The efficacy in treatment of facial atrophic acne scars in Asians with a fractional radiofrequency microneedle system

Advances in the Application of Noninvasive Skin Imaging Techniques in Acne Scars

Acne scarring is a common sequela of acne vulgaris, which seriously affects facial esthetics. The treatment options for acne scars vary depending on the development stage, color, type, and location of scarring. The objective and precise assessment of acne scars is a prerequisite for treatment, and it is also an important means of monitoring the treatment effect. The traditional methods to evaluate the types and severity grade of acne scars are primarily based on subjective assessment by physicians, which lacks objectivity and accuracy. Novel noninvasive skin imaging techniques, such as skin surface imaging analysis systems, dermoscopy, reflectance confocal microscopy (RCM), high-frequency ultrasound (HFUS), optical coherence tomography (OCT), and multiphoton tomography (MPT), provide new tools for the rapid and objective assessment of acne scars. This article reviews the progress of skin imaging techniques in the diagnosis, classification, and efficacy evaluation of acne scars.

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.

Alternating Treatment With Nonablative Fractional Laser and Radiofrequency Microneedling for the Treatment of Acne Scars: A Prospective, Randomized, Split-Face Study

BACKGROUND

Acne scarring is an unfortunate sequela affecting up to 95% of patients with acne and carries profound psychosocial impact. Both nonablative fractional lasers (NAFL) and microneedling with radiofrequency (MNRF) have demonstrated comparable efficacy in the treatment of atrophic acne scars.

OBJECTIVE

To determine whether alternating NAFL and MNRF is superior to NAFL alone in the treatment of atrophic acne scars.

METHODS AND MATERIALS

This was a prospective, single-center, double-blinded, split-face clinical trial. Twenty patients with atrophic acne scars who had their facial halves randomized to receive either NAFL alone or NAFL alternating with MNRF. Patients received 4 total treatments at 4-week intervals.

RESULTS

Ninety days after the final treatment, both facial halves demonstrated a significant improvement in the mean global échelle d'évaluation clinique des cicatrices d'acné (ECCA) score from baseline ( p < .001 for both halves). The average percentage improvement at the final end point was 20% to 30% from baseline. No significant difference was noted between facial halves for mean global ECCA score or percentage improvement at any time point.

CONCLUSION

Although both NAFL and MNRF are safe and effective in the treatment of atrophic acne scars, alternating NAFL and MNRF does not seem to be superior to NAFL alone.

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.

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 .

Review of Lasers and Energy-Based Devices for Skin Rejuvenation and Scar Treatment With Histologic Correlations

BACKGROUND

Lasers and energy-based devices (EBD) are popular treatments for skin rejuvenation and resurfacing. Achieving desired outcomes and avoiding complications require understanding the effects of these devices at a histologic level. Currently, no comprehensive review summarizing the histologic effects of laser and energy-based treatments exists.

OBJECTIVE

To describe how lasers and EBD alter skin histology and improve the overall understanding of these devices.

MATERIALS AND METHODS

A PubMed search was conducted for studies with histologic analysis of fractional picosecond laser, fractional radiofrequency microneedling, nonablative lasers, and ablative lasers.

RESULTS

Fractional picosecond lasers induce intraepidermal and/or dermal vacuoles from laser-induced optical breakdown. Fractional radiofrequency microneedling delivers thermal energy to the dermis while sparing the epidermis, making it safer for patients with darker skin phototypes. Fractional nonablative lasers induce conical zones of coagulation of the epidermis and upper dermis. Ablative lasers vaporize the stratum corneum down to the dermis. Traditional ablative lasers cause diffuse vaporization while fractional ablative lasers generate columns of tissue ablation.

CONCLUSION

Lasers and EBD are effective for skin resurfacing and rejuvenation and have different mechanisms with disparate targets in the skin. Safe and effective use of devices requires understanding the histologic laser-tissue interaction.

Evaluation of the cumulative effect of Radiofrequency Microneedling and fractional Erbium: Glass 1565 laser in moderate to severe acne scars in skin of color

AIM AND OBJECTIVES

Evaluation of the cumulative effect of Radiofrequency Microneedling and fractional Erbium: Glass 1565 laser in moderate to severe acne scars in skin of color.

MATERIAL AND METHODS

This retrospective study was conducted on 20 patients of skin types III -V having moderate to severe atrophic acne scars. The study was carried out over 1 year from March 2019 to March 2020.

PROCEDURE

All patients underwent 4 sessions of non-ablative Fractional Erbium: Glass 1565 laser to alternate with 4 sessions of Fractional Radiofrequency Microneedling once a month over 8 months.

RESULTS

Of the 20 patients enrolled, 18 completed treatment protocol. Two patients were withdrawn from the study because they were unable to attend follow-up treatment sessions. The subjective evaluation was performed using photographs at baseline, 8 months, and 12 months. A photographic evaluation was performed using the following numeric responses: <25%, 25-50%, 51-75%, and 76-100% difference in severity. None of the patients had worsening of their scars. The improvement in scars was statistically significant.

CONCLUSION

The combination of Fractional Erbium: Glass 1565 laser and Fractional Radiofrequency Microneedling can be used in the treatment of acne scars in skin of color. Our protocols helped achieve significant improvement of scars.

