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

Background:

A number of treatments for reducing the appearance of acne scars are available, but general guidelines for optimizing acne scar treatment do not exist. The aim of this study was to compare the clinical effectiveness and side effects of fractional carbon dioxide (CO₂) laser resurfacing combined with punch elevation with fractional CO₂ laser resurfacing alone in the treatment of atrophic acne scars.

Materials and Methods:

Forty-two Iranian subjects (age range 18–55) with Fitzpatrick skin types III to IV and moderate to severe atrophic acne scars on both cheeks received randomized split-face treatments: One side received fractional CO₂ laser treatment and the other received one session of punch elevation combined with two sessions of laser fractional CO₂ laser treatment, separated by an interval of 1 month. Two dermatologists independently evaluated improvement in acne scars 4 and 16 weeks after the last treatment. Side effects were also recorded after each treatment.

Results:

The mean ± SD age of patients was 23.4 ± 2.6 years. Clinical improvement of facial acne scarring was assessed by two dermatologists blinded to treatment conditions. No significant difference in evaluation was observed 1 month after treatment (P = 0.56). Their evaluation found that fractional CO₂ laser treatment combined with punch elevation had greater efficacy than that with fractional CO₂ laser treatment alone, assessed 4 months after treatment (P = 0.02). Among all side effects, coagulated crust formation and pruritus at day 3 after fractional CO₂ laser treatment was significant on both treatment sides (P < 0.05).

Conclusion:

Concurrent use of fractional laser skin resurfacing with punch elevation offers a safe and effective approach for the treatment of acne scarring.     

The efficacy of fractional ablative carbon dioxide laser combined with other therapies in acne scars

Fractional ablative carbon dioxide laser resurfacing is a frontline treatment for acne scars. It creates multiple microscopic treatment zones to accelerate the collagen formation and the healing process of reepithelialization, according the principle of fractional photothermolysis. At present, the fractional CO₂ laser with a wavelength of 10,600 nm is commonly used in the field of cosmetology and clinical therapies for various skin diseases, and it can effectively improve skin regeneration and scar formation. To obtain satisfactory results for patients with scars, repetitive fractional laser therapy is always required; however, this treatment could easily lead to complications such as erythema, edema, infection, and post‐inflammatory hyperpigmentation. In addition, different types of acne scars may have different responses to laser, further limiting its widespread use. In recent studies both home and abroad, a new pattern of fractional laser combined with other therapies to improve acne scar has been recommended to guarantee the safety and effective of treatment. This article reviews the recent pertinent literatures and summarized the progression of ablative fractional CO₂ laser combined with other therapies on acne scar.     

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.     

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.     

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.     

Clinical trial of a pinpoint irradiation technique with the CO2 laser for the treatment of atrophic acne scars

Ablative laser resurfacing is an effective treatment for atrophic acne scars. However, it often induces complications such as edema, prolonged erythema, scarring and hyperpigmentation. Therefore, a new concept of laser treatment called fractional photothermolysis has been designed to create microscopic thermal wounds to achieve skin rejuvenation treatment of atrophic acne scars. This study was designed to prospectively evaluate the use of a technique similar to fractional photothermolysis using only the standard CO₂ laser without the fractional laser device in the treatment of atrophic scars and demonstrates it as a safe, effective and economical treatment option. Clinical improvement was achieved in all 35 patients with minimal adverse effects.     

超脉冲CO2点阵激光治疗面部萎缩性痤疮瘢痕40例分析

目的：评价超脉冲CO2点阵激光治疗面部萎缩性痤疮瘢痕的疗效.方法：面部萎缩性痤疮瘢痕40例,根据患者皮肤类型、痤疮瘢痕形状、深度、密度选用超脉冲CO2点阵激光的参数治疗,并进行治疗前后对比.结果：与治疗前相比,总有效率为92.5%,治疗中未观察到严重不良反应.结论：超脉冲CO2点阵激光治疗面部萎缩性痤疮瘢痕疗效显著,副作用小,安全性高.     

