Acne Scarring Management: Systematic Review and Evaluation of the Evidence

Energy-based devices for the treatment of acne scars: 2021 international consensus recommendations

BACKGROUND AND OBJECTIVES

Acne scars are one of the most distressing and long-term consequences of acne vulgaris, with damaging effect on a person's physical, mental, and social well-being. Numerous treatment options are available including surgical and nonsurgical techniques, depending on the clinical presentation. Although considerable advances in the development of new treatment technologies and applications have been made in the last decade, international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the potential utility of energy-based devices (EBDs) for acne scarring, offer recommendations for safe and efficacious treatment, and provide consensus-based EBD treatment options based on varying presentations demonstrated in a series of real-life clinical photographs.

STUDY DESIGN/MATERIALS AND METHODS

An international panel of 24 dermatologists and plastic surgeons from 12 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the treatment of acne scars. A two-step modified Delphi method took place between March 2020 and February 2021 consisting of two rounds of emailed questionnaires. The panel members approved the final manuscript via email correspondence.

RESULTS

The manuscript includes a comprehensive discussion and panel recommendations regarding the following topics: 1. the role of EBD in mitigating and treating acne scars in a patient with active acne, 2. the use of various EBDs for the treatment of different acne scar types with special focus on commonly used laser platform such as vascular lasers, ablative fractional lasers (AFLs) and non-AFLs (NAFLs), 3. treatment combinations, and 4. acne scar treatments in skin of color. The last part comprised of 10 photos of real-life clinical cases with the panel recommendation treatment plan to achieve best aesthetic outcome.

CONCLUSION

Panel members were unanimous in their view that EBDs have a role in the management of acne scars, with AFLs, NAFLs, vascular lasers, and RF devices preferentially selected by most of the panel experts. EBDs are considered a first-line treatment for a variety of acne scar types and patients without access to these treatments may not be receiving the best available care for optimal cosmetic results. Future high-quality research and updated international treatment guidelines and reimbursement schemes should reflect this status.

Acne scar treatment using high-energy fractional nanosecond Q-switched 1064 nm laser

Aims

The objective of this study was to evaluate the effectiveness and safety of high‐energy ablative fractional nanosecond Q‐switched 1064 nm laser therapy for acne scars.

Material and methods

Forty‐six patients aged from 16 to 69 years and of Fitzpatrick skin type from 2 to 4 were included in this retrospective study. Multiple passes were delivered with a fractional 1064‐nm handpiece at high energy. Results were evaluated using blinded analysis of patient before and after photographs and also by evaluating patient satisfaction.

Results

Most patients (75%) were improved or very improved according to blinded evaluation. Patient satisfaction was high. No hypo/hyperpigmentation, scarring, or any other side effects were reported by any of the patients.

Conclusions

The study demonstrated good clinical outcomes in facial acne scar management with a high patient satisfaction rate and no adverse side effects.

Insights into the mechanism of Cymbopogan martinii essential oil in topical therapy of acne vulgaris

Aim: The present study investigated the essential oil of Cymbopogan martinii (palmarosa oil; PRO) as a potential topical therapy in acne vulgaris. Materials & methods: GC-MS profiling and biocompatibility studies of PRO were undertaken. The antimicrobial potential was assessed against Cutibacterium acnes. anti-inflammatory, antityrosinase activity and lipid peroxidation were also evaluated. Results: Geraniol was identified as the major phytoconstituent, and the oil was found to be safe for topical application. The minimum inhibitory concentration and minimum bactericidal concentration values were noted as 16 μl/ml. PRO reduced the cytokine levels of TNF-α, IL-12 and IL-8 and inhibited tyrosinase. A low concentration of the oil (up to 0.5 μl/ml) produced malondialdehyde levels equivalent to that of untreated cells. Conclusion: PRO may prove useful as a natural topical agent in the management of acne.

