissue in non-healing postsurgical defects of 9 patients [1]. Herein we report an additional four cases of hypergranulation tissue of the scalp, which were successfully treated using the 595 nm long pulsed dye laser and a hydrocolloid dressing, without the aid of topical corticosteroids.

Case 1

An 82-year-old male presented with atypical melanocytic hyperplasia on the left scalp. Following excision with Mohs micrographic surgery (MMS), the resultant 6.5 cm x 5.0 cm defect was allowed to granulate and epithelialize. At the 2-month post-operative visit, a patch of 1.5 cm x 1.4 cm of hypergranulation tissue was observed in the non-healing defect site. After two failed attempts using trichloroacetic acid (TCA) 35 percent, we instructed the patient to use a hydrocolloid dressing (DuoDERM®, ConvaTec, Skillman, NJ).

After another month, the wound had still not healed, so we began a series of 7 treatments with the 595 nm long pulsed dye laser (Vbeam® Perfecta, Candela; Wayland, MA) at 7-9 day intervals. A topical anesthetic cream (BLT) (benzocaine 10%, lidocaine 6%, tetracaine 4%, New England Compounding Center; Framingham, MA) was first applied to the area for thirty minutes under occlusion. Laser settings included a spot size of 7 mm, pulse width of 1.5 mm, and energy fluences of 9.0-10.0 J/cm² for 2-3 passes (endpoint was visible purpura in treated area) and 25-53 pulses, with the dynamic cooling device (DCD) set at 30 ms spray and 30 ms delay. The patient continued to use the hydrocolloid dressing. Ten days after the final laser treatment, the patient returned with complete resolution of his hypergranulation tissue.

Case 2

An 87-year-old man presented with a 3.5 cm x 2.1 cm area of hypergranulation tissue on the frontal scalp. He had a history of cryotherapy with liquid nitrogen and field aminolevulinic acid photodynamic therapy. The patient was treated unsuccessfully with TCA 35 percent three times.

We began a series of five 595 nm pulsed dye laser treatments at 7-8 day intervals. After 30 minutes of BLT application under occlusion, the laser was utilized at settings including a spot size of 7 mm, a pulse width of 1.5 mm, energy fluences of 9.0-10.0 J/cm² for 2 passes (endpoint was visible purpura in treated area) and a total of 20-40 pulses, with DCD at 30 ms spray and 30 ms delay. The patient used a hydrocolloid dressing in conjunction with the laser treatments. One week after the final treatment, the patient returned; complete resolution of the hypergranulation tissue was achieved.

Case 3

Figure 1a	Figure 1b
Figure 1a. Case 3: Non-healing wounds on the scalp on the location of a split thickness skin graft, which was placed after Mohs Micrographic Surgery. Figure 1b. Case 3: 10 days after the last laser treatment

A 70-year-old woman presented with 3 non-healing wounds on the scalp: 2.5 cm x 1.5 cm on the anterior scalp, 3.0 cm x 2.5 cm on the mid-scalp, and 2.5 cm x 1.0 cm on the posterior scalp. The patient had a history of MMS in the area with placement of a split thickness skin graft for repair of a 4.9 cm x 3.5 cm defect. Multiple discrete areas of hypergranulation tissue were present (Figure 1a).

We began a series of 4 treatments with the 595 nm long pulsed dye laser at 7-8 day intervals. After 30 minutes of BLT application under occlusion, the laser was utilized at settings including a spot size of 7 mm, a pulse width of 1.5 mm, and energy fluences of 9.0-10.0 J/cm² for 2 passes (endpoint was visible purpura in treated area) and 44-90 pulses, with DCD at 30 ms spray and 30 ms delay. The patient was instructed to use a hydrocolloid dressing in conjunction with the laser treatments. One week after the final laser treatment, the patient returned and exhibited resolution of the hypergranulation tissue (Figure 1b).

Case 4

A 79-year-old man presented with a non-healing wound on his mid-scalp following MMS to remove a malignant melanoma (Figure 2a). The 6.5 cm x 5.0 cm surgical wound was originally closed with an intermediate linear repair. Hypergranulation tissue, 3.4 cm x 1.8 cm, was observed in the non-healing area that corresponded to the center of the linear repair. For 3 months we attempted to treat the area with TCA 35 percent, but observed no response.

Figure 2a	Figure 2b
Figure 2a. Case 4: Hypergranulation tissue, which developed at the site of an intermediate linear repair following Mohs micrographic surgery. Figure 2b. Case 4: 10 days after the last laser treatment.

