Combination of microneedling and glycolic acid peels for the treatment of acne scars in dark skin

Introduction Acne scars can cause emotional and psychosocial disturbance to the patient. Various modalities have been used for the treatment of acne scars like punch excision, subcision, peels, microdermabrasion, unfractionated and fractioned lasers. The latest in the treatment armamentarium is microneedling. Acne scars commonly coexist with postinflammatory hyperpigmentation. A combination of microneedling and glycolic acid (GA) peels was found to give excellent results in the treatment of such scars. The aim was to study the efficacy of a combination of microneedling with glycolic peel for the treatment of acne scars in pigmented skin. Method Thirty patients in the age group of 20–40 years with atrophic box type or rolling scars with postinflammatory hyperpigmentation were chosen for the study. Two groups were made. The first group comprised of 30 patients in whom only microneedling was performed once in 6 weeks for five sessions. In the second group of 30 patients, a combination of microneedling and 35% GA peels was carried out. Patients from both groups were evaluated on the basis of Echelle d’Evaluation clinique des Cicatrices d’acné classification. Results Based on the objective scoring and its statistical analysis, there was significant improvement in superficial and moderately deep scars (grade 1–3). There was also improvement in skin texture, reduction in postacne pigmentation in the second group. Conclusion Microneedling is a simple, inexpensive office procedure with no downtime. It is safe in Indian skin (skin types III–IV). The combined sequential treatment with GA peel caused a significant improvement in the acne scars without increasing morbidity.     

Treatment of acne vulgaris with fractional radiofrequency microneedling

Fractional radiofrequency microneedling is a novel radiofrequency technique that uses insulated microneedles to deliver energy to the deep dermis at the point of penetration without destruction of the epidermis. It has been used for the treatment of various dermatological conditions including wrinkles, atrophic scars and hypertrophic scars. There have been few studies evaluating the efficacy of fractional radiofrequency microneedling in the treatment of acne, and none measuring objective parameters like the number of inflammatory and non‐inflammatory acne lesions or sebum excretion levels. The safety and efficacy of fractional radiofrequency microneedling in the treatment of acne vulgaris was investigated. In a prospective clinical trial, 25 patients with moderate to severe acne were treated with fractional radiofrequency microneedling. The procedure was carried out three times at 1‐month intervals. Acne lesion count, subjective satisfaction score, sebum excretion level and adverse effects were assessed at baseline and at 4, 8 and 12 weeks after the first treatment as well as 4, 8 and 12 weeks after the last treatment. Number of acne lesions (inflammatory and non‐inflammatory) decreased. Sebum excretion and subjective satisfaction were more favorable at every time point compared with the baseline values (P < 0.05). Inflammatory lesions responded better than non‐inflammatory lesions (P < 0.05). Adverse effects such as pinpoint bleeding, pain and erythema were noted, but were transient and not severe enough to stop treatment. Fractional radiofrequency microneedling is a safe and effective treatment for acne vulgaris.     

黄金微针射频联合自体富血小板血浆治疗面部痤疮凹陷性瘢痕的疗效评估

目的 探讨黄金微针射频联合自体富血小板血浆(PRP)治疗面部痤疮凹陷性瘢痕的疗效。方法 选择河南大学第一附属医院皮肤科门诊2019年4月—2021年4月接收且诊治的74例凹陷性痤疮瘢痕患者为对象,随机分为2组。观察组采用黄金微针射频联合PRP治疗,对照组采用滚轮微针联合PRP治疗,两组均治疗间隔4周,连续治疗3次,3次为1疗程。1个疗程结束后6个月随访,比较两组ECCA权重评分和临床疗效分析、记录治疗引起的皮肤损伤相关时间指标。结果 观察组治疗前ECCA权重评分为53.38±19.15,对照组为52.43±25.94,两组差异无统计学意义(Z=-0.64,P=0.524);治疗后观察组ECCA权重评分降低为24.46±14.38,对照组降低为36.08±20.38,观察组低于对照组(Z=-2.20,P<0.05)。观察组和对照组总体有效率分别为91.89%和72.97%,两组差异有统计学意义(χ²=4.57,P<0.05)。观察组患者的红肿持续时间、愈合时间和停工时间均短于对照组患者,差异均有统计学意义(均P<0.05)。结论 黄金微针射频联合P...     

