Energy-based devices in the treatment of acne scars in skin of color

Background

Acne scarring is disfiguring and psychologically taxing on patients. Many energy-based modalities have emerged and been studied for the treatment of acne scarring; however, there is a paucity of these studies in skin phototypes IV–VI.

Objective

To review the medical literature and discuss the most significant studies regarding safety and efficacy of energy-based devices (ablative lasers, non-ablative lasers, and radiofrequency microneedling) in the treatment of ethnic skin (skin phototypes IV–VI).

Methods

A literature search was conducted using the PubMed database and bibliographies of relevant articles.

Results

Ablative and non-ablative lasers have proven to be effective for treatment of acne scars in ethnic skin. The risk of developing adverse effects such as post-inflammatory hyperpigmentation is contingent upon several factors including skin phototype, laser device, fluence, and moreso density settings. Non-ablative fractional lasers have been considered first line for the treatment of acne scars in skin of color due to their better safety profile; however, they are less efficacious and require more treatments compared to ablative lasers. Studies regarding efficacy and safety of radiofrequency microneedling for treatment of acne scarring in skin of color are limited, but are promising.

Conclusion

Ablative lasers, non-ablative lasers, and radiofrequency microneedling are all useful treatments for acne scarring in ethnic skin when appropriate settings are used. Further head-to-head studies are needed to evaluate their efficacy and safety in darker skin phototypes V–VI.     

Laser treatment for facial acne scars: A review

Background and Objectives: Acne scarring is a widely prevalent condition that can have a negative impact on a patient’s quality of life and is often worsened by aging. A number of options are available for the treatment of acne scarring, including retinoids, microdermabrasion, dermal fillers, and surgical techniques such as subcision. The aim of this review is to evaluate the different laser modalities that have been used in peer-reviewed clinical studies for treatment of atrophic acne scars, and summarize current clinical approaches.

Materials and Methods: A Medline search spanning from 1990 to 2016 was performed on acne scarring. Search terms included “atrophic acne scars,” “ablative’’, “nonablative,” “fractional,” “nonfractional,” “neodymium,” “alexandrite,” “pulsed dye” lasers, and results are summarized.

Results: Various types of lasers have been evaluated for the treatment of atrophic acne scars. While they are efficacious overall, they differ in terms of side effects and clinical outcomes, depending on patients skin and acne scar type. A new emerging trend is to combine lasers with other energy-based devices and/or topicals.

Conclusion: Evaluation of the literature examining acne scar treatment with lasers, revealed that clinical outcomes are dependent on various patient factors, including atrophic acne scar subtype, patient skin type, treatment modality, and side-effect profile.     

Fractional CO2 lasers for the treatment of atrophic acne scars: A review of the literature

Abstract

This review examines the efficacy and safety of fractional CO₂ lasers for the treatment of atrophic scarring secondary to acne vulgaris. We reviewed 20 papers published between 2008 and 2013 that conducted clinical studies using fractional CO₂ lasers to treat atrophic scarring. We discuss the prevalence and pathogenesis of acne scarring, as well as the laser mechanism. The histologic findings are included to highlight the ability of these lasers to induce the collagen reorganization and formation that improves scar appearance. We considered the number of treatments and different laser settings to determine which methods achieve optimal outcomes. We noted unique treatment regimens that yielded superior results. An overview of adverse effects is included to identify the most common ones. We concluded that more studies need to be done using uniform treatment parameters and reporting in order to establish which fractional CO₂ laser treatment approaches allow for the greatest scar improvement.     

Post acne scarring: a review

Historically, post acne scarring has not been well treated. New techniques have been added and older ones modified to manage this hitherto refractory problem. The patient, his or her expectations and overall appearance as well as the morphology of each scar must be assessed and treatment designed accordingly. Upon reaching an understanding of what the pathology of the scar is and where it resides in the skin, the most pertinent treatment for that scar may be devised. Post acne scars are polymorphous and include superficial macules, dermal troughs, ice picks, multi‐channelled fistulous tracts and subcutaneous atrophy. The wide variety of new methods includes the latest resurfacing tools such as CO₂ and erbium infrared lasers, dermasanding and possibly some future techniques such as non‐ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous (including fat and blood transfer) and non‐autologous tissue augmentation and the advent of tissue undermining has greatly improved the treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser and intralesional cytotoxics are interesting developments. Most often occurring extra‐facially and in males, these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.     

