A Review and Update of Treatment Options Using the Acne ......acne scar pathology that divided atrophic acne scars into icepick, rolling, and boxcar scars, and this review will evaluate

A Review and Update of Treatment Options Using theAcne Scar Classification SystemMonica Boen, MD* and Carolyn Jacob, MD†

BACKGROUND An unfortunate consequence of acne vulgaris is residual scarring that can negatively affect apatient’s quality of life.

OBJECTIVE Jacob and colleagues have previously described an acne scar classification system based onacne scar pathology that divided atrophic acne scars into icepick, rolling, and boxcar scars, and this review willevaluate new and developing treatment options for acne scarring.

METHODS A Medline search was performed on the various treatments for acne scars, and particular attentionwas placed on articles that used the acne scar classification system of icepick, rolling, and boxcar scars.

RESULTS Therapies for acne scarring included surgical modalities, such as subcision, and punch excisionand elevation, injectable fillers, chemical peels, dermabrasion, microneedling, and energy-based devices. Inthe past decade, there has been a trend toward using cosmetic fillers and energy-based devices to improveacne scarring.

CONCLUSION There were few high-quality evidence-based studies evaluating the management of acnescarring. Many disparate acne severity scores were used in these studies, and the acne scar type was frequentlyundefined, making comparison between them difficult. Nonetheless, research into interventions for acnescarring has increased substantially in the past decade and has given patients more therapeutic strategies.

The authors have indicated no significant interest with commercial supporters.

Acne is a very common inflammatory disorder ofthe pilosebaceous unit that consists of

comedones, inflammatory papules, pustules, andnodules involving the face, chest, and back.1 Thepathogenesis of acne is complex and involvesinflammation and release of cytokines around thepilosebaceous unit, abnormal keratinization,increased sebum production, and Propionibacteriumacnes.2 An unfortunate sequelae of acne is residualscarring and disfigurement. Acne and acne scarringcan have a detrimental impact on the quality of life andlead to feelings of embarrassment and low self-esteem.3

Jacob and colleagues4 have previously described aclassification system to define atrophic acne scars into3 basic types: icepick, rolling, and boxcar scars. This

classification system has allowed a consistent andstandardized definition of acne scars that has beenadopted into clinical research and has aided in treat-ment regimens. Each of these scar types has beenclassified based on the underlying scar pathology. Byclassifying acne scars into distinct types, treatmentoptions can be better tailored to each individualpatient (Table 1).

Icepick scars are narrow (<2 mm) and extend verti-cally into the deep dermis or subcutaneous tissue.4

Because of the deep extension of icepick scars, con-ventional skin resurfacing options will not ade-quately treat these types of scars. Rolling scars havesloped and shallow borders with a normal skin tex-ture at the base and are about 4 to 5mmwide.4 Thesescars result from abnormal fibrous bands anchoring

*Department of Dermatology, University of Illinois at Chicago, Chicago, Illinois; †Department of Dermatology,Northwestern Feinberg School of Medicine, Chicago, Illinois

© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.ISSN: 1076-0512 · Dermatol Surg 2019;45:411–422 · DOI: 10.1097/DSS.0000000000001765

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© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

the dermis to the subcutis, which produces a dell inthe skin. Treatment is aimed at correcting theabnormal fibrous anchoring of these scars. Finally,boxcar scars are round to oval, or rectangular,depressions with sharply defined vertical edges thatcan be shallow (0.1–0.5 mm) or deep ($0.5). Shal-low boxcar scars, rather than deep boxcar scars, aremore amenable to treatment with resurfacingmodalities. Other scar types, including, hypertro-phic, keloidal, and sinus tract scars are less common.In this review, we will provide an update on thetreatment options available for acne scarring,focusing on the 3 types of atrophic acne scars.

