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21 Ashkenazi H, Malik Z, Harth Y et al Eradication of
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22 Kjeldstad B, Johnsson A An action spectrum for blue and
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23 Kjeldstad B Photoinactivation of Propionibacterium acnes
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24 Melo TB Uptake of protoporphyrin and violet light
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25 Elman M, Lebzelter J Light therapy in the treatment of
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26 Charakida A, Seaton ED, Charakida M et al Phototherapy
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27 Mills OH, Porte M, Kligman AM Enhancement of
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28 van Weelden H, de Gruihl FR, van der Putte SC et al.The
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29 Kawada A,Aragane Y, Kameyama H et al.Acne
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30 Omi T, Bjerring P, Sato S et al 420 nm intense continuous
light therapy for acne J Cosmet Laser Ther 2004;6:156–162.
31 Shalita AR, Harth Y, Elman M et al Acne phototherapy
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32 Elman M, Slatkine M, Harth Y.The effective treatment of
acne vulgaris by a high-intensity, narrow band 405–420 nm light source J Cosmetic & Laser Ther 2003;5:111–117.
33 Tzung TY,Wu KH, Huang ML Blue light phototherapy in
the treatment of acne Photodermatol Photoimmunol Photomed 2004;20:266–69.
34 Gold MH, Rao J, Goldman MP et al A multicenter
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35 Sigurdsson V, Knults AC, van Weelden H Phototherapy of
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38 Edwards C, Hill S, Anstey A A safe and effective yellow light-emitting diode treatment for mild to moderate acne: A within-patient half-face dose ranging study Abstract J Am Acad Dermatol AB15; March 2006.
39 Gupta A Efficacy and safety of intense pulsed light apy using wavelengths of 400–700 nm and 870–1200 nm for acne vulgaris J Am Acad Dermatol AB27, March 2006.
ther-40 Elman M, Lebzelter J Evaluating pulsed light and heat energy in acne clearance Radiancy White paper, June
2002 Retrieved from http://www.radiancy.com/USA/ appdocs.htm.
41 Herd RM, Dover JS, Arndt KA Basic laser principles Dermatol Clinic 1997;15:355–72.
42 International Union of Pure and Applied Chemistry Compendium of Chemical Terminology 2nd edition,
1997 Retrieved from book/A00446.pdf.
http://www.iupac.org/gold-43 Elman M, Lask G.The role of pulsed light and heat energy (LHE) in acne clearance J Cosmet Laser Ther 2004;6: 91–95.
44 Gregory AN,Thornfeldt CR, Leibowitz KR et al A study
on the use of a novel light and heat energy system to treat acne vulgaris Cosmet Dermatol 2004;17:287–300.
45 Baugh, WP and Kucaba WD Nonablative phototherapy for acne vulgaris using the KTP 532 nm Laser Dermatol Surg 2005;31:1290–6.
46 Bowes LE, Manstein D, Anderson RR Effects of 532 nm KTP laser exposure on acne and sebaceous glands Lasers Surg Med 2003;18:S6–S7.
47 Lee CMW Aura 532nm laser for acne vulgaris – a 3 year experience, Annual Combined Meeting of the American Society for Dermatologic Surgery and the American Society for Mohs Micrographic Surgery and Cutaneous Oncology, New Orleans, LA, October 2003.
48 Seaton ED, Charakida A, Mouser PE et al Pulsed-dye laser treatment for inflammatory acne vulgaris: ran- domised controlled trial Lancet 2003;362:1347–52.
49 Orringer J, Kang S, Hamilton T et al Treatment of acne vulgaris with a pulsed dye laser: a randomized controlled trial.JAMA 2004;291:2834–9.
50 Chu A Pulsed dye laser treatment of acne vulgaris JAMA 2004;292:1430.
51 Alam M, Peterson SR, Silapunt S et al Comparison of the 1450nm diode laser for the treatment of facial acne: a left-right randomized trial of the efficacy and adverse effects Lasers Surg Med 2003;32:S30.
Trang 252 Ortiz A, Van Vilet M, Lask GP,Yamauchi PS A review of
laser and light sources in the treatment of acne vulgaris.
J Cosmetic and Laser Therapy 2005;7:69–75.
