Medium-depth chemical peels in the treatment of acne scars in dark-skinned individuals

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.

Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for patient and physician alike. Laser treatment plays an important role in scar management with additional support from ancillary modalities. Subsequent to part 1: Burns scars, part 2 focuses on our strategies and literature review of treatment of keloid, hypertrophic, pigmented and acne scars where lasers are used in conjunction with other measures, and illustrated with case studies.

Efficacy of Modified Jessner's Peel and 20% TCA Versus 20% TCA Peel Alone for the Treatment of Acne Scars

Introduction:

There is a paucity of studies on the use of chemical peels for acne scars among the Asian population. A trichloroacetic acid (TCA) and Jessner's combination chemical peel, originally described by Monheit, is said to be better than a TCA peel alone.

Aims:

The aim of the study was to compare the efficacy of 20% TCA and Jessner's solution versus 20% TCA alone for the treatment of acne scars.

Materials and Methods

: The patients were divided into two groups of 25 patients each. Chemical peeling was done in both the groups. In Group I, chemical peeling with Jessner's peel followed by 20% TCA was done and in Group II patients chemical peeling with 20% TCA peel alone was done.

Results:

In Group I (Jessner's peel and 20% TCA), mild improvement of acne scars was seen in 8% cases, moderate improvement in 32% cases and marked improvement of acne scars was seen in 60% patients. In Group II (20% TCA), mild improvement of acne scars was seen in 32% cases, moderate improvement in 40% cases and marked improvement of acne scars was seen in 28% patients. But, the difference in improvement of acne scars was not statistically significant in both the groups (P value > 0.05).

In vitro cytogenetic assessment of trichloroacetic acid in human peripheral blood lymphocytes

Trichloroacetic acid (TCA), a common water disinfection byproduct and a persistent metabolite of trichloroethylene (TCE), has been examined for its genotoxic potential in human lymphocytes. Chromosomal aberration (CA) and cytokinesis-block micronucleus (CBMN) assay were employed to assess the toxicity of TCA. Lymphocytes obtained from three healthy donors were exposed to 25, 50, and 100 μg/ml concentration of TCA separately. TCA exposure resulted in chromosomal anomalies and the formation of micronuclei in lymphocytes. Chromosome analysis revealed the dose-dependent and significant induction of CA. Chromatid break/chromosome break, fragments, and chromatid exchanges were commonly observed. Exposure of higher concentration (50 and 100 μg/ml) significantly inhibited mitotic index. Data obtained with CBMN assay indicated that the induction of micronucleus (MN) formation was greater than that of CA. At 25 μg/ml, TCA induced significant frequencies of MN as compared to control cells. Significant induction of MN at the lowest concentration indicates TCA may also interact with mitotic spindles. Lower percentage of CA and MN at 100 μg/ml as compared to 50 μg/ml indicates occurrence of severe cytotoxicity on exposure of 100 μg/ml TCA in lymphocytes. Collectively, results of both cytogenetic assays indicate that exposure of TCA can induce significant genotoxic and cytotoxic effects.

Chemical peels for acne and acne scars in asians: evidence based review

Chemical peeling is a widely used procedure in the management of acne and acne scars, but there are very few studies on Asian populations who are more prone to develop hyper pigmentation. This article aims to summarize and evaluate the existing studies on the role of chemical peels in the treatment of acne and acne scars among Asians. An online search was conducted to identify prospective studies published in English that evaluated the use of chemical peels in active acne and acne scars in Asian populations. There were six studies for acne and eight studies for acne scars that were identified using our search parameters. Most were single-centre, open label and with small sample sizes. Acne severity was not uniformly reported and the objective outcome measures of some studies were not explicitly reported as well. The general trend of the results of the studies support the safety and efficacy of chemical peels for acne and acne scars including those of darker skin types. The existing studies support the use of chemical peels in the treatment of acne and acne scars in Asians. Further clinical trials with better study design and more subjects are needed to further establish the role of chemical peels in Asian acne patients.

Subcision for treatment of rolling acne scars in Iraqi patients: a clinical study

BACKGROUND

Acne scarring is a common dermatologic problem causing a great cosmetic disfigurement. Subcision is one of the effective modalities for treatment of rolling acne scars.

OBJECTIVE

To evaluate the efficacy and safety of subcision for rolling acne scars in Iraqi patients.

PATIENTS AND METHODS

Forty patients (21 males and 19 females) with moderate to severe grades of facial rolling acne scars were enrolled in this study. Subcision was done for all patients. Patients were followed up at 2, 6, 12 weeks, and 6 months after the last session. The response to treatment was evaluated by objective and subjective methods.

RESULTS

Thirty-four patients completed the study and follow up period. Eight of them were complaining of severe and 26 of moderate grade of acne scars. At the end of the study, 18 (52.94%) patients had mild grade, 15 (44.11%) patients had moderate grade, and one (2.92%) patient had severe grade. This change was statistically highly significant (P-value = 0.0000001). The average scar score before treatment was 13.264 ± 1.675; and it improved to 9.47 ± 2.71 after 6 months (P-value = 0.0000001). Regarding the photographic assessment, the difference in the visual analogue scale before and after the treatment was statistically highly significant (P-value = 0.0000001). All patients were satisfied regarding the improvement after treatment with varying degrees. All reported side-effects were mild and transient.