Fractional microneedle radiofrequency device and fractional erbium-doped glass 1,565-nm device treatment of human facial photoaging: a prospective, split-face, random clinical trial

Microneedle fractional radiofrequency (MFR) and non-ablative 1565 nm fractional laser (NAFL) have recently been introduced as new techniques to address the growing concern of facial photoaging. In this prospective randomized split-face study, we wanted to compare the safety and efficacy of MFR with that of NAFL for the treatment of facial photoaging in Asian patients. Fifteen healthy Chinese patients were enrolled for this randomized split-face study. Each patient underwent three sessions of treatment with MFR and NAFL on opposite sides of their face, one month apart. A blinded outcome assessment of the photoaging severity was performed by two independent plastic surgeons on a 5-point visual analogue scale (VAS, 0-4). Patient satisfaction was also scored based on a 5-point VAS (0 = dissatisfaction, 4 = extremely satisfied). Sagging of the nasolabial groove was evaluated using the Antera 3D camera, facial wrinkles and pores using the VISIA skin analysis system. Any adverse events that occurred during the study were also evaluated. Based on the VAS scores and results from the Antera 3D and VISIA, it was noted that there was a significant improvement in facial skin laxity, wrinkles, and pores, and lesser sagging of the nasolabial groove on both the MFR and NAFL sides of the face, compared with that of the baseline. Most patients were satisfied with the treatment and reported tolerable pain and crusting. Although no significant differences were observed between the MFR and NAFL treatments, the NAFL treatment resulted in a shorter downtime(4.56 ± 2.72d) than the MFR treatment(6.96 ± 3.27d). This study confirms the efficacy of MFR and NAFL treatments for facial skin rejuvenation in Asian patients. Furthermore, the therapies were found to be safe and well-tolerated. Our findings suggest that NAFL may be a more convenient treatment modality for facial photoaging because of its shorter downtime. However, sagging of the nasolabial groove was more improved by the MFR treatment than by the NAFL treatment.

Evaluating the effectiveness and safety of radiofrequency for face and neck rejuvenation: A systematic review

BACKGROUND

Radiofrequency technology has emerged as a treatment for aesthetic rejuvenation.

OBJECTIVE

To examine radiofrequency for facial and neck rejuvenation, clinical studies were assessed on effectiveness and safety of radiofrequency for acne, acne scars, and facial aging by subjective and objective measures.

METHODS

A systematic literature review was performed. Eligibility criteria included articles in English, primary literature, clinical or ex vivo studies, use of radiofrequency, and face or neck treatment. Ablative techniques, home-use devices, combined modalities, and studies unrelated to rejuvenation were excluded. All studies were appraised for quality and biases.

RESULTS

We identified 121 articles. Radiofrequency effectively treated acne by reducing sebum levels and lesion count and improving acne scars. Radiofrequency demonstrated a volumetric reduction in facial fat, and improved skin laxity, elasticity, and global skin aesthetic. Patient satisfaction was higher for those desiring modest rejuvenation. There were histological changes consistent with repair response, neocollagenesis, and neoelastinogenesis. Radiofrequency was safe apart from one patient who developed a neck fistula.

CONCLUSION

Most studies demonstrated radiofrequency treatment of acne, scars, or facial rhytids had positive subjective improvement ratings. Objective studies demonstrated reduction of acne, decreased scarring, lifting effect, improvement in elasticity and collagen, volumetric fat changes, and wrinkle reduction.

A randomized, split-face controlled trial on the safety and effects of microneedle fractional radiofrequency and fractional erbium-doped glass 1,565-nm laser therapies for baggy lower eyelids

The non-ablative fractional erbium-doped glass 1,565-nm laser (NAFL) and the microneedle fractional radiofrequency (MFR) procedures are effective treatments that enable periorbital skin rejuvenation. To compare the clinical effectiveness and side effects of MFR and the NAFL for baggy lower eyelids (BLEs) in the Chinese population. Fifteen Chinese subjects with BLEs received three split-face treatments on a monthly basis randomly. Objective and subjective assessments were performed at baseline, as well as 1 month and 3 months after the third treatment. The results were evaluated using Antera-3D and CineScan systems. Blinded investigator assessments were performed by two plastic surgeons using a 0 to 4 score in six anatomic categories of BLEs. The patients also reported their level of satisfaction based on a four-point score. Most of the patients reported a greater than 47% satisfaction rate with both treatments. The cumulative contribution scores of prolapse of orbital fat, hollow tear trough, and skin laxity for each category variable declined with time. Using Antera 3D, the volume of elevation (mm³) decreased from 0.6 ± 0.4 to 0.4 ± 0.3 and from 0.6 ± 0.3 to 0.3 ± 0.3, the elevation area (mm²) decreased from 17.0 ± 8.4 to 13.0 ± 7.1 and from 17.0 ± 7.8 to 10.0 ± 5.6, and the maximum peak height (mm) also decreased from 0.10 ± 0.04 to 0.06 ± 0.04 and from 0.10 ± 0.03 to 0.06 ± 0.02 in the MFR and NAFL groups, respectively. Using CineScan, the depth of middle orbital fat (mm) decreased significantly from 10.2 ± 2.2 to 8.0 ± 0.7 and from 9.8 ± 1.1 to 8.0 ± 0.9 and the length of orbital fat significantly decreased from 9.2 ± 1.2 to 7.7 ± 0.7 and from 9.7 ± 1.4 to 7.8 ± 0.6 in the MFR and NAFL groups, respectively. MFR and NAFL therapies were effective for the treatment of BLEs, especially in BLE patients with skin elasticity in addition to tear trough deformity and orbital fat prolapse. Trial registration number: NCT04237324. Trial register: ClinicalTrials.gov. Level of Evidence: Level I, therapeutic study.

An Innovative Approach of Treating Acne Scars Using Bipolar Rotational Stamping and Monopolar Criss-cross Technique with Insulated Microneedling Radiofrequency in Asians

Introduction

Microneedling radiofrequency (MNRF) using insulated microneedles offers a great advantage to overcome the limitations of fractional lasers such as achieving greater depth, long downtime, and high risk of postinflammatory hyperpigmentation (PIH).

Aims

The aim of this study was to assess the efficacy and safety of a novel multiple depth bipolar rotational stamping and monopolar criss-cross method (Wosyet vital technique) with MNRF using insulated needles for the improvement of facial acne scars in Asians.

Materials and Methods

Thirty-two patients (20 females, 12 males, average age 30.3 years) with facial atrophic acne scars were treated with insulated MNRF by applying Wosyet vital technique. Most of the patients started noticing improvement in 4-6 weeks after the first session. All patients underwent four sessions at 1-month interval. Outcome assessments included subjective and physician evaluation of acne scars, pores, smoothness, tightness, and overall appearance. Objective assessment was determined by Goodman and Baron's quantitative and qualitative analysis of the acne scars.