Adjuvant alternative treatment with chemical peeling and subsequent iontophoresis for postinflammatory hyperpigmentation,erosion with inflamed red papules and non‐inflamed atrophic scars in acne vulgaris

The standard management of acne vulgaris in Japan includes a combination of topical treatment with benzoyl peroxide (BPO) and BPO/clindamycin (CLDM), topical adapalene and systemic antimicrobials. However, the treatment of therapy‐resistant complications such as postinflammatory hyperpigmentation (PIH), erosions with inflamed red papules and atrophic scars has not been established. We performed chemical peeling with glycolic acid and iontophoresis with ascorbyl 2‐phosphate 6‐palmitate and DL‐α‐tocopherol phosphate for the treatment of PIH, erosions with inflamed red papules and non‐inflamed atrophic scars in 31 patients with acne vulgaris (mild to severe severity), and evaluated the efficacy and safety of these interventions. In most of cases, there was remarkable improvement in PIH and erosions with inflamed red papules after treatment. There was also some improvement in non‐inflamed atrophic scars without erythema. Mild redness and irritation was observed in four cases as adverse reactions. Early initial treatment of PIH and erosions with red papules by chemical peeling and iontophoresis is an effective and safe method to prevent the formation of atrophic scars in patients with acne vulgaris.     

黄金微针射频治疗面部痤疮瘢痕的疗效评估

目的 评价黄金微针射频治疗面部痤疮瘢痕的有效性及安全性。方法 广州市皮肤病防治所2016年6月至2017年6月采用黄金微针射频治疗的42例痤疮瘢痕患者（观察组）和CO2点阵激光治疗的47例痤疮瘢痕患者（对照组）,分别用疗效四级单盲法和临床痤疮瘢痕评估量表（ECCA）权重评分对两组治疗前后照片分析统计,评估疗效。统计方法采用χ2检验,两独立样本t检验及配对资料Wilcoxon秩和检验。结果 治疗后,观察组和对照组总体有效率分别为92.9%（39例）和89.4%（42例）,两组差异无统计学意义（χ2 = 0.042,P > 0.05）。治疗前观察组ECCA权重评分为46.7 ± 16.3,对照组为45.7 ± 15.8,两组差异无统计学意义（t = 0.271,P > 0.05）。治疗后,观察组ECCA权重评分降低为29.5 ± 15.1,前后比较差异有统计学意义（Z = -5.713,P < 0.05）;对照组降低为31.3 ± 14.9,前后比较差异有统计学意义（Z = -6.086,P < 0.05）。结论 黄金微针治疗面部痤疮瘢痕疗效确切,安全性高且创伤小。     

Microneedling and PRP for acne scars: A new tool in our arsenal

A common complication of acne vulgaris is clinically significant scarring, which can greatly impact patient quality of life. While treatment options have included microneedling, the recent addition of platelet‐rich plasma (PRP) to this regimen has led to an increased popularity of combination treatment. Here, we offer backgrounds on microneedling and PRP therapies and review the literature on combination treatment for acne scars.     

Efficacy and tolerability of a microneedling device for treating wrinkles on the face

Objectives

A microneedling pen has been cleared by the US Food and Drug Administration, indicated for improving the appearance of adult facial acne scars. The objective of this study was to assess the device's effectiveness for treating wrinkles of the face area.

Materials and Methods

Healthy adults seeking to improve the appearance of face wrinkles were enrolled (N = 35), receiving four monthly microneedling procedures by a trained aesthetician who treated the face skin per manufacturer instructions. Wrinkle assessments were performed by two trained blinded raters by comparing baseline images of each subject with images obtained at 90 days post-procedure. Subsequently, the two raters were unblinded for the Clinician's Global Aesthetic Improvement Scale (CGAIS) assessment. Subjects completed the Subject's Global Aesthetic Improvement Scale (SGAIS) and a Satisfaction Questionnaire at 30 and 90 days post-treatment.

Results

The study was completed by 32 subjects with a mean (SD) age of 56.3 (5.0) years. Wrinkle assessments demonstrated significant improvement in the face areas (p < 0.001). The SGAIS scores showed significant improvements after 30 and 90 days post-treatment (for each, p < 0.001). The CGAIS scores also showed significant improvements at 90 days post-treatment (p < 0.001). Most subjects reported some level of improvement in their appearance at 30 days (73.3%) and 90 days (68.8%) post-treatment. The satisfaction questionnaire showed high levels of improvement in wrinkles (93.8%), satisfaction with the treatment procedure (87.5%) and would recommend microneedling to friends and family members (80.6%) on the face and neck.

Conclusion

Microneedling is a viable, minimally invasive option for treating wrinkles of the face. ClinicalTrials.gov Identifier: NCT03803059.     