A Neglected Acne Scar Type: Papular Acne Scars and Their Correlations With Keloid Scars

BACKGROUND

Acne scarring can be divided into 2 types: atrophic and hypertrophic scars. Papular acne scars are commonly encountered, skin-colored papules on the chin and back.

OBJECTIVE

This study aimed to estimate the prevalence of each acne scar type and to investigate the clinical manifestations of papular acne scars.

METHODS

This retrospective study included 416 patients with acne scars. Dermatologists classified the scars into 3 types (atrophic, papular, and keloid type) based on clinical photographs and analyzed the clinical and histologic features of papular acne scars.

RESULTS

Among 416 patients with acne scars, 410 patients (98.56%) had atrophic scars, 53 patients (12.74%) had keloid scars, and 46 patients (11.06%) had papular acne scars. Twenty patients (4.81%) had both papular and keloid acne scars. Histologic analysis showed fibrotic tissue in both keloid and papular acne scars. Fibrosis of the papular scar was limited to the upper dermis.

CONCLUSION

Papular acne scars were significantly more prevalent in patients with keloid scars than in those without keloid scars. These results provide a basis for understanding papular acne scars, which have been under-recognized. The association between papular and keloid acne scars can suggest the decision for scar treatment.

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

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

Transplantation of autologous fat, stromal vascular fraction (SVF) cell, and platelet-rich plasma (PRP) for cell therapy of atrophic acne scars: Clinical evaluation and biometric assessment

BACKGROUND

Scarring is an unfortunate result of acne because it causes the psychological and cosmetic problems for the patients. Unfortunately, no single treatment is suitable, and using multiple methods may have a better result. The autologous fat and stromal vascular fraction (SVF) cells and their secretory factors can enhance the angiogenesis, collagen synthesis, and migration of fibroblasts, therefore regenerate hurt tissues. Moreover, other treatments for acne scarring, such as platelet-rich plasma (PRP), induce the increase in scare.

AIMS

This study aimed to verify the effectiveness of transplantation of autologous fat, SVF cells, and PRP as cell therapy techniques on atrophic acne scars.

PATIENTS/METHODS

This study included 9 adult patients with atrophic acne scars on face. All patients received the transplantation of autologous fat, stromal vascular fraction (SVF) cells, and PRP. The treatment outcome was measured by biometric assessment (VisioFace 1000 D, Colorimeter, multi-probe adapter Cutometer, Tewameter, Mexameter, and skin ultrasound imaging system), and also, the satisfaction of patients was evaluated. The patients were followed 6 months after the treatment.

RESULTS

There was a significant improvement in the skin pores, spots, skin lightness and melanin content of skin, skin elasticity, and TEWL (transepidermal water loss) after 6 months of the treatment. Furthermore, denser skin layers were observed both in the epidermis and in the dermis. Moreover, 66.6% of patients showed good satisfaction after the treatment.

CONCLUSION

In brief, the transplantation of autologous fat, SVF cells, and PRP is an effective cell therapy for atrophic acne scars.

[Scientometric analysis of evidence-based studies of physical methods of post-acne scar correction]

The scope of physical methods for correcting the pathological skin scars is rapidly growing but the results of their use are often unsatisfactory. An inadequate approach to therapy without taking into account the assessment of their effectiveness leads to relapses, increased growth of scar tissue or the absence of a clinically significant effect which requires strict scientific evidence in the course of benign scientific studies.

OBJECTIVE

Scientometric analysis of evidence-based studies on the use of therapeutic physical factors in the correction of post-acne scars.

MATERIAL AND METHODS

The analysis of evidence-based studies in electronic databases (PEDro, PubMed, eLibrary) and in databases of systematic reviews (Cochrane database) for the period from 2015 to 2020 was carried out. The following terms in Russian and English were taken as key words: acne scars (acne scarring), physical therapy (physical therapy). The final assessment of physical methods of correction included mainly data from foreign systematic reviews, meta-analyzes of RCTs, data from individual RCTs in English and/or Russian and tests rated at 4 points or higher on the PEDro scale.

