ECCA Grading Scale: An Original Validated Acne Scar Grading Scale for Clinical Practice in Dermatology

Acne scarring-pathophysiology, diagnosis, prevention and education: Part I

Acne scarring is common and can occur even with effective acne management. In addition, patients with acne scarring suffer from significant psychosocial morbidity, including depression and suicidality. Despite the availability and advancement of therapeutic modalities, treatment for acne scarring is not always optimized and often overlooked in patients with acne encounters. Using acne scarring assessment tools and identifying specific acne scar subtypes allows for a tailored therapeutic approach. Part I of this continuing medical education series covers the pathophysiology and morphology of textural and pigmented acne scars, scarring assessment tools, and medical treatment options. The principles reviewed will aid in approaching and initiating acne scar treatment in the outpatient setting.

Simultaneous versus sequential fractional CO2 laser and subcision combination for management of post-acne atrophic scars: A split-face comparative study

BACKGROUND

A combination of fractional CO2 laser and subcision is usually employed for the treatment of post-acne atrophic scars. However, the efficacy and safety of both simultaneous and sequential combination therapies should be explored.

AIMS

To compare the efficacy and safety of simultaneous and sequential fractional CO2 laser and subcision combination therapies for post-acne atrophic scars.

PATIENTS AND METHODS

This single-blind, split-face clinical trial included 34 patients with post-acne atrophic scars at our institution. Each patient underwent three sessions of subcision combined with fractional CO2 laser, with a 1-month interval between each session. The left side of the face was treated with simultaneous combination therapy, whereas the right side was treated with sequential combination therapy. Treatment efficacy was assessed at 4, 8, and 12 weeks; and 3 and 6 months after the last session.

RESULTS

Simultaneous and sequential treatments demonstrated comparable efficacy. Regarding the adverse events, the side of the face undergoing simultaneous treatment experienced longer swelling duration, higher pain levels during laser treatment, and shorter downtime.

CONCLUSIONS

Despite the longer swelling time and higher pain levels during laser treatment in the simultaneous treatment side, the effectiveness and satisfaction level of the CO2 fractional laser and subcision for treatment of the acne scars were comparable between the two combinations, with a shorter downtime for the simultaneous than for the sequential combination therapy.

Clinical factors influencing the effectiveness of microplasma fractional radiofrequency treatment for atrophic acne scars: A retrospective analysis

BACKGROUND

Microplasma fractional radiofrequency (MP FRF) technology has been increasingly used for acne scars. Nevertheless, little evidence has analyzed the factors influencing its effectiveness before and during treatment.

AIMS

To evaluate the clinical factors affecting the effectiveness of MP FRF therapy for atrophic acne scars.

METHODS

We analyzed retrospectively the clinical data of 79 acne scar patients treated with MP FRF technology. The outcome of interest included the effectiveness and adverse events after MP FRF treatment. Multivariable logistic regression was utilized to evaluate clinical factors associated with effectiveness after the initial session.

RESULTS

All patients received 115 sessions of MP FRF therapy (average: 1.5 sessions). Twenty-eight (35.4%) patients improved moderately to excellently after one session. We found that the severe grade before treatment was negatively correlated with the effectiveness according to Goodman-Baron qualitative scores (OR = 0.02, 95% CI [0.001, 0.37], p = 0.009). The presence of icepick scars was also a negative correlation factor for the effectiveness (OR = 0.06, 95% CI [0.004, 1.00], p = 0.049). Furthermore, after excluding the effects of icepick scars and Goodman-Baron scores before treatment, ECCA scores were also correlated with effectiveness (OR = 1.04, 95% CI [1.01, 1.06], p = 0.009).

CONCLUSION

MP FRF therapy was effective in treating atrophic acne scars with no permanent adverse events. The severity of Goodman-Baron qualitative scores and icepick scars were independent clinical factors affecting effectiveness, suggesting the possible requirement for additional treatments other than MP FRF for severe acne scars and icepick scars.

Practical Aspects of Acne Scar Management: ASAP 2024

Acne scars are one of the most common complications of acne. They can significantly affect the patient's quality of life. Often, several types of atrophic acne scars are observed simultaneously; therefore, consideration must be given to the type of scar while choosing the treatment modality. Effective treatment is not only important to prevent and improve acne scars but also crucial in preventing psychosocial effects. Treatment of acne scars requires an algorithmic approach that targets each component of the scars, and combination therapy on a patient-specific basis may offer the best chance for significant improvement. The goal of the current article is to discuss the practical aspects of management of atrophic acne scars using the vast modalities of treatment available. The panel of dermatologists and plastic surgeons, each one with at least 20 years of experience in acne scar treatment, participated in a series of 'Practical Aspects of Acne Scar Management' (ASAP) meetings: ASAP 2024. ASAP meetings were organized by "Scar Forum India" from March 2023 to July 2023 in four Indian cities (Mumbai, Delhi, Bengaluru, and Kolkata), each one for a duration of at least three hours. During these meetings and discussions, panelists reviewed and discussed the acne scar-related literature, their clinical experience in its management, available treatment options, along with recent advances. Consequently, a summary of the discussion and practical approach for the management of acne scars is developed. It was concluded that, though there is no specific guideline available to optimize acne scar management despite the multitude of treatment options, the best results can be achieved through the synergy of multiple treatment modalities and using the algorithmic approach.

Efficacy and safety of fractional microneedle radiofrequency for atrophic acne scars: A real-world clinical study of 126 patients

OBJECTIVE

To analyze the clinical efficacy and safety of fractional microneedle radiofrequency (FMR) for facial atrophic acne scars in a real-world setting.

METHODS

The clinical data of patients with atrophic acne scars who had received FMR therapy from February 2018 to August 2022 were retrospectively analyzed. The improvement of atrophic acne scars was assessed using the ECCA Grading Scale (échelle d'évaluation clinique des cicatrices d'acné), Global Aesthetic Improvement Scale (GAIS), and modified Manchester Scar Scale (mMSS). Adverse reactions during FMR treatment were also recorded. Univariate and multivariate logistic regression analyses were performed to evaluate the efficacy and safety of FMR for atrophic acne scars.

RESULTS

A total of 126 patients with facial atrophic acne scars were included. A total of 590 FMR treatment sessions were accomplished, with each of 82 patients receiving 4 or more treatment sessions, and 1 receiving a maximum of 14 sessions. All patients showed improvement in symptoms after FMR treatment, with moderate to significant improvement (ECCA score reduction of 26%-100%) in 92 (73.0%) patients. As the number of treatment sessions increased, the ECCA score gradually decreased from an average of 85.6 before to 35.0 after FMR. The average scores for distortion, color, and visual analogue scale (VAS) of mMSS all showed certain reductions. The change in GAIS score indicated improvement after treatment, with minimal improvement in 16 patients (12.7%), good improvement in 57 patients (45.2%), significant improvement in 45 patients (35.7%), and optimal improvement in 8 patients (6.4%). The univariate and multivariate logistic regression analyses revealed that the long pulse width and the number of FMR treatment sessions were positively associated with clinical efficacy. Compared to the short pulse-width group (200 ms), the longer pulse-width group (300 ms) (odds ratio [OR] = 8.3, p = 0.003) and the even longer pulse-width group (400-500 ms) (OR = 52.6, p < 0.001) demonstrated stronger efficacies. Patients who received more than three treatment sessions had better outcomes compared to those who received three or fewer treatment sessions (OR = 4.0, p = 0.036). All patients experienced posttreatment transient erythema, but no crusting, infection, or blister. Six cases developed grid-like erythema around 1 month posttreatment and one case experienced hyperpigmentation, both of which resolved within 1-3 months after appropriate management.

CONCLUSION

FMR is a safe and effective treatment modality for improving facial atrophic acne scars, and the number of FMR treatment sessions and pulse width are associated with clinical efficacy.