Results

All subjects noticed at least 30%-90% (mean--62.50%) improvement in acne scars, whereas unbiased physicians graded 40%-80% (mean--58.44%) at a 6-month follow-up visit. The mean Goodman and Baron's score decreased significantly from pre- to posttreatment. All patients reported 30%-90% (mean--61.88%) improvement in facial contour and skin tightening. Many patients observe improvement in the open pores as well.

Conclusion

The possible explanation of improvement in the global appearance of skin and acne scars is the application of both monopolar and bipolar RF in the dermis through insulated microneedles. We did not find PIH after this technique in Asian patients despite of more aggressive treatment parameters and several treatment sessions.

Statistical Analysis Used

The results were analyzed using chi-square test, Wilcoxon sign rank test, Pearson's correlation test, Spearman's correlation test, and paired t test.

Subject satisfaction following treatment with nanofractional radiofrequency for the treatment and reduction of acne scarring and rhytids: A prospective study

Background

Skin‐related changes, such as fine lines, wrinkles, and acne scarring, are a source of distress to both men and women. Nanofractional radiofrequency delivers thermal energy to skin layers leading to dermal remodeling that can address skin conditions related to aging. The objective of this study was to evaluate the subject satisfaction of nanofractional radiofrequency for the treatment of facial wrinkles and acne scarring in both lighter and darker skin tones.

Materials and methods

30 subjects (skin types II‐VI) were enrolled in this prospective, evaluator‐blind study. The average age of subjects was 51.9 ± 13.5 years. Subjects received three treatments at 3‐ to 5‐week intervals on both sides of the face using the 80‐ or the 160‐pin tip disposables. Follow‐up visits were conducted at 6‐ and 12 weeks after the last treatment. Subject satisfaction was evaluated using a self‐assessment of a reduction of wrinkles or acne scars, and subject satisfaction questionnaire. Pain, tolerability, and safety were monitored throughout.

Results

Subjects treated for acne or wrinkles were satisfied with their treatment at both the 6‐week and 12‐week follow‐up visit (mean score 3.0; range 0 = very unsatisfied to 4 = very satisfied). The treatments were well tolerated at all treatment sessions, averaging a score of 3.5 on the tolerability scale (0 = very intolerable to 4 = very tolerable) with treatment‐associated pain reported to be mild (3.2 out of 10). There were no adverse events or unanticipated side effects.

Conclusions

This clinical study demonstrates subjects are satisfied with nanofractional radiofrequency treatments for improvement of their wrinkles and acne scars.

Radiofrequency Microneedling: A Comprehensive and Critical Review

BACKGROUND

Many studies have evaluated radiofrequency microneedling (RFMN) in various dermatologic conditions. However, the efficacy and safety of RFMN, and how it compares with other energy-based devices in a clinician's armamentarium, remains unclear.

OBJECTIVE

To review higher-quality evidence supporting RFMN and the dermatologic conditions which it can be used in.

MATERIALS AND METHODS

A search was conducted in MEDLINE and EMBASE from inception to May 13, 2020, using the terms: "radiofrequency microneedling" OR "fractional radiofrequency" OR "radiofrequency needling" OR "radiofrequency percutaneous collagen induction." Only randomized, split body or blinded studies with original data on humans were included. Non-English or non-dermatology-related studies were excluded.

RESULTS

Forty-two higher-quality studies were included after applying the inclusion and exclusion criteria. There were 14 studies for skin rejuvenation, 7 for acne scars, 6 for acne vulgaris, 5 each for striae and axillary hyperhidrosis, 2 for melasma, and 1 each for rosacea, cellulite, and androgenetic alopecia.

CONCLUSION

Radiofrequency microneedling is an effective intervention that can be used repeatedly and safely in combination with other treatment modalities and in individuals with darker skin phototypes. Radiofrequency microneedling-induced dermal remodeling and neocollagenesis are slow and progressive but continue to improve even 6 months after treatment.

Split-face comparative study of fractional Er:YAG laser versus microneedling radiofrequency in treatment of atrophic acne scars, using optical coherence tomography for assessment

BACKGROUND

Efficacy and safety of ablative fractional laser used for treatment of acne scars have been described in several studies. Recently, microneedling radiofrequency treatment has been showing promising results with low risk of side effects and rapid healing time.

OBJECTIVE

To study efficacy and safety of ablative fractional Er:YAG laser 2940 nm and microneedling radiofrequency for facial atrophic acne scar.

METHODS

21 patients with atrophic postacne scars were randomized to MRF for one half of the face and laser for the other half. Four sessions were performed monthly. For evaluation, the validated scale "Quantitative Global Grading System for Postacne Scarring" and patient's satisfaction were used before and 3 months after treatment. Optical coherence tomography imaging of the skin was used as an objective tool for assessment.

RESULTS

Both sides showed significant improvement on clinical evaluation with no significant difference. Optical coherence tomography assessment showed significant increase of both epidermal and dermal thickness compared to baseline.

CONCLUSION

Both MRF and ablative fractional Er. YAG laser 2940 nm are effective in the treatment of post acne scars. Microneedling radiofrequency is better tolerated, with lower downtime and fewer side effects.

Safety of Combined Fractional Microneedle Radiofrequency and CO2 as an Early Intervention for Inflammatory Acne and Scarring Treated With Concomitant Isotretinoin

BACKGROUND

Fractional microneedle radiofrequency (FMRF) systems are popular options for treating acne scars. However, treatment efficacy when used in combination with traditional ablative fractional laser (AFL) and the safety profile with concomitant use of isotretinoin remain unknown.

OBJECTIVE

The aim of this study was to assess the safety and efficacy of an early intervention combination treatment protocol for inflammatory acne and acne scars.