Cosmetic Fillers

In the past decade, there has been a rapid influx ofcosmetic injectable fillers, from temporary hyaluronicacid (HA) fillers to semipermanent and permanentfillers (Table 2).5 Several of these cosmetic fillers havebeen used for atrophic acne scars to increase tissuevolume in these lesions and to stimulate collagenproduction.6 Superficial rolling and boxcar scarsrespond best to cosmetic fillers and have been com-bined with subcision to enhance results.7 A recentCochrane review foundmoderate-quality evidence forthe efficacy of cosmetic fillers in atrophic acne scars.8

TABLE 1. Acne Scar Classification

Acne ScarSubtypes Description Treatment Options

TreatmentEfficacy*

Icepick <2 mm and narrow Punch excision +++

Tapers as extends to deepdermis

TCA CROSSRadiofrequencyLaser skin resurfacing

++++

Rolling 4–5 mm wide

Sloped and shallow borders

SubcisionFillers

++++++

Caused by dermal tethering ofotherwise normal skin

DermabrasionMicroneedling

++++

RadiofrequencyLaser skin resurfacing

++++

Boxcar 1.5–4 mm wide Shallow boxcar:

Round to oval depressions withsharply demarcated vertical edges

Punch elevationDermabrasion

+++++

Can be shallow (0.1–0.5 mm) ordeep ($0.5)

MicroneedlingRadiofrequencyLaser skin resurfacing

++++++

Deep boxcar:

Subcision ++

TCA CROSS ++

Punch excision/elevation

++

Laser skin resurfacing ++

*(+++) highly effective (++) effective (+) adequate.

CROSS, chemical reconstruction of skin scars; TCA, trichloroacetic acid.

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Our article only summarizes the available treatmentoptions for cosmetic fillers approved by the UnitedStates Food and Drug Administration (FDA); how-ever, there are many injectables available interna-tionally that can also be suitable for the treatment ofacne scarring.

Hyaluronic Acid

Hyaluronic acid is composed of a water-retainingglycosaminoglycan polysaccharide, which is a natu-rally occurring component of the body’s connectivetissue. Hyaluronic acids are temporary fillers that lastfor 3 to 12months. Hasson and Romero9 showed thatin 12 patients with atrophic scars from various etiol-ogies treated with HA (Esthelis, Anteis, S.A., Geneva,Switzerland), 74% had good to excellent results1 month after treatment. A 68% reduction in acnescars was seen in a recent study in 5 patientswho had 2treatments of HA in a modified vertical tower tech-nique.10 Although few studies have been performed toinvestigate the use of HAs for acne scars, HAs arewidely used by dermatologists to treat atrophic acnescars.11,12

Calcium Hydroxyapatite

Calcium hydroxyapatite (CaHA; Radiesse, MerzPharma, Frankfurt, Germany) is a semipermanent andbiocompatible filler composed of 25- to 45-mmmicrospheres of synthetic CaHA in an aqueous gelcontaining water, glycerin, and carboxymethylcellu-lose.13 Calcium hydroxyapatite stimulates collagenproduction by invoking a local response of histiocytesand fibroblasts.14 In a study of 10 patients with acne

scars whowere treatedwith 1 to 2 injections of CaHA,30% of patients showed greater than 75% improve-ment and 60% of patients showed between a 50% to75% improvement in acne scars after 12months.15Noimprovement was seen in icepick scars.

Poly-L-Lactic Acid

Poly-L-lactic acid (PLLA; Sculptra, Galderma, FortWorth, TX) is a nonimmunogenic and biodegradablesynthetic polymer that induces the production of col-lagen by increasing the number of fibroblaststhrough a foreign-body reaction, which improves skintexture over time.16 Several injections of PLLA areneeded to restore volume because of its biostimulatorymechanism of action. PLLA has been shown toimprove acne and varicella scarring in an open-labelprospective study with 20 patients.17 After 7 treat-ments, there was a cumulative reduction of 46.4% inthe severity of the scars. Sapra and colleagues18

performed a study on the treatment of hill and valleyacne scarring, also known as rolling scars, in 22patients with 3 to 4 treatments of PLLA, and 54.4%ofpatients had very good results. A new modality offractionated CO2 laser–assisted delivery of topicalPLLA led to a 33% improvement in atrophic scars,including acne scars, in 20 patients after a singletreatment.19 Poly-L-lactic acid necessitates the use ofmore treatment sessions than other cosmetic fillers butcan produce sustained results for over 2 years.