CONCLUSION

Subcision is a safe, easy to perform, well-tolerated, and valuable surgical technique for treatment of rolling acne scars.

Comparative study of 15% TCA peel versus 35% glycolic acid peel for the treatment of melasma

BACKGROUND

Chemical peels are the mainstay of a cosmetic practitioner's armamentarium because they can be used to treat some skin disorders and can provide aesthetic benefit.

OBJECTIVES

To compare 15% TCA peel and 35% glycolic acid peel for the treatment of melasma.

MATERIAL AND METHODS

We selected 30 participants of melasma aged between 20 and 50 years from the dermatology outpatient department and treated equal numbers with 15% TCA and 35% glycolic acid.

RESULTS

Subjective response as graded by the patient showed good or very good response in 70% participants in the glycolic acid group and 64% in the TCA group.

CONCLUSIONS

There was statistically insignificant difference in the efficacy between the two groups for the treatment of melasma.

Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches

Acne scarring is a commonly encountered yet extremely challenging problem to treat for the dermatologist. As acne scarring can lead to significant psychological distress and low self-esteem, it is of utmost importance to have effective and satisfying treatments in the physician's armamentarium. However, many treatments are unsatisfying, leading to patient disappointment and frustration. Although early treatment of acne lesions and inflammation with isotretinoin is beneficial in preventing acne scarring, many patients still present with troubling noticeable scars. Despite the advances in pharmacology and technology, scar treatment still remains suboptimal and is tainted with several adverse effects. However, some treatments can provide benefits. This review article exhaustively discusses and analyzes the various minimally invasive approaches to the treatment of acne scarring with an emphasis on pharmacologic agents, such as isotretinoin for atrophic acne scars and corticosteroids and chemotherapeutic drugs for hypertrophic scars. Intralesional injections of corticosteroids are efficacious in reducing keloid scar formation in addition to preventing recurrence following surgical excision. In-office and minimally invasive procedural management, including chemical peels, dermabrasion, tissue augmentation, and punch excision is also discussed. Superficial chemical peels are efficacious in treating atrophic scars with relatively few adverse effects and complications. Although dermabrasion is used less often with the advent of laser resurfacing, this technique remains as a viable option for those with atrophic scars. Post-inflammatory hyperpigmentation can be managed successfully with topical agents such as azelaic acid and hydroquinone. The efficacy of various treatment modalities is highlighted with a focus on choosing the correct modalities for specific scar types.

Combination of microneedling and glycolic acid peels for the treatment of acne scars in dark skin

INTRODUCTION

  Acne scars can cause emotional and psychosocial disturbance to the patient. Various modalities have been used for the treatment of acne scars like punch excision, subcision, peels, microdermabrasion, unfractionated and fractioned lasers. The latest in the treatment armamentarium is microneedling. Acne scars commonly coexist with postinflammatory hyperpigmentation. A combination of microneedling and glycolic acid (GA) peels was found to give excellent results in the treatment of such scars. The aim was to study the efficacy of a combination of microneedling with glycolic peel for the treatment of acne scars in pigmented skin.

METHOD

  Thirty patients in the age group of 20-40 years with atrophic box type or rolling scars with postinflammatory hyperpigmentation were chosen for the study. Two groups were made. The first group comprised of 30 patients in whom only microneedling was performed once in 6 weeks for five sessions. In the second group of 30 patients, a combination of microneedling and 35% GA peels was carried out. Patients from both groups were evaluated on the basis of Echelle d'Evaluation clinique des Cicatrices d'acné classification.

RESULTS

  Based on the objective scoring and its statistical analysis, there was significant improvement in superficial and moderately deep scars (grade 1-3). There was also improvement in skin texture, reduction in postacne pigmentation in the second group.

CONCLUSION

  Microneedling is a simple, inexpensive office procedure with no downtime. It is safe in Indian skin (skin types III-IV). The combined sequential treatment with GA peel caused a significant improvement in the acne scars without increasing morbidity.

Acne scars: pathogenesis, classification and treatment

Acne has a prevalence of over 90% among adolescents and persists into adulthood in approximately 12%-14% of cases with psychological and social implications. Possible outcomes of the inflammatory acne lesions are acne scars which, although they can be treated in a number of ways, may have a negative psychological impact on social life and relationships. The main types of acne scars are atrophic and hypertrophic scars. The pathogenesis of acne scarring is still not fully understood, but several hypotheses have been proposed. There are numerous treatments: chemical peels, dermabrasion/microdermabrasion, laser treatment, punch techniques, dermal grafting, needling and combined therapies for atrophic scars: silicone gels, intralesional steroid therapy, cryotherapy, and surgery for hypertrophic and keloidal lesions. This paper summarizes acne scar pathogenesis, classification and treatment options.

The management of postacne scarring

BACKGROUND

Therapeutic intervention for postacne scarring has historically been limited by the considerable morbidity of most treatments for only marginal disease improvement. Within the past decade, however, a greater understanding of the pathogenesis of acne scarring has led to the development of techniques that offer more favorable risk-benefit profiles.