MATERIALS AND METHODS

The electronic records of 71 patients with inflammatory acne and acne scars were included in this retrospective observational study. Data were collected for all patients who received combination FMRF and AFL. Within the study group, 43 patients were receiving low-dose isotretinoin or had completed isotretinoin within the past 3 weeks.

RESULTS

The mean Scar Global Assessment score significantly decreased after 3 sessions of combination treatment (n = 71). Patients with inflammatory acne showed a significant decrease in the number of inflammatory lesions (n = 30). Patients with concomitant low-dose isotretinoin use reported a further decrease in Scar Global Assessment score (n = 43). There were no reported persistent side effects, including prolonged inflammatory reaction or scarring.

CONCLUSION

Combination treatment with FMRF and AFL is an effective and well-tolerated treatment modality for acne scars and inflammatory acne.

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.

Microneedling for the Treatment of Scars: An Update for Clinicians

Background

Microneedling (MN) is used for the treatment of scars, amongst other indications. Although used in Asia and the Middle East for decades, related to the supposed lack of post-procedure pigmentary alterations even in darker skin types, MN only recently gained attention in the United States as an effective, well-tolerated aesthetic treatment.

Materials and Methods

A systematic review of the Medline database was completed using search terms “microneedle” or “microneedling” or “micro needle” or “micro needling” and “scar”. Included articles were written in English and discussed the use of MN for the treatment of scars in human subjects.

Results

Fifty-eight studies were included for review, with a total of 1845 patients treated for acne scarring, hypertrophic or keloid scars, and those resulting from surgery, trauma, varicella or smallpox. MN and its counterpart fractional radiofrequency MN (FRF-MN) were used as monotherapy or in combination with topical, surgical or systemic modalities. MN and FRF-MN treatment resulted in clinical improvement of scar appearance from baseline. No serious adverse events occurred.

Conclusion

MN is a well-tolerated, minimally invasive procedure that can be used for the treatment of scars with a high level of patient satisfaction. Further clinical studies are needed to develop standardized treatment protocols.

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.

Objective and Long-Term Evaluation of the Efficacy and Safety of a 1064-nm Picosecond Laser With Fractionated Microlens Array for the Treatment of Atrophic Acne Scar in Asians

BACKGROUND AND OBJECTIVE

Fractional 1064-nm picosecond-domain laser has recently been utilized for the treatment of atrophic acne scars and showed promising results. However, data on the safety and efficacy of this procedure in dark-skinned patients are limited. This prospective, self-controlled study was conducted to objectively evaluate the safety and efficacy of a 1064-nm picosecond laser coupled with a microlens array (MLA) for the treatment of atrophic acne scars on Asian skin.

STUDY DESIGN/MATERIALS AND METHODS

Twenty-six subjects of Fitzpatrick skin types (FSTs) III and IV with atrophic acne scars were enrolled. All subjects were treated with a 1064-nm picosecond laser (spot size of 8 mm, fluence of 1.0 J/cm² , a repetition rate of 10 Hz) in combination with the MLA handpiece for an average of three passes, for 6 monthly sessions. Objective (measurement of scar volume using three-dimensional (3D) photography and skin roughness analysis using ultraviolet A-light video camera) and subjective (clinical evaluation by two blinded dermatologists) assessments were obtained at baseline and at 1, 3, and 6 months after the final treatment.

RESULTS

Statistically significant reduction of the scar volume from baseline at 1, 3, and 6 months after the final treatment were observed by 3D photography and ultraviolet A-light video camera. At the 6-month follow-up, 50% (13 of 26) of the subjects were rated as having at least 50% improvement of the scars. The rate of improvement significantly increased from the 1-month follow-up to the 6-month follow-up (P = 0.013). Similarly, at the 6-month follow-up, the scar volume (P = 0.024) and skin roughness (P = 0.001) also significantly improved, in comparison with the baseline. Mild postinflammatory hyperpigmentation (PIH) was observed to develop in approximately 18% of all the treatment sessions. All cases of PIH were temporary and resolved within 4 weeks on average.

CONCLUSIONS

The 1064-nm picosecond laser with MLA is a safe therapeutic alternative for the treatment of atrophic acne scars in dark-skinned individuals. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

The efficacy and safety of fractional radiofrequency nanoneedle system in the treatment of atrophic acne scars in Asians

BACKGROUND

Multiple treatment modalities have been developed to treat atrophic acne scars with varying degrees of success. Post-inflammatory hyperpigmentation (PIH) after acne scar treatments remain a major concern in Asian patients. Fractional radiofrequency (FRF) has been used in many dermatological skin conditions including acne scars.

AIMS

To determine the efficacy and safety of FRF nanoneedle system in the treatment of acne scars in Asians.

METHODS

This is a prospective, evaluator-blinded study with 25 subjects diagnosed with moderate to severe acne scarring. All subjects received 3 monthly treatments of the FRF nanoneedle system on both cheeks. Primary outcome was the clinical improvement of acne scars graded by 2 blinded dermatologists at baseline, 1-, 3-, and 6-month follow-ups. Objective scar volume analysis was done using ultraviolet A (UVA) light video camera. Subjects' self-assessment, pain score, and adverse events were also recorded.

RESULTS

Twenty-three out of 25 subjects completed the study and attended all follow-up. Clinical improvement of acne scars was observed as early as 1-month follow-up. Objective evaluation of acne scar volume decreased significantly on all follow-up compared to baseline (P < .005). Majority of the subjects (48%) reported marked improvement in their acne scars. Adverse events such as pain, erythema, burning sensation, edema, scab formation, and PIH were mild and temporary.

CONCLUSIONS

FRF nanoneedle system is a safe and effective treatment for acne scars in Asians. However, despite the significant changes in the scar volume, caution should be used to avoid excessive coagulation resulting in PIH.

Evaluation of the efficacy of microneedle fractional radiofrequency in Turkish patients with atrophic facial acne scars

BACKGROUND

Scarring is an undesirable and severe complication of acne resulting in loss of self-esteem in young people. Although microneedle fractional radiofrequency (MFR) system has emerged as a good option to treat acne scars in recent years, it was examined in a few studies which were commonly from Asian countries.

