Histologic Study of Depressed Acne Scars Treated with Serial High-Concentration (95%) Trichloroacetic Acid

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.

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.

Effects of different therapeutic modalities for postacne scars on circulating collagen III

BACKGROUND

Therapies for postacne scarring act through modulation of elastin and collagen, and collagen III might therefore represent a biomarker of treatment effectiveness.

PATIENTS AND METHODS

Patients (n = 70) with postacne scars and individuals without scars (n = 56) were included in this case-control study. Patients were treated with Dermaroller microneedling, trichloroacetic acid chemical reconstruction, punch excision, or scar subcision. Scar severity was graded immediately before and after treatment with a photographic quartile scale and the ECCA scale. Serum levels of collagen III were measured in control individuals and in patients, before treatment, 1 month after the first treatment session, and 4 months after the final session.

RESULTS

Circulating levels of collagen III were significantly higher in patients with postacne scarring (24.1 ± 12.5) before treatment than in control individuals (2.6 ± 0.8). Circulating levels of collagen in patients were significantly lower 4 months posttreatment (14.3 ± 8.1) than at baseline. The mean percentage change in serum collagen III was positively correlated with both the mean percentage improvement by photographic evaluation (r = .530, P < .000) and the mean percentage change in the ECCA scale (r = .632, P < .000).

CONCLUSION

Circulating collagen III is a biomarker for improvement of postacne scarring following different therapies.

Chemical reconstruction of skin scars therapy using 100% trichloroacetic Acid in the treatment of atrophic facial post varicella scars: a pilot study

Context:

Chickenpox (varicella) is a common viral disease caused by Varicella zoster virus. Facial atrophic scars after varicella infection are not uncommon and pose a cosmetic problem. Like atrophic scars of other aetiologies, they are a difficult condition to treat. There are not enough references in the literature regarding efficient treatment of post varicella scars. High strength Trichloroacetic acid (TCA), which is known to cause dermal collagen remodelling, was used to treat varicella scars in the present study.

Aims:

The study was undertaken to assess the efficiency of Chemical Reconstruction of Skin Scars (CROSS) technique using 100% TCA in the treatment of atrophic facial post varicella scars. Settings and Design: Open label, pilot study.

Materials and Methods:

A total of 16 patients with atrophic facial post varicella scars were treated by focal application of 100% TCA solution by pressing down upon the scar surface by a toothpick (CROSS technique). Total 4 sittings were given at 2 weekly intervals and the results evaluated after 3 months of follow-up. Statistical analysis was carried out using Fischer's exact t-test.

Results:

All of the 13 patients who completed the study showed good clinical improvement, with 69% patients grading the response as excellent (>75%) improvement, whereas the rest 31% patients reporting good (51-75%) improvement. No significant complications were seen in any patient.

Conclusions:

CROSS technique using 100% TCA is a safe, cheap and effective therapy for the treatment of post varicella scars.

Multimodal management of atrophic acne scarring in the aging face

Atrophic facial acne scarring is a widely prevalent condition that can have a negative impact on a patient’s quality of life. The appearance of these scars is often worsened by the normal effects of aging. A number of options are available for the treatment of acne scarring, including chemical peeling, dermabrasion, ablative or nonablative laser resurfacing, dermal fillers, and surgical techniques such as subcision or punch excision. Depending on the type and extent of scarring, a multimodal approach is generally necessary to provide satisfactory results. Resurfacing techniques correct surface irregularities, long-lasting dermal fillers address the volume loss resulting from acne, and sub-superficial musculoaponeurotic system (SMAS) face-lift procedures counter the soft tissue laxity and ptosis associated with aging. This article briefly reviews the evolution of individual approaches to treating atrophic acne scarring, followed by case examples illustrating results that can be achieved using a multimodal approach. Representative cases from patients in their 30s, 40s, and 50s are presented. In the author’s clinical practice, multimodal approaches incorporating fractionated laser, injectable poly-l-lactic acid, and sub-SMAS face-lift procedures have achieved optimal aesthetic outcomes, high patient satisfaction, and durability of aesthetic effect over time.

Evaluation of CROSS technique with 100% TCA in the management of ice pick acne scars in darker skin types

BACKGROUND

Acne scars are difficult to treat. Chemical reconstruction of skin scars (CROSS) is a technique using high strength trichloroacetic acid (TCA) focally on the atrophic acne scars to induce collagenization and cosmetic improvement.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of CROSS technique using 100% TCA in ice pick scars in dark skin types IV and V.

METHODS

Thirty patients with ice pick acne scars were initially primed for 2 weeks before the procedure. The priming agents used were hydroquinone 4% applied in the morning and tretinoin 0.025% in the night. Sunscreens were advised to prevent postinflammatory hyperpigmentation. Subsequently, they underwent focal application of 100% TCA with a wooden toothpick in each individual scar, at 2 weekly intervals, for four sessions. Improvement was assessed by the physician, photographic assessment by an independent investigator, and patient feedback by visual analogue scale after the fourth treatment.

RESULTS

Excellent improvement (more than 70%) was observed in the majority of patients (73.3%), while 20% patients showed good improvement (50-70%) and 6.7% patients had fair results (30-49%) at the end of four sessions. Transient hypopigmentation was observed in one patient and hyperpigmentation in two patients. However, no significant adverse effects such as prolonged pigmentary changes or scarring were noted.

CONCLUSION

Treatment of ice pick acne scars with the CROSS technique using high strength 100% TCA is a safe, minimally invasive, efficacious, and cost-effective technique in darker skin. Adequate priming and continued use of hydroquinone and tretinoin reduces complications and promotes healing.

An Assessment of the Efficacy and Safety of CROSS Technique with 100% TCA in the Management of Ice Pick Acne Scars

Background:

Chemical reconstruction of skin scars (CROSS) is a technique using high concentrations of trichloroacetic acid (TCA) focally on atrophic acne scars to induce inflammation followed by collagenisation. This can lead to reduction in the appearance of scars and cosmetic improvement.

Aims:

The aim of this pilot study is to investigate the safety of the CROSS technique, using 100% TCA, for atrophic ice pick acne scars.

Settings and Design:

Open prospective study.

Material and Methods:

Twelve patients with predominant atrophic ice pick post acne scars were treated with the CROSS technique, using 100% TCA, applied with a wooden toothpick, at two weekly intervals for four sittings. Efficacy was assessed on the basis of the physician’s clinical assessment, photographic evaluation at each sitting and patient’s feedback after the fourth treatment, and at the three-month and six-month follow-up period, after the last treatment.

Results:

More than 70% improvement was seen in eight out of ten patients evaluated and good results (50 – 70% improvement) were observed in the remaining two patients. No significant side effects were noted. Transient hypopigmentation and hyperpigmentation was observed in one patient each. Physician’s findings were in conformity with the patient’s assessment. Three months after the last treatment, one patient noted a decrease in improvement with no further improvement even at the six-month follow-up period.

Conclusion:

The CROSS technique with 100% TCA is a safe, efficacious, cost-effective and minimally invasive technique for the management of ice pick acne scars that are otherwise generally difficult to treat. In few patients the improvement may not be sustained, probably due to inadequate or delayed collagenisation.

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.