Aluminum oxide crystal microdermabrasion. A new technique for treating facial scarring

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.

A Comprehensive Review of Non-Energy-Based Treatments for Atrophic Acne Scarring

Scarring is a dire consequence of acne vulgaris. Particularly, atrophic acne scarring is highly prevalent among young adults, and its physical and psychological effects can persist throughout their lives if left untreated. This literature review will analyze various non-energy-based approaches to treating atrophic acne scarring, emphasizing recent advances within the last 5 to 10 years. To accomplish this, we performed a PubMed search for various acne scar treatments such as chemical peels, dermabrasion, microdermabrasion, subcision, microneedling, punch techniques, dermal fillers, and thread lifting. Our findings and analysis show that there is no panacean solution to treating atrophic acne scars, which explains the evolving trend towards developing unique combinatorial treatments. Although a fair comparison of each treatment approach is difficult to achieve due to the studies’ varying sample sizes, strength of evidence, treatment execution, etc, there still remains a level of consensus on what treatments are well suited for particular scar types.

Microdermabrasion: a clinical, histometric, and histopathologic study

BACKGROUND

Microdermabrasion is a nonchemical superficial resurfacing procedure that removes the stratum corneum. Because it is a somewhat subtle procedure, it may be difficult to demonstrate its cosmetic benefit.

OBJECTIVES

To assess the efficacy of microdermabrasion in treatment of melasma, postacne scarring, striae distensae, and photoaging by a series of microdermabrasion sittings through clinical, histometric, and histopathologic analysis.

PATIENTS AND METHODS

The study was conducted on 38 patients constituting four groups (melasma, acne scars, striae destinsae, and photoaging), each patient was subjected to a series of 8 microdermabrasion treatments performed at 1-week interval. Punch biopsies, at base line, 1 week after the 4th and the 8th session, were obtained from each subject for histometric and histopathologic analysis.

RESULTS

Clinically, the improvement in melasma, acne scars, and striae distensae groups was mainly mild to moderate, while in photoaging group was mainly mild. Histometric analysis of epidermal thickness showed insignificant changes in all groups. Histopathologically, decreased melanization and regular distribution of melanosomes in the epidermis were noted in melasma group while increased density of collagen fibers with more regular arrangement in collagen bundles was detected in all candidates of acne scars, striae distensae, and photoaging groups. Meanwhile, Orcein stain did not show any significant changes in elastic fibers.

CONCLUSIONS

Microdermabrasion is an easy and safe technique. In this study, most cases showed mild to moderate improvement. Decreased melanization with regular distribution of melanosomes and increased collagen density with regular arrangement of collagen bundles were the most common observed histologic changes.

The effect of physically applied alpha hydroxyl acids on the skin pore and comedone

OBJECTIVE

Alpha hydroxy acids (AHA) have been recognized as commonly used therapy for acne. Our studies examined whether an additional effect of physical treatment using chemical peeling combined with negative pressure and compared with AHA treatment only occurs in acne-prone subjects.

METHODS

The chemical peeling agent used 4% of an AHA solution (mixture of 1000 mL of carbonated water, 20 mL of glycolic acid and 20 mL of lactic acid). All subjects' faces were randomly divided into test and control groups. The test group was treated with chemical peeling combined with a physical effect, and the control group applied chemical peeling alone. For the 23 healthy females (average age: 30.17 ± 5.06 year), we measured sebum output level by light transmission, pore area and number by optical image analyser, and comedone counting before treatment and at 1, 2 and 4 weeks after a single treatment.

RESULTS

Compared to the before treatment, whiteheads and blackheads were significantly decreased at 1, 2 and 4 weeks in the test group (P < 0.05), but for the control group, whiteheads and blackheads showed a tendency to decrease at 1, 2 and 4 weeks. Also at 1 week, whiteheads and blackheads of the test group significantly decreased compared to the control group (P < 0.05). Pore area and number significantly decreased at 1 week (P < 0.05), and the sebum output level was significantly decreased at 4 weeks (P < 0.05) only in the test group, which did not show any significant group difference for individual parameters.

CONCLUSION

4% AHA solution combined with a physical effect had rapidly improving effects on whiteheads and blackheads synergistically. Combined physical therapy may have more impact on pore size and seborrhoea.

A Systematic Study of the Catalytic Behavior at Enzyme–Metal-Oxide Nanointerfaces

Metal-oxide nanoparticles with high surface area, controllable functionality and thermal and mechanical stability provide high affinity for enzymes when the next generation of biosensor applications are being considered. We report on the synthesis of metal-oxide-based nanoparticles (with different physical and chemical properties) using hydrothermal processing, photo-deposition and silane functionalization. Physical and chemical properties of the user-synthesized nanoparticles were investigated using scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDX), and Raman scattering, respectively. Thus, characterized metal-oxide-based nanoparticles served as nanosupports for the immobilization of soybean peroxidase enzyme (a model enzyme) through physical binding. The enzyme–nanosupport interface was evaluated to assess the optimum nanosupport characteristics that preserve enzyme functionality and its catalytic behavior. Our results showed that both the nanosupport geometry and its charge influence the functionality and catalytic behavior of the bio-metal-oxide hybrid system.

