Acne scarring: A review and current treatment modalities

Effectiveness of onion extract gel on surgical scars in asians

Background. Onion extracts have been shown in vitro to accelerate wound healing. Results from clinical studies on surgical scars in Caucasians were disappointing. The aim of this study is to evaluate the effectiveness of onion extract gel in improving the cosmetic and symptoms of surgical scars in Asians. Patients/Methods. Twenty Asians who had new Pfannenstiel's cesarean section scars were recruited in this prospective double-blinded, split-scar study. Each side was randomly assigned treatment with onion extract gel or placebo at 7 days after surgery. The product was applied three times daily for 12 weeks. Subjects were evaluated at baseline and 4th and 12th weeks. Scar redness was assessed by calorimeter, scar height and pliability were assessed by blinded investigators, and scar symptoms and overall cosmetic improvement were assessed by subjects. Results. Sixteen subjects completed the study. A statistically significant difference between two sides of scar in terms of scar height and scar symptoms was found. There was no statistically significant difference in scar redness, scar pliability, and overall cosmetic appearance between two sides. Conclusions. The early use of topical 12% onion extract gel on Pfannenstiel's cesarean section scar in Asians resulted in the improvement of scar height and scar symptoms.

Fractional CO2 laser resurfacing for atrophic acne scars: a randomized controlled trial with blinded response evaluation

BACKGROUND

The treatment of acne scars with fractional CO(2) lasers is gaining increasing impact, but has so far not been compared side-by-side to untreated control skin.

OBJECTIVE

In a randomized controlled study to examine efficacy and adverse effects of fractional CO(2) laser resurfacing for atrophic acne scars compared to no treatment.

METHODS

Patients (n = 13) with atrophic acne scars in two intra-individual areas of similar sizes and appearances were randomized to (i) three monthly fractional CO(2) laser treatments (MedArt 610; 12-14 W, 48-56 mJ/pulse, 13% density) and (ii) no treatment. Blinded on-site evaluations were performed by three physicians on 10-point scales. Endpoints were change in scar texture and atrophy, adverse effects, and patient satisfaction.

RESULTS

Preoperatively, acne scars appeared with moderate to severe uneven texture (6.15 ± 1.23) and atrophy (5.72 ± 1.45) in both interventional and non-interventional control sites, P = 1. Postoperatively, lower scores of scar texture and atrophy were obtained at 1 month (scar texture 4.31 ± 1.33, P < 0.0001; atrophy 4.08 ± 1.38, P < 0.0001), at 3 months (scar texture 4.26 ± 1.97, P < 0.0001; atrophy 3.97 ± 2.08, P < 0.0001), and at 6 months (scar texture 3.89 ± 1.7, P < 0.0001; atrophy 3.56 ± 1.76, P < 0.0001). Patients were satisfied with treatments and evaluated scar texture to be mild or moderately improved. Adverse effects were minor.

CONCLUSIONS

In this single-blinded randomized controlled trial we demonstrated that moderate to severe atrophic acne scars can be safely improved by ablative fractional CO(2) laser resurfacing. The use of higher energy levels might have improved the results and possibly also induced significant adverse effects.

Acne vulgaris

Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from androgen-induced increased sebum production, altered keratinisation, inflammation, and bacterial colonisation of hair follicles on the face, neck, chest, and back by Propionibacterium acnes. Although early colonisation with P acnes and family history might have important roles in the disease, exactly what triggers acne and how treatment affects the course of the disease remain unclear. Other factors such as diet have been implicated, but not proven. Facial scarring due to acne affects up to 20% of teenagers. Acne can persist into adulthood, with detrimental effects on self-esteem. There is no ideal treatment for acne, although a suitable regimen for reducing lesions can be found for most patients. Good quality evidence on comparative effectiveness of common topical and systemic acne therapies is scarce. Topical therapies including benzoyl peroxide, retinoids, and antibiotics when used in combination usually improve control of mild to moderate acne. Treatment with combined oral contraceptives can help women with acne. Patients with more severe inflammatory acne usually need oral antibiotics combined with topical benzoyl peroxide to decrease antibiotic-resistant organisms. Oral isotretinoin is the most effective therapy and is used early in severe disease, although its use is limited by teratogenicity and other side-effects. Availability, adverse effects, and cost, limit the use of photodynamic therapy. New research is needed into the therapeutic comparative effectiveness and safety of the many products available, and to better understand the natural history, subtypes, and triggers of acne.