Sleep quality correlates with effectiveness of ultrapulse fractional CO2 laser in the treatment of facial atrophic acne scars

Ultrapulse fractional CO2 laser is effective for acne atrophic scars. Whether this effectiveness is affected by sleep quality remains unclear. Aiming to investigate the relationship between sleep quality and postoperative effectiveness, a retrospective clinical study was conducted, enrolling 83 patients with atrophic acne scar. Sleep quality was measured by the Pittsburgh Sleep Quality Index (PSQI) questionnaire at 3 months after the end of the first treatment. The ECCA (échelle d'évaluation clinique des cicatrices d'acné) scale was used to evaluate the clinical effectiveness before and at 3 months after treatment. The patients were divided into a mild to moderate improvement group and a good to excellent improvement group, based on whether they achieved a 50% ECCA improvement rate. PSQI score was higher in the mild and moderate improvement group than in the good to excellent improvement group (7.6 ± 4.5 vs 3.8 ± 1.7, p < 0.001). Multivariate logistic regression showed that both PSQI score (odds ratio = 0.6 [95% CI = 0.5-0.8], p < 0.001) and scar type were correlated with postfractional CO2 laser effectiveness. Pearson correlation analysis suggested that PSQI score was negatively correlated with ECCA decline score (r = -0.6139, p < 0.0001). Receiver operating characteristic curve analysis showed that PSQI score (area under the curve = 0.759) and scar type (area under the curve = 0.737) were all closely correlated with postoperative effectiveness, without statistical difference between their accuracies (p = 0.647). Decision curve analysis demonstrated that both PSQI score and scar type correlated with postoperative effectiveness. Our results demonstrated that sleep quality correlates with the postoperative effectiveness of ultrapulse fractional CO2 laser in the treatment of atrophic acne scars.

The efficacy and safety of low- versus high-fluence fractional picosecond Nd:YAG 1064-nm laser in the treatment of acne scars: A randomized split-face comparison study

BACKGROUND

Differences in clinical efficacy based on the fluence of fractional picosecond laser treatment for acne scars are unknown.

OBJECTIVE

To compare the efficacy and safety of low-fluence versus high-fluence fractional picosecond Nd:YAG 1064-nm laser treatment in acne scar patients.

METHODS

In this 12-week, investigator-blinded, randomized, split-face study, 25 patients with moderate-to-severe acne scars received three sessions of high-fluence laser treatment (1.0 J/cm2 ) on one side of their face and low-fluence (0.3 J/cm2 ) on the other side every 4 weeks. Patients were assessed using acne scar counts, the scar global assessment (SGA), and the ECCA scar grading scale every 4 weeks. The histological analysis compared the acne scars obtained before and 4 weeks after treatment.

RESULTS

At their last visit, 88.00% and 92.00% of the subjects achieved >30% reduction in scar counts on the low- and high-fluence sides, respectively, without a significant difference between the two sides. On both sides, the scar counts, SGA, and ECCA score significantly improved 4 weeks after the last treatment. Although the high-fluence side showed a greater reduction in scar counts (-66.73%) than the low-fluence side (-62.13%), the two sides had no significant difference in the grading scores. The high-fluence side showed significantly more severe pain and higher side-effect scores immediately and 4 weeks after treatment. Histological analysis revealed a significantly increased collagen, elastin, and vimentin expression after treatment on the low-fluence side.

CONCLUSIONS

The low-fluence setting demonstrated comparable efficacy and superior safety in treating acne scars compared with the high-fluence setting.

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.

Comparison of 1064-nm Nd:YAG picosecond laser using fractional micro-lens array vs. ablative fractional 2940-nm Er:YAG laser for the treatment of atrophic acne scar in Asians: a 20-week prospective, randomized, split-face, controlled pilot study

Background

The 1064-nm Nd:YAG picosecond lasers using fractional micro-lens array (P-MLA) was a promising therapy for skin resurfacing. However, no studies have compared P-MLA with ablative fractional 2940-nm Er:YAG lasers (AF-Er) in the treatment of atrophic acne scars.

Objectives

To evaluate the efficacy and safety of P-MLA and AF-Er for the treatment of atrophic acne scars.

Methods

We performed a prospective, randomized, split-face, controlled pilot study. Thirty-one Asian patients with mild to moderate atrophic acne scars underwent four consecutive sessions of randomized split-face treatment with P-MLA and AF-Fr at 4-week intervals. The efficacy of the two devices were evaluated by Echelle d'Evaluation Clinique des Cicatrices d'acne (ECCA) grading scale, Investigator's Global Assessment (IGA) score and patient's satisfaction. VISIA analysis was also performed to evaluate the pore and skin texture. Adverse events were recorded at each follow-up.

Results

The P-MLA afforded comparable clinical responses in scar appearance as AF-Er based on the investigator's assessments (ECCA percent reduction: 39.11% vs. 43.73%; IGA score: 2.97 ± 0.65 vs. 3.16 ± 0.68; P > 0.05 for both). However, the result of patient satisfaction indicated the AF-Er-treated side achieved a slightly greater improvement in scar appearance (3.97 ± 0.78 vs. 3.55 ± 0.71; P < 0.05). Overall, the two devices did not differ largely in terms of efficacy. VISIA analysis revealed similar changing patterns of the pore and skin texture between two devices. For safety profiles, no serious side effects were reported on both sides. The P-MLA showed lower pain level, shortened duration of crust shed and edema, and less occurrence of PIH (P < 0.05 for all).

Conclusion

Compared with AF-Er, P-MLA afforded comparable effect and more safety profiles in treating atrophic acne scars in Asian patients.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05686603.

Cosmetic therapies for Chinese patients with acne taking concomitant or recent intake of oral isotretinoin: A retrospective study

BACKGROUND

The current standard recommendation is to initiate the cosmetic therapies after discontinuing taking oral isotretinoin for at least 6 months. However, this recommendation has been questioned in several recent publications, and it is difficult to operate in clinical practice as early initiation of effective treatment is desirable for patients with acne sequelae.

OBJECTIVE

The purpose of this study is to evaluate the efficacy and safety of chemical peeling and light/laser or radiofrequency treatments combined with oral isotretinoin for patients with acne vulgaris and acne scars.

METHOD

A retrospective study of 511 patients on/or recently administered with isotretinoin treated with glycolic acid, intense pulsed light, nonablative fractional laser, fractional radiofrequency, and ablative carbon dioxide laser. A total of 1352 interventions were performed. The medical follow-up lasted for at least 1 year. The efficacy and safety of different procedures were evaluated.

RESULTS

A total of 511 patients, who were treated with isotretinoin orally or stopped for <6 months, received 477 sessions of glycolic acid chemical peeling treatment, 588 sessions of intense pulsed light treatment, 61 sessions of nonablative fractional laser treatment, 101 sessions of fractional radiofrequency treatment, and 125 sessions of ablative fractional carbon dioxide laser treatment. No hypertrophic scars and keloids were found, and the incidence of serious adverse reactions such as scarring, erythema, blisters, and postinflammatory hyperpigmentation did not increase.

CONCLUSIONS

It is safe to perform skin procedures in patients with acne and acne scars during or after discontinuation of isotretinoin for <6 months. Invasive treatments such as ablative fractional carbon dioxide laser treatment can be performed, as appropriate, by an experienced physician. The guideline of avoiding chemical and physical procedures in such patients taking oral isotretinoin should to revised.

1927nm fractional thulium fiber laser combined with 30% salicylic acid for the treatment of acne and acne scars: A prospective, randomized, and split-face study

OBJECTIVES

Patients with acne usually develops acne scars subsequently, early intervention of scars is crucial in acne management. 1927nm fractional thulium fiber laser (TFL) is effective in scars improvement and chemical peels with 30% supramolecular salicylic acid (SSA) can be applied for the treatment of acne. The purpose of this study is to evaluate and compare the efficacy and safety of TFL monotherapy versus the concomitant application of TFL and 30% SSA on acne and acne scars.