Current status of surgery in dermatology

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Exploration of nonsurgical scar modification options: can the irregular surface of matured mesh graft scars be smoothed with microdermabrasion?

The purpose of this study was to determine, in principle, whether microdermabrasion can alter waffle-pattern (meshed split-thickness skin graft) burn scars after scar maturation. Matured waffle-pattern mesh-graft scars were treated with multiple microdermabrasion sessions over the course of a year (maximum 20). Before and after treatment, the treated scars and the control scar on the same patient were assessed with subjective and objective scar assessment tools (scar scales, cutometer [elasticity], laser Doppler flowmeter [vascularity], Semmes-Weinstein filaments [sensation], and high-resolution ultrasound [thickness]). The treatment resulted in continuous improvement of some physiologic skin functions like perfusion response (feedback), thickness, and elasticity when compared with nontreated scar, although no statistical significance was reached. Both Vancouver scar scale and patient assessment scales showed significant improvement. The study showed that even mature waffle pattern scars can be modified by minimally invasive interventions. Larger study groups and more economic treatment modalities need to be studied in the future.

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.

Microdermabrasion: an evidence-based review

Microdermabrasion is a popular technique used in the treatment of several skin problems, including acne, acne scarring, striae distensae, and photoaging. This article will review the relevant literature and use an evidence-based approach to evaluate the clinical efficacy of microdermabrasion in skin care. In summary, microdermabrasion appears to be a procedure that can produce changes in dermal matrix constituents and result in improvement in skin contour irregularities. It may also be beneficial in improving transepidermal delivery of certain medications. Its role in the treatment of dyschromias and acne vulgaris is limited.

Acne: more than skin deep

Acne is one of the most prevalent skin conditions affecting teenagers. It is a disease of the pilosebaceous unit. Blockage of sebaceous glands and colonisation with Proionobacterium acnes leads to acne. Grading the severity of acne helps to determine the appropriate treatment. Treatment of acne should be started as early as possible to minimise the risk of scarring and adverse psychological effects. It should be tailored to the individual patient, the type of acne, its severity, the patient's ability to use the treatment, and the psychological state. Topical agents are the mainstay for treatment of mild acne. Moderate acne is treated with oral antibiotics. Resistance to antibiotics may be reduced by subsequent use of non-antibiotic topical medications. Severe acne is treated with isotretinoin, and this can lead to permanent remission. With better education and care given by medical profession, acne treatment could be significantly improved.

Microdermabrasion: Reappraisal and brief review of literature

BACKGROUND

Microdermabrasion (MDA) is a recently introduced noninvasive, nonsurgical, office-based esthetic procedure for revitalizing and rejuvenating the skin. It is a closed-loop vacuum-assisted abrasive procedure, which uses the physical action of inert crystals to exfoliate the skin.

OBJECTIVE

The aim was to evaluate the procedure of MDA in postacne scarring, melasma, and facial rejuvenation, and review the relevant literature.

METHODS

Ten patients each of postacne scarring, melasma, and facial rejuvenation were treated by a series of weekly MDA sittings alone or in conjunction with a topical retinoid. The results were assessed by patient questionnaire and an objective assessment by two independent observers. The literature was reviewed to find indications and efficacy of MDA.

RESULTS

All the patients of postacne scarring, melasma, and facial rejuvenation reported a mild but definite improvement, which increased when MDA was performed in conjunction with a topical retinoid. Most of the literature based on subjective and patient-dependent assessment parameters points toward a marginal improvement in the skin appearance following repeated procedures.

CONCLUSION

Reappraisal of this potentially useful procedure points toward a need for well-designed clinical trials and studies with a long follow-up based on objective assessment parameters.

Effect of serial microdermabrasion on the ceramide level in the stratum corneum

BACKGROUND

Microdermabrasion has become a popular method for superficial resurfacing of the epidermis. Despite the popularity of this technique, few studies have examined changes in the levels of lipids (especially ceramide) in the stratum corneum following microdermabrasion.

OBJECTIVE

To assess and analyze changes in the ceramide level in the stratum corneum during the course of serial aluminum oxide microdermabrasion.

METHODS

Eleven healthy volunteers were enrolled in this study. Each participant underwent microdermabrasion once a week for 5 weeks. Following each procedure, the ceramide level in the resulting epidermal scales was measured.