Vitamins and cutaneous wound healing

BACKGROUND

Vitamins have long been thought to modulate the various stages of wound healing through a variety of proposed mechanisms. Our goal was to investigate relevant studies examining the role of different vitamins in wound healing.

METHODS

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched for basic science and clinical studies examining the role of vitamins as adjuncts in wound healing.

RESULTS

Mechanisms of action for each of the vitamins are reviewed. It was suggested by many of the studies that the major vitamins A, C, E, D, K, and B have demonstrated utility as adjuncts in wound care in basic science and clinical trials.

CONCLUSION

There is a vast amount of literature on the effect of vitamins on wound healing at the basic science level. Further understanding and controlled trials will help better understand how to utilize vitamins in wound care.

DECLARATION OF INTEREST

None.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Versatile punch surgery

BACKGROUND

Punch instrument is a circular blade that can be used for many diagnostic and therapeutic purposes in different medical and surgical specialties. Punch surgery (or biopsy) is achieved by using this versatile punch blade under local anesthesia. Basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal. Diagnostic punch surgery can obtain a part of or whole skin lesion for histologic examination. In addition to the skin, nail and mucous membrane tissue can be obtained by punch biopsy. Interestingly, punch biopsy can be used as an adjunctive to fine-needle aspiration to establish the diagnosis of tumors of solid organ such as the breast. Diagnostic punch surgery can be modified to overcome certain problems. The split-punch technique helps avoid crushing the tissue punch when trying to divide it for different examinations. The double-trephine punch facilitates obtaining subcutaneous tissue without the need for full elliptical excision. The string-of-beads technique obviates the need for dissection of tissue into pieces. In other nondermatology and dermatology conditions, such as nerve pathology, arteriosclerosis, melanoma mapping, and eyelid tumors, the diagnosis can be enhanced with the use of punch surgery.Therapeutic punch surgery can be used for excision of unwanted lesions such as nevi, as well as pathologic bone and cartilage tissues. Punch grafting is used in vitiligo surgery and hair transplantion. Punch evacuative surgery can help in the evacuation of unwanted tissue or materials such as lipoma, subungual hematoma, scrotal calcinosis, pseudocyst of the auricle, pilar cyst, and others.Reconstructive punch surgery includes correction of ear lobe defects and acne scars. Enhancement of wound healing can be achieved by use of the punch; therefore, it can help nonhealing ulcers.

Hyaluronic acid filler for steroid atrophy

The use of hyaluronic acid for atrophy has not been documented in the literature. In this manuscript we present a case of a patient treated with the aforementioned filler with enthusiastic results. This case shows yet another potential application for these novel products.

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

Background:

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

Aims:

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

Settings and Design:

Open prospective study.

Material and Methods:

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

Results:

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

Conclusion:

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

Medical and psychosocial impact of acne

The direct and clinically obvious medical sequelae of acne vulgaris are well described. Physical comorbidities associated with classic acne are quite rare. Often more difficult to detect and measure are the short- and long-term psychosocial consequences of acne. These frequently are devastating and life-altering and in some cases are life-threatening.

A review of phytotherapy of Acne vulgaris

Acne vulgaris (acne) is a cutaneous pleomorphic disorder of the pilosebaceous unit involving abnormalities in sebum production and is characterized by both inflammatory (papules, pustules and nodules) and non-inflammatory (comedones, open and closed) lesions. Propionibacterium acnes and Staphylococcus epidermidis are common pus-forming microbes responsible for the development of various forms of acne. This disease remains a common condition in industrialized societies, with many mainstream treatment options available. There are many acne products on the market, and making an appropriate selection can be daunting. Common therapies that are used for the treatment of acne include topical, systemic, hormonal, herbal and combination therapy. Topically used agents are benzoyl peroxide, antibiotics and retinoid. Systemically used agents are antibiotics and isotretinoin. However, all such treatments carry risks and none is completely satisfactory. Natural alternatives are gaining greater research support, and have much to offer clinically in this disorder. This review focuses primarily on herbal treatments for acne that show scientific evidence of clinical efficacy, as well as the more common herbs shown to be useful in the treatment of this dermatologic disorder.