Polymethylmethacrylate

Polymethylmethacrylate (PMMA) is a permanentfiller composed of 20% PMMA microspheres, 30 to50 mm in diameter, suspended in bovine collagen.20

PMMA adds volume to acne scars and stimulatescollagen production, and it can be a cost-savingalternative to the temporary fillers because only onetreatment is usually required. In 2015, PMMAbecamethe only FDA-approved cosmetic filler for the treat-ment of facial acne scars.21 A pilot study using sub-cision followed by one treatment of PMMA (Artefill;Suneva Medical Inc., Santa Barbara, CA) in 14patients showed a 96% improvement in acne scars byinvestigator ratings 8 months after treatment withoutadverse events.22 Karnik and colleagues23 performed a

TABLE 2. Soft tissue fillers used to treat acnescars

Soft-Tissue FillersDurationof Action Examples

Hyaluronic acid filler 3–12 mo Restylane,Juvederm,Belotero

Calcium hydroxylapatite 1–2 yrs Radiesse

Poly-L-lactic acid 1–2 yrs Sculptra,Newfill

Polymethylmethacrylate Permanent Artecoll, Artefill,Bellafill

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controlled and blinded study with 147 patients withrolling acne scars who were treated with one injectionArtefill or placebo, and improvement in acne scarswasobserved in 64% of patients treated with PMMAversus 33% of control subjects. The most commonadverse effect was injection site reaction.

Cosmetic fillers provide aminimally invasive option totreat acne scars by adding volume to the scar and alsostimulating collagen production to improve skin tex-ture. They can also be used in combination with otherlaser procedures to achieve the best results (Figure 1).The literature evaluating the use of fillers for acne scarsis limited, and more studies are needed to determinethe optimal filler type and number of treatments forsoft-tissue augmentation of acne scars.

Subcision

Subcision is a simple surgical procedure that wasinitially described by Orentreich and Orentreich24 in1995. Traditionally, it involves the use of a tribeveledhypodermic needle to free the tethering subdermalfibrous bands that are responsible for rolling scars,although several other instruments have been usedsuch as conventional needles and blunt blades (Fig-ure 2).4,25 The needle is placed in a horizontal planein the upper subcutaneous tissue and advanced in agentle back and forth motion parallel to the skin torelease the fibrous bands. This causes subdermalbleeding, and the formed blood clot creates apotential space in the tissue to elevate the skin withinthe scar tissue.26 Thus, when the area heals, new

collagen is formed in a plane that is more even withthe surface of the surrounding skin.27 Usually, sev-eral treatments are necessary. Adverse events includetemporary swelling and bruising, and rarely sub-dermal nodule formation.

Subcision works best for rolling scars and is less effec-tive for deep boxcar scars and icepick scars. Severalstudies have demonstrated subcision as a stand-alonetherapy for acne scarring.A studywith 34patientswhohad undergone 1 to 3 subcision treatments reporteddowngrading of acne severity from severe and moder-ate grade acne to mild grade in 53% of patientswith minimal side effects.28 Subcision has shownsuperior results to 100% trichloroacetic acid (TCA)chemical reconstruction of skin scars (CROSS)methodin 20 patients with fewer side effects.29 Subcision hasalso been combined with other acne scar treatmentmodalities. Recently, subcision has been combinedwith the use of cosmetic fillers and nonablative 1,320-nm neodymium-doped:yttrium aluminum garnet(Nd:YAG) laser to enhance the appearanceof scars andskin texture.22,30 Finally, although subcision has beenshown mostly to reduce rolling acne scars, a recentstudy of 18 patients who underwent subcision with ablunt blade under tumescent anesthesia showedmarked to moderate improvement in 15 of the 18patients treated, and deep boxcar and icepick scarsdemonstrated partial leveling as well.25

Subcision is awell-tolerated and effective procedure totreat rolling and shallow boxcar scars and can becombined with other treatments for acne scarring.

