Early pulsed dye laser for erythematous immature scars: Vascular modulation, not anti-angiogenesis

Early erythematous scars are often treated with pulsed dye laser (PDL), but the biological rationale is commonly simplified as reduction of redness. This perspective proposes that early PDL is better conceptualized as controlled vascular modulation after complete epithelialization rather than nonspecific anti-angiogenic therapy. Physiologic angiogenesis is indispensable for oxygen delivery, granulation tissue, re-epithelialization, and matrix repair. In contrast, persistent vascularity in a closed immature scar can maintain inflammatory signaling, fibroblast activation, myofibroblast differentiation, and excess collagen deposition. This distinction is clinically important because indiscriminate suppression of angiogenesis before wound closure may impair healing, whereas conservative nonpurpuric or subpurpuric PDL after closure may reduce excessive vascular-inflammatory activity. The article also discusses why pale or hypopigmented scars should not be interpreted as a simple consequence of vascular regression. Pale scars result from combined changes in vascularity, melanocyte function, adnexal preservation, melanin transfer, collagen architecture, scar width, surface texture, and optical contrast with surrounding skin. A phenotype-based approach is proposed: unstable wounds should be managed with wound care and tension reduction; closed vascular-dominant immature scars may be candidates for conservative PDL; mature collagen-dominant or hypopigmented scars require pigment- and texture-directed strategies. Future studies should integrate objective vascular and pigment imaging with long-term scar quality outcomes.