PracticalDermatology

Grading Acne Scars

It is important to understand the severity of scars, as treatment is directly dependant on such assessment. Grading of scar severity pre- and post-treatment can be assessed objectively using comparisons as in Table 1.2

Ultimately the challenge for providers and patients is that true acne scars never completely fade. However, they visibly improve as time passes and can be concealed.

Acne scars can occur anywhere on the body, although the upper chest and shoulders are especially prone to developing scars. This is due to poorer regeneration capability, due in large part to the lower density of adnexal structures (sebaceous glands, hair follicles).

Unfortunately, hypertrophic or keloid scars (Table 2) tend to reappear even after a good initial result is obtained post treatment. Traditionally, scar revision surgery is employed. Ablative lasers, carbon dioxide, and Erbium Yag lasers are often succesful as an alternative to surgery.

Technologies to Improve Acne Scars

Energy-based devices have shown good efficacy in treating acne scars. The primary laser resurfacing treatments can be divided into the non-ablative and the fractional ablative categories. Ablative lasers may provide the best results in terms of targeting texture and color of scars. Ablative laser resurfacing utilizes electromagnetic waves to erode the entire epidermis and upper layer of dermis. For a time, CO2 ablative laser was the primary modality for the treatment of acne scars. However, it has extensive downtime of two or more weeks. Side effects include redness and swelling, skin dyschromia, scarring, skin infections, and eczematous reactions. Full ablative resurfacing is rarely used today.

Fractional ablative laser treatment addresses both the epidermis and dermis. It delivers hundreds of laser beamlets. The principle is controlled dermal damage in microthermal treatment zones (MTZ) to stimulate fibroblasts to aid collagen remodelling and neocollagenesis. MTZ are selected areas with dermal injury, with adjacent areas spared. The areas with injury would in turn kickstart the process of neocollagenesis, while the adjacent areas maintain cell renewal and healing. In this way, the electromagnetic energy is effective yet safe. The safety profile and speedy recovery associated with these devices are trade-offs for slower results. Patients today want treatments with minimal downtime.

There are three main types of non-ablative modalities: mid-infrared ones, pulsed dye lasers (PDL), and broadband light systems. These devices work well for dyschromia but the textural improvement in scars is minimal.3 PDL can be particularly effective to reduce erythema and texture of a scar. Multiple treatments are needed.

Radio frequency (RF) microneedle devices, an example of which is the Intracel from Korea, have produced significant results. It uses an insulated microneedle that delivers radio frequency energy to the dermis, reducing damage to the epidermis, hence speeding up recovery. In my practice, I use a schedule of four sessions of Intracel, and can achieve results of 60 percent or better improvement in acne scars.

RF microneedling works for both atrophic and hypertrophic scars. The benefit is based on dermal matrix remodelling. Downtime is minimal and less than with fractional lasers. Side effects of post-inflammatory pigmentation on darker skin types is much reduced compared to fractional laser, and the results are comparable.4

More recently, the plasma laser have been used, achieving good results with minimal downtime and epidermal damage. Plasma lasers rely on the fourth state of matter to ionise particles. The laser energy removes oxygen from cells, hence reducing the risk of charring the skin. The heat reaches a sufficiently high temperature to stimulate neocollagenesis to improve scar texture and tone. The safety profile is high, with low risk of hypo- and hyperpigmentation.5

Patient skintype is an important factor in selecting an energy-based device. Skintype can be classified from Fitzpatrick 1-6.6 Darker skin types have a higher risk of post inflammatory hyperpigmentation. Hence, they benefit more from fractional laser compared to traditional full ablative lasers.

Combinations are Key

Energy-based devices alone may not be sufficient to reduce acne scars. Other modalities that may be used include microneedling, high intensity focused ultrasound systems, and platelet rich plasma (PRP) among others.6 (See Dr. Chang’s review of PRP in the November edition of PracticalDermatology, available online at Practicaldermatology.com/2017/11.)

Dermal fillers have emerged as particularly useful to address acne scars. A soft filler like Restylane can be used to fill the depression in atrophic scars, and subcision can be employed to breakdown the fibres that are anchoring the skin down.