Figure 1. Before (left) and after (right) 3 treatments with polymethylmethacrylate dermal filler and RF microneedling. Photocourtesy of Douglas C. Wu, MD, PhD. RF, radiofrequency.




Punch Excision

Punch excision is an excellent option for the treatmentof icepick and deep boxcar scars. In this method, apunch biopsy instrument is used to remove deep atro-phic scar tissue to the level of the subcutaneous fat andthen closed with sutures. The scars should be at least 4to 5 mm apart to prevent excess traction in the skin, orat least a 4-week interval betweenprocedures canavoidthese adverse cosmetic effects. For scars larger than3.5 mm, elliptical or punch elevation is recommendedfor best cosmetic outcome.4 Although a new scar isformed in this method, it is usually less noticeable thanthe previous deep atrophic scar.26 Using a resurfacingprocedure 4 to 6 weeks after punch excision can alsoimprove the appearance of the scar.31,32 Punch excisioncan be safely and effectively combined with laser skinresurfacing on the same day for acne scarring.33

Punch Elevation

Punch elevation is a useful tool for shallow and deepboxcar scars. This technique combines aspects of punchexcision and grafting. A punch biopsy tool is used toexcise the scar down to the subcutaneous fat, and thetissue is then elevated slightly above the plane of the skinand fixed into place with sutures or steristrips. Duringthe wound healing process, the elevated graft retractsslightly to the surfaceof the surrounding skin to improvethe appearance of the scar.26 As with punch excision, aresurfacing procedure performed 4 to 6 weeks afterprocedure can enhance results. Punch elevation andpunch excision has been combined with CO2 lasertreatment and dermabrasion to effectively treat deep

icepick scars.34 Recently, punch elevation combinedwith fractional CO2 laser showed better results for acnescarring than fractional CO2 laser alone.35

Few studies exist in the literature examining the use ofpunch excision and elevation for acne scarring; how-ever, they can be excellent options for deep icepickscars and boxcar scars.

Chemical Peels

A chemical peel is a quick outpatient procedure thatcan be used to treat acne scarring. Mild acne lesionsand shallow atrophic acne scars can respond well tomild and medium depth peels, such as 20% to 35%TCA, alpha hydroxy acids, salicylic acid, and Jess-ener’s solution.36 However, these chemical peels usu-ally work best for macular scars, have limited use fordeeper atrophic scars, and should be used cautiously indarker-skinned patients because of the potential forpigmentary alterations. Deep chemical peels havefallen out of favor for the treatment of acne scarsbecause of their significant side effect profile, such asdyschromia and scarring.11

In the past decade, chemical reconstruction using TCA(CROSS) has come into favor for icepick scars and hasalso been used for rolling and boxcar scars. In theCROSS method, high concentrations of TCA areapplied on a sharp wooden applicator and thenpressed firmly into the atrophic acne scars, and whitefrosting is observed.37 The high concentrations ofTCA cause coagulative necrosis of the epidermis, andthe resultant wound healing causes an increase in theproduction of collagen and improvement in scarappearance.26 The CROSS method allows for shorterrecovery time than medium to deep chemical peelsbecause the peel is applied to only select areas of theskin. Several treatments with TCACROSS are usuallyneeded, and the degree of clinical improvement isproportional to the number of treatments. This tech-nique has been shown to significantly improve deepicepick scars, rolling, and boxcar scars.38–40 Tri-chloroacetic acid has been compared with the 1,550-nm erbium:glass laser in 20 patients with darker skintypes, and both procedures were shown to be equiv-alent in efficacy for icepick scars, but the 1,550-nm

Figure 2. Tribeveled 18G hypodermic needle used forsubcision.