RESULTS

A statistically significant increase in the ceramide level in the stratum corneum was observed following the first and second microdermabrasion sessions. After the third and fourth sessions, the ceramide level returned to baseline.

CONCLUSION

The results suggest that microdermabrasion alters the epidermal ceramide level. These findings provide the first evidence of alterations in the lipid barrier following microdermabrasion.

Microdermabrasion

BACKGROUND

Microdermabrasion has become one of the most popular forms of superficial resurfacing. The benefits and efficacy of microdermabrasion remain an intensely debated topic among dermatologic surgeons.

OBJECTIVE

This article reviews the efficacy, safety, epidermal barrier function, histopathologic effects, complications, advantages, and disadvantages of microdermabrasion.

CONCLUSION

In general, microdermabrasion studies have been conducted in small groups of patients. Protocols, units, and settings have differed. There remains a major disparity between the popularity of microdermabrasion in the public sector and cohesive and comprehensive scientific data documenting the efficacy of the procedure.

Microdermabrasion

Microdermabrasion is a simple, safe, office cosmetic procedure in which aluminum oxide crystals or other abrasive substances are blown onto the face, then vacuumed off, using a single handpiece. This procedure has rapidly become widely utilized for a variety of cosmetic objectives, including the improvement of photoaging, hyperpigmentation, acne, scars and stretch marks. Despite its widespread use, little is known about its actual mechanism of action. The few published studies suggest that patients and physicians alike report a mild benefit when microdermabrasion is utilized for photoaging. Histologic evaluation reveals little actual abrasion of the skin with the procedure, yet changes are seen in the dermis. Given the safety, simplicity and patient satisfaction associated with microdermabrasion, it is likely to remain a popular treatment.

Subcision for acne scarring: technique and outcomes in 40 patients

BACKGROUND

Treatment of acne scars is a therapeutic challenge that may require multiple modalities. Subcision is a technique that has been anecdotally reported to be of value in treating so-called "rolling scars."

OBJECTIVES

To assess the efficacy of subcision in the treatment of "rolling" acne scars.

METHODS

A standard technique was developed for subcision. This was then applied to the treatment of rolling scars in patients, 40 of whom completed treatment and the prescribed follow-up. Six-month follow-up data were obtained from both patients and investigators.

RESULTS

Subcision is associated with patient and investigator reports of approximately 50% improvement. Ninety percent of treated patients reported that subcision improved their appearance. The side effects of swelling, bruising, and pain are transient, but patients may have persistent firm bumps at the treatment site.

CONCLUSIONS

Subcision appears to be a safe technique that may provide significant long-term improvement in the "rolling scars" of selected patients. When complete resolution of such scars does not occur, combining subcision with other scar revision procedures or repeat subcision may be beneficial.

Lasers and microdermabrasion enhance and control topical delivery of vitamin C

The objective of this study was to evaluate the ability of lasers and microdermabrasion, both of which are skin resurfacing modalities, to enhance and control the in vitro skin permeation and deposition of vitamin C. The topical delivery of magnesium ascorbyl phosphate, the pro-drug of vitamin C, was also examined in this study. All resurfacing techniques evaluated produced significant increases in the topical delivery of vitamin C across and/or into the skin. The erbium:yttrium-aluminum-garnet (Er:YAG) laser showed the greatest enhancement of skin permeation of vitamin C among the modalities tested. The laser fluence and spot size were found to play important parts in controlling drug absorption. An excellent correlation was observed in the Er:YAG laser fluence and transepidermal water loss, which is an estimation of skin disruption. Permeation of magnesium ascorbyl phosphate was not enhanced by the Er:YAG laser. The CO2 laser at a lower fluence promoted vitamin C permeation with no ablation of the stratum corneum or epidermal layers. Further enhancement was observed with the CO2 laser at higher fluences, which was accompanied by a prominent ablation effect. Microdermabrasion ablated the stratum corneum layers with minimal disruption of the skin barrier properties according to transepidermal water loss levels. The flux and skin deposition of vitamin C across microdermabrasion-treated skin was approximately 20-fold higher than that across intact skin. The techniques used in this study may be useful for basic and clinical investigations of enhancement of topical vitamin C delivery.