Treatment of acne scarring

Background Post‐acne scarring remains a common entity despite advances in the treatment of acne. This represents limitations in our quality of therapy and a failure of public education. The level of severe scarring remains as much an ongoing challenge to prevent as well as manage. Methods This review will concentrate on the methods by which acne scarring may be improved and the available evidence for their utility. It will also rely on a grading scale of disease burden to classify patients and their ideal therapy. New therapies allowing treatment of scarring in areas other than the face will also be highlighted. Results Tabulated treatment planning will present algorithms summarizing best practice in the treatment of post‐acne scarring. Conclusion Post‐acne scarring is being better managed. Grade 1 scars with flat red, white, or brown marks are best treated with topical therapies, fractionated and pigment or vascular‐specific lasers and, occasionally, pigment transfer techniques. Grade 2 mild scarring as seen primarily in the mirror is now the territory of non‐ablative fractionated and non‐fractionated lasers as well as skin rolling techniques. Grade 3 scarring, visible at conversational distance but distensible, is best managed by traditional resurfacing techniques or with fractional non‐ablative or ablative devices, sometimes including preparatory surgical procedures. Grade 4 scarring, where the scarring is at its most severe and non‐distensible, is most in need of a combined approach.     

Current therapeutic approach to acne scars

The occurrence and incidence of acne scarring is different. Lasting for years, acne can cause both physical and psychological scarring. Scarring frequently results from severe inflammatory nodulocystic acne but may also result from more superficial inflamed lesions or from self-manipulation. There are two general types of acne scars: hypertrophic (keloid) scars, and atrophic (icepick, rolling and boxcar) scars. The management of acne scarring includes various types of resurfacing (chemical peels, lasers, lights, cryotherapy), use of dermal fillers, and surgical methods such as dermabrasion, subcision or punch excision. Individual scar characteristics, including color, texture and morphology, determine the treatment choice. Combining treatment methods may provide additional improvement compared with one method alone. It should be noted that none of the currently available treatments can achieve complete resolution of the scar. The best method of preventing or limiting scarring is to treat acne early enough to minimize the extent and duration of inflammation.     

Treatment of acne scarring with fractional CO2 laser

Abstract

Background: Fractional ablative CO₂ laser therapy is based on the theory of fractional photothermolysis. It can be effective in treating acne scars in a less invasive fashion than conventional ablative CO₂ laser therapy. Objective: In this clinical study, the safety and efficacy of a novel CO₂ fractional ablative laser was investigated for the treatment of facial atrophic acne scarring in Chinese individuals. Materials and methods: A total of 31 patients (11 females, 20 males, Fitzpatrick skin phototypes III–IV) with facial acne scarring received three sequential fractional treatments over a 6-month period. Outcome measurements included blinded evaluations of before and after photographs by two physicians at 3 and 12 months after the final treatment. Global improvement was noted as well as any untoward events. Results: At the 12 months follow-up time period, 12.9% of the patients showed excellent improvement in their acne scars, while 38.71% noted good to fair results. The clinical response at the 12-month follow-up visit tended to be better than at the 3-month follow-up visit, but was not statistically significant. Four patients experienced post-treatment and transient PIH but three patients were noted to have prolonged erythema. There was no evidence hypopigmentation or worsening of the scarring in any of the study patients. Conclusion: This high-energy pulsed and cool-scanned fractional ablative CO₂ laser system is safe and effective for facial atrophic acne scarring. Improvement in scarring was noted in the majority of patients with minimal discomfort and minimal downtime. Continued improvement over time is also an important clinical finding.     

Management of Post-Acne Scarring

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

Evaluation of the efficacy and safety of fractional bipolar radiofrequency with high-energy strategy for treatment of acne scars in Chinese

Background: Fractional technology overcomes several problems of ablative lasers such as a high incidence rate of post- inflammatory hyperpigmentation (PIH). A new technology fractional radiofrequency, which induces deep dermal heating and leaves the epidermal less affected results in less adverse effect in Chinese. Objective: To evaluate the efficacy, safety and tolerance of fractional bipolar radiofrequency (RF) in the treatment of acne scars in Asian people with the strategy of high energy. Methods: Twenty-six healthy Asian patients with acne scars received four monthly high energy (85–95mj/pin) treatments with a fractional bipolar RF device. Improvement and tolerance were evaluated at each treatment and a 4-week and 12-week follow-up visit. Results: Twenty-three patients completed the study. Acne score showed a significantly decrease at 4-week and 12-week follow-up visits. Patients’ evaluation of global improvement and satisfaction increased at the 12-week visit compared with baseline. Side effects were limited to transient pain, erythema, dryness and low risk of PIH. Conclusion: Treatment with high energy of fractional bipolar RF is safe and effective for acne scars in Asian people. Common side effects such as PIH, eschars are less than fractional lasers.     

