Fractional nonablative 1,540-nm laser resurfacing of atrophic acne scars. A randomized controlled trial with blinded response evaluation

Scar Management in Pediatric Patients

Background and Objectives: Pediatric patients can acquire scars from both accidental injury and surgical procedures. While scars cannot be avoided if a full-thickness injury occurs, scar visibility may be minimized through a variety of approaches. In this narrative review, we evaluate the current evidence and propose an algorithm for scar management in pediatric patients. Materials and Methods: A review of the literature was performed for scar management techniques for pediatric patients. Management modalities based on the type of scar and dosing, treatment regimen, and safety profiles are described in this article and used to create a scar management algorithm. Results: The initial step to scar management in the pediatric population involves ensuring minimal wound tension, which can be achieved through making the incision along relaxed skin tension lines, and early, minimal tension wound closure. Subsequent treatments to optimize scar care should begin 2-3 weeks following wound closure and involve the application of silicone gel or sheets and scar massaging. When topical products are insufficient, laser therapy can be utilized for the management of immature erythematous or thick scars. When mature, pathological scars form such as atrophic scars, hyperpigmentation, hypertrophic scars, or keloids, a combination of modalities is recommended. These modalities vary by scar type and include retinoids and dermabrasion for atrophic scars; retinoids, hydroquinone, and laser therapy for hyperpigmentation; and pressure therapy, corticosteroids, and laser therapy for hypertrophic scars and keloids. When mature, pathological scars persist following 12 months of non-invasive therapies, surgical excision should be considered. Conclusions: Several treatment options are available to manage scars in the pediatric population depending on scar type.

An Assessment of Current Clinician- and Patient-Reported Outcome Measures for Acne Scarring and Dyspigmentation: A Scoping Review

Acne-associated scarring and dyspigmentation (ie, erythema, hyperpigmentation) are common sequelae with significant psychosocial impact, but little is known about what measures are most often used to assess these outcomes. This scoping review evaluates the use of current patient-reported outcome measures (PROMs) and clinician-reported outcome measures (ClinROMs) for acne scars and dyspigmentation. For scars, 7 PROMs and 18 ClinROMs were used, with most being unvalidated. Similarly, for dyspigmentation, 4 PROMs and 8 ClinROMs were identified, but no validated PROMs were identified. These results highlight reliance on unvalidated measures in research and clinical trials and suggest the need for developing high-quality validated measures, particularly PROMs, to improve research quality and develop better treatments.

The 2910-nm Fiber Laser Is Safe and Effective for Improving Acne Scarring

BACKGROUND

Acne scarring results from the inflammation associated with acne papules, which alters dermal collagen, typically producing depressed scars. Lasers have been used to remodel skin improving the texture and appearance of acne scars. Herein, we investigate a new 2910 nm, erbium-doped, fluoride glass, fiber laser for improving acne scars. This novel laser delivers up to 5000 Hz low-energy pulses, providing a unique treatment modality.

METHODS

Fourteen subjects with rolling and/or boxcar acne scars were enrolled in this study. Thirteen subjects completed the final visit and received three treatments with the 2910 nm fiber laser at 6-8-week intervals. Eight subjects were Fitzpatrick type II and five were Fitzpatrick type III. Digital images were taken pre- and 1- and 3-months posttreatment and evaluated by two blinded reviewers in a randomized fashion for improvement. Subjects and the treating physician completed a Global Aesthetic Improvement Scale (GAIS) before treatment and at each visit to subjectively evaluate treatment effect. Histological analysis was performed on ex vivo lower eyelid skin samples. Side effects were evaluated by the treating physician and included erythema, edema, and pinpoint bleeding.

RESULTS

Evaluation of blinded digital images revealed a mean improvement of 47.3% ± 14.2% (mean ± SEM) 3 months following the final treatment. GAIS scores demonstrated improvement as evaluated by both the subjects and the treating physician. Side effects averaged trace-to-mild erythema, edema, and pinpoint bleeding.

CONCLUSION

This study shows that the 2910 nm, erbium-doped, fluoride glass, fiber laser is safe and effective for improving the appearance of acne scars.

Procedural and surgical treatment modalities for acne scarring: Part II

The optimal treatment of acne scarring is challenging because several factors need to be considered, including the type and number of scars, Fitzpatrick skin type, and the amount of downtime permissible to the patient. This second article in the continuing medical education series discusses the procedural treatments available for acne scarring, including the use of chemical peels, fillers, radiofrequency microneedling, lasers, and surgical procedures. The indications for each modality, evidence for its benefits, and the adverse effects are discussed. This section aims to help guide the reader select and implement the most appropriate treatment based on the patient's preferences, acne scarring, and skin type.