We then began a series of 5 treatments with the 595 nm pulsed dye laser at 7-8 day intervals. After 30 minutes of BLT application under occlusion, the laser was utilized at settings including a spot size of 7 mm and pulse width of 1.5 mm; the laser was set to energy fluences of 9.0-10.0 J/cm² for 2 passes (endpoint was visible purpura in treated area) and a total of 17-39 pulses, with DCD at 30 ms spray and 30 ms delay. The patient used a hydrocolloid dressing in conjunction with the laser treatments. Ten days after the final treatment, the patient returned and showed complete resolution of the hypergranulation tissue (Figure 2b).

Discussion

Hypergranulation tissue can be defined as excessive granulation tissue within a wound that hinders the normal healing process by preventing re-epithelialization and wound contraction [2]. Clinically, it appears as pink to reddish exophytic, fragile tissue that spills over the edges of the wound; it tends to bleed freely with the slightest trauma. Pathologically, it is an aberrant development during wound healing, impeding the normal healing process and contributing to persistent wounds that often remain resistant to treatment. Hypergranulation tissue commonly complicates gastrostomy tube sites [3] and has also been reported to be a common problem in wounds on the lower extremities of horses [2]. However, it is not frequently reported in the human population.

Not only does hypergranulation tissue interfere with the wound healing process by causing the wound to arrest in the granulation tissue phase, but it also causes an increased risk for subsequent infection [2]. It is highly resistant to available treatment modalities. The most frequently used treatment is chemical cautery with silver nitrate sticks, directly applied to the wound twice daily [3]. Less commonly, copper sulphate has been used [4]. These caustic substances produce fibroblast destruction and a subsequent decrease in the viscosity of ground substance [4]. Limitations to treatment with chemical cautery include pain, discomfort, and rarely, electrolyte abnormalities [4, 5]. Another commonly employed treatment is topical corticosteroids, which inhibit the inflammatory response and essentially allow healing to continue. Some people argue that instead of aiding the healing process, topical corticosteroids actually impede the wound healing process [5]. Although controversial, we previously reported resolution of hypergranulation tissue using both topical corticosteroids and the Vbeam laser [1]. Now we report success with the Vbeam laser and a hydrocolloid dressing, without the use of concomitant corticosteroids. In our series, the patients did require more laser treatments [4, 5, 6, 7] than in our previously reported series [1, 2]. However, the wounds in this series completely healed within 7 to 10 days after the final laser treatment, whereas in the previous series the time to healing was 2-9 weeks. There were no adverse events in either series.

The main pathogenic factor contributing to hypergranulation tissue is enhanced vascularity secondary to excessive angiogenesis without corresponding apoptosis [1, 2]. The hypothesized mechanism of action for the pulsed dye laser is that ablation of wound-associated vessels with laser treatment ultimately promotes healing and halts angiogenesis [1]. The endpoint of each laser treatment was observation of purpura within the treated area. Additionally, hydrocolloid dressings have been shown to keep wounds moist, enabling epithelialization [6]. The dressing also aids autolytic debridement and protects the wound by creating a bacterial and viral barrier [6].

Conclusion

We effectively treated hypergranulation tissue of the scalp in four patients using multiple pulsed dye laser sessions without the use of topical corticosteroids. Instead, we complimented the laser treatments with a hydrocolloid dressing. Ultimately, the successful resolution of all wounds was achieved. Accordingly, we have shown that the effects of the laser alone are enough to treat wounds complicated by hypergranulation tissue without requiring supplementary corticosteroids. A randomized controlled trial is necessary to determine whether this intervention has an advantage over watchful waiting or other treatment modalities.

References

1. Wang, S.Q. and L.H. Goldberg, Pulsed dye laser for the treatment of hypergranulation tissue with chronic ulcer in postsurgical defects. J Drugs Dermatol, 2007. 6(12): p. 1191-4. [PubMed]

2. Engelen, M., et al., Effects of ketanserin on hypergranulation tissue formation, infection, and healing of equine lower limb wounds. Can Vet J, 2004. 45(2): p. 144-9. [PubMed]

3. Borkowski, S., G tube care: managing hypergranulation tissue. Nursing, 2005. 35(8): p. 24. [PubMed]

4. Dunford, C., Hypergranulation tissue. J Wound Care, 1999. 8(10): p. 506-7. [PubMed]

5. Young, T., Common problems in wound care: overgranulation. Br J Nurs, 1995. 4(3): p. 169-70. [PubMed]

6. Nelson, E.A. and M.D. Bradley, Dressings and topical agents for arterial leg ulcers. Cochrane Database Syst Rev, 2007(1): p. CD001836. [PubMed]

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