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erbium:glass laser was slightly more effective for roll-ing scars.41 Rare complications of TCA CROSSinclude dyschromia, erythema, scarring, and atro-phy.42 Nonetheless, high-concentration TCA CROSShas been used in dark-skinned patients with minimalor without any prolonged pigmentary changes orscarring.37–39

Optimal concentration of TCA and number of treat-ments should be tailored to patient response to eachtreatment and observation of possible side effects.Deep boxcar and icepick scars are especially hard totreat, and TCA CROSS can be a useful method tomanage these lesions.

Dermabrasion

Dermabrasion involves the use of manual derma-sanding using sandpaper and hydrogen peroxide forhemostasis, or a rotating motorized hand pieceattached to either a serrated wheel, wire brush, ordiamond-embedded fraises to remove the epidermisand upper dermis.43,44 By removing the superficiallayers of the skin, the wound healing process creates asmoother and more regular appearance of the scar,and new collagen is formed.45 Dermabrasion is usefulfor superficial atrophic acne scars, such as rolling orshallow boxcar scars, but is less effective for icepickscars.26

Advantages of dermabrasion include improvement inthe appearance of superficial atrophic scars with onlyone treatment. However, the dermabrasion techniqueis operator-dependent, and that the procedure ispainful and requires local or general anesthesia. Thereis significant postoperative pain and a lengthy healingtime lasting up to several weeks with prolonged ery-thema and postprocedural dyschromia.11 There areother resurfacing modalities that offer fewer sideeffects and have a quicker recovery time, such asfractional ablative lasers. Jared Christophel and col-leagues46 demonstrated in a split-face study of scarsfrom Mohs procedures that dermabrasion and frac-tional ablative CO2 lasers produced similar improve-ments in scar appearance, but the fractional ablativeCO2 laser had a better side effect profile and quickerhealing time.

Microneedling

Microneedling is an inexpensive treatment option foracne scars. It consists of a sterile rolling device withseveral fine sharp needles applied to acne scars tocreate multiple small micropunctures in the papillaryto mid-dermis. By creating these small wounds in thedermis, a cascade of growth factors is initiated thatresults in collagen stimulation and production.36 Asmicroneedling penetrates only to the depth of theupper dermis, it is most useful for shallow boxcar androlling scars. A usual treatment course with micro-needling consists of 3 to 5 sessions spaced 4 weeksapart, and results are seen in 3 months. Patients usu-ally experience a moderate improvement in acne scarappearance.

Several recent studies have shown the efficacy ofmicroneedling in the treatment of acne scars. El-Domyati and colleagues47 showed a 51% to 60%improvement of acne scars after 6 sessions of micro-needling. In this study, skin biopsies were also per-formed before and after the microneedlingprocedures, and they showed a statistically significantincrease in collagen Types I, III, and VII. Whenmicroneedling was combined with platelet-richplasma or glycolic acid peels, improvements in acnescar appearance increased to 62%.48,49 A studycomparing microneedling with fractional non-ablative erbium 1,340-nm laser in 46 patients showedimprovement in both groups and no statistically sig-nificant difference between the 2 treatments.50

Approximately 14%of the patients in the laser groupexperienced postinflammatory hyperpigmentationand, no pigmentary changes were seen in the micro-needling group.

Microneedling has shown benefit in the reduction ofshallow boxcar and rolling scars and can be a goodoption for darker-skinned patients because there is alow risk of hyperpigmentation.