铒激光联合E光治疗痤疮凹陷性瘢痕的临床效果评价

目的：评价铒激光联合E光治疗痤疮凹陷性瘢痕的临床疗效和安全性。方法：将大连市皮肤病医院美容皮肤科2013年1月至2016年6月就诊患者采用双色球方法随机分成治疗组和对照组,治疗组为铒激光联合E光治疗组;对照组为铒激光治疗组,每个月治疗一次,共3次。对照组与治疗组均于疗程结束1个月后比较两组患者治疗前后皮肤红斑、色沉,瘢痕,皱纹,粗糙度,光滑度的变化。结果：共就诊62例痤疮凹陷性瘢痕患者,治疗组31例,对照组31例,治疗组与对照组患者皮损治疗前光滑度、瘢痕、皱纹、粗糙度、色沉、红斑比较,差异无统计学意义(P＞0.05)。治疗后,治疗组,患者皮肤的光滑度,瘢痕,皱纹,粗糙度,红斑,色沉评分分别为73.32±0.236、2.21±0.152、168.6±0.177、63±0.128、8.63±0.122、5.20±0.232,对照组分别为70.45±0.354、3.28±0.138、180.6±0.412、66±0.422、13.62±0.121、11.22±0.121,两组比较差异有统计学意义(均P<0.05)。所有患者未见严重不良反应。结论：铒激光联合E光治疗痤疮凹陷性瘢痕较单独应用铒激光治疗组疗效明显提升。     

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.     

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.     

Fractional CO2 laser for the treatment of acne scars

Background Numerous reports have been published on skin rejuvenation by the so‐called fractional laser device that delivers a laser beam in a dot form over a grid pattern. Aims In this study, we characterized the effects of a fractional CO₂ laser on atrophic acne scars at the clinical and ultrastructural levels. Methods Seven healthy adult Japanese volunteers (aged 32–46 years, mean 37.6, five men and two women of Fitzpatrick skin type III) were recruited for this study. A fractional CO₂ laser device, SmartXide DOT (DEKA, Florence, Italy), was used with irradiation parameters set as follows: output power 10 W, pulse width 600 μs, dot spacing 800 μm, and stack 2 (irradiation output power 0.91 J/cm²). A clinical examination and punch biopsy of each subject was performed before and just after the irradiation, and also at week 3 after three irradiation sessions. The biopsy specimens were stained with toluidine blue and were examined ultrastructurally. Results Clinical improvement of the atrophic acne scars was observed at week 3 after the third irradiation session in all cases compared with the condition before treatment. Histologically, outgrowths of many degenerated elastic fibers were observed as irregular rod‐shaped masses in the superficial dermis prior to the treatment in the region of the acne scars. At week 3 after the third irradiation, the degenerated elastic fibers were no longer observed, and the elastic fibers were elaunin‐like. Conclusions The fractional CO₂ laser is considered to be very effective for treating atrophic acne scars.     

富血小板血浆联合CO2点阵激光治疗萎缩性痤疮瘢痕疗效和安全性Meta分析

目的：系统评价富血小板血浆联合CO₂点阵激光治疗面部萎缩性痤疮瘢痕的有效性及安全性。方法：检索从建库到2019年7月Cochrane Library、Embase、Medline、中国知网、万方数据库及维普数据库中富血小板血浆联合CO₂点阵激光治疗面部萎缩性痤疮瘢痕的随机对照试验,筛选符合要求的文献并根据Cochrane偏倚风险评估方法评价纳入文献质量, 采用Revman5.3软件进行Meta分析。结果：最终纳入5个RCTs和Meta分析,结果显示：①联合疗法的总有效率和治愈率均高于单用激光组（P=0.008,0.0002）;②联合疗法和单用激光组的红斑、水肿持续时间及疼痛评分无统计学差异（P=0.21,0.35,0.50）。结论：富血小板血浆联合CO₂点阵激光治疗萎缩性痤疮瘢痕的疗效优于单独使用CO₂点阵激光,不良反应无明显差异。     