RESULTS

The clinical effects and supposed mechanisms of action of the currently proven therapeutic physical factors in the treatment of patients with post-acne scars are considered in detail. The most studied physical methods are technologies of high-intensity laser therapy (44.2%), fractional radiofrequency therapy (17%), combined methods of exposure (high-intensity laser therapy or micro-needling in combination with peels, fillers, PRP injection) (25%), micro-needling as monotherapy (5.8%) and microdermabrasion (4.5%) causing the most significant clinical changes and pronounced remodeling of the extracellular matrix of the skin in the area of scars.

CONCLUSION

There is a need for regular synthesis and analysis of existing evidence-based studies, as well as the implementation of new high-quality randomized controlled clinical trials to study the effect of physical correction methods on post-acne scars which serve as the basis for the development of clinical guidelines.

ABT-263 Reduces Hypertrophic Scars by Targeting Apoptosis of Myofibroblasts

Background: Inhibiting proliferation and inducing apoptosis of myofibroblasts is becoming one of the promising and effective ways to treat hypertrophic scar. ABT-263, as an orally bioavailable BCL-2 family inhibitor, has showed great antitumor characteristics by targeting tumor cell apoptosis. The objective of this study was to explore whether ABT-263 could target apoptosis of overactivated myofibroblasts in hypertrophic scar. Methods: In vivo, we used ABT-263 to treat scars in a rabbit ear scar model. Photographs and ultrasound examination were taken weekly, and scars were harvested on day 42 for further Masson trichrome staining. In vitro, the expression levels of BCL-2 family members, including prosurvival proteins, activators, and effectors, were detected systematically in hypertrophic scar tissues and adjacent normal skin tissues, as well as in human hypertrophic scar fibroblasts (HSFs) and human normal dermal fibroblasts (HFBs). The roles of ABT-263 in apoptosis and proliferation of HSFs and HFBs were determined by annexin V/PI assay, CCK-8 kit, and cell cycle analysis. Mitochondrial membrane potential was evaluated by JC-1 staining and the expression of type I/III collagen and α-SMA was measured by PCR, western blotting, and immunofluorescence staining. Furthermore, immunoprecipitation was performed to explore the potential mechanism. Results: In vivo, ABT-263 could significantly improve the scar appearance and collagen arrangement, decrease scar elevation index (SEI), and induce cell apoptosis. In vitro, the expression levels of BCL-2, BCL-XL, and BIM were significantly higher in scar tissues and HSFs than those in normal skin tissues and HFBs. ABT-263 selectively induced HSFs apoptosis by releasing BIM from binding with prosurvival proteins. Moreover, ABT-263 inhibited HSFs proliferation and reduced the expression of α-SMA and type I/III collagen in a concentration- and time- dependent manner. Conclusion: HSFs showed increased mitochondrial priming with higher level of proapoptotic activator BIM and were primed to death. ABT-263 showed great therapeutic ability in the treatment of hypertrophic scar by targeting HSFs.

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.

Nonprescription acne vulgaris treatments: Their role in our treatment armamentarium-An international panel discussion

BACKGROUND

Acne vulgaris (acne), a common inflammatory skin disorder, has its peak incidence between 14 and 19 years of age, with girls frequently developing acne earlier than boys. Over recent years, persistent acne is becoming more prevalent in adult women.

OBJECTIVES

This review and panel discussion addresses challenges in acne management, particularly in adult women. The role which nonprescription acne treatment can play is explored when used as monotherapy or as an adjunctive treatment for acne of all severity.

METHODS

The best available evidence on nonprescription acne treatment was coupled with the opinion of an international expert panel of dermatologists to adopt statements and recommendations discussed in this review.