Erbium:YAG laser resurfacing in patients with inflamed cystic acne

Background: Inflammatory cystic acne has been treated by a variety of modalities including antibiotics, topical agents, isotretinoin and chemical peels with variable degrees of success. Erbium:YAG lasers have been used for the treatment of acne scarring and photoaged skin but have not been thought of as treatment for actively inflamed lesions. Objective: We sought to ascertain the effectiveness of using low fluence erbium:YAG settings without topical anesthesia for the treatment of two patients with inflamed cystic acne. Methods: Two female patients with type 4 skin of Hispanic (32 years old) and south Asian (21 years old) origin were treated with the 2940 erbium:YAG LaserPeel laser. The Hispanic patient was treated twice with a 2‐month interval between treatments using the 200 mJ setting. The Asian patient had a combination of 200 and 400 mJ settings for her first treatment and 400 mJ for the subsequent two treatments. She was treated three times with an interval of 1 month between the first two treatments and a 2‐month interval between the second and third treatments. Results: Both patients healed within 6 days of each treatment and demonstrated progressive improvement. Results were excellent in both. Conclusion: Low fluence erbium:YAG facial resurfacing was effective for the treatment of inflamed cystic acne. Its use as a treatment modality should be further explored.     

Cosmetic therapies for Chinese patients with acne taking concomitant or recent intake of oral isotretinoin: A retrospective study

Background

The current standard recommendation is to initiate the cosmetic therapies after discontinuing taking oral isotretinoin for at least 6 months. However, this recommendation has been questioned in several recent publications, and it is difficult to operate in clinical practice as early initiation of effective treatment is desirable for patients with acne sequelae.

Objective

The purpose of this study is to evaluate the efficacy and safety of chemical peeling and light/laser or radiofrequency treatments combined with oral isotretinoin for patients with acne vulgaris and acne scars.

Method

A retrospective study of 511 patients on/or recently administered with isotretinoin treated with glycolic acid, intense pulsed light, nonablative fractional laser, fractional radiofrequency, and ablative carbon dioxide laser. A total of 1352 interventions were performed. The medical follow-up lasted for at least 1 year. The efficacy and safety of different procedures were evaluated.

Results

A total of 511 patients, who were treated with isotretinoin orally or stopped for <6 months, received 477 sessions of glycolic acid chemical peeling treatment, 588 sessions of intense pulsed light treatment, 61 sessions of nonablative fractional laser treatment, 101 sessions of fractional radiofrequency treatment, and 125 sessions of ablative fractional carbon dioxide laser treatment. No hypertrophic scars and keloids were found, and the incidence of serious adverse reactions such as scarring, erythema, blisters, and postinflammatory hyperpigmentation did not increase.

Conclusions

It is safe to perform skin procedures in patients with acne and acne scars during or after discontinuation of isotretinoin for <6 months. Invasive treatments such as ablative fractional carbon dioxide laser treatment can be performed, as appropriate, by an experienced physician. The guideline of avoiding chemical and physical procedures in such patients taking oral isotretinoin should to revised.     

Fractional radiofrequency treatment in acne scars: Systematic review of current evidence

Fractional radiofrequency (FRF) is renowned for its use in cosmetic dermatology, with regard to the treatment of rhytides, striae, scarring and cellulite. We have systemically analysed its evidence for the use of FRF in acne scars. Our search identified 15 articles, one single-blinded randomised controlled trial, two split-face trials and thirteen prospective clinical studies, mostly single-centred. Case reports were excluded. In total 362 patients were treated. The longest follow-up was for 210 days, and on average the follow-up was for three months, varying between one and seven months. This review has found that there are many small studies showing promising results for the use of FRF in acne scars, either as an adjunct or more importantly as the sole treatment. There is however a need for larger trials against ablative and non-ablative lasers, in order to affirm the evidence present already. This is the first systematic review on the use of FRF in acne scars.     

