Efficacy of Punch Elevation Combined with Fractional Carbon Dioxide Laser Resurfacing in Facial Atrophic Acne Scarring: A Randomized Split-face Clinical Study

Practical Aspects of Acne Scar Management: ASAP 2024

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

Atrophic Postacne Scar Treatment: Narrative Review

Acne scarring is a frequent complication of acne. Scars negatively impact psychosocial and physical well-being. Optimal treatments significantly improve the appearance, quality of life, and self-esteem of people with scarring. A wide range of interventions have been proposed for acne scars. This narrative review aimed to focus on facial atrophic scarring interventions. The management of acne scarring includes various types of resurfacing (chemical peels, lasers, and dermabrasion); the use of injectable fillers; and surgical methods, such as needling, punch excision, punch elevation, or subcision. Since the scarred tissue has impaired regeneration abilities, the future implementation of stem or progenitor regenerative medical techniques is likely to add considerable value. There are limited randomized controlled trials that aimed to determine which treatment options should be considered the gold standard. Combining interventions would likely produce more benefit compared to the implementation of a single method.

To evaluate the efficacy and safety of laser interventions for facial acne scars: a systematic review and Bayesian network meta-analysis

Background

There are numerous laser treatments for acne scars in clinical practice. However, there are no clinical studies comparing all laser methods to provide an evidence-based bias for clinicians to choose the best strategy. Therefore, this systematic review and network meta-analysis was conducted to explore the efficacy of different types of laser treatment on acne scars. This study can provide the most effective treatment for acne scars in clinical practice.

Methods

The databases of PubMed, Embase, Cochrane Library, and Web of Science were searched from their inception to July 2022. The Cochrane risk of bias assessment tool was used to assess the bias of the included original studies. Bayesian network meta-analysis was used to investigate the efficacy of laser treatment strategies in scar improvement, cure rate, and satisfaction.

Results

As shown by the results, the top 3 treatment options for scar improvement were fractional carbon dioxide laser (FCL) + platelet-rich-plasma (PRP) [surface under the cumulative ranking curve (SUCRA): 0.699], 1064Nd (1,064-nm neodymium-doped yttrium aluminum garnet picosecond laser) + 15%VC (Vitamin C; SUCRA: 0.675), and 1064Nd (SUCRA: 0.627). The standard mean difference (SMD) of FCL + PRP was -1.76 (95% CI: -3.49, -0.03), compared with that of FCL. The top 3 treatment options for improving cure rate were Er (Er:YAG laser treatment) + PRP (SUCRA: 0.873), FCL (SUCRA: 0.773), and FCL + 30% salicylic acid (30%SC) (SUCRA: 0.772). The RR of Er + PRP cure rate was 13.86 (95% CI: 1.79, 107.22), compared with non-laser radiofrequency therapy.

Conclusions

The findings suggested that combined therapies should be used to treat acne scars. Er + PRP showed the highest cure rate of acne scar, followed by FCL + 30%SC or FCL monotherapy. FCL combined with PRP could improve acne scarring to the greatest extent, and 1064Nd combined with 15%VC can also exert a good effect. As for satisfaction, FCL monotherapy was the most satisfactory methods for patients, followed by PRP monotherapy. Therefore, Er + PRP and FCL + PRP can be used as the first choice for clinical treatment of acne scars. Additionally, using FCL alone is also an effective and elective treatment method due to its affordable cost and comfort.

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

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

A systematic review of evaluating the efficacy of acne scar treatment by Fractional Laser with or without using adjunctive treatments

Fractional laser (FL) resurfacing has proved its effectiveness in acne scars treatments. To evaluate the efficacy of Fractional laser systems for treatment of acne scars as a monotherapy, and as adjunctive therapy with other treatment types. A systematic literature review was performed by searching the electronic databases PubMed, Google Scholar, and Embase. Fractional laser has proven therapeutic efficacy of over 26% in treating acne scars, with minor and transient side effects, and well-tolerant pain. The application of PRP not only accelerated recovery and reduced adverse events, but also enhanced localized collagen neogenesis and redistribution. The addition of surgical treatments to Fractional Laser Systemes (FLS) therapy delivers the best treatment results for Icepick scars. Fractional laser is an effective tool for treating acne scars. The degree of effectiveness varies according to the laser parameters, the number of treatment sessions, skin photo type, the severity and the type of scars. The application of Platelet-Rich Plasma (PRP) and Fractional Radiofrequency Microneedle (FRM) in addition to the FL treatment improves the therapeutic efficacy and reduces the appearance of Post Inflammatory Hyper-Pigmentation (PIH), and is the ideal treatment for dark-skinned patients. FL therapy along with surgical methods such as subsicion and punch techniques provided the best improvements for deep scars.

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.

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.

Efficacy of fractionated microneedle radiofrequency with and without adding subcision for the treatment of atrophic facial acne scars: A randomized split-face clinical study

BACKGROUND

There is no gold standard treatment for facial acne scars, and overall, little literature exists about the combination therapy for treatment of acne scar.

AIMS

The aim of this study was to evaluate the efficacy of fractionated microneedle radiofrequency (FMR) vs FMR combined with subcision for the treatment of atrophic acne scars.

PATIENTS/METHODS

This was a randomized, split-face clinical study of 25 patients with II-IV Fitzpatrick skin types with moderate to severe facial atrophic acne scars. Initially, standard subcision by Nokor needle was performed on one side. Two weeks after subcision, FMR treatment was performed on both cheeks of each participant. Second and third FMR treatment sessions were performed within 4-week intervals. Two-blinded dermatologists performed clinical assessments using a quartile grading scale, and patients were also asked to judge their satisfaction using a visual analog scale (VAS) scoring system.

RESULTS

The age of the patients varied from 24 to 40 years (mean: 30.08±4.94 years). Only nine patients (36%) were males. Clinical assessment by two-blinded dermatologists showed statistically significant improvement in the combination (FMR+subcision) group (P=.009). Patient satisfaction was statistically significantly better in the combination group (P=.001). A darkening of skin phototype was associated with a decrease in patient's satisfaction VAS score (P=.07).

CONCLUSION

The combination of subcision and FMR is a safe and effective modality for mixed type acne scars. Additional randomized clinical study with long-term follow-up is necessary for further evaluation of FMR in combination with other procedures. The full trial protocol can be accessed in: http://www.irct.ir/searchresult.php?keyword=%20%20IRCT2016103130597N1&id=30597&number=1&field=a&prt=1&total=1&m=1. The clinical trial registration number is IRCT2016103130597N1.

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.