53 Ashkenazi H, Malik Z, Harth Y et al Eradication of
Propionibacterium acnes by its endogenic porphyrins after illumination with high-intensity blue light FEMS Immunol Med Microbiol 2003;35:17–24.
54 Gold MH, Bradshaw VL, Boring MM et al The use of a
novel intense pulsed light and heat source and ALA-PDT
in the treatment of moderate to severe inflammatory acne vulgaris J Drugs Dermatol 3(6 Suppl):S15–9, 2004 Nov-Dec.
55 Hongcharu W, Taylor CR, Change Y et al Topical
ALA-photodynamic therapy for the treatment of acne vulgaris.
J Invest Dermatol 2000;115:183–92.
56 Itoh Y, Ninomiya Y, Tajima S et al Photodynamic therapy
for acne vulgaris with topical 5-aminolevulinic acid Arch Dermatol 2000;136:1093–1095.
57 Itoh Y, Ninomiya Y, Tajima S et al Photodynamic therapy
for acne vulgaris with topical delta-amenolevulinic acid and incoherent light in Japanese patients Br J Dermatol 2001;144:575–579.
58 Goldman MP Using 5-aminolevulinic acid to treat acne
and sebaceous hyperplasia Cosmet Dermatol 2003;16:
57–58.
59 Gold MH, Bradshaw VL, Boring MM et al The use of a
novel intense pulsed light and heat source and ALA-PDT
in the treatment of moderate to severe inflammatory acne vulgaris J Drugs Dermatol 2004;3:S15–S19.
60 Pollock B,Turner D, Stringer MR et al.Topical
amenole-vulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism
of action Br J Dermatol 2004;151:616–22.
61 Kimura M, Itoh Y, Tokuoka Y et al Delta-aminolevulinic
acid-based photodynamic therapy for acne on the body.
J Dermatol 2004;31:956–60.
62 Hwang EJ and Seo K Topical photodynamic therapy for
treatment of acne vulgairs: comparison of two IPL cators and different application times of ALA Abstract
appli-290 American Society for Laser Medicine and Surgery Abstracts pg 86.
63 Alexiades-Armenakas, M Long-pulsed dye laser-mediated
photodynamic therapy combined with topical therapy for mild to severe comedonal, inflammatory, or cystic acne.
J of Drugs in Dermatol 5(1); 2006 January 45–55.
64 Parrish JA New concepts in therapeutic photomedicine:
Photochemistry, optical targetings, and the therapeutic windown J Invest Dermatol 1981;77:44–50.
65 Tuchin VV, Genina EA, Bashkatov AN, et al A pilot study
of ICG laser therapy of acne vulgaris: photodynamic and photothermolysis treatment Lasers Surg Med 2003;33:
296–310.
66 Genina EA, Bashkatov AN, Simonenko GV, et al intensity indocyanine-green laser phototherapy of acne vulgaris: pilot study J Biomed Opt 2004;9:828–34.
Low-67 Lloyd JR and Mirko M Selective photothermolysis of the sebaceous glands for acne treatment Lasers Surg Med 2002;31:115–20.
68 Paithankar DY, Ross EV, Saleh BA, et al Acne treatment with a 1,450nm wavelength laser and cryogen spray cool- ing Lasers Surg Med 2002;31:106–114.
69 Mazer JM.Treatment of facial acne with a 1450 nm diode laser: a comparative study Lasers Surg Med 2004:34: S67.
70 Mazer JM and Fayard V Eighteen months results after treatment of facial acne with the 1450 nm diode laser Abstract 103 American Society for Laser Medicine and Surgery.
71 Santhanam A, Shah A and Kumar P The 1450-nm diode laser in the treatment of inflammatory facial acne vulgaris
in Indian patients – A pilot study J Am Acad Dermatol Abstract P45.
72 Jih MH, Friedman PM, Goldberg LH et al.The 1450-nm diode laser for facial inflammatory acne vulgaris: dose- response and 12-month follow-up study J Am Acad Dermatol 2006;55:80–7.
73 Bernstein EF Lower-energy double-pass 1450 nm laser treatment of acne dramatically decreases discomfort with similar efficacy as compared to standard high-energy treatment Abstract 104 American Society for Laser Medicine and Surgery Abstracts.
74 Friedman PM, Jih MH, Kimyai-Asadi A, et al.Treatment of inflammatory facial acne vulgaris with the 1450 nm diode laser: a pilot study Dermatol Surg 2004;30:147–51.