MATERIALS AND METHODS

Thirty-three patients with acne and acne scars were enrolled, and two sides of the face were randomly divided to receive either TFL and SSA chemical peeling or TFL. Four sessions of TFL treatments were applied with 4-week intervals for both sides, SSA combined treatment side received eight SSA chemical peels with 2-week intervals additionally. GAGS, ECCA score, the number of acne lesions, melanin index (MI) and erythema index (EI), transepidermal water loss (TEWL), and side effects were recorded at Weeks 0, 4, 8, 12, and 18. Satisfaction of patients was recorded on both sides at the end of the study.

RESULTS

Thirty patients completed the study. Both control group (TFL monotherapy) and SSA group (TFL combined with SSA chemical peeling) significantly improved GAGS and ECCA score. SSA group showed higher efficacy in terms of GAGS and ECCA score, acne lesion count, TEWL, MI, EI, and satisfaction than control group. All the side effects were temporary and tolerable, no adverse effects were observed.

CONCLUSIONS

Both TFL and the TFL combined with 30% SSA chemical peeling are safe and effective for the treatment and prevention of acne and acne scars, though the combined group has higher efficacy.

Acne among Patients Visiting Outpatient Department of Dermatology Centres

Introduction

Acne vulgaris is a common chronic inflammatory skin disease affecting the pilosebaceous unit. The clinical manifestations of acne include the development of comedones, papules, and pustules. Although generally considered benign, acne can have psychological impacts and cause disfiguring scars. The aim of this study was to find out the prevalence of acne among patients visiting outpatient department of dermatology centres.

Methods

A descriptive cross-sectional study was conducted among patients visiting tertiary care skin centres from 15 June 2023 to 15 August 2023. The ethical approval was obtained from the Institutional Review Committee. The severity of acne severity and scarring was determined. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 2036 patients, acne was found in 386 (18.96%) (17.26-20.66, 95% Confidence Interval). The majority of participants have acne scar grade 2 (65.20%).

Conclusions

The prevalence of acne among patients was found to be higher than in other studies done in similar settings.

Keywords

acne; scars; prevalence.

Efficacy of fractional CO2 laser therapy combined with hyaluronic acid dressing for treating facial atrophic acne scars: a systematic review and meta-analysis of randomized controlled trials

The present work aimed to systematically identify the efficacy and safety of fractional carbon dioxide (CO2) laser plus hyaluronic acid (HA) dressing in dealing with facial atrophic acne scars. Randomized controlled trials (RCTs) concerning fractional CO2 laser in combination with HA dressing for treating atrophic acne scars were screened in 8 electronic databases (containing PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Internet, Wanfang, Sinomed as well as VIP). Besides, for the purpose of evaluating the risk of bias of the enrolled RCTs, the Cochrane Collaboration tool was adopted. Statistical analysis was completed using Revman5.3 software and Stata 14.0 software. Meanwhile, the quality of evidence was assessed by the GRADE system. Finally, 6 studies involving 623 patients were enrolled. According to the findings in this study, compared with fractional CO2 laser alone, fractional CO2 laser therapy combined with HA dressing reduced the scores of ECCA (échelle d'évaluation clinique des cicatrices d'acné) grading scale (MD=-3.37,95% CI [-5.03, -1.70], P<0.0001), shortened the time of crust formation (MD=-0.42,95% CI [-0.80, -0.04], P=0.03) and the time of crust removal(MD=-1.31,95% CI [-1.67, -0.95], P<0.00001), enhanced patient satisfaction (RR=1.85, 95% CI [1.44, 2.38], P<0.00001). All the reported adverse events including hyperpigmentation, erythema, edema, mild itching, and slight burning pain were controllable. In addition, fractional CO2 laser combined with HA dressing therapy had a lower incidence of hyperpigmentation than fractional CO2 laser alone (RR=0.37, 95% CI [0.23, 0.61], P<0.0001). The level of evidence for outcomes was classified to be low to moderate. According to our findings, fractional CO2 laser combined with HA dressing is efficacious and safe option for facial atrophic acne scars. Nevertheless, more high-quality trials are required for further verification in the future.

Fractional carbon dioxide laser combined with subcision for the treatment of three subtypes of atrophic acne scars: a retrospective analysis

Fractional carbon dioxide (CO2) laser combined with subcision has been widely used for the clinical treatment, but the efficacy of the combined therapy on three types of atrophic acne scars remains unreported. This retrospective study analyzed the clinical data of 413 patients with atrophic acne scars, treated with fractional CO2 laser combined with subcision in the combined group and with fractional CO2 laser in the control group. The treatment efficacy was evaluated by the Investigator's Global Assessment (IGA) and the Échelle d'évaluation clinique des cicatrices d'acné (ECCA). We reported adverse reactions such as erythema, lump, skin sensitivity, acne recurrence, and hyperpigmentation that occurred in both treatment groups. The treatment efficiency of the combined group was significantly higher than that of the control group (P < 0.001). Among the three subtypes of atrophic acne scars, the ECCA scores in the combined group of boxcar-type and rolling-type scars after treatment were lower than those in the control group (P = 0.041, P < 0.001, respectively), and no statistical difference in scores between the two groups for icepick-type scars was seen (P = 0.062). There was no statistical difference in adverse reactions between the two groups (P = 0.361). Fractional CO2 laser combined with subcision is more effective than fractional CO2 laser in the treatment of boxcar-type and rolling-type scars, but there is no significant difference in the treatment of icepick-type scars.

"Multiple Mode Procedures" of Ultra-Pulse Fractional CO2 Laser: A Novel Treatment Modality of Facial Atrophic Acne Scars

BACKGROUND AND AIM

Fractional CO₂ laser is therapeutic for acne atrophic scar, but its effect usually is limited after multiple sessions, with occasional adverse reactions. This study aimed to evaluate the efficacy and safety of a new modality combining ultra-pulse CO₂ laser and fractional CO₂ laser (multiple mode procedures [MMP]) in the treatment of acne atrophic scars.

METHOD

From December 2017 to January 2023, a total of 103 patients with facial acne atrophic scars treated with MMP technique were retrospectively analyzed. MMP was performed for 1-4 sessions with an interval of approximately three months. Based on photographs taken before and after treatment, overall atrophic scar improvement was assessed according to the ECCA grading scale, the modified Manchester Scar Scale and the 4-point Global Assessment Scale (GAS). The safety was evaluated by the degree of pain during treatment and postoperative adverse reactions.

RESULTS

All the 103 patients received treatment and completed follow-up, with an average of two sessions. The mean ECCA score decreased from 162.7 to 93.1 with statistically significant difference (p < 0.001). The mean GAS score increased by an average of 2.3 ± 0.9. The GAS improvement more evident for "boxcar" atrophic scars (2.7 ± 0.8) than for "rolling" (2.3 ± 0.8) and "icepick" scars (1.7 ± 0.8) (p < 0.001). The average improvement scores for color, distortion and texture were 2.0 ± 0.9, 2.2 ± 0.9 and 2.3 ± 0.8, respectively. The mean pain score during treatment was 3.9 ± 0.8, and the mean duration of erythema was 30.7 ± 3.5 days. Only three patients developed hyperpigmentation at the treated site within a few months.

DISCUSSION

Ultra-pulse CO₂ fractional laser MMP technique can effectively improve the condition of facial atrophic acne scars with limited adverse reactions.