Platelet-Rich Plasma

Plasma-rich plasma (PRP) is an emerging therapeutictool that consists of a preparation of the patient’sown concentrated platelets in plasma to promote




wound healing through several growth factors andcytokines present in the concentrate. Plasma-richplasma has been used in several areas of medicine,including for tendon injury, chronic ulcers, and alo-pecia.52–54 Only a few studies have investigated PRPfor acne scars, and they have shown that this treat-ment is safe and mild to moderate clinical improve-ment after intradermal or laser-assisted PRPdelivery.48,55–57 Lee and colleagues56 treated 14patients with acne scars with an ablative CO2 laser,and on one side of the face applied PRP. They showedslightly faster healing and clinical improvement onthe PRP-treated side. Nofal and colleagues57 com-pared intradermal PRP, TCA CROSS, and combi-nation of PRP and microneedling for a mixture ofatrophic acne scar types and showed that half of thepatients had a one-grade improvement in acne and nodifference between the treatment groups. Furtherresearch and comparative studies are needed toevaluate the efficacy of PRP for acne scars.

Radiofrequency

Radiofrequency (RF) is an evolving tool that wasused initially in dermatology for skin rejuvenation.This device uses electromagnetic radiation to gen-erate an electric current that heats the dermiscausing neocollagenesis and skin contraction.58,59

Radiofrequency has decreased downtime and riskof scarring and infection compared with ablativelasers, and it can be safe to use in all skin types as it ischromophore-independent, unlike other energy-based modalities, such as CO2 laser.60 The initialRF device was monopolar and has evolved intobipolar and later fractional bipolar RF (FRF)(Table 2).

The earliest studies using RF to treat acne scars werewith the monopolar and bipolar RF devices. In onestudy, 22 patients with active cystic acne and acnescars were treatedwith amonopolar RF device for 1 to2 sessions (ThermaCool TC; Thermage Inc., Hay-ward, CA), and 82% showed an excellent improve-ment in acne.61 No side effects were observed, andthere was no downtime after the procedure. BipolarRF delivers a more focused current to the dermis thanmonopolar RF.62 A study byMontesi and colleagues63

showed at least a 25% to 50% improvement after 6 to8 sessionswith bipolarRF in improvement in 3 of the 4patients with acne scars. Adverse effects includedtransient erythema (Table 3).

In the past few years, there have been several studiesusing fractional RF for the treatment of acne scars.Fractional RF is a newer technology that consists ofthe application of bipolar RF to the skin by electrodesor pairs of microneedles to create small columns ofthermal damage.59 Peterson and colleagues64 used anew device that combined RF with FRF for acnescarring in 15 patients and showed a 73.4% reduc-tion of the scars after 5 procedures. The investigatorsfound that rolling and boxcar scars responded betterthan icepick scars. Ramesh and colleagues65 showedthat FRF had good to excellent results in 22 of 30patients after 4 sessions. Unlike the previous study,icepick scars responded better than rolling and box-car scars. Gold and Biron66 used an FRF to treat 15patients for 3 sessions and showed a 60% markedimprovement in acne scars. Fractional bipolar RFwas studied by Cho and colleagues67 in 30 patientstreated with 2 sessions with a 73.3% reduction inacne scars. In addition, skin surface roughnessimproved, and there was a decrease in the size offacial pores. Adverse effects included pain with theprocedure and transient erythema. Another studywith FRF showed an improved appearance of scars

Table 3. Types of radiofrequency devices used totreat acne scars

Radiofrequency(RF) Devices Description

Monopolar RF Two electrodes with one in contactwith the skin and the other as thegrounding pad to target deepdermis.

Bipolar RF Two active electrodes that areplaced a short distance apartfrom the intended treatment areato create more focused energydelivery and less painful thanmonopolar RF.

Fractional bipolarRF

Creates fractional zones ofelectrothermal damage in thedermis using electrodes ormicroneedles inserted into theskin.

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without damaging the epidermal layer in all 31patients after 4 sessions.68 As with previous FRFstudies, a major adverse effect was procedural-related pain, even with nerve blocks, or topicalanesthesia.

Of the RF devices available, FRF offers the best resultsfor acne scarring.69 An improvement of 25% to 75%in acne scars can be expected after 3 to 4 sessions(Figure 3). Radiofrequency is a safe and effectiveapproach to treat all 3 types of atrophic acne scarswithlimited downtime and adverse effects, but furtherstudies are needed for optimal treatment parameters.