AIMS

We sought to evaluate the efficacy of MFR in Turkish patients with facial acne scars.

METHODS

Nine patients with atrophic facial acne scars treated with MFR device were included in the study. The number of treatment sessions was varied from one to five (median three) with 4-week intervals. Demographic and basal clinical features were recorded. Efficacy of the device was evaluated by the physicians' global assessment and patients' self-assessment scales 4 weeks after the last treatment session.

RESULTS

Of nine patients, two were male and seven were female (mean age, 31.33 years). Two patients had mild, four had moderate, and three had severe facial acne scars. Mean acne scar age was 13.22 ± 8.79 years. According to the predominant scar subtype, three patients had V-shaped, three had U-shaped, and three had M-shaped atrophic acne scars. A clinical improvement of >25% has been reported in seven patients (77.7%) and eight patients (88.9%) by the physicians and patients, respectively. U-shaped atrophic acne scars responded better to the treatment than the other types, as statistically nonsignificant. There were no severe side effects.

CONCLUSIONS

Microneedle fractional radiofrequency system showed a quite good efficacy and safety in the treatment of atrophic facial acne scars (Department of Dermato-Cosmetology, Uludag University Medical School).

Use of combined fractional carbon dioxide laser and fractional microneedle radiofrequency for the treatment of acne scars: A retrospective analysis of 1-month treatment outcome on scar severity and patient satisfaction

BACKGROUND

Acne scars lead to social and psychological problems for patients, and they should be treated effectively. Ablative and nonablative lasers have been used for the treatment of acne scars in recent years.

AIMS

The aim of this study was to evaluate the effectivity of combined FCL and FmRF treatment for acne scars retrospectively.

METHODS

A total of 72 patients with acne scars who received FCL + FmRF treatment between 2014 and 2016 were included in this study. Photographs of patients before treatment and 1 month following the last treatment session were scored by two blinded researchers, according to the ECCA acne scar scoring method. Patients were contacted via telephone after 1 month following the last treatment and asked to evaluate their satisfaction with the treatment outcome using a 5-point Likert-type scale.

RESULTS

A significant decrease was noted in ECCA scores after the treatment along with temporary side effects. Change from pretreatment scores was significantly higher in patients very satisfied vs satisfied with treatment. The number of treatment sessions was positively correlated with treatment-related change in ECCA scores.

CONCLUSIONS

In conclusion, our findings revealed association of FCL + FmRF treatment with significantly improved ECCA scores, mild pain experience, and low rate of side effects in patients with acne scars, despite usage of high-energy FLC dose and five sessions of treatment on average. More remarkable improvement in ECCA scores during treatment seems to be associated with higher patient satisfaction and to be more likely in patients with darker skin types.

The efficacy of micro-insulated needle radiofrequency system for the treatment of lower eyelid fat bulging

BACKGROUND AND OBJECTIVES

Conventional treatment options for eyelid fat bulging are generally limited to surgical approaches. However, many attempts have been made recently to manage this disfigurement using non-surgical interventions. The purpose of this study was to evaluate the efficacy and safety of a micro-insulated needle radiofrequency system for the treatment of lower eyelid fat bulging.

METHODS

This is a single center pre-post comparative study. Twenty-two subjects with lower eyelid fat bulging were treated twice using the needle radiofrequency system, at an interval of four weeks. Two types of partially insulated needles with different lengths were used in each session. A three-dimensional photogrammetry system was used to objectively measure changes in the extent of the fat bulge. The investigator's global assessment (IGA) of the severity of fat bulging was also evaluated.

RESULTS

The average extent of fat bulging was decreased significantly after twelve weeks, and was maintained until 24 weeks. The IGA score was significantly decreased after four weeks and further decreased after twelve weeks, and then maintained until 24 weeks. There were no side effects, except for lower eyelid swelling and bruising that lasted for about a week.

CONCLUSION

The micro-insulated needle radiofrequency system can be a beneficial and well-tolerated treatment for lower eyelid fat bulging.

Combined treatment of melasma involving low-fluence Q-switched Nd:YAG laser and fractional microneedling radiofrequency

Background: While low fluence Q-switched Nd:YAG laser (QSNY) demonstrates moderate efficacy in the melasma treatment for darker skin types, this single regimen still remains challenges. Fractional microneedling radiofrequency (FMR) is known to enhance dermal microenvironment, possibly offsetting pathogenic factors of melasma aggravation. Objectives: To compare the effectiveness and safety of combination therapy using low-fluence QSNY and FRM with QSNY monotherapy in Asian melasma patients Methods: A retrospective study was undertaken for melasma patients to compare clinical data between 56 patients receiving combination regimen and 58 patients with QSNY only. For the 10 sessions at 1-week intervals, combination group was consecutively treated with QSNY and FRM, while QS toning group with QSNY alone. Two blinded dermatologists evaluated the efficacy based on modified Melasma Area and Severity Index (mMASI) and the physician's global assessment (PGA) at baseline and 3 months after the final treatment. Treatment-related side effects and disease course was recorded in detail. Results: Combination group demonstrated better efficacy compared with QS toning only group. Both median degrees of mMASI decrease (2.9 vs. 1.8) and proportions of PGA achieving better than 'good' grades (68% vs. 54%) showed superior efficacies of combination group. No significant difference was observed for treatment-related side effects between two groups, while the prevalence of mottle hypopigmentation and rebound hyperpigmentation was higher in QSNY only group. Conclusion: A novel dual mode of low-fluence QSNY and FRM represents a safe and effective treatment for melasma in Asian melasma patients.