Truncal Acne and Scarring: A Comprehensive Review of Current Medical and Cosmetic Approaches to Treatment and Patient Management

Acne vulgaris is one of the most common skin disorders worldwide. It typically affects skin areas with a high density of sebaceous glands such as the face, upper arms, chest, and/or back. Historically, the majority of research efforts have focused on facial acne vulgaris, even though approximately half of patients with facial lesions demonstrate truncal involvement. Truncal acne vulgaris is challenging to treat and poses a significant psychosocial burden on patients. Despite these characteristics, studies specifically examining truncal acne vulgaris are limited, with treatment guidelines largely derived from facial protocols. Therefore, truncal acne remains an understudied clinical problem. Here, we provide a clinically focused review on the epidemiology, evaluation, and available treatment options for truncal acne vulgaris. In doing so, we highlight knowledge gaps with the goal of spurring further investigation into the management of truncal acne vulgaris.

Efficacy and safety of low-dose oral isotretinoin monotherapy versus combined therapy with picosecond laser for the treatment of acne scars in Asian population

PURPOSE

Acne scars are common in patients with moderate to severe acne. Isotretinoin is the first-line treatment for those patients, but whether oral isotretinoin can improve acne scar is not clear. Picosecond lasers (FxPico) has been reported to improve acne scars. In the present study, we evaluated the clinical efficacy of low-dose isotretinoin with or without FxPico treatment for acne scars.

MATERIALS AND METHODS

A total of 48 patients with acne scars were enrolled and were randomly assigned to receive low dose oral isotretinoin or not. For all the patients in both treatment groups, one side of face were randomly assigned to be treated with picosecond laser. Assessments, including photos, échelle d'évaluation clinique des cicatrices d'acné (ECCA) and Global Acne Grading System (GAGS) score, the number of lesions, melanin and erythema indexes, transepidermal water loss were assessed at 0, 1, 2, and 3 month. Side effects, Dermatology Life Quality Index (DLQI) and satisfaction were recorded before and after the study.

RESULTS

A total of 44 patients completed the study (24 received oral low dose isotretinoin and 20 did not). Low dose oral isotretinoin treated group showed significant improvement on ECCA (from 112.5 [50-180] to 105 [50-160]), GAGS score (from 12.6 ± 3.3 to 10.1 ± 3.0), the count of papules (from 4.3 ± 3.7 to 1.0 ± 1.5) than the blank group, and higher improvement were noticed after isotretinoin combined with FxPico. All the side effects were temporary and tolerable, no adverse effects were observed. Higher DLQI and patients' satisfaction were achieved by oral isotretinoin alone and isotretinoin combined with FxPico.

CONCLUSIONS

This is the first paper showing the improvement of scars by early low dose-isotretinoin intervention with or without the combination of picosecond laser. Early intervention with oral low-dose isotretinoin is effective for the treatment and prevention of acne scars, the combined therapy with FxPico can achieve better outcome.

Microneedling in Combination With 15% Trichloroacetic Acid Peel Versus 25% Pyruvic Acid Peel in the Treatment of Acne Scars

BACKGROUND

Acne scars are a permanent disfiguring sequel of acne.

OBJECTIVE

To compare the efficacy of microneedling with 15% trichloroacetic acid (TCA) peel versus microneedling with 25% pyruvic acid peel in the management of postacne scars.

MATERIAL AND METHODS

Thirty patients with atrophic acne scars were randomized into 2 groups receiving microneedling on both sides of the face at 0,6, and 12 weeks and 15% TCA on one side and 25% pyruvic acid on other side at 3,9, and 15 weeks. Acne scar scoring performed using the Echelle D'Evaluation Clinique des Cicatrices D'Acne (ECCA) and visual analogue scales by patient and physician were used to grade improvement at all visits and at 21 weeks.

RESULTS

The mean ECCA score on the TCA side declined from 151.17 ± 26.90 to 138.83 ± 30.56 and on the pyruvic side declined from 151.83 ± 27.53 to 141.33 ± 28.92 after 21 weeks (statistically significant: p-value <.05). Comparing the ECCA on the TCA and pyruvic sides at 21 weeks was not significant. VAS showed moderate-to-marked improvement after 3 months in both groups.

CONCLUSION

In our study, the combination modality showed early reduction in rolling and boxcar compared with icepick scars. These peels led to improvement in overall texture of the skin, hence more patient satisfaction. On comparing ECCA, a significant difference was not observed.

Efficiency and safety of microneedling fractional radiofrequency in the treatment of Chinese atrophic acne scars: A retrospective study of 3 consecutive treatments with 1-month intervals

BACKGROUND

Atrophic acne scars (AAS) impact the aesthetic appearance, inducing social and psychological problems. Effective and safe therapy for AAS is urgently needed now. Microneedling fractional radiofrequency (MFRF) has emerged as a minimal invasive alteration for treating AAS lately, while the existing data on Chinese population was few.

AIMS

We aimed to explore the effectivity and safety of MFRF in Chinese patients with facial AAS and analyze the response of different subtypes to MFRF treatment.

METHODS

We conducted a retrospective analysis using data from medical records and clinical photographs of 40 Chinese patients with AAS with Fitzpatrick skin type III-IV, all of them had received 3 MFRF treatments with 1-month intervals and were followed up 3 months after the last treatment. The clinical severity was assessed through échelle d'évaluation clinique des cicatrices d'acné (ECCA) score at each visit. Clinical photographs were taken by VISIA. Patients were asked to evaluate their satisfaction of the treatment using a 5-point Likert scale at the last visit.

RESULTS

ECCA score decreased more than a half at the last visit based on the baseline. Among the three types of AAS, the M-shaped scars respond most quickly to MFRF and the U-shaped scars improved the most after 3 months follow-up. A significant improvement was seen in clinical appearance, parallel to the change of ECCA, indicating the remarkable improvement of AAS after the MFRF treatment. Concomitant active acne was controlled along with the improvement of AAS. Statistics from VISIA showed excellent improvement in pores and texture as well. Side effects including pain and erythema were transient and mild. The number of MFRF treatment sessions was positively associated with the degree of improvement. Of the total 39 patients who had given a score of satisfaction, more than 89% (35 patients) were very satisfied or satisfied with the outcome.

CONCLUSIONS

To sum up, our study reveals that MFRF provides high efficiency in treating Chinese AAS patients with high satisfaction and low risk of adverse effects. M-shaped scars are the most sensitive type to the treatment, but the U-shaped scars improve most at the last visit. The simultaneous minimization of pores and improvement of skin texture imply the increased collagen stimulated by MFRF. Regular MFRF should be considered a good choice in treating AAS.

Which is more effective in atrophic acne scars treatment microneedling alone or platelet rich plasma alone or combined both therapeutic modalities?

Acne scarring usually causes cosmetic and psychological problems. Our aim of the study was to compare the efficacy of microneedling alone, intradermal injection of platelet rich plasma (PRP) alone and combined microneedling with PRP in the treatment of atrophic post-acne scars. Thirty adult patients with facial post-acne scars were randomly recruited and divided into two groups: A and B. Group A: included 15 patients; the left sides of their faces were treated with microneedling by dermapen followed by PRP while on the right side of the faces microneedling alone was performed. Group B: included 15 patients; the left sides of their faces were treated with microneedling by dermapen followed by PRP while the right sides of the faces were treated with intradermal injection of PRP. For both groups, the treatment session was repeated every 3 weeks until clearance of the atrophic acne scars or for four sessions maximally. Patients' evaluation was done pre-treatment and 3 weeks after the last session by photography, Goodman and Baron qualitative grading system and Echelle d'Evaluation Clinique des Cicatrices d'Acné (ECCA) scale. By using all of these evaluation methods, group A showed that there was better improvement on the left side but without statistical significant difference. However, group B showed that there was a significant reduction in the total number of post-acne scars on the left side compared to the right side by using photographic assessment and ECCA grading scale. Skin microneedling, PRP and combined microneedling with PRP are effective therapeutic modalities in atrophic post-acne scars treatment. However, combined microneedling with PRP gives better results and is better tolerated in all types of atrophic acne scars.