Dermabrasion in dermatology

Dermabrasion has been used for a number of years to treat a variety of dermatologic conditions, including facial skin resurfacing and scar revision. The popularity of this procedure has diminished with the advent of newer procedures including chemical exfoliation, laser resurfacing, non-ablative laser resurfacing, and microdermabrasion. Dermabrasion found its niche in treating acne and traumatic facial scars, and in cosmetic facial resurfacing. Small, portable hand-held dermabraders are the most popular units available today and are able to generate rotation speeds of 18,000-35,000 revolutions per minute. End pieces, including wire brushes, diamond fraises and serrated wheels, attach to the end of the dermabrader to allow precise resurfacing and treatment. As with all cosmetic surgical procedures, appropriate patient selection and room preparation (with appropriate lighting and monitoring equipment) are essential to assure optimal outcomes with the dermabrasion procedure. Patients must understand all of the potential risks, benefits and limitations associated with the procedure. Patients must also be aware of alternative therapies that are available. Dermabrasion is technique-dependent and the surgeon should be well versed on the technique prior to performing this therapy. Gentian violet solution is used to delineate the areas to be treated. Refrigerant topical anesthesia is used to freeze the skin prior to the procedure. Holding the skin taut, the dermabrasion procedure occurs in a routine manner, treating one anatomic unit at a time. Postoperatively, patients may have an open or closed dressing system. Postoperative medical treatment is also recommended, including the use of antiviral agents, antibacterials and corticosteroids. The re-epithelialization process is usually complete in 5-7 days and residual erythema is common for up to 4 weeks. Adequate sun protection is essential following dermabrasion. Dermabrasion has also been used in combination with other dermatologic procedures, including chemical exfoliation, soft tissue augmentation and laser procedures, to enhance the results of dermabrasion. Dermabrasion remains a useful facial skin resurfacing and scar revision technique, particularly when performed by a trained and skilled surgeon. Most dermatologic surgeons argue that pure dermabrasion is a useful modality in skilled surgical hands and should be considered when appropriate.

Post acne scarring: a review

Historically, post acne scarring has not been well treated. New techniques have been added and older ones modified to manage this hitherto refractory problem. The patient, his or her expectations and overall appearance as well as the morphology of each scar must be assessed and treatment designed accordingly. Upon reaching an understanding of what the pathology of the scar is and where it resides in the skin, the most pertinent treatment for that scar may be devised. Post acne scars are polymorphous and include superficial macules, dermal troughs, ice picks, multi-channelled fistulous tracts and subcutaneous atrophy. The wide variety of new methods includes the latest resurfacing tools such as CO(2) and erbium infrared lasers, dermasanding and possibly some future techniques such as non-ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous (including fat and blood transfer) and non-autologous tissue augmentation and the advent of tissue undermining has greatly improved the treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser and intralesional cytotoxics are interesting developments. Most often occurring extra-facially and in males, these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.

Microepidermabrasion: an adjunct to medical skin care

Microepidermabrasion has become a common modality in aesthetic skin care in doctor's offices as well as in the hands of skin care specialists. The basics of particle beam resurfacing are discussed, with an emphasis on patient selection, technique, and after care. Concerns about current technology are reviewed, and insight into the evolution of new technologies is given.

The epidermal and dermal changes associated with microdermabrasion

BACKGROUND

Microdermabrasion has become a popular method of skin rejuvenation for treating dyschromia, fine wrinkles, and mild scarring.

OBJECTIVE

To analyze the onset and extent of the dermatologic changes associated with microdermabrasion.

METHODS

Ten volunteers, ages 31-62 years, underwent a series of six aluminum oxide microdermabrasion facial treatments 7-10 days apart. Skin biopsy specimens were obtained prior to the study, after three treatments, and after six treatments.

RESULTS

Compared to the controls, the treated areas demonstrated the following histologic changes: thickening of the epidermis and dermis, flattening of the rete pegs, vascular ectasia and perivascular inflammation, and hyalinization of the papillary dermis with newly deposited collagen and elastic fibers.

CONCLUSION

This study suggests that microdermabrasion produces clinical improvement by a mechanism resembling a reparative process at the dermal and epidermal levels.

Management of post-acne scarring. What are the options for treatment?

Post-acne scarring is a very distressing and difficult problem for physician and patient alike. Recently, newer techniques and modifications to older ones may make this hitherto refractory problem more manageable. Options for dealing with post-acne scarring are explored. The patient, his or her overall appearance and the morphology of each scar must be assessed and treatment designed accordingly. To adequately address the patient with scarring, a thorough knowledge of the pathophysiology and anatomy of the different types of scars should be sought. Once an understanding of what the pathology is and where it is occurring is attained, the most pertinent treatment for that scar may be devised. A variety of post-acne scars is produced including superficial macules, dermal troughs, ice picks, multi-channelled fistulous tracts and subcutaneous atrophy. The wide variety of new treatment methods for post-acne scarring includes newer resurfacing tools such as CO2 and erbium infrared lasers, dermasanding and possibly some future techniques such as non-ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous and nonautologous tissue augmentation and the advent of tissue undermining have greatly improved treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser, and intralesional cytotoxics are interesting developments. Most often occurring extra-facially and in males these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.