Acne Scarring Management: Systematic Review and Evaluation of the Evidence

BACKGROUND

Modalities for atrophic acne scarring can be classified depending upon the needs they satisfy; that is, resurfacing, lifting/volumization, tightening, or surgical removal/movement of tissue that is required for correction. A plethora of treatment options have resulted from the need to treat various acne scar types, variability of responses noted in various skin types, and increasing popularity of minimally invasive modalities. Still, there is a lack of consensus guidelines on treatment or combination therapies for various clinical scenarios.

OBJECTIVE

This systematic review includes a critical evaluation of the evidence relevant to these modalities and various multimodality therapies.

METHODS

We performed a systematic literature search in Medline and EMBASE databases for studies on acne scar management. Also, we checked the reference lists of included studies and review articles for further studies. A total of 89 studies were included in our quality of evidence evaluation.

RESULTS

The efficacy of lasers and radiofrequency in atrophic acne scarring is confirmed by many comparative and observational studies. Other modalities can be used as an adjunct, the choice of which depends on the type, severity, and number of atrophic scars. Minimally invasive procedures, such as fractional radiofrequency and needling, provide good outcomes with negligible risks in patients with dark or sensitive skin types.

CONCLUSIONS

There is a lack of high-quality data. Fractional lasers and radiofrequency offer significant improvement in most types of atrophic acne scars with minimal risks and can be combined with all other treatment options. Combination therapies typically provide superior outcomes than solo treatments.

Comparison of Moderate and High Energy of a Nano-Fractional Radiofrequency Treatment on a Photoaging Hairless Mice Model

BACKGROUND

Fractional radiofrequency (FRF) has been widely used in skin rejuvenation. To explore optimal settings, it is important to compare different treatment parameters.

OBJECTIVE

This study was designed to compare the effect of moderate-energy and high-energy FRF treatment on a hairless mice model.

METHODS

Fifteen photoaged hairless mice were assigned to 3 groups: control, moderate energy, and high energy. Two treatment sessions (T × 1 and T × 2) were performed at 1-month interval. Transepidermal water loss was measured at baseline, immediately, 1, 2, and 4 weeks after T × 1. Skin samples were harvested before each treatment, 1 and 2 months after T × 2. Neocollagenesis was evaluated by hematoxylin and eosin staining, Masson staining, and immunohistochemistry analysis.

RESULTS

Transepidermal water loss of high-energy group was significantly higher than the moderate-energy group (p = .008) immediately after T × 1. Remarkable fibroblast proliferation was observed at 1 month after T × 1, followed by significant dermal thickening, and increase of Type I collagen and Type III collagen. There was no significant difference between 2 energy groups in fibroblast proliferation, dermal thickness, and collagen density.

CONCLUSION

The effect of moderate-energy treatment was comparable with that of high energy in neocollagenesis, whereas moderate energy yielded less damage to skin barrier function.

A systematic review of treatments for acne scarring. Part 2: Energy-based techniques

INTRODUCTION

Acne scarring is a very common problem, which can be extensive, and may lead to significant psychosocial morbidity. Multiple types of treatments are used to ameliorate atrophic scars with varying degrees of success. This paper provides an overview of the various energy-based modalities that are commonly employed against acne scarring.

OBJECTIVES AND METHODS

A comprehensive literature search of papers published since 2008 was performed in order to determine the efficacy and adverse reactions of commonly used energy-based treatments against post-acne scarring.

RESULTS

A total of 59 relevant articles were identified covering a multitude of different devices.

DISCUSSION

Ablative lasers seem to achieve the highest degree of efficacy, albeit this is associated with significant pain and downtime, and the risk for long-term pigmentary changes. Non-ablative fractional photothermolysis (FP) has a much safer profile but cannot achieve as good cosmetic results. The efficacies of fractional radiofrequency microneedling and radiofrequency are slightly inferior to that of FP but offer an even safer adverse profile. Little evidence is available on the remaining devices, with larger studies required in order to reach more solid conclusions.

CONCLUSION

Multiple devices have been used with varying levels of efficacy and very different safety profiles. There is an overall lack of high-quality evidence about the effects of different interventions. Furthermore, no standardised scale is available for acne scarring, leading to variability in evaluation and interpretation of data in different studies.

Novel device-based acne treatments: comparison of a 1450-nm diode laser and microneedling radiofrequency on mild-to-moderate acne vulgaris and seborrhoea in Korean patients through a 20-week prospective, randomized, split-face study

BACKGROUND

While device-based acne treatments are widely applied for patients not tolerating conventional medications, related controlled studies have been still limited. Recently, non-ablative 1450-nm diode laser (DL) and fractional microneedling radiofrequency (FMR) have been effectively used for acne, in addition to well-recognized dermal remodelling effects.

OBJECTIVE

To compare the clinical course of acne treatment between DL and FMR.

METHODS

Twenty-five Korean patients with mild-to-moderate facial acne completed treatments with DL and FMR through a 20-week, randomized split-face study. One randomly assigned half side of each patient's face received DL and the other side by FMR. Treatments were scheduled to receive three consecutive sessions at 4-week intervals. Objective assessments including revised Leeds grades, lesion counts, sebum output measurements, and patients' subjective satisfaction were investigated.

RESULTS

Both DL and FMR demonstrated steady improvement of acne and seborrhoea during treatment sessions. While results between two devices were similar during treatment sessions, FMR was superior to DL in the 12-week follow-up. Patients' subjective assessments for seborrhoea improvement were similar between two devices, while those for acne, skin texture, and acne scars were more satisfactory for FMR. For safety profile, no significant difference was observed between two regimens, while mild postinflammatory hyperpigmentation was observed only in DL side.

CONCLUSION

Both DL and FMR demonstrated efficacies for acne and seborrhoea, with reasonable safety profile. FMR was more effective than DL for the long-term maintenance, and subjective assessments for texture and scar improvements. Therefore, a few sessions of these devices would be a viable option for acne treatments.

Curative effects of microneedle fractional radiofrequency system on skin laxity in Asian patients: A prospective, double-blind, randomized, controlled face-split study

BACKGROUND

To date, no studies compared curative effects of thermal lesions in deep and superficial dermal layers in the same patient (face-split study).