Lasers

Lasers are another popular treatment option for acnescarring (Table 4). They are grouped into the tradi-tional ablative lasers that cause epidermal and dermaldestruction and the less-invasive nonablative lasersthat target the dermis but leave the epidermis intact.More recently, fractional laser resurfacing has beenused for acne scarring and consists of delivering energyin microscopic columns of epidermal and dermal tis-sue.70 Each of these laser modalities has varying risks,downtime, and varying efficacy on the 3 atrophic acnescar types.

Ablative Lasers

The ablative lasers, CO2 10,600-nm and Er:YAG2,940-nm lasers, are considered the gold standard fortreating acne scars with a laser modality. They targetwater in the skin causing dermal injury, along withdamage to the epidermis, and in this process create theformation of new collagen.71

The ablative lasers produce excellent results for acnescars. In one study, there was a 75% mean improve-ment in atrophic facial scars with high-energy pulsedCO2 laser.72 A long-pulsed Er:YAG laser in a studywith 35 dark-skinned patients for pitted facial acnescars showed good to excellent results in 74% ofpatients.73 However, postinflammatory hyperpig-mentation occurred in 29% of patients, and allpatients experienced prolonged erythema. Because ofthe long recovery time and side effects from ablativelasers and the development of new nonablative andfractional lasers with less downtime, ablative lasershave become a less popular option for the treatment ofacne scars.

Nonablative Lasers

Nonablative lasers are amorenoninvasiveway to treatacne scars. Commonly used nonablative lasers includethe 1,064-nmNd:YAG, 1,320-nmNd:YAG, and 585/595-nmpulsed dye laser (PDL) (Table 4). Nonablativelasers target tissues in the dermis by selective photo-thermolysis to stimulate collagen and dermal remod-eling to reduce acne scar appearance.74 Theyworkbestfor shallow boxcar and rolling scars and are lessbeneficial for icepick scars.

There have been several studies using different types ofnonablative lasers for acne scarring with mild tomoderate benefit, and usually 4 to 6 treatments arerequired. The 1,064-nm Nd:YAG laser is used fre-quently for acne scarring and has shown to produce a20% to 50% improvement in these lesions.75,76 In onestudy, PDLhas shown similar efficacy to the 1,064-nmNd:YAG for acne scars with a mean improvement of

Figure 3. Before (left) and after (right) 2 radiofrequency microneedling treatments. Photo courtesy of Douglas C. Wu, MD,PhD.




about 18%. Wada and colleagues77 treated 24 Japa-nese patients with various atrophic scars with 5 ses-sions of the 1,450-nm diode laser, and 75% of thepatients hadmoderate tomarked improvement in acnescars. Patients with a combination of rolling andboxcar scars respondedbest in this studywithminimaladverse events; however, one patient did have post-inflammatory hyperpigmentation. When nonablativelasers are compared with fractional ablative lasers foracne scarring, fractional ablative lasers overall pro-duce better results albeit can cause more complica-tions. Asilian and colleagues78 compared thefractional CO2 and Q-switched 1640-nm laser in astudy of 64 patients and found that the fractional CO2

laser producedbetter outcomes for acne scars.Adverseevents were similar in both laser groups and consistedof postinflammatory hyperpigmentation.

Nonablative lasers are becoming more popular foracne scarring because they have a faster post-procedural recovery time andabetter side effect profilethan ablative lasers. However, more sessions arerequired, and acne scar improvement may not matchthe level of the ablative lasers.