75 Astner S, Anderson R and Tsao S.
76 Glaich A, Friedman P, Jih M, et al Treatment of matory facial acne vulgaris with combination 595-nm pulsed-dye laser with dynamic-cooling-device and 1450-
inflam-nm diode laser Lasers Surg Med 2005;Epub May 2005.
77 Wang SQ, Counter JT, Flor Me and Zelickson BD Treatment of inflammatory facial acne with the 1,450 nm diode laser alone versus microdermabrasion pluse the 1,450 nm laser: a randomized, split-face trial Dermatol Surg 2006;32:249–55.
78 Lupton JR,William CM, Alster TS Nonablative laser skin resurfacing using a 1540nm erbium glass laser: a clinical and histologic analysis Dermatol Surg 2002;28:833–5.
79 Fournier N,Dahan S, Barneon G, et al Nonablative remodeling: clinical, histologic, ultrasound imaging, and profilometric evaluation of a 1540 nm Er:glass laser Dermatol Surg 2001;27:799–806.
80 Boineau D, Angel S, Nicole A, et al Treatment of active acne with an Er:glass (1.54 um) laser Lasers Surg Med 2004;34:S55.
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laser for the treatment of facial acne vulgaris Lasers Surg Med 2004;34:S65.
82 Angel S, Boineau D, Dahan S, Mordon S Treatment of
active acne with an Er:Glass (1.54 um) laser: A 2-year follow-up study Journal of Cosmetic and Laser Therapy 2006;8:171–6.
83 Ruiz-Esparza J, Gomez JB Nonablative radiofrequency
for active acne vulgaris: the use of deep dermal heat in the
treatment of moderate to severe active acne vulgaris (thermotherapy): a report of 22 patients Dermatol Surg 2003;29:333–9.
84 Avram, DK and Fitzpatric RE Treatment of active acne and acne scars with SmoothBeam (1,450 nm) and Thermage (radio frequency): A comparative study ASLMS abstracts 56.
85 Retrieved from http://www.myzeno.com.
Trang 4Optimal treatment of acne scarring is prevention of
the same by aggressive treatment of active acne.1,2
Failing that, the treatment of acne scarring may require
the sequential application of several corrective
proce-dures Even so, the degree of improvement is
typi-cally incomplete, as scar can be concealed but not
removed
DEFINITION AND CLASSIFICATION
OF ACNE SCARS
Before appropriate therapies can be selected, acne
scar-ring needs to be qualitatively and quantitatively assessed.3,4
The simplest operational definition of acne scar is a
visi-ble textural abnormality that was historically preceded
by active acne at the same site, and if biopsied, would
reveal histological evidence of a scar In practice, it may
be difficult to confidently assert the provenance of a
particular scar, since the active process – acne or
some-thing else – leading to its creation may be temporally
remote.Yet there are typical configurations of scarring
that are usually believed, based on visual inspection
alone, to be highly likely to have been caused by acne
Acne scars can be classified based on shape and
depth One recently proposed classification recognizes
three types of scars (Fig 8.1):4
• ice-pick scars are V-shaped nicks with a pinpoint
base that may culminate in the shallow papillarydermis or in the deep reticular dermis
• boxcar scars are rectangular scars with vertical
walls and a flat base, and these may also be shallow
or deep
• rolling scars are gently undulating scars that ble hills and valleys, are less well-demarcated, andtend to be less focally deep
resem-Alternatively, acne scars can be considered trophic, atrophic, or a combination thereof:3,5
hyper-• grade 1 acne scarring is distinguished by tous, hypopigmented, or hyperpigmented macules(Fig 8.2)
erythema-• grade 2 is distinguished by mild atrophy or phy, similar to the rolling scars described previously
hypertro-• grade 3 is distinguished by moderate hypertrophy
or atrophy that is visible at social distances of 50 cm
or greater, and rolling and shallow box car scars, aswell as moderate hypertrophic and keloidal scars
• grade 4 is distinguished by severe atrophy or trophy that cannot be flattened by stretching theskin between thumb and forefinger
hyper-8 Treatment of acne scarring
Murad Alam and Greg Goodman
Fig 8.1 Stylized cross-sectional view of ice-pick, rolling,shallow boxcar, and deep boxcar scars (from left to right).Theupper horizontal dashed line denotes the normal depth ofablation with resurfacing procedures, the three lines in apyramidal array represent fibrous bands securing the rollingscar to the dermal–subcutaneous junction (Based on the acneclassification popularized by Jacob, Dover, and Kaminer.)