OBJECTIVE

To evaluate skin laxity effects of microneedle fractional radiofrequency induced thermal lesions in different dermal layers.

METHODS AND MATERIALS

13 patients underwent three sessions of a randomized face-split microneedle fractional radiofrequency system (MFRS) treatment of deep dermal and superficial dermal layer. Skin laxity changes were evaluated objectively (digital images, 2 independent experts) and subjectively (patients' satisfaction numerical rating).

RESULTS

12 of 13 subjects completed a course of 3 treatments and a 1-year follow-up. Improvement of nasolabial folds in deep dermal approach was significantly better than that in superficial approach at three months (P=.0002) and 12 months (P=.0057) follow-up. Effects on infraorbital rhytides were only slightly better (P=.3531).

CONCLUSION

MFRS is an effective method to improve skin laxity. Thermal lesion approach seems to provide better outcomes when applied to deep dermal layers. It is necessary to consider the skin thickness of different facial regions when choosing the treatment depth.

Fractional resurfacing in the Asian patient: Current state of the art

BACKGROUND AND OBJECTIVE

Fractionated photothermolysis (FP) has revolutionized modern laser technology. By creating selective columns of microthermal damage, fractionated devices allows for greater treatment depths to be achieved without the prolonged downtime and risk of complications seen in traditional fully ablative laser resurfacing. Fractional resurfacing is a proven method to treat a variety of cutaneous conditions. In the Caucasian patient, a wide range of devices and treatment settings can be utilized safely and effectively. However, ethnic skin requires special consideration due to its unique pigmentary characteristics and clinical presentations. In this review article, we detail the current indications and strategies to optimize results and mitigate complications when utilizing fractional resurfacing for the Asian patient.

METHODS

A review of the MEDLINE English literature was conducted on fractionated laser devices studied in the Asian population. Articles included describe non-ablative devices including fractionated erbium glass, thulium fiber, diode, and radiofrequency devices; and ablative devices including fractionated carbon dioxide (CO₂ ) laser, erbium yttrium aluminum garnet and yttrium scandium gallium garnet (YSGG) laser. These data were integrated with the expert opinion of the authors.

CONCLUSION

Taking into account the unique characteristics and cosmetic concerns of the Asian population, fractional resurfacing can be considered a safe and effective option for the treatment of atrophic and hypertrophic scarring, and photorejuvenation in ethnic skin types. Select cases of melasma may be treated with fractionated non-ablative devices, but utilized with caution. The predominant complication associated with fractional resurfacing for these conditions is post-inflammatory hyperpigmentation (PIH) and rebound worsening of melasma. A greater number of treatments at lower density settings and wider treatment intervals typically produce the lowest risks of PIH without compromising treatment efficacy. Lasers Surg. Med. 49:45-59, 2017. © 2016 Wiley Periodicals, Inc.

Thermal Response of In Vivo Human Skin to Fractional Radiofrequency Microneedle Device

Background. Fractional radiofrequency microneedle system (FRMS) is a novel fractional skin resurfacing system. Data on thermal response to this fractional resurfacing technique is limited. Objectives. To investigate histologic response of in vivo human skin to varying energy settings and pulse stacking of a FRMS in dark-skinned subjects. Methods. Two female volunteers who were scheduled for abdominoplasty received treatment with a FRMS with varying energy settings at 6 time periods including 3 months, 1 month, 1 week, 3 days, 1 day, and the time immediately before abdominoplasty. Biopsy specimens were analyzed using hematoxylin and eosin (H&E), Verhoeff-Van Gieson (VVG), colloidal iron, and Fontana-Masson stain. Immunohistochemical study was performed by using Heat Shock Protein 70 (HSP70) antibody and collagen III monoclonal antibody. Results. The average depth of radiofrequency thermal zone (RFTZ) ranged from 100 to 300 μm, correlating with energy levels. Columns of cell necrosis and collagen denaturation followed by inflammatory response were initially demonstrated, with subsequent increasing of mucin at 1 and 3 months after treatment. Immunohistochemical study showed positive stain with HSP70. Conclusion. A single treatment with a FRMS using appropriate energy setting induces neocollagenesis. This wound healing response may serve as a mean to improve the appearance of photodamaged skin and atrophic scars.

Interventions for acne scars

BACKGROUND

Acne scarring is a frequent complication of acne and resulting scars may negatively impact on an affected person's psychosocial and physical well-being. Although a wide range of interventions have been proposed, there is a lack of high-quality evidence on treatments for acne scars to better inform patients and their healthcare providers about the most effective and safe methods of managing this condition. This review aimed to examine treatments for atrophic and hypertrophic acne scars, but we have concentrated on facial atrophic scarring.

OBJECTIVES

To assess the effects of interventions for treating acne scars.

SEARCH METHODS

We searched the following databases up to November 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers, and checked the reference lists of included studies and relevant reviews for further references to randomised controlled trials.

SELECTION CRITERIA

We include randomised controlled trials (RCTs) which allocated participants (whether split-face or parallel arms) to any active intervention (or a combination) for treating acne scars. We excluded studies dealing only or mostly with keloid scars.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data from each of the studies included in this review and evaluated the risks of bias. We resolved disagreements by discussion and arbitration supported by a method expert as required. Our primary outcomes were participant-reported scar improvement and any adverse effects serious enough to cause participants to withdraw from the study.