Atrophic Postacne Scar Treatment: Narrative Review

Acne scarring is a frequent complication of acne. Scars negatively impact psychosocial and physical well-being. Optimal treatments significantly improve the appearance, quality of life, and self-esteem of people with scarring. A wide range of interventions have been proposed for acne scars. This narrative review aimed to focus on facial atrophic scarring interventions. The management of acne scarring includes various types of resurfacing (chemical peels, lasers, and dermabrasion); the use of injectable fillers; and surgical methods, such as needling, punch excision, punch elevation, or subcision. Since the scarred tissue has impaired regeneration abilities, the future implementation of stem or progenitor regenerative medical techniques is likely to add considerable value. There are limited randomized controlled trials that aimed to determine which treatment options should be considered the gold standard. Combining interventions would likely produce more benefit compared to the implementation of a single method.

Alternating Treatment With Nonablative Fractional Laser and Radiofrequency Microneedling for the Treatment of Acne Scars: A Prospective, Randomized, Split-Face Study

BACKGROUND

Acne scarring is an unfortunate sequela affecting up to 95% of patients with acne and carries profound psychosocial impact. Both nonablative fractional lasers (NAFL) and microneedling with radiofrequency (MNRF) have demonstrated comparable efficacy in the treatment of atrophic acne scars.

OBJECTIVE

To determine whether alternating NAFL and MNRF is superior to NAFL alone in the treatment of atrophic acne scars.

METHODS AND MATERIALS

This was a prospective, single-center, double-blinded, split-face clinical trial. Twenty patients with atrophic acne scars who had their facial halves randomized to receive either NAFL alone or NAFL alternating with MNRF. Patients received 4 total treatments at 4-week intervals.

RESULTS

Ninety days after the final treatment, both facial halves demonstrated a significant improvement in the mean global échelle d'évaluation clinique des cicatrices d'acné (ECCA) score from baseline ( p < .001 for both halves). The average percentage improvement at the final end point was 20% to 30% from baseline. No significant difference was noted between facial halves for mean global ECCA score or percentage improvement at any time point.

CONCLUSION

Although both NAFL and MNRF are safe and effective in the treatment of atrophic acne scars, alternating NAFL and MNRF does not seem to be superior to NAFL alone.

Evidence-based management of cutaneous scarring in dermatology part 2: atrophic acne scarring

Atrophic acne scars are the most common type of acne scars and are classified into three main types: icepick, boxcar, and rolling scars. Various procedures and techniques for atrophic acne scarring are discussed in detail, with stronger evidence-based support for lasers (non-fractional, fractional, ablative, and non-ablative), platelet-rich plasma as adjunctive treatment, chemical peels (glycolic acid, trichloroacetic acid, and Jessner's solution), dermal fillers such as hyaluronic acid, and microneedling, and lesser quality evidence for microdermabrasion, subcision, and lipoaspirate grafting. Further research is needed to optimize treatment protocols, assess the efficacy of monotherapies, and establish standardized guidelines for clinicians. This paper will provide a comprehensive review of the evidence-based management of atrophic acne scars, including currently commonly utilized therapies as well as more innovative treatment options.

Comparative appraisal with meta-analysis of erbium vs. CO2 lasers for atrophic acne scars

Recent advances in laser technology allowed the development of systems that improve texture, appearance and pliability of skin in acne scars (AS). Currently, comprehensive comparative studies on the efficacy of the most commonly used fractional systems in AS are lacking. Thus, the aim of this work was to appraise and compare the clinical response to erbium versus CO₂ lasers in AS in the form of a meta-analysis. The databases MEDLINE, EMBASE, Cochrane library were searched. Main clinical outcomes were investigator-reported scar improvement and participant-reported scar improvement. Five studies were included in this meta-analysis. Scar improvement was similar for both types of laser in terms of investigator-reported scar improvement (RR: 0.60 95 % CI: 0.35-1.02) and participant-reported scar improvement (RR: 0.99 95 % CI: 0.79-1.25). A sensitivity analysis that excluded studies with high risk of bias found the CO₂ lasers to be superior to the erbium lasers (RR: 0.47 95 % CI: 0.24-0.93): However, the subgroup analysis showed the CO₂ laser not to be significantly different from either the non-ablative erbium (RR: 0.65 95 % CI: 0.34-1.24) or the ablative erbium laser (RR: 0.60 95 % CI: 0.35-1.02). The CO₂ laser produced a slightly greater clinical response compared to the erbium lasers based on the physician's assessment. Overall, the two devices do not differ largely in terms of efficacy but may be complementary, with each resurfacing laser better suited for different clinical tasks.