Trang 5The classification of acne scarring as a function of
indi-vidual skin type is less well described It is known that
some individuals are more prone to develop scarring
following resolution of acne papulopustules or cysts,
whereas others may only have transient erosions
or discoloration that eventually remits In general,
patients who have previously developed acne scarring
remain at risk for further scarring following active
acne in the future Acne scarring of equivalent depth
and type may also be more noticeable on patients with
darker skin types or pigmentary abnormality For
instance, the light and shadow of darker skin may
accentuate the apparent depressions associated with
acne scarring; similarly, rosacea or centrofacial redness
may demarcate and define the borders of acne scars on
the cheeks
AGE OF ACNE SCARS AND
ACTIVE ACNE
To some extent, the appropriate treatment for acne
scars is predicated on their age Specifically, if scars are
red, a series of laser treatments with pulsed-dye laser
or intense pulsed light may be especially useful for
reducing this blush if the scars are not more than a fewyears old.6,7 In cases when active acne has resolvedduring the past 6–12 months, caution should be exer-cised when approaching the treatment of scarring It ispossible that the superficial resolution of acne may not
be indicative of a cessation of the deep process, andinvasive procedures such as subcision or resurfacingmay restimulate cyst formation
It is essential to adequately treat and inactivate allongoing acne before treatment on any scarring cancommence The presence of active acne strongly mili-tates against the treatment of any coexisting acnescars.These acne scars may either not be mature – andhence may be susceptible to exacerbation or inflam-mation – or mature themselves but their treatmentmay trigger nearby active acne An in-depth consulta-tion with the patient is required to convey this con-cern It should be explained that the deferment of acnescar treatment does not indicate reluctance to treatacne scars or lack of expertise in such treatment;rather, the postponement is necessary because imme-diate treatment may worsen the combined adversevisual effect and symptomatology of the active acneand acne scarring Active acne cysts may enlarge anddrain, or become painful, and the active acne inflamed
by manipulation may lead to further acne scarring
A final caveat entails the treatment of acne scarring
in patients with pre-existing conditions that may lead
to poor scar healing Such conditions may be managedlike acne scarring in the context of active acne: treat-ment of the scars may be delayed or embarked uponvery gingerly so as to preclude inadvertent exacerba-tion Most authorities suggest that invasive proceduresfor acne scarring be undertaken only 1 year after com-pletion of oral isotretinoin treatment for resistant cys-tic acne A complete history should elicit informationabout such treatment; the timing, type and degree ofsuccess associated with prior acne scarring improve-ment procedures; any tendency to produce keloids orhypertrophic scars after surgery or injury; any ten-dency to hyperpigment after injury; disorders, such ascollagen vascular diseases, that impede wound healing;bleeding diatheses; disorders that predispose to infec-tion; recurrent cold sores; allergies to antibiotics andmedications; and psychological disorders, includingdepression, anxiety, factitial disorders (e.g., compulsiveFig 8.2 Postinflammatory hyperpigmented macules of the
cheek after resolution of active acne
Trang 6picking, self-mutilation, etc.) and medication for these.