MAIN RESULTS

We included 24 trials with 789 adult participants aged 18 years or older. Twenty trials enrolled men and women, three trials enrolled only women and one trial enrolled only men. We judged eight studies to be at low risk of bias for both sequence generation and allocation concealment. With regard to blinding we judged 17 studies to be at high risk of performance bias, because the participants and dermatologists were not blinded to the treatments administered or received; however, we judged all 24 trials to be at a low risk of detection bias for outcome assessment. We evaluated 14 comparisons of seven interventions and four combinations of interventions. Nine studies provided no usable data on our outcomes and did not contribute further to this review's results.For our outcome 'Participant-reported scar improvement' in one study fractional laser was more effective in producing scar improvement than non-fractional non-ablative laser at week 24 (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.25 to 12.84; n = 64; very low-quality evidence); fractional laser showed comparable scar improvement to fractional radiofrequency in one study at week eight (RR 0.78, 95% CI 0.36 to 1.68; n = 40; very low-quality evidence) and was comparable to combined chemical peeling with skin needling in a different study at week 48 (RR 1.00, 95% CI 0.60 to 1.67; n = 26; very low-quality evidence). In a further study chemical peeling showed comparable scar improvement to combined chemical peeling with skin needling at week 32 (RR 1.24, 95% CI 0.87 to 1.75; n = 20; very low-quality evidence). Chemical peeling in one study showed comparable scar improvement to skin needling at week four (RR 1.13, 95% CI 0.69 to 1.83; n = 27; very low-quality evidence). In another study, injectable fillers provided better scar improvement compared to placebo at week 24 (RR 1.84, 95% CI 1.31 to 2.59; n = 147 moderate-quality evidence).For our outcome 'Serious adverse effects' in one study chemical peeling was not tolerable in 7/43 (16%) participants (RR 5.45, 95% CI 0.33 to 90.14; n = 58; very low-quality evidence).For our secondary outcome 'Participant-reported short-term adverse events', all participants reported pain in the following studies: in one study comparing fractional laser to non-fractional non-ablative laser (RR 1.00, 95% CI 0.94 to 1.06; n = 64; very low-quality evidence); in another study comparing fractional laser to combined peeling plus needling (RR 1.00, 95% CI 0.86 to 1.16; n = 25; very low-quality evidence); in a study comparing chemical peeling plus needling to chemical peeling (RR 1.00, 95% CI 0.83 to 1.20; n = 20; very low-quality evidence); in a study comparing chemical peeling to skin needling (RR 1.00, 95% CI 0.87 to 1.15; n = 27; very low-quality evidence); and also in a study comparing injectable filler and placebo (RR 1.03, 95% CI 0.10 to 11.10; n = 147; low-quality evidence).For our outcome 'Investigator-assessed short-term adverse events', fractional laser (6/32) was associated with a reduced risk of hyperpigmentation than non-fractional non-ablative laser (10/32) in one study (RR 0.60, 95% CI 0.25 to 1.45; n = 64; very low-quality evidence); chemical peeling was associated with increased risk of hyperpigmentation (6/12) compared to skin needling (0/15) in one study (RR 16.00, 95% CI 0.99 to 258.36; n = 27; low-quality evidence). There was no difference in the reported adverse events with injectable filler (17/97) compared to placebo (13/50) (RR 0.67, 95% CI 0.36 to 1.27; n = 147; low-quality evidence).

AUTHORS' CONCLUSIONS

There is a lack of high-quality evidence about the effects of different interventions for treating acne scars because of poor methodology, underpowered studies, lack of standardised improvement assessments, and different baseline variables.There is moderate-quality evidence that injectable filler might be effective for treating atrophic acne scars; however, no studies have assessed long-term effects, the longest follow-up being 48 weeks in one study only. Other studies included active comparators, but in the absence of studies that establish efficacy compared to placebo or sham interventions, it is possible that finding no evidence of difference between two active treatments could mean that neither approach works. The results of this review do not provide support for the first-line use of any intervention in the treatment of acne scars.Although our aim was to identify important gaps for further primary research, it might be that placebo and or sham trials are needed to establish whether any of the active treatments produce meaningful patient benefits over the long term.

High versus moderate energy use of bipolar fractional radiofrequency in the treatment of acne scars: a split-face double-blinded randomized control trial pilot study

Bipolar fractional radiofrequency (FRF) device was firstly FDA-approved for treating atrophic acne scar in 2008 through the process of dermal coagulation and minimal epidermal ablation. The average energy at 60 mJ/pin was widely used to treat atrophic acne scars. However, the higher energy was delivered, the deeper ablation and coagulation were found. At present, the new generation of a device with bipolar FRF technology with electrode-pin tip was developed to maximize ability to deliver energy up to 100 mJ/pin. The objective of the study was to explore and compare the efficacy of utilizing high energy (100 mJ/pin) and moderate energy (60 mJ/pin) of bipolar fractional radiofrequency in treatment of atrophic acne scar in Asians. This is a split-face, double-blinded, randomized control trial, pilot study by using parallel group design technique. Thirty healthy subjects with Fitzpatrick skin phototype III-IV diagnosed as atrophic acne scares were enrolled. All subjects received four monthly sessions of bipolar FRF treatment. Left and right facial sides of individual patients were randomly assigned for different energy (high energy at 100 mJ/pin versus moderate energy at 60 mJ/pin). Acne scars improvement was blinded graded by dermatologist using global acne scarring score (GASS) which was subjectively evaluated at baseline, 1-, 3-, and 6-month follow-up. Objective scar analysis was also done using UVA-light video camera to measure scar volume, skin smoothness, and wrinkle at baseline, 3-, and 6-month follow-up after the last treatment. Side effects including pain, erythema, swelling, and crusting were also recorded. Thirty subjects completed the study with full 4-treatment course. The mean GASS of high energy side and moderate energy side was significantly reduced at 1-, 3-, and 6-month follow-up visits. At 1 month follow-visit, high energy side demonstrated significant improvement compared with moderate energy side (p = 0.03). Postinflammatory hyperpigmentation (PIH) developed in 21/120 sessions in high energy side (17.5 %) and 16/120 sessions in moderate energy side (13.3 %). Pain score and the duration of erythema after treatments were significant higher on the side that was treated with high energy. Bipolar FRF device was safe and effective in the treatment of atrophic acne scars in Asians. High energy setting demonstrated significant higher efficacy at 1 month follow-visit. However, the efficacy of both energy settings was comparable at 3- and 6-month follow-up. In addition, side effects were significantly more intense on the side treated with high energy.