Fractional Lasers

Fractional lasers are divided into nonablative laser(NAFL) and ablative laser (AFL) and have beenevaluated in several studies for the treatment of acnescars. Improvement in acne scarring for NAFLranges from 25% to 75% in several studies, andsome patients show greater than 75% improvement.The number of treatment sessions with NAFL is

proportional to the degree of improvement.79 Sar-dana and colleagues80 classified each acne scar sub-type and recorded the response of each scar to thetreatment with the 1,540-nm fractional nonablativelaser. After 6 treatments with the 1,540-nm frac-tional laser, boxcar and rolling scars were found torespond better than icepick scars, with a 52.9% and43.1% improvement in boxcar and rolling scars,respectively, while icepick scars only responded in25.9% of patients. The 1,550-nm erbium-dopedfiber fractional laser has also been shown to be safeand effective in treating acne scarring with multiplesessions in Fitzpatrick skin Type IV to VI; however,some patient developed self-limited post-inflammatory hyperpigmentation.81 Some authorsadvocate using lower total treatment densities,decreased number of passes, and pre-treatment andpost-treatment with hydroquinone in darker-skinned patients to decrease the risk of post-inflammatory hyperpigmentation.81,82

Ablative laser has been evaluated for acne scarring byJung and colleagues83 who performed a study tocompare the optimal laser settings for the treatment ofscars with a fractional CO2 laser in 10 patients in asplit-face study. They showed that high-fluence andlow-density settings showed greater improvements inacne scar appearance than on the low-fluence andhigh-density settings. A study by Cho and colleaguescompared one treatment with fractional CO2 laserwith a nonablative fractional 1,550-nm erbium:glasslaser in a split-face randomized, blinded study foratrophic acne scarring in 8 patients. At the 3-monthfollow-up, the authors found that the fractional CO2

TABLE 4. Laser Modalities Available for Acne Scarring79

Traditional Ablative Traditional Nonablative Fractional Nonablative Fractional Ablative

Ablative 10,600-nm CO2 1,320-nm Nd:YAG Fractional 1,550-nm Er-doped Fractional 10,600-nm CO2

Ablative 2,940-nm Er:YAG 1,064-nm Nd:YAG Fractional 1,540-nm Er:glass Fractional 2,940-nm Er:YAG

1,450-nm Nd:YAG Fractional 2,790-nm YSGG

755-nm picosecond

585-/595-nm PDL

532-nm KTP

Intense pulse light*

*Not a laser.

PDL, pulsed dye laser.

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exhibited greater improvement scores and subjectsatisfaction than the NAFL, but this was not found tobe statistically significant because of the small studysample. The fractional CO2 laser also had moreadverse events, such as erythema and crusting.84 Thus,although NAFL can produce excellent reduction inacne scars, multiple treatments are needed to reach thesame effect as a single treatment with a fractional CO2

laser (Figure 4).

Fractional lasers are a good option for acne scars,especially rolling and boxcar scars. The NAFL hasfewer side effects and downtime than the AFL; none-theless, NAFL requires more treatment sessions thatAFL. Both the NAFL and AFL have been used indarker skin types, but caution must be exercisedbecause there is a higher risk of postinflammatoryhyperpigmentation in these patients.85,86

Conclusion

A myriad of treatment options are available for the 3atrophic acne scar types, but there is a paucity of high-quality clinical studies for many of these therapies.8

Furthermore, the studies use many disparate acneseverity scores,whichmake comparisonbetween themdifficult. In daily practice, combinations of these var-ious therapies are used, and correct patient selectionfor each treatment modality is necessary to obtainoptimal results.

Acknowledgments The authors thank Dr. Mitchel P.Goldman and Dr. Douglas C. Wu for providingpatient photographs.

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Figure 4. Before (above), 4 weeks after (middle), and 1year (below) after ablative laser resurfacing. Photo cour-tesy of Mitchel P. Goldman, MD.




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Address correspondence and reprint requests to: MonicaBoen, MD, Cosmetic Laser Dermatology, 9339 GeneseeAve, Suite 300, San Diego, CA 92121, or e-mail:[email protected]




A Review and Update of Treatment Options Using the Acne ......acne scar pathology that divided atrophic acne scars into icepick, rolling, and boxcar scars, and this review will evaluate

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