RESULTS

All severity of acne has a significant burden on patients. Addressing environmental factors that are important for the individual with acne may help to educate, prevent, effectively manage, and maintain acne, as per the panel. They agreed that the adult female acne population has unique needs because of their aging skin and social environment. Nonprescription acne treatment products may help to balance the efficacy and tolerability of prescription acne treatment. Currently, there are no specific guidelines for how to use nonprescription acne treatment products in these patients.

CONCLUSION

The panel agreed that guidelines including nonprescription acne treatment either as monotherapy for mild acne or in combination with prescription treatments for more severe acne would address a significant unmet need.

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.

Treatment of atrophic acne scars with combination therapy of chemical reconstruction of skin scars method and fractionated nonablative laser: A retrospective analysis

BACKGROUND

Patients with acne scarring often have several types of acne scars, and combination therapies have demonstrated superior success to single treatment modalities. Chemical reconstruction of skin scars (CROSS) has gained popularity as the treatment for ice-pick scars and fractionated laser therapy for rolling and boxcar scars. However, no study has looked at combination therapy with CROSS and fractionated nonablative laser for the treatment of atrophic acne scars.

AIMS

We sought to evaluate the efficacy and safety of combination therapy with CROSS and fractionated nonablative laser for atrophic acne scars.

METHODS

We conducted a retrospective analysis of patients treated with CROSS followed by fractionated nonablative laser treatment in the same visit for acne scars from 2016 to 2020. Treatment efficacy, defined as the percentage improvement in the appearance of acne scars, was assessed using a 5-point scale: score 0 (worsening or 0% improvement), 1 (1% - 25%), 2 (26% - 50%), 3 (51%-75%), and 4 (76%-100%).

RESULTS

Twenty-five patients (14 females and 11 males, Fitzpatrick Skin Type II -V) were enrolled. The average improvement score was 2.07 after 3 sessions and 2.78 after 5 sessions. All subjects reported satisfaction, while 24% were very satisfied. There were no permanent adverse effects, and only one patient developed a temporary hypertrophic scar.

CONCLUSION

We concluded that combination therapy with CROSS and fractionated nonablative laser in the same visit is an effective and safe treatment option for atrophic acne scars in patients with various skin types, including skin of color.

Fractional carbon dioxide laser combined with intradermal injection of autologous platelet-rich plasma versus noncross-linked hyaluronic acid in the treatment of atrophic postacne scars: A split face study

BACKGROUND

Atrophic acne scarring is a common cosmetic problem that may affect 95% of patients with acne.

AIMS

The objective is to evaluate the efficacy of the fractional CO₂ laser combined with intradermal injection of PRP versus intradermal injection of noncross-linked hyaluronic acid in the treatment of different types of atrophic postacne scars.

METHODS

The study included 30 patients with postacne scars. All the patients received 3 treatments of fractional CO₂ laser combined with intradermal injection of PRP at one side of the face compared with intradermal injection of noncross-linked hyaluronic acid at the other side of the face. Efficacy of the treatment was assessed by the physician's clinical assessment using Goodman and Baron's qualitative and quantitative grading systems and histopathological evaluation from six participants.

RESULTS

The study included 30 patients ages ranging from 25 to 44 years old. There was a statistically significant reduction in the severity of acne scars on both sides after treatment using qualitative and quantitative Goodman and Baron. Histopathological evaluation showed an increase in the collagen and elastic fiber content in both modalities with a more favorable outcome in the PRP-treated side.

CONCLUSION

Both treatment modalities resulted in a significant clinical and histopathological improvement in atrophic postacne scar with insignificant difference between them.

Update in minimally invasive periorbital rejuvenation with a focus on platelet-rich plasma: A narrative review

BACKGROUND

The periorbital region is among the first areas to be affected by the process of aging, which is influenced by genetic and constitutional factors. As the region plays an important role in overall facial appearance, rejuvenation of the area has immense cosmetic benefit and various treatment modalities have been used to achieve the same.