Autologous platelet-rich plasma 'fluid' versus 'gel' form in combination with fractional CO2 laser in the treatment of atrophic acne scars: a split-face randomized clinical trial

BACKGROUND

The treatment of atrophic acne scars represents a therapeutic challenge. Recently, plasma gel has been introduced among treatment modalities.

OBJECTIVE

To compare the efficacy of platelet-rich-plasma 'fluid' versus 'gel' form combined with fractional CO₂ laser in the treatment of atrophic acne scars.

METHODS

Twenty-seven patients with atrophic acne scars were included. Treatment with fractional CO₂ laser plus plasma fluid/gel was randomly assigned to the right/left sides of the face. Clinical and Optical Coherence Tomography (OCT) assessments were scheduled at baseline, one month, and three months after the last session.

RESULTS

There was a significant improvement in clinical assessment scores at third-month follow-up on the plasma gel- and plasma fluid-treated sides compared to those at the first-month follow-up (p < .001). Scar depth decreased significantly at third-month follow-up when compared to baseline on both plasma gel- and plasma fluid-treated sides (p < .001). The numerical pain score was significantly lower on the plasma fluid-treated side compared to the plasma gel-treated side (p = .004).

CONCLUSION

The use of platelet-rich plasma in combination with fractional CO₂ laser, both in fluid and gel form, produced significant results in the treatment of atrophic acne scars. Patients reported an immediate more noticeable effect with plasma gel. However, the fluid injection was less painful.

Microneedling Monotherapy for Acne Scar: Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Acne scarring, formed by the deposition of collagen following inflammatory acne, not only represents a cosmetic problem but also poses a psychological health risk to patients. As microneedling has become a common treatment for acne scarring, an increasing number of studies have compared the efficacy and safety of microneedling. In this study, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing microneedling with other treatments.

METHOD

Three databases, namely Embase, PubMED, and Cochrane library, were searched until June 20, 2021, for RCTs only. Studies using microneedling in both treatments were excluded.

RESULTS

Twelve studies, totaling 414 participants, were included in our meta-analysis. For objective scar improvement, the pooled estimate analysis of the first group, treated with microneedling without radiofrequency, yielded a mean difference of 0.42 (95% CI-0.12-0.73%) with a significant difference at the 5% significance level. The second group, treated with fractional radiofrequency microneedling, exhibited no significance at the 5% significance level. Regarding subjective satisfaction, most results exhibited no significant difference between microneedling and other treatments. Although no case of secondary scarring or infection was reported in our study, the pooled result of postinflammatory hyperpigmentation was significant at the 5% significance level and preferred microneedling treatment.

CONCLUSION

Microneedling without radiofrequency achieved superior results in terms of scar improvement. No form of microneedling caused postinflammatory hyperpigmentation-an advantage in acne scar treatment. Thus, microneedling is a favorable choice for the treatment of acne scarring.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Single-center, assessor-blind study to evaluate the efficacy and safety of DA-5520 topical gel in patients with acne scars: A pilot study

BACKGROUND

Unlike various topical treatment options for acne vulgaris, options for acne scars mostly involve invasive interventions. So far, only a few clinical trials have investigated the effects of topical treatment for acne scars.

OBJECTIVES

We evaluated the safety and efficacy of DA-5520, a recently developed topical gel for the treatment of different types of acne scars.

METHODS

A 12-week prospective, randomized, active-controlled, evaluator-blind, single-center study involving 36 participants with acne scars was performed. Participants were randomized into four different groups at a 1:1:1:1 ratio: laser resurfacing with DA-5520 application (test 1); laser resurfacing without DA-5520 application (control 1); comedone extraction with DA-5520 application (test 2); and comedone extraction without DA-5520 application (control 2). For 12 weeks, participants in the two test groups applied DA-5520 twice daily, while participants in the control groups applied moisturizers alone. Participants in the test 1 and control 1 groups received a single session of laser resurfacing at visit 1 (week 0). All participants were followed up at 1, 4, 8, and 12 weeks, and objective scar evaluation using the échelle d'évaluation clinique des cicatrices d'acné (ECCA) score was performed at each visit.

RESULTS

Clinical improvement of acne scars, confirmed by the ECCA grading scale (1 for atrophic scar and 2 for hypertrophic scar), was observed after using DA-5520 when combined with laser resurfacing or individually, and no associated adverse reactions were noted.

CONCLUSIONS

Preliminary results of this study revealed that DA-5520 may be a promising new formulation for treating all type of acne scars.

Guidance for the pharmacological management of acne vulgaris

INTRODUCTION

Many international guidelines and expert consensuses are available to help the clinician diagnose and treat acne vulgaris; however, a simplified practical guidance that integrates current existing published recommendations is still lacking. This article aims to give practical and simplified insight into the treatment of acne.

AREAS COVERED

Herein, the author discusses the treatment of comedonal, papulopustular, and nodular/cystic/conglobate acne. The author also proposes a simplified treatment escalation strategy that is based on disease severity and extension, starting with topical treatments for mild cases and progressing over to systemic therapies in more severe cases.

EXPERT OPINION

The ideal acne treatment would simultaneously and safely target all the pathogenic factors implicated in the appearance of acne lesions with minimal side effects. Since no such treatment currently exists, combination therapies are usually recommended for most types of acne. A major limitation in choosing an appropriate treatment plan is the discrepant use of classification systems across the published literature making it difficult to draw clear and succinct conclusions about the recommendations given. Acne is not a traditional infectious disease and so while antibiotics may improve symptoms, they do not reliably resolve the condition. Thus, there is currently a tendency to opt for antibiotic-sparing treatment strategies whenever possible.

A pilot study evaluating the efficacy and safety of retinaldehyde-loaded niosomes against mild-to-moderate acne

BACKGROUND

Retinoids are the mainstay of topical therapy for acne. To improve the efficacy and minimize the side effects of retinoids, various novel drug delivery mechanisms, including nanoparticles, have been developed.

AIM

To evaluate the efficacy and safety of a retinaldehyde-loaded niosome (RA-N) nanoemulsion against sebum secretion and keratinization on mild-to-moderate acne.

PATIENTS/METHODS

Twenty-three participants exhibiting mild-to-moderate acne with both closed and open comedones were included. They applied a 0.05% RA-N nanoemulsion daily for 4 weeks, did not to use any other emollient or topical pharmaceutical, and were asked to report any symptoms and treatment satisfaction.

RESULTS

The participants demonstrated significantly fewer closed and open comedones after 2 and 4 weeks of treatment than at baseline (*p < 0.05). The mean sebum secretion, measured using Sebumeter®, was 327.95 ± 90.20 μg cm^-2 at baseline and reduced to 282.60 ± 99.70 and 250.65 ± 97.6 μg cm^-2 , respectively, after 2 and 4 weeks of treatment (*p < 0.05). The mean desquamation index, determined using Visioscan®, was 10.99 ± 1.69 at baseline and decreased to 9.81 ± 1.10 and 8.89 ± 1.32, respectively, after 2 and 4 weeks of treatment (*p < 0.05). The application of the RA-N nanoemulsion resulted in a significantly lower desquamation level, suggesting that the RA-N nanoemulsion was well-tolerated without any skin irritation. None of the participants reported a serious adverse event during this study.

CONCLUSION

Our findings suggest that the RA-N nanoemulsion was effective in improving comedones in acne-prone skin and safe for long-term application. Further studies are necessary to investigate the long-term effects of the application of the RA-N nanoemulsion in participants with inflammatory acne and acne scars.

A Comparative Study of Microneedling Alone Versus Along with Platelet-Rich Plasma in Acne Scars

Context:

There are several modalities of treating acne scars. The combination of microneedling and platelet-rich plasma (PRP) is a synergistic approach to treat acne scars.

Aims:

The aim was to compare the efficacy of microneedling alone versus microneedling with PRP in acne scars.

