Acne scars are no longer untreatable

Acne scars are no longer untreatable. Here are the 3 most popular technologies to use!

Acne is a very common and universal problem effecting over 80% of people ages 11-30 and 5-14% of adults at age 30 years and older.

Acne lesions can form on all body areas with high concentrations of pilosebaceous glands but it usually develop on the face, back and chest. The acne lesion life cycle includes a process where micro-comedones transform into closed comedones and then to inflammatory lesions, leading to follicular rupture, follicular abscess formation and stimulation of the wound healing process. This complex cascade may involve post inflammatory erythema (PIE), post inflammatory hyperpigmentation (PIH), and scarring. Acne scarring, a possible outcome of inflammatory acne lesions, may have a negative psychological and social impact.

There are two basic types of scars, depending on whether there is a net loss or gain of collagen. In 80-90% of cases, there is a net destruction of collagen in the dermis leading to the creation of atrophic scars. Less commonly, a net gain of collagen may lead to a creation of keloids or hypertrophic scars. Atrophic scars have been sub-classified according to their depth and diameter into icepick, boxcar and rolling scars. Icepick scars, narrow, deep, v-shaped scars, comprise 60-70% of atrophic scars. Boxcar scars which comprise 20-30% of atrophic scars are wider, with a round to oval depressions and a sharply demarcated vertical edges. Dermal tethering of the dermis to the subcutis characterises rolling scars, which comprise15-25% of atrophic scars. These scars are usually 4-5mm wide and give the skin a rolling appearance. In a lot of cases, all three subtypes appear in the same patient.

Up until the last 5-10 years, treatment results were not satisfactory with the derma-aesthetic systems, so most treatment techniques included only different topicals and peeling solutions. Though chemical peels, when performed properly, may have very satisfying results - it is in most cases not indicated for dark skin types, treat only boxcar scars and my have various contraindications and side effects.

This article will review 3 of the most popular systems technologies prescribed for the treatment of facial acne scarring.

CO2 fractional laser is considered to be one of the best technology choice today for treatment of boxcar and rolling atrophic scars. With its wavelength in the mid-infrared at 10,600 nm, CO2 laser energy is well absorbed in water. As skin contains a very high water percentage, this makes the CO2 laser ideal for precise, safe ablation of the superficial skin layers and promotion of wound healing by amplified production of myofibroblasts and matrix proteins such as hyaluronic acid. In addition to its efficacy in ablating benign raised lesions, the CO2 laser has been reported to be effective in the field of aesthetic dermatology in the revision of acne scars as well as in photo-rejuvenation. The effectiveness of ablative fractional laser (AFL) was first demonstrated by Chapas et al,52 in which 13 patients with acne scarring received 2 or 3 monthly treatments with fractional CO2 resulting in a mean scar depth improvement by topographic analysis of 66.8 percent. Side effects included post-procedure erythema, edema, and petechiae, which resolved by seven days. Since then, different manufacturers are offering new CO2 fractional lasers, most well-known are UltraPulse and AcuPulse by Lumenis, eCO2 by Lutronic, Pixel CO2 by Alma Lasers and Fraxel Re:pair by Solta Medical.

Another popular treatment technology is the use of picosecond pulse duration lasers. the evolution from traditional nanosecond to picosecond lasers has been observed to produce a photomechanical effect that causes fragmentation of a pigment or a scar tissue, and has the possibility to create better clinical results with lower fluencies, hence shorter downtime and fewer adverse events. Various types of pico lasers are used to treat acne scars. most popular are 532 Nd:YAG PicoWay (Syneron Candela), 532nm/755nm/10d4nm PicoSure (Cynosure) and 532nm/1064nm together with Q switched 694nm DISCOVERY PICO (Quanta System). According to multiple studies with this type of technology, 4 to 6 sessions were recommended at 1 month interval between them, treatment were usually well received with up to 3 (out of 10) patients pain assessment and treatment results showed skin texture and acne scars improvement of 25-75%.

Lately, a different approach for acne scars treatment appeared. Microneedling (MN), also known as collagen induction therapy, can be traced back to 1995, when Orentreich and Orentreich developed the concept of “subcision”, or using hypodermic needles to induce wound healing in depressed cutaneous scars. Though initial MN products are mainly the Dermaroller or the Dermapen? (Dermapen, Salt Lake City, UT, USA), there are many new systems that are based on a combination of MN (or other skin perforation method) with another technology or injected materials, such as Lutronic INFINI which combine RF and MN, Alma lasers Legato II, which uses fractional microplasma to perforate the skin and push topical compounds inside, or Lumenis Hybrid Energy?solution that uses an array of ultra-thin electrodes that thermally ablate the outer surface of the skin to reach the deep dermis. these technologies are considered safer on darker skin types, allows for less downtime and enable a better improvement in difficult to treat acne scars. Even though these technologies are considered very safe - they are a medical procedure and they come with possible side effects. depending on the power used, the patient may experience skin redness and swelling for a few days, infection can occur when there is the use of needles and an acne outbreak may occur due to sebaceous glands stimulation.

Each of the above technologies will give a certain amount of improvement, either in the scars depth, color or general skin texture smoothness but combination treatment in a patient-specific way can still offer the best chance of significant improvement. A patient-centereed approach, involving both the technologies mentioned here and the use of additional techniques and materials such as sobcision, CROSS, peelings and fillers will yield the best cosmetic results and highest patient satisfaction.

References:

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G. Fabbrocini, M.C. Annunziata, V. D'Arco, V. De Vita, G. Lodi, M.C. Mauriello, F. Pastore, G. Monfrecola. Acne scars: pathogenesis, classification and treatment. derm research & practice. 2010;893080.

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M. El-Domyati, M. Barakat, S. Awad, W. Medhat, H. El-Fakhany, H. Farag. Microneedling therapy for atrophic acne scars, an objective evaluation. J Clin Aesthet Dermatol. 2015 Jul. 8;7;36-42.

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