Picking behaviors are exceedingly common, especially
in young women who have an obsessive need to ensure
the perfection of their skin, and a consequent urge to
extirpate pimples and textural abnormalities with their
nails and other implements.The physician should
care-fully explain that picking after procedures to reduce
acne scarring will worsen this scarring and be highly
counterproductive If the patient seems unable or
unwilling to grasp this concept, or appears unlikely to
to adhere to a postoperative regimen, expert
consulta-tion with a psychologist or psychiatrist is desirable
prior to proceeding with surgery
PATHOGENESIS OF ACNE SCARRING
The pathogenesis of acne scarring is too complex an
issue to discuss fully here, but recent research indicates
that intensity of scarring may be associated with the
extent of inflammation associated with active acne
Specifically, the type and timing of the cell-mediated
immune response may be associated with the degree of
post-acne scarring.8In one study, the cellular infiltrate
and nonspecific immune response were initially greater
but later reduced in patients who did not subsequently
develop scars However, in patients who did develop
post-acne scarring, the initially smaller specific immune
response later increased
MANAGEMENT OF ACTIVE ACNE
If the patient does have active acne, a brief discussion
about treatment of acne scars should be followed by
implementation of a plan to stop the production of
new acne lesions Treatment of active acne can take
12–18 months or more before a steady state of
near-clearance is reached If prior measures to control
active acne have included the use of isotretinoin, a
minimum of 12 months and as much as 18 months
should elapse prior to treatment of acne scarring
Once patients understand that treatment of active acne
is a necessary prerequisite for treatment of acne
scar-ring, they may be more compliant with acne treatment
than in the past
Lack of new acne lesions for a few weeks or 1–2months does not necessarily presage a remission ofactive acne.This may simply be a cyclical or fortuitousreduction in acne that may not persist If some degree
of active acne remains persistent, continuing efforts tomanage this should continue even as invasive treat-ments for acne scarring are commenced Sometimespatients will continue to develop one or two smallpapules every few weeks even when on maximal ther-apy for acne At some point, after treatment with topi-cal and oral antibiotics and retinoids, the surgeon mayhave to decide to proceed with acne scarring treat-ment despite the occasional occurrence of active acne
TYPES OF TREATMENTS FOR ACNE SCARRING: RESURFACING,
NONABLATIVE THERAPY, INCISIONAL SURGERY, INJECTION, CYTOTOXIC THERAPIES
The number and range of treatments for acne scarring
is vast Indeed, the options are so plentiful that evenexperienced practitioners need to group and classifytherapeutic options to simplify decision-making Onegrouping recognizes four major categories:
• treatments for altering the color of the acne mark
Trang 7in near-total resolution of scarring, a series of
treat-ments that work synergistically should be selected
Some procedures are more risky and may be
associ-ated with delayed healing, and the practitioner should
determine the level of risk preferred by the patient In
sum, for best outcomes, it is preferable to be (1)
expert at a few procedures rather than to be passably
familiar with a large number and (2) collaboratively
with the patient, develop a rational, sequential
treat-ment plan that cumulatively provides the best possible
outcome
‘Resurfacing’ denotes treatments that entail removal
or destruction of the epidermis and partial-thickness
dermis Subsequent to resurfacing procedures, dermal
and epidermal re-epithelialization occurs, usually over
a period of 1–2 weeks Post treatment, there is a
reduc-tion in acne scars that occurred in the skin strata that
were resurfaced Resurfacing is associated with risk of
hypopigmentation and scar, which can occur if the
depth of ablation reaches the bulge region of the hair
follicle Common resurfacing procedures can rely on
thermal, chemical, or mechanical injury, and include
laser ablation, medium to deep chemical peels,
dermabrasion, and plasma resurfacing
‘Nonablative’ therapies are those that do not fully
de-epithelialize the epidermis and dermis but rather deliver
subdestructive energies that induce skin remodeling
Most commonly, nonablative therapies induce thermal
injury by application of a range of laser and light sources,
but other energy devices, such as bipolar and
mono-polar radiofrequency (RF), may be used
Between resurfacing and nonablative therapies are
an intermediate set of treatments referred to as
‘par-tially ablative’ or ‘minimally ablative’ Typically, these
create a penetrating epidermal and dermal injury only
over a small percentage of the treated skin surface
area Downtime is consequently reduced over that of
resurfacing, but efficacy may be better than for
non-ablative treatments Common examples of partially
ablative therapies are fractional resurfacing as well
as skin needling and rolling