AIMS

This article reviews commonly used non-surgical and minimally invasive modalities for periorbital rejuvenation.

METHODS

The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles. Only articles available in English were considered for this review.

RESULTS

Autologous platelet rich plasma (PRP) is increasingly used in dermatology for skin and hair conditions. The use of PRP is rapidly growing in popularity as a modality to achieve skin rejuvenation. The mechanism by which PRP leads to skin rejuvenation is by increasing the dermal fibroblast proliferation, expression of matrix metalloproteinase and collagen synthesis.

CONCLUSION

The evidence discussed in this article indicates the increasing importance of minimally invasive modalities in periorbital rejuvenation and a promising role for PRP as solo therapy or in multimodality regimens.

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

BACKGROUND AND OBJECTIVES

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

STUDY DESIGN/MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Low-Level Radiofrequency Exposure Does Not Induce Changes in MSC Biology: An in vitro Study for the Prevention of NIR-Related Damage

Background

The ubiquitous diffusion of radiofrequency (RF) radiation across human living environments has attracted the attention of scientists. Though the adverse health effects of RF exposure remain debatable, it has been reported that the interaction of such radiation with biological macromolecular structures can be deleterious for stem cells, inducing impairment of their main functions involving self-renewal and differentiation.

Purpose

The purpose of this study was to determine whether exposure to RF of 169 megahertz (MHz) that is part of very high radiofrequency (VHF) range 30–300 MHz, could cause damage to stem cells by inducing senescence and loss of regenerative and DNA repair capacity.

Methods

The study was conducted on mesenchymal stromal cells (MSCs) containing a subpopulation of stem cells. The MSCs were exposed to RFs of 169 MHz administered via an open meter 2G “Smart Meter” for different durations of time.

Result

We did not observe modifications in MSC biology as a result of the RF exposure conducted in our experiments.

Conclusion

We concluded that MSCs are insensitive to RF radiation exposure at 169 MHz for various time intervals, including longer durations.

Analysis of acne-related judicial precedents from 1997 to 2018 in South Korea

Medicolegal disputes are increasing in practical medicine. Medications or procedures related to acne could lead to medical malpractice. This study analyzed medical litigation associated with acne in South Korea. Acne-related judgments were searched using the Supreme Court of Korea's Written Judgment Management System based on the keyword "acne". Eleven cases were selected; eight cases were related to acne scar and three cases were related to acne. Treatment modalities such as peeling, laser treatment, photodynamic therapy and antibiotics resulted in lawsuits. Claimed sequelae of the treatments were hyperpigmentation, scar worsening, erythema, skin bumps and liver transplant. Eight cases were awarded to the plaintiff, and the others were dismissed. This study shows that various treatments for acne can cause medical disputes.

Evaluation of autologous adipose-derived stem cells vs. fractional carbon dioxide laser in the treatment of post acne scars: a split-face study

BACKGROUND

Scarring is a distressing outcome of acne, as it causes cosmetic and psychological problems to the patients. Unfortunately no single treatment is satisfactory; instead, employing multiple modalities may have better outcome. Autologous adipose tissue-derived adult stem cells (AT-ASCs) and their secretory factors can stimulate collagen synthesis; angiogenesis and migration of fibroblasts thus regenerate damaged tissues. Also, conventional treatments for acne scarring, such as lasers and topical regimens, induce new collagen synthesis via activation of dermal fibroblasts or growth factors. The aim of the study was to verify the effectiveness of AT-ASCs for the treatment of acne scarring vs. the fractional carbon dioxide laser (FxCR).

SUBJECTS AND METHODS

Split face comparative study included 10 adult patients with post-acne scars on both sides of the face. One side received AT-ASCs single injection while the other received three sessions of FxCR. Scars were then assessed using the global scoring system Goodman and Baron, scar area percent using NIH ImageJ software and functional assessment by measuring the transepidermal water loss (TEWL) and skin hydration. Both sides were followed for three months.