Subcision in acne scarring: A review of clinical trials

Post-acne scarring is the most common permanent consequence of acne vulgaris. Subcision is an intervention in which a needle or blunt cannula is inserted under the scar and moved back and forth to cut fibrotic strands and form new connective tissue, thereby elevating the atrophic scars. In this study, we reviewed the efficacy and adverse effects of different subcision techniques alone or in combination with other modalities to manage acne scars. The terms (subcision), (subcision AND acne scar), and (subcision AND scar) were searched in PubMed and Google Scholar. We included all available reports on clinical trials written in English and published before June 2022. A total of 16 relevant articles were identified after reviewing the abstracts and full texts. Four articles compared blunt cannula-based subcision as a modified technique with needle-based subcision as a conventional method, while the others investigated the combination of subcision with other modalities. According to our findings, subcision is a safe and effective method for treating atrophic acne scars. Needle-based subcision and cannula-based subcision offer comparable efficacy, with the latter causing fewer side effects and inducing greater patient satisfaction. Combining subcision with the application of autologous tissues (platelet gel) or artificial materials (hyaluronic acid gels and threads) as fillers can improve outcomes and prevent the re-depressing of scars, as can its combination with frequent suctioning. Combinations with microneedling or fractionated microneedle radiofrequency have also been safe and effective. We conclude that modifications of the subcision procedure lessen its side effects, and combination therapies improve its efficacy.     

Prevalence of scars and “mini‐scars”, and their impact on quality of life in Japanese patients with acne

There have been very few studies on the prevalence and severity of acne scars in Japanese patients. The aim of the present study was to investigate the prevalence of acne scars and their impact on the quality of life (QOL) in Japanese acne patients. Acne scars were classified as mini‐scars (atrophic scars of ≥0.5 and <2 mm in diameter) atrophic scars (≥2 mm in diameter), and hypertrophic scars. The severity of acne and acne scars were evaluated. The background of patients and their QOL in relation to acne were assessed. Of 240 subjects, 218 (90.8%) had scars. All patients with scars had mini‐scars; 61.2% and 14.2% of 240 had atrophic scars and hypertrophic scars, respectively. Severe scarring was found in patients who had experienced severe acne symptoms, although 15.0% of patients with scars had experienced only mild acne symptoms. The total Dermatology Life Quality Index score was significantly higher in patients with scars than in patients without scars (5.9 ± 4.4 vs 4.2 ± 4.1). Almost all the patients had small atrophic scars with a diameter of 0.5 or more and less than 2 mm, which we have termed “mini‐scars”. Acne scars had a negative impact on patient QOL. Early initiation of treatment is recommended to avoid acne scars.     

Subcision‐suction method: a new successful combination therapy in treatment of atrophic acne scars and other depressed scars

Background Among therapeutic modalities of acne scars, subcision is a simple, safe procedure with a different and basic mechanism for correcting atrophic and depressed scars. Subcision releases scar surfaces from underlying attachments and induces connective tissue formation beneath the scar directly, without injury to the skin surface. Therefore, subcision is a valuable method, but due to high recurrence rate, its efficacy is mild to moderate. Objectives To increase the efficacy of subcision, a new complementary treatment of repeated suction sessions was added at the recurrence period of subcised scars. Methods In this before and after trail, 58 patients with mild to severe acne scars of various types (rolling, superficial and deep boxcar, pitted), chicken pox, traumatic and surgical depressed scars were treated by superficial dermal undermining, with mainly 23‐guage needles. The protocol for suctioning was: start of suction on third day after subcision for flat and depressing subcised scars and its continuation at least every other day for 2 weeks. Results Forty‐six patients followed the protocol completely, had 60–90% improvement in depth and size of scars (significant improvement) with mean: 71.73%. 28.2% of them had ‘80% improvement or more’ (excellent improvement). Twelve patients started suction late and/or had long interval suction‐sessions, had 30–60% improvement (moderate improvement) with mean: 43.75%. Conclusion Frequent suctioning at the recurrence period of subcision increases subcision efficacy remarkably and causes significant and persistent improvement in short time, without considerable complication, in depressed scars of the face. Therefore, subcision‐suction method is introduced as a new effective treatment.     