Materials and Methods:

This was a split face study conducted on 36 patients with acne scars who underwent four sessions of microneedling with PRP on right side and microneedling alone on left side at monthly interval. The total scars with subtypes and Ecchelle D’Evaluation Cliniques des Cicatrices D’Acne (ECCA) score were assessed at baseline and second, fourth, and sixth visits. Visual analog score (VAS) was evaluated by both physicians and patients.

Statistical Analysis:

The statistical analysis was carried out using Statistical Package for Social Sciences. Paired-t test and Wilcoxon signed rank test were used to compare the results.

Results:

Mean age was 23.7±3.2 years with 17 male and 19 female patients. The mean total scars on right and left sides declined from 42.14±21.15 to 25.08±14.14 and 43.28+23.08 to 27.17±15.68, respectively, with insignificant differences (P-value = 0.094). ECCA score on right and left sides declined from 88.31±32.78 to 62.92±23.68 and 89.58±32.43 to 66.25±23.89, respectively (P-value = 0.058). VAS evaluated by patient and physician showed maximum improvement at second and third visits, respectively.

Conclusions:

This study showed no added advantage of topical application of PRP over microneedling in acne scars.

The Efficacy and Safety of Fractional 1064 nm Nd:YAG Picosecond Laser Combined With Intense Pulsed Light in the Treatment of Atrophic Acne Scar: A Split-Face Study

BACKGROUND AND OBJECTIVES

To evaluate the efficacy and safety of fractional 1064 nm Nd:YAG picosecond laser combined with intense pulsed light (IPL) in the treatment of atrophic acne scar with post-inflammatory erythema (PIE). © 2021 Wiley Periodicals LLC.

STUDY DESIGN/MATERIALS AND METHODS

Seventeen patients received five sessions of treatment at weeks 0, 4, 8, 12, 16 and were followed up at week 28. One half of the face was randomly treated by fractional 1064 nm Nd:YAG picosecond laser combined with IPL (FxPico + IPL), and the other by IPL alone as a control.

RESULTS

For the 15 patients who completed the study, the FxPico + IPL side demonstrated significant median Échelle D'évaluation clinique des cicatrices D'acné (ECCA) score improvement (P < 0.01), while IPL alone side did not (P = 0.1250). The pore counts for both sides decreased but more pore count reduction was seen on the FxPico + IPL side (P < 0.05). Better scar improvement was observed on the FxPico + IPL-treated side (P < 0.05) while no difference in erythema improvement was seen between the two sides. There was no difference between the two treatments in terms of overall satisfaction. Pain, erythema, edema, petechiae, crusting, reactive acneiform eruptions, and pruritus were common adverse effects and were mild to moderate.

CONCLUSION

FxPico + IPL is an effective, efficient, and safe treatment regimen for atrophic acne scars complicated by PIE.

Epidemiological Risk Factors Associated with Acne Vulgaris Presentation, Severity, and Scarring in a Singapore Chinese Population: A Cross-Sectional Study

BACKGROUND

Acne vulgaris is classified based on the severity of skin lesions and post-healing scar types of these lesions. Numerous epidemiology studies have investigated the risk factors associated with acne presentation and severity, but studies for acne scarring are lacking.

OBJECTIVE

To investigate the prevalence of acne, severity, and scarring grades and their associated risk factors among Singapore Chinese.

METHODS

A total of 3,888 subjects (2,090 cases/1,798 controls; median age = 21 ± 4.589; range 17-71) completed an investigator-administered questionnaire as part of a cross-sectional study, which included sociodemographics, familial medical history, lifestyle factors, dietary habits, and acne history. Acne cases were further evaluated for their severity (n = 991) and scarring (n = 988) grades by a trained personnel.

RESULTS

The majority of the acne cases had mild acne/grade 1 scarring, while less than 1% had severe acne/grade 4 scarring. Parental acne was significantly associated with acne presentation and moderate/severe acne, while sibling acne was significantly associated with grade 3/4 scarring. Gender and age affected acne severity and scarring but not acne presentation, while tertiary maternal education level and the possession of ≥3 siblings were particularly associated with acne scarring. Underweight BMI was protective against acne presentation, while atopic diseases (asthma, allergic rhinitis, eczema) were its predisposing factors. Of the evaluated lifestyle factors, computer/TV usage had significant association with acne presentation, while alcohol consumption was significantly associated with acne severity. Frequent milk consumption was associated with a protective effect for moderate-severe acne, while frequent butter consumption had a detrimental effect on acne scarring extent.

CONCLUSION

Positive familial history is a strong predisposing factor in determining acne presentation, severity, and scarring. Demographic factors (gender, age) and sedentary lifestyle (increased computer/TV usage) influence acne presentation, while dietary habits (milk and butter consumption) influence acne severity and scarring. The predisposing factors revealed in this study could help us to gain insights into acne pathophysiology and hence develop interventions especially targeting modifiable risk factors.

Benefits of fractional radiofrequency treatment in patients with atrophic acne scars - Literature review

OBJECTIVE

Acne scars carry a huge physical and psychological impact on people. This article aims to evaluate the role of fractional radiotherapy in treatment of atrophic acne scars. The main objective includes providing an up-to-date review of existing literature, presenting the most significant studies conducted in this field.

METHODS

In order to study the impact of fractional radiotherapy on the appearance of atrophic acne scars, we conducted a search on Pubmed using the keywords "fractional radiotherapy", combined with/or "acne", "atrophic acne scars" and "acne scars" and found 75 papers, from which we selected 39.

RESULTS

There are several therapeutic approaches for the improvement of acne scars with variable results and possible side effects. Fractional radiofrequency system has been used widely in the last years, as it turned out to be an effective treatment method, either in combination with other modalities, or alone.

CONCLUSION

There are no generalized clinical guidelines adopted to standardize atrophic acne scar treatment. The multiple therapeutic options available create a dilemma in choosing the proper method in order to enhance its efficacy and to minimize its risks. The accumulated experience in nonablative collagen stimulating devices like fractional radiofrequency has proven that thickening of interstitial fibers in the dermis is possible with a controlled thermal injury, without epidermal damage and development of side effects.

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.

Comparison of Fractional Micro-Plasma Radiofrequency and Fractional Microneedle Radiofrequency for the Treatment of Atrophic Acne Scars: A Pilot Randomized Split-Face Clinical Study in China

BACKGROUND AND OBJECTIVE

Both fractional micro-plasma radiofrequency (RF) and fractional microneedle RF are novel devices that can be applied for the treatment of atrophic acne scars, and they have both been proved to be effective. To compare the clinical effectiveness and adverse reactions of fractional micro-plasma RF and fractional microneedle RF for the therapy of facial atrophic acne scars in a randomized split-face study.

STUDY DESIGN/MATERIALS AND METHODS

Sixty patients with facial atrophic acne scars received three applications at 2-month intervals in a randomized split-face study using fractional micro-plasma RF and fractional microneedle RF on different sides of the face. Three independent dermatologists evaluated the improvement in acne scars using the ECCA grading scale (Echelle d'Evaluation Clinique des Cicatrices d'Acné) by comparing the digital images and graded the improvement in the acne scars. Patients were asked to provide a self-evaluation of satisfaction for efficacy and safety. Adverse effects were also recorded after each treatment.

RESULTS

In total sixty patients completed the entire study. A significant improvement was observed in the appearance of acne scars, and the mean ECCA scores improved significantly after both modalities. The mean decrease in ECCA scores from the baseline was significantly more pronounced in fractional micro-plasma RF as compared with fractional microneedle RF (41.33 ± 20.19 vs 32.17 ± 17.35; P < 0.05). The degree of clinical improvement was also significantly better for fractional micro-plasma RF. Pain, erythema, and swelling were observed in all patients after both treatments. The pain was more intense during micro-plasma RF treatment (P = 0.000), and the duration of pain and erythema were longer than with fractional microneedle RF (P = 0.000). Postinflammatory hyperpigmentation (PIH) was observed in one patient on the fractional micro-plasma RF side while no PIH was observed on the fractional microneedle RF side. No infections or worsening of scarring was observed with either treatment. No subject was dissatisfied with the efficacy of either device. Rolling scars tended to respond better to fractional micro-plasma RF treatment compared with fractional microneedle RF (P = 0.000).