Identifying and appraising patient-reported outcome measures on treatment satisfaction in acne: a systematic review

BACKGROUND

After dermatitis, acne is the next skin disease to contribute most to the burden of skin diseases worldwide. Recently, seven core outcome domains have been identified, which together form an Acne Core Outcome Set (ACORN). One of these was satisfaction with acne treatment.

OBJECTIVES

To identify studies that described the development of patient-reported outcome measures (PROMS), evaluated one or more measurement properties of a PROM, or evaluated the interpretability of a PROM in patients with acne regarding treatment satisfaction.

METHODS

The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) search strategy for identifying PROMS on acne treatment satisfaction was used. We searched PubMed, MEDLINE, Embase, LILACS, Web of Science, Cochrane Library, Emcare, PsycINFO and Academic Search premier (June 2020). Study selection, data extraction and assessment of methodological quality according to COSMIN guidance were carried out independently by two authors.

RESULTS

Only one study could be included, describing the development of a treatment satisfaction measure in patients with acne. The development was assessed as inadequate and data on measurement properties were lacking. Additionally, we found 188 studies reporting treatment satisfaction solely as an outcome, using a wide variety of methods, none of them standardized or validated.

CONCLUSIONS

We could not find a PROM on treatment satisfaction to recommend for a core outcome set in acne. There is an unmet need for a PROM on treatment satisfaction in acne that is robustly developed, designed and validated.

Self-contrast study of pinprick therapy combined with super pulse fractional CO2 laser for the treatment of atrophic acne scars

AIMS

This study is to evaluate the clinical efficacy and safety of a "double-layer" mode of super pulse fractional CO₂ laser and a combined treatment of pinprick therapy with fractional CO₂ laser for the treatment of atrophic acne scars.

METHODS

A split-face and self-contrast method was applied. A total of 20 patients with atrophic acne scars randomly received the above mentioned therapy on the left or right side of the cheek for 3 times with an interval of 3 months. ECCA scores, IVA scores, patients' satisfaction, VAS scores, and adverse reactions were evaluated.

RESULTS

Atrophic acne scars on both sides of the cheek were improved obviously. The ECCA scores showed a significant decrease, while IVA scores significantly increased. Compared with the super pulse fractional CO₂ laser group, the decrease of ECCA scores, the increase of IVA scores, and the patients' satisfaction were significantly higher and improvement on V-shaped and U-shaped acne scars was significantly better in the combined treatment group. No patients had severe adverse reactions such as blister, infection, or hypertrophic scars.

CONCLUSIONS

Super pulse fractional CO₂ laser and pinprick treatment combined with fractional CO₂ laser are both safe and effective therapy for the treatment of atrophic acne scars.

A Prospective Study of Fractionated Dual-Wavelength Picosecond Laser in Treating Acne Scar

BACKGROUND AND OBJECTIVES

The picosecond (PICO) laser has been a new and promising device. But, so far, there have not been many prospective studies investigating the efficacy in acne scar treatment. This study evaluated the efficacy and safety of the dual-wavelength picosecond laser in the treatment of acne scar.

STUDY DESIGN/MATERIALS AND METHODS

A total of 20 patients with skin type III-IV were enrolled in this study. Eighteen patients completed the study. All patients completed six treatment sessions within a 1-month interval. All patients were treated using both 532 and 1,064 nm fractionated dual-wavelength picosecond handpieces. In evaluation, Goodman and Baron's quantitative global acne scarring grading system (GSS) was scored by two physicians. Patients also judged the results themselves by Visual Analog Scale (VAS) and pain score.

RESULTS

The average baseline score of GSS quantity and quality were 15.22 and 3.00, respectively. The final scores were 10.61 and 2.33. The average baseline of patient VAS score was 4.28. The final score was 2.00. All scores achieved statistical significance (P < 0.05). No serious long-term side effects were recorded.

CONCLUSION

Acne scar treatment with the fractionated dual-wavelength picosecond laser has shown both efficacy and safety in this study. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Sequential facial skin rejuvenation with intense pulsed light and non-ablative fractionated laser resurfacing in fitzpatrick skin type II-IV patients: A prospective multicenter analysis

Background

While skin aging is triggered by multiple factors and typically presents with multiple manifestations, conventional treatment regimens deploy a single treatment modality. Typical approaches exploit ablative techniques, which involve considerable patient discomfort and downtime and can induce adverse events. Non‐ablative fractionated laser (NAFL) resurfacing promotes neocollagenesis, with significantly fewer complications and discomfort. At the same time, intense pulsed light (IPL) therapies have a marked impact on skin tone, with an effect on collagen deposition. This study evaluated the combined effect of same‐day, sequential IPL‐NAFL treatment on photoaging of the face.