Non‐ablative 1550‐nm erbium‐glass and ablative 10 600‐nm carbon dioxide fractional lasers for acne scars: a randomized split‐face study with blinded response evaluation

Background Non‐ablative 1550‐nm erbium‐doped fractional photothermolysis systems (FPS) and 10 600‐nm carbon dioxide fractional laser systems (CO₂ FS) have been effectively used to treat scars. Objective We compared the efficacy and safety of single‐session treatments of FPS and CO₂ FS for acne scars through a randomized, split‐face, evaluator‐blinded study. Methods Eight patients with acne scars were enrolled in this study. Half of each subject’s face was treated with FPS and the other half was treated with CO₂ FS. We used a quartile grading scale for evaluations. Results At 3 months after the treatment, the mean grade of improvement based on clinical assessment was 2.0 ± 0.5 for FPS and 2.5 ± 0.8 for CO₂ FS. On each side treated by FPS and CO₂ FS, the mean duration of post‐therapy crusting and scaling was 2.3 and 7.4 days respectively and that of post‐therapy erythema was 7.5 and 11.5 days respectively. The mean VAS pain score was 3.9 ± 2.0 with the FPS and 7.0 ± 2.0 with the CO₂ FS. Conclusion We demonstrated the efficacy and safety of single‐session acne scar treatment using FPS and CO₂ FS in East Asian patients. We believe that our study could be used as an essential reference when choosing laser modalities for scar treatment.     

Microneedling with glutathione versus microneedling alone in treatment of facial melasma: Split-face comparative study

Background

Melasma is a distressing disfiguring acquired pigmentary disorder especially affecting females and it is of high tendency of recurrence. Up till now, treatment of melasma is a challenging problem.

Objectives

We evaluated the effectiveness of microneedling with glutathione versus microneedling alone in treatment of melasma.

Patients and Methods

In this study, 29 adult females with epidermal type of melasma (confirmed with Wood's light examination) were enrolled. The affected area was subjected to microneedling using dermapen followed by application of glutathione solution on the right side only. This session was performed every 2 weeks for 3 months (six sessions for every patient). The response to therapy was measured using modified melasma area and severity index (m MASI) that were calculated on each side of the face (Hemi- m MASI) before treatment sessions.

Results

There was statistically significant reduction in the mean of Hemi- m MASI score over the sessions on both sides of the face but the right side (microneedling with glutathione) showed more reduction and earlier response to therapy than the left side (microneedling alone). On the left side, mean of Hemi- m MASI score before and after sessions was (4.06 ± 1.91, 2.31 ± 1.450) and on the right side, it was (4.21 ± 2.08, 1.96 ± 1.30), respectively and this was statistically significant. Percentage of improvement on the left side was 46.92 ± 16.30 (%) while on the right side was 55.17 ± 15.50 (%) and this was statistically significant.

Conclusions

Microneedling is an effective promising tool in treatment of melasma and its combination with glutathione as a whitening agent, increases and accelerates its efficacy. So, combined therapy is more preferred than monotherapy in treatment of facial melasma.     

A case of fractional microneedling radiofrequency induced rosacea

Fractional microneedling radiofrequency (FMR) has been reported to improve cutaneous wrinkles due to its effects of inducing neoelastogenesis and neocollagenosis. Furthermore, FMR has shown to be effective in acne scars, acne lesions, hyperhidrosis, acne-related postinflammatory erythema and recently in rosacea. FMR treatment has been suggested to improve rosacea by reducing inflammation and abnormal vessel proliferation. Here we present a 61-year-old female who developed rosacea symptoms after the treatment of FMR for cutaneous wrinkles. Since the case shows conflictory findings with the previous data, it was found worthy presentation.     

The role of fillers in the management of acne scars

Acne scars are present in 95% of patients with acne, and can cause profound psychosocial morbidity. Fillers are commonly used for facial soft tissue augmentation, and there is increasing interest in their use for the treatment of acne scars, particularly for the atrophic subtype. We review the evidence for the use of temporary, semi‐permanent and permanent fillers for acne scars. The use of permanent methylmethacrylate fillers for acne scarring is supported by a randomized controlled trial, and is approved by the United States Food and Drug Administration. There is initial evidence supporting the use of poly‐L‐lactic acid and hyaluronic acid fillers, but evidence is still lacking about the use of polyacrylamide and polyalkylimide fillers.     

Evaluation of effectiveness of erbium:yttrium–aluminum–garnet laser on atrophic facial acne scars with 22‐MHz digital ultrasonography in a Turkish population