‘Incisional surgery’ entails cutting into the skin, and
may also include removal of skin, or excision Pitting
or ‘ice-pick’ scarring can be treated by punch excision,
punch grafting, or punch elevation Rolling scarring
can be improved by subcision: minute cuts in the skin
followed by abrasion of the underside of the dermis
Large, mixed acne scarring in a linear array can beremoved by standard elliptical excision
In some cases, the skin may be pierced but not cut aspre-packaged injectable fillers or autologous fillers areinstilled under acne scars to raise them flush to theskin ‘Injection’ therapy for acne scars has advancedsince the introduction of a range of new soft-tissueaugmentation materials over the past decade Suchmaterials include autologous fat, human collagen,hyaluronic acid derivatives, calcium hydroxyapatite,silicone, and other agents
Cytotoxic therapies may be most relevant for trophic acne scars Either medical or radiation thera-pies may be used to mitigate the growth of exuberantscars on the chest, face, and back Intralesional agentssuch as 5-fluorouracil (5-Fu), bleomycin, and verapamil,topical agents such as imiquimod, as well as radiationtreatment may help flatten scars
hyper-ACNE SCAR TREATMENT BY RESURFACING
Resurfacing is commonly accomplished by laser, cal application, or dermabrasion To some extent, thechoice of procedure is a function of the age of thetreating dermatologist, and prevailing fashions when
chemi-he or schemi-he trained
Laser resurfacing remains a gold standard for safety
in ablative resurfacing In this procedure, a carbondioxide (CO2), erbium : yttrium aluminum garnet (Er:YAG), or hybrid laser device is used to vaporize theepidermis and partial-thickness dermis.As a calibratedlaser is used, tissue removal is precise, reproducible,and minimally operator-dependent; especially when acomputerized pattern generator (CPG) is used, evenand consistent skin removal is achieved.The CO2laserprovides the deepest injury, some immediate tissuecontraction, hemostasis through its cauterizing effect,and the overall best clinical effect achievable by laser,but downtime with multiple-pass resurfacing can be1–2 weeks The Er:YAG laser is associated with lessinvasive ablation that is more suited to the treatment offine acne scarring or photoaging, but downtime untilcomplete re-epithelialization can be half as long Sinceintraoperative bleeding can complicate and hencelimit multiple-pass Er:YAG laser resurfacing, some
Trang 8hybrid devices include a small CO2laser to facilitate
coagulation; alternatively, a low-power and
high-power Er:YAG laser can be paired in the same box for
this purpose Hybrid devices may also provide a
clini-cal effect intermediate between classic Er:YAG and
CO2 laser resurfacing Using an Er:YAG laser after
CO2laser resurfacing can remove a thin layer of debris
and devitalized tissue, and speed healing Notably,
post-treatment erythema after CO2laser resurfacing
can last 2–3 months, although it can be concealed with
make-up Outcome data indicate that most patients are
very pleased with the outcome of their laser
resurfac-ing procedure at 3 months post treatment, and remain
so at 18 months; in the immediate postoperative
period, the anxiety associated with wound-healing
and temporary disfigurement causes mild, transient
concern in some.9
In dermabrasion, the skin is smoothened by
mechani-cal abrasion analogous to sanding The skin is scraped
away with a wire brush or a spinning disk-like burr
covered with diamond particles; in some cases, true
medium- or fine-grit sandpaper that has been
auto-claved and wrapped around the finger or instrument
like a thimble may be used to treat small areas
Dermabrasion has become less popular since the advent
of HIV and other bloodborne infectious diseases that
can be spread by aerosolized particles of skin and blood
Unlike laser resurfacing, dermabrasion is more
opera-tor-dependent, as the pressure applied can modify the
depth of treatment.Acquiring and maintaining adequate
anesthesia during dermabrasion can be challenging, and
certain areas, including the eyelids, nose, malar
promi-nence, and jawline, can be difficult to treat.There are no
controlled studies comparing laser resurfacing with
der-mabrasion for acne scarring, but in the anecdotal
expe-rience of the authors, laser resurfacing appears to be
more consistently efficacious Dermabrasion may,
how-ever, be less prone to cause post-treatment erythema
than laser resurfacing Hypopigmented macules
associ-ated with acne scars (Fig 8.3) have in some cases been
reported to be improved following needle
dermabra-sion (using a tattoo gun without pigment) or focal
manual dermabrasion.10,11
Medium and deep chemical peels are another
resur-facing technique Medium-depth peels typically consist
of sponge application of trichloroacetic acid (TCA),
20–35%, after degreasing of the skin; sometimes, a