OBJECTIVE

The aims of this article are to highlight a number of newer techniques and to assign their appropriateness to particular grades of acne scarring.

MATERIALS AND METHODS

Current modalities are discussed as they relate to disease process and specific acne scar types. Techniques are presented in order of most effectual therapeutic interventions for defined grades of acne scarring. Acne scarring grades have been described previously in terms of disease load, severity, and lesion morphologies.

RESULTS

A comprehensive discussion of updated therapeutic techniques and their biologic rationales in the treatment of acne scarring is presented. These include targeted interventions of inflammatory and postinflammatory processes, angiogenesis, immunologic processes, dermal and subcutaneous fibrosis, hypertrophy, and keloid scarring.

DISCUSSION

A requirement for developing successful treatments for postacne scarring is a greater understanding of its pathogenesis, variability among afflicted individuals, and the inflammatory mediators and immunology of the scarring process. Many innovative techniques introduced in the past decade attempt to counteract these pathologic processes while keeping the procedural and postoperative risks to a minimum.

[Chemical peels]

Chemical peels have become established over the past 40 years as an effective outpatient method for skin rejuvenation as well as the treatment of a variety of skin conditions. Although laser skin rejuvenation has claimed much attention in recent years, phenol peels, despite problems with scarring and hypopigmentation, remains the gold standard for skin resurfacing [11], against which other methods should be evaluated [21]. We present both a theoretical overview of chemical peels and practical step-for-step instructions.

Acne: treatment of scars

Acne is a common disease affecting a significant proportion of the population.(1-3) It causes considerable morbidity through soreness, disfigurement, and social handicap due to inflammatory lesions.(4,5) Modern therapy ensures that a considerable proportion of all patients can be offered effective treatment of their disease, but the morbidity is not restricted solely to the inflammatory lesions of acne.(6,7) Despite appropriate and effective primary prevention of scarring, scarring occurs in some degree in 95% of all patients irrespective of the severity of inflammatory acne (although severe acne causes more scarring than the milder forms). The scarring causes long-term morbidity that requires specific therapy.(7)

RALGA (Diacnéal®), a Retinaldehyde and Glycolic Acid Association and Postinflammatory Hyperpigmentation in Acne – A Review

Acne vulgaris affects 3 out of 4 adolescents and usually vanishes at the end of puberty with either no sequelae or mild to moderate sequelae, such as postinflammatory hyperpigmenation (PIH), which may result in psychological and emotional damages. The poor tolerability of the actual treatments (secondary inflammation) is a hindrance to therapy. Retinaldehyde (RAL), a precursor of retinoic acid, has shown depigmenting activity. Glycolic acid (GA) decreases the excess of pigment by a wounding and re-epithelization process. Thus, a synergistic effect was expected from the combination of RAL 0.1% and GA 6% RALGA (Diacneal) in the treatment of acne vulgaris and PIH. Efficacy results of preclinical and clinical trials tend to confirm the expectations for both acne and PIH treatment. A good tolerability was observed. In conclusion, the cosmetic cream Diacneal is a well-tolerated treatment for the prevention and healing of PIH in acne patients.

Medium depth peels

Medium depth chemical peels offer an excellent tool for skin rejuvenation. The improvement in rhytids, dyschromias, and photodamage with relatively little downtime confirms its importance in the facial plastic armamentarium.

Acne in ethnic skin: special considerations for therapy

Acne vulgaris occurs in people of all ethnicities and races. Although the pathophysiology and treatment options are similar in all skin phototypes, darker-skinned patients have higher incidence rates of two sequelae of acne: postinflammatory hyperpigmentation and keloidal scarring. Postinflammatory hyperpigmentation may also be triggered by skin irritation. In choosing therapies for patients of color, therefore, clinicians must find a balance between aggressive early intervention to target inflammatory acne lesions, and gentle treatments to increase tolerability and avoid skin irritation. For most patients, a combination of topical retinoids, and topical or oral antibiotics with hydroquinone (as needed) to control hyperpigmentation will be successful. For patients with sensitive skin, topical agents in lower concentrations and cream vehicles are preferred. If tolerated, the retinoid strength can be titrated upward after four to six weeks. Ethnic patients also need to be counseled on use of noncomedogenic and nonirritating skin and hair-care products. Individualized care and close monitoring is required.

Update on pathogenesis and treatment of acne

Acne vulgaris is a common cutaneous disorder of the pilosebaceous follicle. More than 45 million people are affected with acne vulgaris. In addition, 80% of people in the United States report that they suffered from acne at one point in life. It is estimated that US consumers spend $1.2 billion each year for the treatment of acne. Typically, lesions are pleomorphic and range from open and closed comedones to inflammatory papules, pustules, cysts, and nodules, and scarring may result. The disease is important, with a significant effect on patients' self-esteem. The pathogenesis is only partially understood and is multifactorial. Successful management of acne requires an understanding of the pathophysiology of disease. The first half of this review discusses new discoveries in the pathogenesis of acne, and the second half introduces new and time-honored therapies.