CONCLUSIONS

Both fractional micro-plasma RF and fractional microneedle RF are effective and safe methods for improving atrophic acne scars. Fractional micro-plasma RF is significantly more effective for atrophic acne scars, especially for rolling scars. However, fractional microneedle RF has fewer side effects plus shorter downtime, and patients are more comfortable after the treatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Fractional carbon dioxide laser-assisted delivery of lyophilized-growth factors is a promising treatment modality of post-acne scars

Lyophilized-growth factors (L-GFs), is a new platelet rich plasma (PRP) preparation that is standardized in growth factors concentrations. The aim of this study was to compare the therapeutic efficacy of ablative fractional CO₂ laser in combination with L-GFs vs PRP in post-acne scars. This study was conducted on 45 patients presented with facial post-acne scars. Each patient received three sessions of fractional CO₂ laser on both sides of the face followed by topical application of L-GFs on one side and conventional PRP on the other side. Assessment was done before and after treatment semiquantitatively by Echella d'Èvaluation Clinique des Cicatrices d'Acné (ECCA) score and qualitatively by Goodman and Baron's qualitative scar (GBQS) scale, in addition to dermoscopic evaluation. The current study reported significant clinical improvement of post-acne scars on both sides of the face evidenced by significant reduction of both ECCA score and GBQS scale with minimal side effects. The degree of clinical improvement and patients' satisfaction were significantly higher with shorter downtime in response to fractional CO₂ laser combined with L-GFs rather than its combination with PRP. In conclusion, laser assisted delivery of L-GFs via fractional CO₂ laser could be considered a novel successful therapeutic modality for post-acne scars.

Development and Initial Validation of a Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes

Importance

The qualitative grading of acne is important for routine clinical care and clinical trials, and although many useful systems exist, no single acne global grading system has had universal acceptance. In addition, many current instruments focus primarily on evaluating primary lesions (eg, comedones, papules, and nodules) or exclusively on signs of secondary change (eg, postinflammatory hyperpigmentation, scarring).

Objectives

To develop and validate an acne global grading system that provides a comprehensive evaluation of primary lesions and secondary changes due to acne.

Design, Setting, and Participants

This diagnostic study created a multidimensional acne severity feature space by analyzing decision patterns of pediatric dermatologists evaluating acne. Modeling acne severity patterns based on visual image features was then performed to reduce dimensionality of the feature space to a novel 2-dimensional grading system, in which severity levels are functions of multidimensional acne cues. The system was validated by 6 clinicians on a new set of images. All images used in this study were taken from a retrospective, longitudinal data set of 150 patients diagnosed with acne, ranging across the entire pediatric population (aged 0-21 years), excluding images with any disagreement on their diagnosis, and selected to adequately span the range of acne types encountered in the clinic. Data were collected from July 1, 2001, through June 30, 2013, and analyzed from March 1, 2015, through December 31, 2016.

Main Outcomes and Measures

Prediction performance was evaluated as the mean square error (MSE) with the clinicians' scores.

Results

The scale was constructed using acne visual features and treatment decisions of 6 pediatric dermatologists evaluating 145 images of patients with acne ranging in age from 0 to 21 years. Using the proposed scale to predict the severity scores on a new set of 40 images achieved an overall MSE of 0.821, which is smaller than the mean within-clinician differences (MSE of 0.998).

Conclusions and Relevance

By integrating primary lesions and secondary changes, this novel acne global grading scale provides a more clinically relevant evaluation of acne that may be used for routine clinical care and clinical trials. Because the severity scores are based on actual clinical practice, this scoring system is also highly correlated with appropriate treatment choices.

The early and late efficacy of single-pass fractional carbondioxide laser, fractional radiofrequency, and their combination in acne scars: A prospective, split-face, single-blinded, controlled clinical study

We investigated the effectiveness of fractional carbon dioxide laser (FCO₂ ) vs fractional radiofrequency (FRF) and FCO₂ vs FRF plus FCO₂ combination in the treatment of acne scars. Twenty-seven patients were included. Scar severity was scored with "Echelle d'évaluation clinique des cicatrices d'acné" (ECCA) by a dermatologist blinded to treatment. FCO₂ and FRF were administered to the right and left halves of the patients' faces, respectively, at the first three visits, once a month. At the fourth visit, FCO₂ was administered to both sides. Last evaluation was performed 6 months after the last treatment. Mean ECCA scores for both face halves decreased gradually at each visit compared with Visit-1; however, the effect size of decrease was higher in the right half of the face and in terms of gender differences was higher in women for both sides that the difference was more pronounced for the FRF side. There was no statistically significant change in the mean VAS patient satisfaction scores in the following visits compared with Visit-2 on both halves (P > .05). Side effects were similar; but lasted longer in the FCO₂ side. Both FCO₂ and FRF are effective treatment methods in the treatment of atrophic acne scars. Combining FCO₂ to FRF improves patient satisfaction. FRF may achieve better results in women compared with men. To our knowledge the study is unique prospective, controlled clinical study comparing the efficacy of FCO₂ and FRF plus FCO₂ combination treatments.

A randomized split-face, investigator-blinded study of a picosecond Alexandrite laser for post-inflammatory erythema and acne scars

The 755 nm picosecond Alexandrite laser has been demonstrated to be effective and well tolerated in patients with acne scars. In this split-face, investigator-blinded study, 16 patients with post-inflammatory erythema (PIE) and acne scars were randomized to receive laser treatment on half the face, with the other half serving as a control. The treatment side demonstrated a significant improvement in both PIE and scars compared to the baseline and also when compared to the control side. Treatment was well-tolerated, with only transient and mild erythema and edema reported as side-effects. In our study, the picosecond Alexandrite laser was safe and effective in the treatment of PIE and acne scars. Comprehensive treatment outcomes should be taken into consideration when deciding on which device to use.

Efficacy of non-ablative fractional 1440-nm laser therapy for treatment of facial acne scars in patients with rosacea: a prospective, interventional study

Acne scarring is one of the most common facial skin disorders. The appropriate treatments for acne scars in patients with rosacea have not been studied. This study was designed to evaluate the efficacy and safety of non-ablative fractional 1440-nm laser (1440-nm NAFL) therapy for treatment of atrophic acne scars in patients with rosacea. In this prospective, interventional study, 32 patients with rosacea and acne scars underwent three sessions of 1440-nm NAFL therapy. Therapy efficacy, epidermal barrier function, and side effects were evaluated. Thirty patients completed and the median acne scar scores significantly reduced from 45 (30, 50) to 15 (15, 30) after three treatments (P < 0.001). The improvement score of acne scars was 2.7 ± 0.7; 22 (73.3%) were satisfied or highly satisfied. The rosacea erythema scores changed from 2.1 ± 0.4 to 1.9 ± 0.5 (P = 0.326), and flushing, burning, and stinging were not worse. The oil content after treatments was significantly reduced (P < 0.001), while there was no significant difference in other indicators of skin barrier function. The quality-of-life score decreased from 17.5 ± 3.8 to 14.1 ± 3.0 (P < 0.001). No serious side effects were observed. The 1440-nm NAFL therapy is effective in the treatment of acne scaring in patients with rosacea with little damage to the skin barrier.

Chemical reconstruction of skin scars (CROSS) method for atrophic scars: A comprehensive review

BACKGROUND

Chemical reconstruction of skin scars (CROSS) applies a high strength acid focally to treat atrophic scars. Although this method has gained popularity over the past two decades, no standardized treatment guideline exists for CROSS method in the treatment of atrophic scars.