Design

In this prospective study, 30 patients presenting Fitzpatrick skin types II–IV, elastosis scores 3–6 and mild to moderate pigmentation, underwent three sessions, of full‐face IPL therapy, followed immediately by NAFL treatment, conducted at 4–6 weeks intervals. Wrinkle/elastosis and skin qualities were scored at 1, 3, and 6 months after the last treatment session. Immediate responses were evaluated up to 30 min following treatment and adverse events were monitored throughout the study period.

Results

Wrinkle/elastosis scores gradually improved over the treatment period, with 59% of patients presenting a ≥1‐point improvement in FES scores by the 1‐month follow‐up session, which persisted also at the 6 months follow‐up visit. Good to excellent pigmentation responses were recorded for ≥63% and improvements in texture, brightness, and tightness were recorded for ≥80% of patients throughout the follow‐up period. Over 90% of the treated patients exhibited improved or much improved overall appearance. Patient scorings and satisfaction level reflected physician assessments. Treatments were well tolerated and the social downtime observed was of 1.5 ± 0.25 days.

Conclusion

The same‐day combined IPL‐NAFL regimen proved safe and elicited a significant skin rejuvenating effect, in a similar manner to that shown in other same‐day combined therapies, without prolonging downtime of each individual modality. Lasers Surg. Med. 51:141–149, 2019. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

A systematic review of treatments for acne scarring. Part 2: Energy-based techniques

INTRODUCTION

Acne scarring is a very common problem, which can be extensive, and may lead to significant psychosocial morbidity. Multiple types of treatments are used to ameliorate atrophic scars with varying degrees of success. This paper provides an overview of the various energy-based modalities that are commonly employed against acne scarring.

OBJECTIVES AND METHODS

A comprehensive literature search of papers published since 2008 was performed in order to determine the efficacy and adverse reactions of commonly used energy-based treatments against post-acne scarring.

RESULTS

A total of 59 relevant articles were identified covering a multitude of different devices.

DISCUSSION

Ablative lasers seem to achieve the highest degree of efficacy, albeit this is associated with significant pain and downtime, and the risk for long-term pigmentary changes. Non-ablative fractional photothermolysis (FP) has a much safer profile but cannot achieve as good cosmetic results. The efficacies of fractional radiofrequency microneedling and radiofrequency are slightly inferior to that of FP but offer an even safer adverse profile. Little evidence is available on the remaining devices, with larger studies required in order to reach more solid conclusions.

CONCLUSION

Multiple devices have been used with varying levels of efficacy and very different safety profiles. There is an overall lack of high-quality evidence about the effects of different interventions. Furthermore, no standardised scale is available for acne scarring, leading to variability in evaluation and interpretation of data in different studies.

Split face evaluation of long-pulsed non-ablative 1,064 nm Nd:YAG laser for treatment of direct browplasty scars

PURPOSE

To investigate 1,064 nm long-pulse Nd:YAG laser for postoperative treatment of direct browplasty scars.

METHODS

Nine patients who underwent direct browplasty were enrolled in this prospective study. Subjects were randomized to unilateral laser treatment at 2-week intervals for six total treatments, with the contralateral scar used as a control. Prior to each treatment, subjects rated treated and control scars on overall cosmesis. Post-treatment, subjects rated each for erythema, swelling, discomfort, and perceived hair loss. Finally, examiners masked to treatment side were asked to judge side-by-side photographs of first and final visits for improvement and side effects.

RESULTS

Subjects rated the overall appearance of the treated scar significantly higher at the time of treatment number 5 (mean score 5.13 ± 2.03, P = 0.008) and treatment number 6 (6.25 ± 1.98, P = 0.005) compared to treatment 1 (3.75 ± 2.12); by contrast, they failed to rate the control scar more highly. On masked examination of photographs, the treated scar was selected as most improved 50.0 ± 12.5% of the time. Both subjects and graders reported side effects as transient and mild to moderate (mean score 1-4), with no reports of hair loss from either subjects or observers.

CONCLUSIONS

The 1,064 nm Nd:YAG laser provided significant improvement in scar cosmesis after direct browplasty, as rated by subject self-report, but not by masked observers, and appears to be a useful tool for increasing satisfaction among those dissatisfied with direct browplasty scars. Side effects-including erythema, edema, and discomfort-were transient and universally rated as mild to moderate. Lasers Surg. Med. 48:742-747, 2016. © 2016 Wiley Periodicals, Inc.

Interventions for acne scars

BACKGROUND

Acne scarring is a frequent complication of acne and resulting scars may negatively impact on an affected person's psychosocial and physical well-being. Although a wide range of interventions have been proposed, there is a lack of high-quality evidence on treatments for acne scars to better inform patients and their healthcare providers about the most effective and safe methods of managing this condition. This review aimed to examine treatments for atrophic and hypertrophic acne scars, but we have concentrated on facial atrophic scarring.