The Asian Dermatologic Patient

The Asian patient with Fitzpatrick skin types III–V is rarely highlighted in publications on cutaneous disorders or cutaneous laser surgery. However, with changing demographics, Asians will become an increasingly important group in this context. Although high melanin content confers better photoprotection, photodamage in the form of pigmentary disorders is common. Melasma, freckles, and lentigines are the epidermal disorders commonly seen, whilst nevus of Ota and acquired bilateral nevus of Ota-like macules are common dermal pigmentary disorders. Post-inflammatory hyperpigmentation (PIH) occurring after cutaneous injury remains a hallmark of skin of color. With increasing use of lasers and light sources in Asians, prevention and management of PIH is of great research interest. Bleaching agents, chemical peels, intense pulsed light (IPL) treatments, and fractional skin resurfacing have all been used with some success for the management of melasma. Q-switched (QS) lasers are effective for the management of epidermal pigmentation but are associated with a high risk of PIH. Long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and IPL sources pose less of a PIH risk but require a greater number of treatment sessions. Dermal pigmentary disorders are better targeted by QS ruby, QS alexandrite, and QS 1064-nm Nd:YAG lasers, but hyper- and hypopigmentation may occur. Non-ablative skin rejuvenation using a combination approach with different lasers and light sources in conjunction with cooling devices allows different skin chromophores to be targeted and optimal results to be achieved, even in skin of color. Deep-tissue heating using radiofrequency and infra-red light sources affects the deep dermis and achieves enhanced skin tightening, resulting in eyebrow elevation, rhytide reduction, and contouring of the lower face and jawline. For management of severe degrees of photoaging, fractional resurfacing is useful for wrinkle and pigment reduction, as well as acne scarring. Acne, which is common in Asians, can be treated with topical and oral antibacterials, hormonal treatments, and isotretinoin. Infra-red diode lasers used with a low-fluence, multiple-pass approach have also been shown to be effective with few complications. Fractional skin resurfacing is very useful for improving the appearance of acne scarring. Hypertrophic and keloid scarring, another common condition seen in Asians, can be treated with the combined used of intralesional triamcinolone and fluorouracil, followed by pulsed-dye laser. Esthetic enhancement procedures such as botulinum toxin type A and fillers are becoming increasingly popular. These are effective for rhytide improvement and facial or body contouring. We highlight the differences between Asian skin and other skin types and review conditions common in skin of color together with treatment strategies.     

Modulated dual mode erbium/CO2 lasers for the treatment of acne scars

BACKGROUND: Treatment of acne scarring is a challenging problem for dermatologists and cosmetic surgeons. Combining skin resurfacing with other procedures, especially the use of filling agents, has proven to be superior to the use of a single modality. Carbon dioxide laser resurfacing has been popularized for the treatment of acne scarring, but post operative morbidity with stimulation of active acne has been problematic. Conventional erbium resurfacing is effective when sufficient fluences are used, particularly when treating relatively superficial acne scars. Deeper resurfacing for acne scars is difficult with erbium lasers, owing to bleeding and heavy exudation, which decreases ablation efficiency and makes 'end points' difficult to visualize. The newer modulated hybrid erbium/CO2 lasers (Derma K, ESC Sharplan, Yokneam, Israel) produce efficient ablation by the reduction of bleeding, yet at the same time incur little post operative morbidity. This is suitable for treating deeper acne scars, and may be combined with other procedures, e.g. fat grafting. Of particular importance is the lack of acne stimulation associated with the use of the erbium/CO2 hybrid lasers. RESULTS: In my series of 78 patients, improvement in acne scarring was > 70% in the majority of patients. Post operative morbidity and complications were minor compared to conventional CO2 laser resurfacing.     

A novel fractional micro-plasma radio-frequency technology for the treatment of facial scars and rhytids: A pilot study

Abstract

Introduction: Fractional ablative and non-ablative lasers have gained popularity in the treatment of acne scars and rhytids due to their efficacy and improved tolerability. Plasma and radio frequency (RF) have also emerged as methods for ablative or non-ablative energy delivery. We report preliminary experience with a novel fractional micro-plasma RF device for the treatment of facial acne scars and rhytids. Methods: Sixteen patients with facial acne scars or rhytids were treated at 4-week intervals. Treatment parameters were titrated to an immediate end point of moderate erythema. The clinical end point for cessation of treatment was the attainment of satisfactory clinical results. Results were monitored photographically up to 3 months after treatment. Results: Acne scars showed marked improvement after two to four treatments. Facial rhytids demonstrated reduced depth after two treatments and marked improvement after four treatments. Treatment was well tolerated by all participants, with transient erythema and short downtime. These results provide initial evidence for the safety and effectiveness of fractional micro-plasma RF as a low-downtime and well-tolerated modality for the treatment of acne scars and facial rhytids.     

Novel Opportunities in the Treatment and Prevention of Scarring

Numerous treatments have been described for the treatment and prevention of scars, but the optimal management strategy is yet to be defined. In this article we present and evaluate new opportunities for the treatment and prevention of hypertrophic scars, keloids, and atrophic scars. Clinical, animal, and in vitro studies reporting novel techniques for the treatment and prevention of scarring were identified primarily from the MEDLINE/PubMed database. We found that a variety of new treatments exist with potential effectiveness for the treatment of hypertrophic scars and keloids, including interferon, imiquimod 5% cream, tacrolimus, botulinum toxin, 5-fluorouracil, bleomycin, and verapamil. For atrophic scars, different types of lasers represent modern treatment modalities with satisfactory results. Several agents have been reported to be effective in reducing scarring in vitro and in animal studies, representing potential opportunities for scarring management. We conclude that several novel modalities may be potential therapies for scarring.