微等离子体与超脉冲CO2点阵激光治疗痤疮凹陷性瘢痕的对比研究

目的 比较微等离子体与超脉冲CO2点阵激光治疗痤疮凹陷性瘢痕的疗效及不良反应。 方法 对21例痤疮凹陷性瘢痕患者进行自身对照试验,一侧面部进行微等离子体治疗,另一侧进行CO2点阵激光治疗,1次治疗后随访6个月,观察两种治疗方法的疗效和不良反应。对各组治疗前后及组间痤疮瘢痕权重评分（ECCA）、患者自身评估（四分值法）微等离子体治疗1次后6个月的瘢痕改善值及治疗后疼痛评分、水肿评分、结痂时间和炎症性红斑持续时间进行非参数秩和检验,比较治疗前后及不同方法间的临床疗效及不良反应。选用1只新西兰大耳兔,在双侧兔耳分别造瘢痕模型,分别用微等离子体和CO2点阵激光在两侧兔耳瘢痕模型上扫描1遍,即刻取下组织,观察组织学改变。结果 痤疮凹陷性瘢痕治疗1次后,微等离子体组ECCA从50.71降至34.76,评分下降率为31.5%,21例中有19例治疗后ECCA评分下降,有效率为90.5%;超脉冲CO2点阵激光组评分从53.57降至38.10,评分下降率为29.9%,其中18例治疗后ECCA评分下降,有效率为86.7%,两组间有效率差异无统计学意义（P > 0.05）。治疗后微等离子组水肿较轻,红斑持续时间为13.95 d,结痂持续时间为6.95 d,而超脉冲CO2点阵激光组分别为45.81 d和10.10 d。微等离子体侧无1例发生色素沉着,而CO2点阵激光治疗侧色素沉着发生率达19%。兔耳瘢痕组织HE染色显示,微等离子体的微剥脱区宽而浅,CO2点阵激光的微剥脱区窄而深。结论 微等离子体和超脉冲CO2点阵激光对痤疮凹陷性瘢痕均有较好疗效,但微等离子体相对不良反应较小,色素沉着发生率低。     

Significant reduction of inflammation and sebaceous glands size in acne vulgaris lesions after intense pulsed light treatment

Intense pulsed light (IPL) has been used for years in treatment of acne vulgaris. However, quantitative evaluation of histopathological changes after its use as a sole therapy was poorly investigated. Accordingly, this study aims to objectively evaluate inflammatory infiltrate and sebaceous glands in acne vulgaris after IPL. Twenty‐four patients of acne were treated with six IPL sessions. Clinical evaluation was done at 2 weeks after last session by counting acne lesions. Patient satisfaction using Cardiff Acne Disability Index (CADI) was recorded at baseline, 2 weeks and 3 months after IPL. Using histopathological and computerized morphometric analysis, quantitative evaluation of inflammatory infiltrate and measurement of surface area of sebaceous glands were performed for skin biopsies at baseline and 2 weeks after last session. After IPL, there was significant reduction of all acne lesions especially inflammatory variety with significant decrease of CADI score at 2 weeks and 3 months after IPL (p < .05). Microscopically, there was significant decrease in density of inflammatory infiltrate and surface area of sebaceous glands (p < .05). So, IPL is fairly effective therapy in acne vulgaris especially inflammatory variety. The results suggest that IPL could improve acne lesions through targeting both inflammation and sebaceous glands.     

黄金微针射频联合低能量超脉冲CO2点阵激光治疗面部痤疮凹陷性瘢痕的疗效观察

 目的 观察黄金微针射频联合低能量超脉冲CO2点阵激光治疗面部痤疮凹陷性瘢痕的疗效。方法选取2018年4月—2020年4月就诊于河南大学第一附属医院的74例凹陷性痤疮瘢痕患者为对象,随机分为2组,每组各37例。治疗组采用黄金微针射频联合低能量超脉冲CO2点阵激光治疗;对照组采用黄金微针射频治疗。比较2组治疗前后痤疮瘢痕权重评分（ECCA）、瘢痕改善程度IGA评估及术后不良反应。结果2组治疗后ECCA评分均明显降低,但治疗组评分降低更明显(Z=-2.65,P＜0.05);治疗组IGA评估有效率较对照组高。2组不良反应发生率无统计学差异。结论黄金微针射频联合低能量超脉冲CO2点阵激光能更好地改善痤疮后凹陷性瘢痕,两种方法联合能够起到协同作用且不增加治疗相关副作用。     

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.     