OBJECTIVES

To assess the effects of interventions for treating acne scars.

SEARCH METHODS

We searched the following databases up to November 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers, and checked the reference lists of included studies and relevant reviews for further references to randomised controlled trials.

SELECTION CRITERIA

We include randomised controlled trials (RCTs) which allocated participants (whether split-face or parallel arms) to any active intervention (or a combination) for treating acne scars. We excluded studies dealing only or mostly with keloid scars.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data from each of the studies included in this review and evaluated the risks of bias. We resolved disagreements by discussion and arbitration supported by a method expert as required. Our primary outcomes were participant-reported scar improvement and any adverse effects serious enough to cause participants to withdraw from the study.

MAIN RESULTS

We included 24 trials with 789 adult participants aged 18 years or older. Twenty trials enrolled men and women, three trials enrolled only women and one trial enrolled only men. We judged eight studies to be at low risk of bias for both sequence generation and allocation concealment. With regard to blinding we judged 17 studies to be at high risk of performance bias, because the participants and dermatologists were not blinded to the treatments administered or received; however, we judged all 24 trials to be at a low risk of detection bias for outcome assessment. We evaluated 14 comparisons of seven interventions and four combinations of interventions. Nine studies provided no usable data on our outcomes and did not contribute further to this review's results.For our outcome 'Participant-reported scar improvement' in one study fractional laser was more effective in producing scar improvement than non-fractional non-ablative laser at week 24 (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.25 to 12.84; n = 64; very low-quality evidence); fractional laser showed comparable scar improvement to fractional radiofrequency in one study at week eight (RR 0.78, 95% CI 0.36 to 1.68; n = 40; very low-quality evidence) and was comparable to combined chemical peeling with skin needling in a different study at week 48 (RR 1.00, 95% CI 0.60 to 1.67; n = 26; very low-quality evidence). In a further study chemical peeling showed comparable scar improvement to combined chemical peeling with skin needling at week 32 (RR 1.24, 95% CI 0.87 to 1.75; n = 20; very low-quality evidence). Chemical peeling in one study showed comparable scar improvement to skin needling at week four (RR 1.13, 95% CI 0.69 to 1.83; n = 27; very low-quality evidence). In another study, injectable fillers provided better scar improvement compared to placebo at week 24 (RR 1.84, 95% CI 1.31 to 2.59; n = 147 moderate-quality evidence).For our outcome 'Serious adverse effects' in one study chemical peeling was not tolerable in 7/43 (16%) participants (RR 5.45, 95% CI 0.33 to 90.14; n = 58; very low-quality evidence).For our secondary outcome 'Participant-reported short-term adverse events', all participants reported pain in the following studies: in one study comparing fractional laser to non-fractional non-ablative laser (RR 1.00, 95% CI 0.94 to 1.06; n = 64; very low-quality evidence); in another study comparing fractional laser to combined peeling plus needling (RR 1.00, 95% CI 0.86 to 1.16; n = 25; very low-quality evidence); in a study comparing chemical peeling plus needling to chemical peeling (RR 1.00, 95% CI 0.83 to 1.20; n = 20; very low-quality evidence); in a study comparing chemical peeling to skin needling (RR 1.00, 95% CI 0.87 to 1.15; n = 27; very low-quality evidence); and also in a study comparing injectable filler and placebo (RR 1.03, 95% CI 0.10 to 11.10; n = 147; low-quality evidence).For our outcome 'Investigator-assessed short-term adverse events', fractional laser (6/32) was associated with a reduced risk of hyperpigmentation than non-fractional non-ablative laser (10/32) in one study (RR 0.60, 95% CI 0.25 to 1.45; n = 64; very low-quality evidence); chemical peeling was associated with increased risk of hyperpigmentation (6/12) compared to skin needling (0/15) in one study (RR 16.00, 95% CI 0.99 to 258.36; n = 27; low-quality evidence). There was no difference in the reported adverse events with injectable filler (17/97) compared to placebo (13/50) (RR 0.67, 95% CI 0.36 to 1.27; n = 147; low-quality evidence).

AUTHORS' CONCLUSIONS

There is a lack of high-quality evidence about the effects of different interventions for treating acne scars because of poor methodology, underpowered studies, lack of standardised improvement assessments, and different baseline variables.There is moderate-quality evidence that injectable filler might be effective for treating atrophic acne scars; however, no studies have assessed long-term effects, the longest follow-up being 48 weeks in one study only. Other studies included active comparators, but in the absence of studies that establish efficacy compared to placebo or sham interventions, it is possible that finding no evidence of difference between two active treatments could mean that neither approach works. The results of this review do not provide support for the first-line use of any intervention in the treatment of acne scars.Although our aim was to identify important gaps for further primary research, it might be that placebo and or sham trials are needed to establish whether any of the active treatments produce meaningful patient benefits over the long term.

