Pediatric Scar Management Using Tangential Excision With Intralesional Injections and Laser-Assisted 5-Fluorouracil Delivery

BACKGROUND: Pediatric hypertrophic and keloid scars have traditionally been treated via intralesional steroid injections. The advent of modalities such as 5-fluorouracil (5-FU) and tangential excision present opportunities for improved therapy; however, 5-fluorouracil (5-FU) safety and efficacy in the pediatric population are not well established. The aim of this study is to compare the risk and efficacy of 5-FU in pediatric scar management. METHODS: A multi-institution retrospective study from 2012 to 2023 was designed with identification of 108 patients aged ≤17, undergoing CO2 laser-assisted 5-FU delivery, or tangential excision with immediate or delayed 5-FU/triamcinolone injections. Modified Scar Rating Scale assessed individual scar outcomes comparing the following groups: 5-FU alone versus triamcinolone use; tangential excision with immediate versus delayed injections; and number of injections above/below the median of 4 episodes of injections. Mann-Whitney U test determined significance. Fisher exact test compared complication and recurrence rates. RESULTS: Total scar quality scores improved (P < 0.05) with tangential excision plus <4 injections (n = 44; Δ = -0.581) and tangential excision with 5-FU only (n = 39; Δ = -0.775). Tangential excision with 5-FU alone decreased height (P < 0.05; Δ = -0.5878) compared to tangential excision with triamcinolone use (n = 46). Color match improved (P < 0.05) with tangential excision plus <4 injections (Δ = -0.449) and tangential excision with delayed injections (n = 29; Δ = -0.380).Tangential excision with any 5-FU use (n = 62) had higher complication rates (4.84%) than tangential excision with triamcinolone only (n = 30; 0%) or tangential excision with 5-FU only (n = 37; 5.41%), but complication rates did not significantly differ. CO2 laser-assisted 5-FU (n = 16) complication rates (6.25%) did not significantly differ from tangential excision with 5-FU or triamcinolone. No systemic complications were identified. Recurrence rates between all groups did not differ significantly. CONCLUSIONS: Tangential excision with 5-FU monotherapy demonstrated lower scar height and improved overall scar quality, further solidifying the benefits of 5-FU. CO2 laser-assisted 5-FU delivery had similar complication rates as the other studied modalities. This pediatric study had no systemic complications and overall similar complication rates compared to adult studies. This study demonstrates the utility of 5-FU in pediatric scar therapy and provides data regarding novel approaches to difficult pediatric scar management.