Acne scarring is common, occurring in about 40 percent of all patients who have acne. Previous research has suggested that a given acne lesion has about a 5.7 percent risk of developing into a scar. Besides recognizing that acne scars can affect an individual’s self-confidence, there is also evidence that acne scars can affect the perception that others have of an affected individual.
Dreno, et al. conducted a study to assess perceptions of acne scarring.1 Photos of individuals without acne scarring were altered to show scarring. A panel of individuals then looked at either the original photos (no scars) or the enhanced images (with scars). Consistently, reviewers said that the skin was the first feature they noticed in the pictures with scars. But other features—the eyes, the mouth, the nose, the hair—were the first features noticed in the pictures without scars. Furthermore, when reviewers were asked their perceptions of the individuals in the pictures, those with scarring were described as less confident, less happy, less healthy, and even less successful.
Despite promising advancements in both device-based technologies and injectable fillers, acne scars remain challenging to treat, and the consensus is that it is best to reduce the risk of developing scars in the first place. We know that the risk for scarring increases as the severity of acne increases. We also recognize that as the duration from onset of acne to successful treatment increases, the risk for scarring also increases. With these thoughts in mind, the mandate for dermatologists is to implement treatment as early in the disease process as possible and with a course of treatment suited to the level of disease severity.
There are now available some energy-based devices that provide benefit in the management of active acne and may also be used to treat acne scarring. However, very few patients are treated for acne with devices alone. Therefore, topical acne therapy is a component of care for the vast majority of those individuals affected by acne. A new study2 provides important support for the role of early and effective topical acne treatment to reduce the risk for scar formation. Findings also have intriguing implications for our approach to preventing—and managing—acne scars.
The OSCAR Study
The OSCAR Study was a multicenter, randomized, investigator-blinded, vehicle-controlled, intra-individual comparison study (right/left half-face). Eligible subjects had to have 25 or more inflammatory lesions and 10 or more atrophic scars, evenly distributed on the face, at baseline.
For the first 24 weeks of the study, subjects received treatment with Epiduo Forte Gel or vehicle (half-face) and full-face skin care. At 24 weeks, based on satisfactory investigator-assessed efficacy and subject agreement, subjects could be treated with once-daily Epiduo Forte Gel on the full face for up to 24 additional weeks with two additional visits at weeks 36 and 48. Assessments included acne lesions, Investigator Global Assessment (IGA), investigator atrophic acne scar count, Scar Global Assessment (SGA), and safety/tolerability. It should be noted that patients were equipped with iPads that allowed investigators to monitor drug application and ensure that there was no mix-up regarding which product was applied to which side of the face.
Results demonstrated Epiduo Forte Gel significantly decreased acne lesions over a period of 24 weeks compared to vehicle (P < .0001), with acne lesion reduction as early as week one. At week 24, a significantly larger percentage of subjects were rated clear/almost clear on Investigator’s Global Assessment (IGA) with Epiduo Forte Gel treatment (64.2 percent vs. 19.4 percent vehicle, P < .0001).
Of consequence, at week 24, Epiduo Forte Gel also reduced the risk of atrophic acne scars in patients with moderate-to-severe acne. The overall Scar Global Assessment (SGA) also improved by week 24 in the portion of the face treated with Epiduo Forte Gel (32.9 percent clear/almost clear vs. 16.4 percent vehicle, P < .01).
Patient satisfaction with treatment ranked high. Overall, 90.1 percent of subjects said they were satisfied to very satisfied with Epiduo Forte Gel vs. 59 percent with vehicle.
That there were, in fact, no scars forming on the treated side of the face in this cohort substantiates our emphasis on early effective treatment of acne to reduce the risk of scar formation. It is somewhat surprising, however, to note that at the end of the study, there was a 30 percent difference in scars between the treated and the untreated sides of the face; most patients had improvement of or resolution of pre-existing scars.
It seems plausible—though not proven—that improvement in acne scarring may be attributed to the activity of adapalene (at 0.3% concentration in Epiduo Forte gel), which is a retinoid. We have, in fact, been prescribing retinoids as a treatment for acne scarring for some time. As a class, retinoids are shown to reduce inflammation, support collagen remodeling, and affect matrix metalloproteinases. As such, topical retinoids have been shown to help decrease redness associated with scars and to help reduce the appearance of raised scars. The results of this study are especially noteworthy because of the evident improvement in atrophic or depressed scars.
Retinoids may be used in conjunction with energy-based treatments for acne scarring. However, when it comes to procedurally-based interventions like chemical peels, it may be advisable to discontinue topical retinoids for at least a week in advance of the peel. This is something to keep in mind when considering procedures for patients on active acne treatment.
A New Treatment Paradigm
For years, the approach to topical acne management has involved a two-step process: first, improve active acne, then address any evident scarring. Even when we have employed energy-based devices, though they have been shown variously to affect both scarring and active acne lesions, the emphasis has often been on one aspect of the disease or the other.
The potential to make acne better and reduce scars at the same time is a new concept in topical therapy. Prescribers should now consider the potential to not only reduce but potentially improve the appearance of acne scars through the selective use of topical therapies. Topical retinoids are well established as first-line agents in the topical management of acne. Evidence that a topical retinoid such as adapalene may have the added effect of improving scars only adds to the list of potential benefits associated with these agents.
1. Dréno B, Tan J, Kang S, Rueda MJ, Torres Lozada V, Bettoli V, Layton AM. How People with Facial Acne Scars are Perceived in Society: an Online Survey. Dermatol Ther (Heidelb). 2016 Jun;6(2):207-18.
2. Dréno, B., Bissonnette, R., Gagné-Henley, A. et al. Prevention and Reduction of Atrophic Acne Scars with Adapalene 0.3%/Benzoyl Peroxide 2.5% Gel in Subjects with Moderate or Severe Facial Acne: Results of a 6-Month Randomized, Vehicle-Controlled Trial Using Intra-Individual Comparison. Am J Clin Dermatol (2018) 19: 275.