AIMS

The purpose of this comprehensive review was to evaluate the indications, detailed techniques, efficacy, and safety of CROSS method.

MATERIALS AND METHODS

An extensive literature review was conducted to identify articles relating to CROSS method for atrophic scars from 2002 to 2018.

RESULTS

The literature search yielded 19 articles meeting criteria. CROSS method has been used for the treatment of acne scars, varicella scars, enlarged pores, and depressed surgical scars. In studies using the quantile grading scale for acne scars, 60%-100% of patients showed >25% improvement. In two studies for varicella scars, 83%-100% of patients showed >25% improvement. CROSS method seems to be effective specifically for ice-pick scars. It is well tolerated and safe in Fitzpatrick skin phototypes I-V. Most reported complications are temporary and include postinflammatory dyspigmentation, erythema, pain, pruritus, infection, and widening of scars.

CONCLUSION

This literature review suggests that CROSS method is a safe and effective treatment for atrophic scars, especially ice-pick scars, in skin types I-V. However, current published works have several limitations, including small sample sizes, lack of control group, different concentrations of acid, different frequency of treatments, and follow-up periods. Larger, randomized, controlled studies are needed to elucidate the optimal treatment protocol of CROSS method.

Comparison of a 1064-nm neodymium-doped yttrium aluminum garnet picosecond laser using a diffractive optical element vs. a nonablative 1550-nm erbium-glass laser for the treatment of facial acne scarring in Asian patients: a 17-week prospective, randomized, split-face, controlled trial

BACKGROUND

Novel picosecond lasers using a diffractive optical element (P-DOE) have been available for skin resurfacing with distinct mechanisms. However, there are limited data directly comparing P-DOE and conventional fractional lasers for the treatment of atrophic acne scarring.

OBJECTIVES

We sought to compare the efficacy and safety of a 1064-nm neodymium-doped yttrium aluminium garnet P-DOE and a non-ablative fractional laser (NAFL) in the treatment of acne scarring.

METHODS

A prospective, randomized, split-face, controlled trial was performed. One randomly assigned half-side of each patient's face (n = 25) was treated with four consecutive sessions of P-DOE at 3-week intervals and the other side with NAFL, with subsequent follow-up for 8 weeks after the final sessions. The efficacy and safety of the two lasers were determined by the Echelle d'Evaluation Clinique des Cicatrices d'acné (Scale of Clinical Evaluation of Acne Scars; ECCA) grading scale, Investigator's Global Assessment (IGA) score and patients' reports at the final visit. Histologic analysis was also performed.

RESULTS

The P-DOE-treated side achieved a significantly better improvement in acne appearance (ECCA per cent reduction: 55% vs. 42%) with less severe pain (4.3 vs. 5.6) (P < 0.05). The IGA score and subjective satisfaction were consistent with ECCA score results. Occurrences of treatment-related side-effects were also lower in the group treated with P-DOE (P < 0.05). Histologic analysis revealed elongation and increased density of neocollagen fibres, elastic fibres and mucin throughout the dermis from both sides.

CONCLUSIONS

Compared with NAFL, P-DOE afforded better clinical outcomes and fewer side-effects in the treatment of acne scarring in Asian patients.

Efficacy of 595- and 1319-nm pulsed dye laser in the treatment of acne vulgaris: a narrative review

Acne is one of the commonest problems of adolescence with almost half of the patients experiencing persistence into adulthood. Pulsed dye lasers (PDL) with wavelengths of 585 and 595 nm targeting hemoglobin have been used for the treatment of this condition and its sequelae. Recent introduction of PDL with a higher wavelength of 1319 nm has been reported to offer some benefit to acne patients. We reviewed the literature on the use of 595-nm and 1319-nm PDL in the management of acne. A PubMed literature search for search terms "pulsed dye laser," "acne laser therapy," "light therapy for acne," "595 nm and acne," "1319 nm and acne" was done. Studies, series and case reports were included. These lasers were compared to other lasers and light sources such as 532-nm Potassium Titanyl Phosphate laser, 585-nm PDLs, 1450-nm diode laser, 1540-nm erbium glass laser, intense-pulsed light (IPL), photodynamic therapy, red and blue light and short-pulsed 1064 nm laser utilized in acne management regarding their efficacy. Improvement in acne grading, scale severity or reduction in lesion count indicated substantial efficacy of the laser system utilized.

A novel technique for treating atrophic facial scars in Asians using ultra-pulse CO2 laser

BACKGROUND AND AIMS

Fractional lasers have become increasingly popular for treating atrophic scars, but their effectiveness is limited for deeper scars. We developed a novel technique (manual fractional thermal contraction technology, MFTCT) using an ultra-pulse CO₂ laser and evaluated its efficacy and safety for treating atrophic facial scars.

METHODS

A total of 44 patients with atrophic facial scars were treated with MFTCT every 8 weeks for 1-4 times. Overall scar improvement was assessed by photographs taken at baseline and 3 months after the last treatment according to the 4-point global assessment scale (GAS) and ECCA grading scale. Improvements in color, distortion, and texture were assessed by the modified Manchester Scar Scale and scored individually from 1 to 4. Pain degrees and adverse reactions during and after treatment were recorded.

RESULTS

A total of 44 patients completed the treatment and follow-ups; of them, 89% reported at least 50% overall improvement after the last treatment. The mean ECCA scores fell from 67.50 ± 23.98 to 45.68 ± 18.57 (a 32% improvement), and the change was significant (P = .000). The average score for overall improvement was 3.48. The average scores for color, distortion, and texture were 3.07 ± 0.62, 3.27 ± 0.50, and 3.52 ± 0.51, respectively. Mean pain degree score was 4.27 ± 1.04, and mean erythema duration was 28.43 ± 6.58 days. Some patients developed pigmentation for a few months that resolved with topical treatment.

CONCLUSION

Manual fractional thermal contraction technology has definite clinical efficacy in the treatment of atrophic facial scars with fewer adverse reactions and is worth using in the clinical setting.

Evaluation of the Safety and Efficacy of a Picosecond Alexandrite Laser With DLA for Acne Scars in Chinese Patients

BACKGROUND AND OBJECTIVES

Recently, picosecond laser treatment has been used as an effective treatment for acne scars. To evaluate the efficacy and safety of a picosecond alexandrite laser with a diffractive lens array in the treatment of acne scars in Chinese patients.

STUDY DESIGN/MATERIALS AND METHODS

Patients with facial acne scars were treated with a picosecond alexandrite laser in three sessions at 4- to 6-week intervals and followed up for 2 months. Primary outcomes were measured by physicians' blinded evaluation of the acne scar using the ECCA (échelle d'éva physicians'luation clinique des cicatrices d'acné) grading scale. The secondary outcomes included the investigator global assessment (IGA) on the improvement of post-inflammatory erythema (PIE), patients' assessment of improvement on a 4-point scale and of satisfaction on a 5-point scale. Pain scores and adverse effects were also evaluated.

RESULT

Twenty patients with Fitzpatrick skin types III and IV were enrolled in the study and completed all treatment and follow-up visits. The mean ECCA scores fell from 197.75 ± 35.26 to 142.00 ± 35.92 (a 28% improvement), and the change was significant (P = 0.000). The mean IGA score of PIE improvement was 3.03 ± 0.75 (0 = no improvement and 4 = 76-100% improvement). On the basis of the patients' self-assessment, the average improvement scores were 2.30 ± 0.98 (0 indicating 0-25% improvement and 3 indicating >75% improvement). In total, 50% and 30% of the patients were "satisfied" and "very satisfied," respectively, with the treatment. The mean pain score was 3.20 ± 0.50 (0 = no pain, 10 = maximum pain) with topical anesthesia. The adverse effects included transient and mild erythema, edema, and scabbing.

CONCLUSIONS

Treatment with a picosecond alexandrite laser with a diffractive lens array is effective and safe for acne scars in Chinese patients. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

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.