     

A clinical evaluation of acne scarring and its incidence

Despite scarring being a recognized sequel of acne, the actual extent and incidence of residual scarring remains unknown. One hundred and eighty-five acne patients were included in this study (101 females, 84 males). Patients were selected from acne clinics and their acne scarring was examined. The scarring was quantified according to a lesion count and allocated a score. The type and extent of scarring was correlated to the age and sex of the patient, the site of the acne, the previous acne grade according to the Leeds Technique,¹ acne type (noted in clinic at the original referral time) and duration of acne, before adequate therapeutic measures had been instituted. Results indicate that facial scarring affects both sexes equally and occurs to some degree in 95% of cases. Total scarring on the trunk was significantly greater in males, as was hypertrophic and keloid scarring in these sites (P <0.05). There were significant correlations between the initial acne grade and the overall severity of scarring in all sites and in both sexes (P<0.01). Superficial inflamed papular acne lesions as well as nodular lesions were capable of producing scars, A time delay up to 3 years between acne onset and adequate treatment related to the ultimate degree of scarring in both sexes and in all three sites. This emphasizes the need for earlier adequate therapy in an attempt to minimize the subsequent scarring caused by acne.     

Lasers and laser‐like devices: Part two

Part two of this review series evaluates the use of lasers and laser‐like devices in dermatology based on published evidence and the collective experience of the senior authors. Dermatologists can laser‐treat a wide range of dermatoses, including vascular, pigmentary, textural, benign proliferative and premalignant conditions. Some of these conditions include vascular malformation, haemangioma, facial telangiectases, café‐au‐lait macules, naevi of Ota, lentigines, acne scarring, rhytides, rhinophyma and miscellaneous skin lesions. Photodynamic therapy with lasers and intense pulsed light is addressed, with particular reference to actinic keratosis and actinic cheilitis. A treatment algorithm for acne scarring based on scar morphology and severity is comprehensively outlined. Following from part one, the various devices are matched to the corresponding dermatological conditions with representative pictorial case vignettes illustrating likely clinical outcomes as well as limitations and potential complications of the various laser and light therapies.     

Proceedings of the Facial Aesthetics Conference and Exhibition,Royal College of Physicians,London, 24–25 June 2006

BACKGROUND: Treatment of acne scarring is a challenging problem for dermatologists and cosmetic surgeons. Combining skin resurfacing with other procedures, especially the use of filling agents, has proven to be superior to the use of a single modality. Carbon dioxide laser resurfacing has been popularized for the treatment of acne scarring, but post operative morbidity with stimulation of active acne has been problematic. Conventional erbium resurfacing is effective when sufficient fluences are used, particularly when treating relatively superficial acne scars. Deeper resurfacing for acne scars is difficult with erbium lasers, owing to bleeding and heavy exudation, which decreases ablation efficiency and makes 'end points' difficult to visualize. The newer modulated hybrid erbium/CO 2 lasers (Derma K, ESC Sharplan, Yokneam, Israel) produce efficient ablation by the reduction of bleeding, yet at the same time incur little post operative morbidity. This is suitable for treating deeper acne scars, and may be combined with other procedures, e.g. fat grafting. Of particular importance is the lack of acne stimulation associated with the use of the erbium/CO 2 hybrid lasers. RESULTS: In my series of 78 patients, improvement in acne scarring was >70% in the majority of patients. Post operative morbidity and complications were minor compared to conventional CO 2 laser resurfacing.     

Fractional carbon dioxide (CO2) laser combined with topical tretinoin for the treatment of different forms of cystic acne

Nodulocystic acne is prone to scarring and difficult to treat with treatments other than oral isotretinoin. The aim of this article is to discuss the role of a single session of a fractional carbon dioxide (CO₂) laser combined with a topical treatment with a tretinoin and antibiotic gel for a month as a successful treatment to improve nodulocystic acne and chronic microcystic acne. Two cases were involved: the first with nodulocystic acne lesions that persisted after oral retinoids and the second with chronic microcystic acne resistant to topical treatments. After only one session of treatment with the CO₂ laser and the topical treatment, a complete healing of the nodulocystic acne lesions was observed with minimal secondary effects. The microcystic acne showed great improvement. No other topical or oral treatment was needed. This treatment could be a safe and effective treatment for nodulocystic acne lesions and microcystic acne when other treatments fail. More studies should be performed to confirm our results.