CO2点阵激光联合胶原贴敷料治疗面部痤疮凹陷性瘢痕的临床观察

目的 观察胶原贴敷料对CO2点阵激光治疗面部痤疮凹陷性瘢痕术后的修复作用及安全性。 方法 选择70例面部痤疮凹陷性瘢痕患者,随机分为试验组和对照组各35例。试验组CO2点阵激光治疗后外敷胶原贴敷料20 min,共10 d;对照组不用敷料,其余处理同试验组。治疗后随访6个月,观察治疗后急性炎症反应情况、痂皮脱落时间、患者舒适度评价、误工期、炎症后色素沉着率及其他不良反应发生情况。 结果 试验组急性炎症反应评分（W = 312,P < 0.01）、痂皮脱落时间（t = 2.08,P < 0.05）、激光术后自身舒适程度评价（W = 172,P < 0.01）均优于对照组,试验组炎症后色素沉着发生率（χ2 = 6.06,P < 0.05）、误工期（t = 3.14,P < 0.05）均低于对照组,两组均无新发生的瘢痕。 结论 CO2点阵激光术后应用胶原贴敷料可减少术后不良反应发生率,提高患者满意度。     

Fractional 1320 nm Nd : YAG laser in the treatment of acne vulgaris: a pilot study

Thirty-five patients with moderate to severe acne were treated with a fractional 1320 nm neodymium : yttrium aluminum garnet (Nd : YAG) laser. These patients received six treatment sessions at a 2-week interval. Inflammatory and non-inflammatory lesions were counted before and after treatment. Fractional 1320 nm Nd : YAG laser therapy was well tolerated, resulting in the reduction of inflammatory lesions by 57% ( P <0.05) and the reduction of non-inflammatory lesions by 35% ( P <0.05). A significant reduction in the skin sebum level by 30% ( P <0.05) was also noted after treatment.     

Fractional CO2 laser treatment for a skin graft

Skin grafts are widely used in reconstructive and plastic surgery, leaving an inevitable scar appearance on the body, affecting the quality of life of the patients. Fractional ablative lasers have become a leading procedure for the treatment of acne and burn scars. We report a case of a skin graft showing excellent improvement in overall appearance after three sessions of fractional CO₂ laser. The undamaged tissue left between the microthermal treatment zones is responsible of collagen formation and reepithelialization. Remodeling and collagen formation are observed even 6 months after a fractional CO₂ laser session.     

Intense pulsed light vs. pulsed‐dye laser in the treatment of facial acne: a randomized split‐face trial

Background Various laser and light therapy have been increasingly used for the treatment of acne vulgaris. Patients and methods Twenty patients with facial acne were treated using intense pulsed light (IPL) on one side of the face and pulsed dye laser (PDL) on the other to compare the efficacy and safety of IPL and PDL. Treatment was performed 4 times at 2‐week intervals. Treatment effectiveness was determined using lesion counts, acne severity, patient subjective self‐assessments of improvement, and histopathological examinations, which included immunohistochemical staining for transforming growth factor‐β (TGF‐β). Results Numbers of total acne lesions decreased following both treatments. For inflammatory lesions such as papules, pustules and nodules, IPL‐treated sides showed an earlier and more profound improvement than PDL‐treated sides. However, at 8 weeks after the 4th treatment, a rebound aggravation of acne was observed on IPL‐treated sides. On the contrary, PDL produced gradual improvements during the treatment sessions and these improvements lasted 8 weeks after the 4th treatment. Non‐inflammatory lesions as open and closed comedones also showed improvement following both treatments and PDL‐treated sides showed better improvement as the study proceeded. Histopathological examinations showed amelioration in inflammatory reactions and an increase in TGF‐β expression after both treatments, which were more prominent for PDL‐treated sides. Conclusion Both PDL and IPL were found to treat acne effectively, but PDL showed a more sustained effect. TGF‐β might play a key role in the resolution of inflammatory acne lesions.