RESULTS

A significant improvement in the degree of scar severity, scar area percent, skin hydration, and TEWL after 3 months of treatment on both sides of the face with insignificant differences between both treatment modalities, provided that AT-ASCs treatment was employed once vs. three sessions of FxCR.

CONCLUSION

One injection of AT-ASCs is as effective as three sessions of FxCR in the treatment of atrophic acne scars.

Combination therapy using subcision, needling, and platelet-rich plasma in the management of grade 4 atrophic acne scars: A pilot study

BACKGROUND

Multimodality therapies including minimally invasive modalities are increasingly used in atrophic scarring.

OBJECTIVE

To evaluate the role of platelet-rich plasma (PRP) as adjunctive therapy to a combined subcision and needling treatment in severe (grade 4) atrophic acne scarring.

METHODS

A total of 30 patients with grade 4 acne scars were randomly divided into two groups, 15 patients each: Group A underwent three sequential treatments of subcision and needling while Group B, three sequential treatments of subcision, needling, and topical application of PRP that were performed at 3-week intervals. Scar grading was assessed 3 months following the final session. Participant's assessment of treatment response was registered.

RESULTS

Scar improvement ≥50% was reported significantly more often by Group B than Group A patients (P = 0.025). Regarding physician-based assessment of scar grading post-therapy (number of patients with two grades improvement vs one grade or no improvement), there was a trend toward more improvement in Group B (P = 0.195). Physician's evaluation of acne scar improvement correlated with the patient's assessment of improvement: 60% of Group A and 66.6% of Group B patients appreciated an improvement of 25%-49% and 50%-74%, respectively. Mean duration of postprocedure erythema/edema was shorter among Group B than Group A patients (16.1 vs 32.9 hours, respectively). Overall, substantial improvement was noticed in rolling and boxcar scars with only a mild change in icepick scars.

CONCLUSION

Platelet-rich plasma appears to add to the improvement of grade 4 atrophic acne scars when combined with needling and subcision. These findings require further evaluation by future studies.

Efficacy of Autologous Platelet-Rich Plasma Combined With Ablative Fractional Carbon Dioxide Laser for Acne Scars: A Systematic Review and Meta-Analysis

BACKGROUND

Acne scars are common and challenging clinical complications of acne vulgaris. Ablative fractional carbon dioxide (CO2) laser is a well-established treatment for acne scars; however, some postlaser adverse effects have been noted. Autologous platelet-rich plasma (PRP) can improve tissue regeneration. Several studies have investigated the efficacy of combination therapy of CO2 laser and PRP for acne scars.

OBJECTIVES

The authors sought to conduct a meta-analysis of the efficacy of PRP combined with ablative fractional CO2 laser for treating acne scars by examining clinical trial results.

METHODS

A systematic review was performed by searching PubMed, Embase, Cochrane Library, and Web of Science, and a meta-analysis was conducted to assess the clinical outcomes after combination therapy of PRP and ablative fractional CO2 laser compared with laser alone.

RESULTS

We identified 4 eligible studies for the meta-analysis, including 3 randomized controlled trials. Our results demonstrated that clinical improvement after combination therapy was significantly higher than that after laser alone (odds ratio = 2.992, P = 0.001). Regarding major side effects, patients who underwent combination therapy experienced significantly shorter duration of crust compared with CO2 laser alone (standard mean difference = -1.140, P < 0.001); relatively shorter durations of erythema and edema were also noted after combination therapy. Furthermore, patient satisfaction rates were significantly higher after combination therapy than after laser alone (odds ratio = 3.169, P = 0.002).

CONCLUSIONS

The combination of autologous PRP and ablative fractional CO2 laser has synergistic positive effects on the clinical outcomes for acne scars and can accelerate the recovery of laser-damaged skin.

LEVEL OF EVIDENCE: 2