Comparison of four different lasers for acne scars: Resurfacing and fractional lasers

BACKGROUND

Acne scars are common and cause cosmetic problems. There is a multitude of treatment options for acne scars, including dermabrasion, chemical peeling, and fillers, but the advent of laser technology has greatly improved the treatment of acne scars. Although several laser systems are available, studies comparing their efficacy are limited. This study compares the results of treatments using resurfacing (carbon dioxide, CO2; erbium-doped yttrium aluminum garnet, Er:YAG) versus fractional (nonablative fractional laser, NAFL; ablative fractional laser, AFL) lasers.

METHODS

A retrospective photographic analysis of 58 patients who underwent laser treatment for facial atrophic acne scars was performed. Clinical improvement was assessed by six blinded investigators with a scale graded from 0 to 10. Adverse events were also noted.

RESULTS

Mean improvement scores of the CO2, Er:YAG, NAFL, and AFL groups were 6.0, 5.8, 2.2, and 5.2, respectively. The NAFL group showed a significantly lower score than the other groups. The mean number of treatments was significantly greater in the fractional laser groups than in the resurfacing laser groups. The resurfacing laser groups had a prolonged recovery period and high risk of complications. The Er:YAG laser caused less erythema or pigmentation compared to the CO2 laser.

CONCLUSIONS

Although the CO2 laser, Er:YAG laser, and AFL improved the acne scars, the CO2 laser had a greater downtime. Three consecutive AFL treatments are as effective as a single treatment with resurfacing lasers, with shorter social downtime periods and less adverse effects.

Acne scarring: A review of available therapeutic lasers

BACKGROUND AND OBJECTIVE

The utilization of lasers in dermatology has greatly expanded in recent decades. Acne scarring is a common indication in which lasers play an important therapeutic role.

STUDY DESIGN/MATERIALS AND METHODS

Available lasers include traditional ablative lasers, such as carbon dioxide and erbium lasers, traditional non-ablative lasers, such as neodymium, diode, alexandrite, pulsed dye lasers and intense pulse light, as well as both ablative, and non-ablative fractional laser systems.

CONCLUSION

We sought to provide a framework for understanding the various types of lasers available to treat acne scars and review the primary literature pertaining to the efficacy, safety, and advantages of each laser discussed.

[Nonablative fractional lasers: Acne scars and other indications]

Nonablative photothermolysis has become an established technique in laser dermatology. It is mainly used for restructuring dermal connective tissue in order to treat, for example, acne scars or solar elastosis. It is also applied to the treatment of melasma and other benign cutaneous pigment disorders. This article discusses various indications in light of published observations and with regard to practical considerations.

Fractional CO2 Laser Resurfacing as Monotherapy in the Treatment of Atrophic Facial Acne Scars

BACKGROUND

While laser resurfacing remains the most effective treatment option for atrophic acne scars, the high incidence of post-treatment adverse effects limits its use. Fractional laser photothermolysis attempts to overcome these limitations of laser resurfacing by creating microscopic zones of injury to the dermis with skip areas in between.

AIM

The aim of the present study is to assess the efficacy and safety of fractional CO2 laser resurfacing in atrophic facial acne scars.

MATERIALS AND METHODS

Sixty patients with moderate to severe atrophic facial acne scars were treated with 3-4 sessions of fractional CO2 laser resurfacing at 6-week intervals. The therapeutic response to treatment was assessed at each follow up visit and then finally 6 months after the last laser session using a quartile grading scale. Response to treatment was labelled as 'excellent' if there was >50% improvement in scar appearance and texture of skin on the grading scale while 25-50% response and <25% improvement were labelled as 'good' and 'poor' response, respectively. The overall satisfaction of the patients and any adverse reactions to the treatment were also noted.

RESULTS

Most of the patients showed a combination of different morphological types of acne scars. At the time of final assessment 6 months after the last laser session, an excellent response was observed in 26 patients (43.3%) while 15 (25%) and 19 patients (31.7%) demonstrated a good and poor response respectively. Rolling and superficial boxcar scars responded the best while pitted scars responded the least to fractional laser monotherapy. The commonest reported adverse effect was transient erythema and crusting lasting for an average of 3-4 and 4-6 days, respectively while three patients developed post-inflammatory pigmentation lasting for 8-12 weeks.

CONCLUSIONS

Fractional laser resurfacing as monotherapy is effective in treating acne scars especially rolling and superficial boxcar scars with minimal adverse effects.