Scar formation due to acne is a common problem among the young population and significantly affects their quality of life. The aim of this study was to evaluate the efficacy of erbium:yttrium–aluminum–garnet (Er:YAG) laser resurfacing for acne scars and to objectively demonstrate the altering of collagen density in the dermis by 22‐MHz digital ultrasonography. Twenty‐one patients, aged 19–55 years, with facial acne scars were treated with Er:YAG laser. The results of the laser resurfacing were evaluated for the degree of clinical improvement, alteration of the collagen density by 22‐MHz digital ultrasonography and any adverse effects at 3 months. At 3 months after the treatment, good (in 12 patients) and near total (in four patients) clinical improvement was noted in most of the patients compared to baseline. Overall treatment results were 76% (both near total and good) in 16 patients. By ultrasonographic evaluation, the average density of dermal collagen (total density/number of patients) of 21 patients was 32.714 (right cheek) and 32.142 (left cheek) before laser facial resurfacing. At the third month after treatment, the average density of dermal collagen of 21 patients was 36.380 (right cheek) and 38.809 (left cheek). In conclusion, Er:YAG laser skin resurfacing was found to be a safe and effective treatment modality for treatment of atrophic facial acne scars. As public demand grows for less invasive modalities to approach clinical diagnosis and evaluation, digital ultrasonography seems to provide an easy and confidential method for collagen density evaluation.     

A cross‐sectional,multi‐center study on treatment of facial acne scars with low‐energy double‐pass 1450‐nm diode laser

Acne scars are the ultimate outcome of acne vulgaris, a prevalent skin disorder affecting the pilo‐sebaceous unit. Laser resurfacing has been demonstrated to be an efficient therapy option for acne scars. Hence, we adopted this concept and conducted a study to evaluate the safety and efficacy of low‐energy double‐pass 1450‐nm diode laser on acne scars. This study was conducted on 48 patients with acne scars, treated at 4‐week interval with low‐energy double‐pass 1450‐nm diode laser. Patients were evaluated clinically and with photographs, at day 0, first month and third month post the final treatment and during follow‐up visit. Five treatment sessions were completed by all patients. Approximately, 79.2% of patients showed around 30% improvement. At the end of third month follow‐up, 92.9% of the patients demonstrated >30% improvement. Vesicle formation was observed in two cases, with no post‐inflammatory hyperpigmentation and transient hyperpigmentation was observed in one case, which vanished within 2 months. Our study showed that 1450‐nm diode laser treatment was efficient and well endured in facial acne scars when used with double‐pass at low‐energy.     

Combined subcision,autologous platelet-rich plasma,and CROSS technique in the treatment of atrophic acne scars: Prospective split face study.

Acne scars represent a therapeutic dilemma. This study aimed to evaluate the efficacy of combined subcision, autologous platelet-rich plasma (PRP), and chemical reconstruction of skin scars (CROSS) technique in the treatment of acne scars. In 20 patients with atrophic acne scars, one facial side was treated with subcision plus PRP, and the other was treated with the same combination plus CROSS technique (trichloroacetic acid 50%) for 3 sessions at 3-week intervals. Clinical evaluation, digital photography, quantitative global scarring grading system, and Lipper and Perez score were done at baseline, every session, and 1 month after the last session. Participants assessed their improvement at the end of the follow-up period using a scale (0 to 10). There was a significant reduction in quantitative global scarring grading system (P < .001) and Lipper and Perez score (P < .001) after treatment compared with baseline in both sides. No significant difference was found when the two treated sides were compared after treatment by both scores. Patients’ satisfaction was excellent (12 patients [60%]) and good (eight patients [40%]) with no significant difference between both sides. In conclusion, combined subcision and PRP is recommended for acne scars. Adding CROSS technique (trichloroacetic acid 50%) did not further ameliorate the condition.     

Clinical studies of the treatment of facial atrophic acne scars and acne with a bipolar fractional radiofrequency system

Few clinical studies have examined the utility of bipolar fractional radiofrequency (FRF) therapy as a treatment for atrophic acne scars and active acne in people with darker skin. This study was designed to compare the safety and efficacy of bipolar FRF therapy as a treatment for atrophic acne scars and acne vulgaris. Twenty‐three Japanese patients with atrophic acne scars and mild to severe acne on both cheeks were treated with a bipolar FRF system (eMatrix; Syneron, Yokneam Illit, Israel). Five treatment sessions were carried out at 1‐month intervals, and the patients were followed up for 3 months after the final treatment. Assessments of scar severity and the number of acne lesions and 3‐D in vivo imaging analysis were performed. Evaluations of the treatment outcomes and their effects on the patients’ quality of life (QOL) were also carried out. We demonstrated that the improvement in scar volume was marked in the patients with mild scars and was at least moderate in 23 (57.5%) of the treated areas. With regard to the number of acne lesions, the treated areas exhibited significantly fewer lesions compared with the baseline at each time point (P < 0.05). The patients’ assessments of the treatment outcomes and their QOL indicated that both had improved significantly by the end of the study. Furthermore, significant reductions in the patients’ sebum levels, skin roughness and scar depth were observed. Bipolar FRF treatment significantly improved the atrophic acne scars and acne of Japanese patients and had minimal side‐effects.     

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.