In my practice, I commonly combine this approach with RF microneedling or fractional laser, over four sessions. The results are significant. Studies have suggested that the use of platelet rich plasma can speed up recovery from in-office procedures, including energy-based interventions.7

An emerging concept is the use of “Microbotox” to improve the appearance of acne scars.

Conclusion

The major complication of acne is scarring, which results in severe comorbidity for patients. On the bright side, there exist several options to treat acne scarring. Studies support combination treatment to achieve the best results. The safety and efficacy has good evidence, but there is a dearth of split-face trials.8

Fractional laser resurfacing and radio frequency energy devices used alone or with other devices are a foundation of treatment, but combinations of energy-based interventions and other techniques are the norm. Energy-based devices are important for their ability to stimulate new collagen production, with results visible within three months.9,10 Look for increasing evidence for and adoption of plasma lasers.

Microneedling, fillers, PRP, and microbotox will continue to gain prominence in the future for acne scar revision. Dermal fillers11can be used to fill atrophic scars and lift the sunken, depressed skin.

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3. Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: Nonablative, fractional, and ablative laser resurfacing. J Am AcadDermatol2008;58:719-37

4. Cho, S. I., Chung, B. Y., Choi, M. G., Baek, J. H., Cho, H. J., Park, C. W., Lee, C. H. and Kim, H. O. (2012), Evaluation of the Clinical Efficacy of Fractional Radiofrequency Microneedle Treatment in Acne Scars and Large Facial Pores. Dermatologic Surgery, 38: 1017–1024. doi: 10.1111/j.1524-4725.2012.02402

5. Bentkover, Stuart H. “Plasma skin resurfacing: personal experience and long-term results.” Facial plastic surgery clinics of North America 20.2 (2012): 145-162.

6. Tanzi EL, Lupton JR, Alster TS. Lasers in dermatology: four decades of progress. J Am AcadDermatol2003;49:1-31

7. LEE, J. W., KIM, B. J., KIM, M. N. and Mun, S. K. (2011), The Efficacy of Autologous Platelet Rich Plasma Combined with Ablative Carbon Dioxide Fractional Resurfacing for Acne Scars: A Simultaneous Split-Face Trial. Dermatologic Surgery, 37: 931–938. doi: 10.1111/j.1524-4725.2011.01999.x

8. Hession MT, Graber EM. Atrophic acne scarring: a review of treatment options. The Journal of clinical and aesthetic dermatology. 2015;8:50-58.

9. Fabbrocini G, Fardella N, Monfrecola A et al. Acne scarring treatment using skin needling. ClinExpDermatol. 2009 Dec; 34(8):874

10. Rahman Z, Alam M, Dover JS. Fractional Laser Treatment for Pigmentation and Texture Improvement. Skin Therapy Lett. 2006; 11(9): 7-11

11. Goodman GJ, Van Den Broek A. The modified tower vertical filler technique for the treatment of post-acne scarring: The modified tower filler technique. Australasian Journal of Dermatology. 2016;57:19-23.

12. Cohen BE, Brauer JA, Geronemus RG. Acne scarring: A review of available therapeutic lasers. Lasers in Surgery and Medicine. 2016;48:95-115.

13. Rao J. Treatment of acne scarring. Facial plastic surgery clinics of North America. 2011;19:275.

14. Rose AE. Therapeutic update on acne scarring. Journal of drugs in dermatology : JDD. 2014;13:651.

15. Goodman GJ. Treatment of acne scarring. International Journal of Dermatology. 2011;50:1179-1194.

16. Rahman Z, Alam M, Dover JS. Fractional Laser Treatment for Pigmentation and Texture Improvement. Skin Therapy Lett. 2006; 11(9): 7-11

17. Fraxel® Laser Treatment Reliant Technologies, Inc.

18. Carniol PJ, Hamilton MM, Carniol ET. Current Status of Fractional Laser Resurfacing. JAMA Facial Plast Surg. 2015 Jul 2. doi: 10.1001/jamafacial.2015.0693. [Epub ahead of print] PubMed PMID: 26133312.