Evaluating evidence for atrophic scarring treatment modalities

Introduction

Atrophic scars cause significant patient morbidity. Whilst there is evidence to guide treatment, there does not appear to be a systematic review to analyse the efficacy of treatment options.

Objectives

To retrieve all evidence relating to atrophic scar treatment and evaluate using the Clinical Evidence GRADE score in order to allow clinicians to make evidence-based treatment choices.

Method

Searches were performed in Medline, EMBASE, CINHL and Cochrane to identify all English studies published evaluating treatment of atrophic scars on adults excluding journal letters. Each study was allocated a GRADE score based on type of study, quality, dose response, consistency of results and significance of results. The end score allowed categorisation of evidence into high, moderate, low or very low quality.

Results

A total of 41 studies were retrieved from searches including randomised controlled trials, observational studies, retrospective analyses and case reports of which 7% were allocated a high-quality score, 10% a moderate score, 7% a low score and 75% a very low score. Treatment modalities included ablative laser therapy, non-ablative laser therapy, autologous fat transfer, dermabrasion, chemical peels, injectables, subcision, tretinoin iontophoresis and combination therapy.

Conclusion

There is a paucity of good-quality clinical evidence evaluating treatment modalities for atrophic scarring. Evidence supports efficacy of laser, surgery and peel therapy. Further biomolecular research is required to identify targeted treatment options and more randomised controlled trials would make the evidence base for atrophic scar treatment more robust.

Which type of atrophic acne scar (ice-pick, boxcar, or rolling) responds to nonablative fractional laser therapy?

BACKGROUND

Few studies have examined the role of fractional lasers in individual acne scars (ice-pick, box car, rolling) using objective assessment tools in darkly pigmented skin.

OBJECTIVE

To evaluate the effect of 1,540-nm fractional lasers on individual acne scars.

METHODS AND MATERIALS

A prospective interventional study was conducted in 35 patients using a 1,540-nm fractional laser. Six sessions were performed with four passes per session and a dose varying from 70 to 100 mJ to maximize the DWR. A self-devised objective assessment tool with dose settings to optimize the depth-to-width ratio (DWR) and a visual analog scale (VAS) were used to count individual atrophic scars. Final results were assessed 6 months after final laser treatment.

RESULTS

Acne scar reduction efficiency was used to validate the improvement of individual scars, a meaningful difference was considered as 51% or greater improvement. The boxcar scars (52.9%) responded better than the rolling (43.1%) and ice-pick scars (25.9%), with statistically significant improvement (p < .05) seen in boxcar scars after four sessions. Overall VAS scores revealed significant improvement (p < .001).

CONCLUSION

Using an objective evaluation tool, an erbium-doped glass laser was found to improve atrophic acne scars, markedly so for boxcar and rolling scars. The VAS score overestimated improvement because of its subjective nature.

Autologous platelet rich plasma: topical versus intradermal after fractional ablative carbon dioxide laser treatment of atrophic acne scars

BACKGROUND

A proposal has recently been made regarding the potential adjuvant use of platelet-rich plasma (PRP) with fractional carbon dioxide laser (FCL) for the correction of acne scars.

OBJECTIVE

To compare the efficacy and safety of two administration modes of autologous PRP (intradermal injection (ID) and topical application) after FCL with that of FCL alone in the treatment of atrophic acne scars.

PATIENTS AND METHODS

Thirty patients were randomly divided into two groups. Both underwent split-face therapy. Group 1 was administered FCL followed by ID PRP on one side and FCL followed by ID saline on the other. In group 2, one cheek was treated with FCL followed by ID PRP, and the other received FCL followed by topical PRP. Each patient received 3 monthly sessions. The final assessment took place at 6 months.

RESULTS

Combined PRP- and FCL-treated areas had a significantly better response (p = .03), fewer side effects, and shorter downtime (p = .02) than FCL-treated areas, but there were no significant differences in ID- and topical PRP-treated areas in degree of response and downtime (p = .10); topically treated areas had significantly lower pain scores.

CONCLUSION

The current study introduces the combination of topical PRP and FCL as an effective, safe modality in the treatment of atrophic acne scars with shorter downtime than FCL alone and better tolerability than FCL combined with ID PRP.

Treatment of acne scars with fractional CO2 laser at 1-month versus 3-month intervals: an intra-individual randomized controlled trial

BACKGROUND

Treatment of acne scars with ablative fractional CO2 laser appears to be an effective and well-tolerated treatment. However, so far the influence of treatment interval has not been evaluated.

OBJECTIVE

To evaluate whether treatment of acne scars with fractional CO2 laser resurfacing at 1-month interval achieves better results with no difference in the occurrence of adverse effects, than treatment given at 3-months interval.

METHODS

Patients (n = 13) with symmetrical atrophic acne scars on right and left sides of the mid-face and lower-face were randomized to two fractional CO2 laser treatments at 1-month versus 3-month intervals. Blinded on-site evaluations were performed 1 and 6 months after the last treatment on 10-point scales. Endpoints were scar atrophy, patient satisfaction, and adverse effects.

RESULTS

Pre-operatively, acne scars were moderately atrophic (5.86 ± 1.87). After treatment acne scars appeared with less atrophy on both treated sides 1 month postoperatively (1-month interval 1.96 ± 1.23, P < 0.0001; 3-months interval 1.82 ± 1.08, P = 0.0006) and 6 months postoperatively (1-month interval 1.56 ± 1.24, P = 0.0021; 3-months interval 1.33 ± 1.66, P = 0.0002). The treatment interval did not influence the improvement of scar atrophy at any time postoperatively (P = 0.81). Patients were moderately and equally satisfied with the treatment result on facial sides (P = 0.93). Postoperative adverse effects were minor and not influenced by the treatment interval.

CONCLUSIONS

Fractional CO2 laser resurfacing improves atrophic acne scars and a treatment interval of either 1-month or 3-months does not seem to influence the improvement of scar atrophy nor the occurrence of postoperative adverse effects.

Histological validity and clinical evidence for use of fractional lasers for acne scars

Though fractional lasers are widely used for acne scars, very little clinical or histological data based on the objective clinical assessment or the depth of penetration of lasers on in vivo facial tissue are available. The depth probably is the most important aspect that predicts the improvement in acne scars but the studies on histology have little uniformity in terms of substrate (tissue) used, processing and stains used. The variability of the laser setting (dose, pulses and density) makes comparison of the studies difficult. It is easier to compare the end results, histological depth and clinical results. We analysed all the published clinical and histological studies on fractional lasers in acne scars and analysed the data, both clinical and histological, by statistical software to decipher their significance. On statistical analysis, the depth was found to be variable with the 1550-nm lasers achieving a depth of 679 μm versus 10,600 nm (895 μm) and 2940 nm (837 μm) lasers. The mean depth of penetration (in μm) in relation to the energy used, in millijoules (mj), varies depending on the laser studied. This was statistically found to be 12.9–28.5 for Er:glass, 3–54.38 for Er:YAG and 6.28–53.66 for CO₂. The subjective clinical improvement was a modest 46%. The lack of objective evaluation of clinical improvement and scar-specific assessment with the lack of appropriate in vivo studies is a case for combining conventional modalities like subcision, punch excision and needling with fractional lasers to achieve optimal results.

Management of acne scarring, part I: a comparative review of laser surgical approaches

Acne scarring is the result of a deviation in the orderly pattern of healing and can have profound psychosocial implications for patients. While the most effective means of addressing acne scarring is to prevent its formation through good acne control, there are a number of therapeutic interventions that improve the appearance of acne scars. Many of these procedural modalities have flaws and are limited by operator skill and experience. Laser scar revision, on the other hand, is a precise, well tolerated procedure with clinically demonstrable efficacy and minimal adverse effects that may be used alone or in combination with other scar treatments. The last 20 years has seen a dramatic evolution in laser treatment of acne scars, spanning ablative and nonablative technologies, to the current popularity of fractional laser scar revision. Determining which laser system to use depends upon the type and severity of acne scarring, the amount of recovery a patient can tolerate, and the ultimate goals and expectations of each patient. The importance of proper acne scar classification, laser scar revision techniques, and the evidence that addresses each laser system is reviewed in this article.

New approaches in light/laser therapies and photodynamic treatment of acne

Acne is a domain in which the technology and understanding of light/laser therapeutic procedures have advanced considerably. The aim of the paper was to revisit adjunctive physical treatments of acne, including light/laser treatments and photodynamic therapy. This review summarizes findings about such treatment modalities with particular emphasis on efficacy and safety. A number of laser/light-based modalities have been developed to meet the increasing demand for new acne treatments. The current devices correspond, on the one hand, to light-emitting diode therapy and, on the other hand, to the 532-nm potassium titanyl phosphate laser, the 585- and 595-nm pulsed dye laser, the 1450-nm diode laser, the 1320-nm Nd:YAG laser and intense pulsed light. Photodynamic therapy is also available. It is claimed that light/laser treatments might induce a faster response compared with the 1-3 months needed for response to traditional oral and topical treatments. In conclusion, pulsed dye laser shows efficacy in some patients with mild to moderate acne. The relative effectiveness compared with other treatments is unconfirmed; from the published information, evidence-based efficacy assessment of light/laser therapies in acne remains almost impossible.