prepeel with Jessner’s solution may be performed toimprove even peel penetration Depending on theduration of application and the number of layers ofsolution, a deeper or shallower effect can be achieved.The benefits of medium-depth peeling are that noexpensive machinery, such as a laser, is required Also,there is no aerosolization of infectious particles At thesame time, peels are relatively operator-dependent,and pooling of solution in facial crevices can result inuneven treatment from less experienced practitioners
In general, medium-depth peels provide a shallowerablation than CO2laser resurfacing Deep chemicalpeels, most notably the Baker–Gordon or phenol peel,are deeper-penetrating but carry two potential risks:(1) the potential cardiotoxicity of phenol requiresintraoperative monitoring during full-face peeling;and (2) porcelain-white hypopigmentation will occurafter treatment For patients with focal acne scarringwho always wear make-up, deep peels may be a safeoption due to the small surface area treated and theability to conceal depigmentation post-operatively Aspecial localized case occurs when a toothpick, or thesharp wooden end of a cotton-tip applicator createdafter the applicator has been deliberately broken, isdipped in a very concentrated solution of 95% or100% TCA and then applied to the base of an ice-pick scar This resurfaces the pinpoint base of thescar, and permits repair by granulation, which can fill
in the scar.12Fig 8.3 Hypopigmented cheek scars that are slightlyatrophic
Trang 9A more recent variant of resurfacing is plasma
resur-facing.This uses the ‘fourth state of matter’ to precisely
injure epidermis and underlying dermis without
induc-ing immediate sloughinduc-ing of the epidermis As such,
plasma resurfacing has similarities to single-pass CO2
laser resurfacing A plasma cloud of electrons removed
by radiofrequency sparking of nitrogen gas is absorbed
by the skin, but the epidermis is not truly ablated In
process, it seems to resemble a medium-strength TCA
peel, but may give deeper and more impressive
results, seemingly without much risk of
hypopigmen-tation and scarring, although it is a comparatively new
technique The gentler approach, and the persistence
of partially injured epidermis as a biological dressing,
minimizes fluid loss, crusting, and delayed healing
Healing usually occurs within a week
There are some similarities regardless of the
resur-facing technique used Tumescent or local anesthetic,
combined with nerve blocks and at least oral sedation,
is usually employed Beyond this, conscious sedation
or general anesthetic may be used, especially for laser
resurfacing Post treatment, some method of dressing
(either closed or open) is used to protect the
de-epithelialized skin as it heals For at least 1 week, the
patient cannot be present at work or social
engage-ments In darker-skinned patients, post-inflammatory
hyperpigmentation is a virtual certainty; in Asian and
African-American patients, such color change may last
a year or longer before gradually resolving.The risk of
infection is mitigated by initiating oral antibiotics and
antivirals before the resurfacing procedure
ACNE SCAR TREATMENT BY
NONABLATIVE THERAPY
During the past 5 years or so, nonablative therapy has
largely replaced ablative therapy for the treatment of
acne scars In nonablative therapy, directed energy,
usually thermal, is used to induce tissue modification
and collagen remodeling in the dermis The benefits
compared with ablative therapy are that skin
de-epithelialization does not occur, and nonablative
therapy is therefore a ‘lunchtime’ procedure that is
associated with little or no downtime Transient
ery-thema and mild edema resolving over hours to days
are often the only post-treatment effects Since
nonablative therapy tends to be a milder procedurethan ablation, multiple treatments may be requiredand/or these treatments may be combined with otheracne treatment methods
Since heating of the dermis can induce remodeling ofthe dermis and improvement of embedded acne scars,
a range of laser and light devices can be used Indeed,virtually any laser or light device, used appropriately,can achieve modest improvement in acne scars Amongthose that have been used in this capacity are thepulsed-dye laser, the potassium titanyl phosphate(KTP) laser, and intense-pulsed light These are vascu-lar-selective machines that, apart from improving sur-face topography, can also reduce the erythema that mayencircle and hence accentuate acne scars of the centralface Multiple treatments, often 3–6 or more about amonth apart, are needed to reduce redness and causesome textural change
A class of nonablative lasers has been especially cessful at improving acne scars These mid-infraredlasers include the 1064 nm neodymium (Nd):YAG,13
suc-1320 nm Nd:YAG (Cool Touch),14–181450 nm diode(Smoothbeam),19and 1540 nm Er:glass (Aramis), aswell as intense-pulsed light machines with a similarrange (Titan, 1100–1800 nm) Such devices have beenshown in numerous studies to significantly improverolling, boxcar, and ice-pick scars of the cheeks, peri-oral areas, and elsewhere.The main limitation is intra-operative discomfort, which may be sufficient to requiretopical and oral pain medications In darker-skinnedpatients, the risk of postinflammatory hyperpigmenta-tion is significant and may suggest the use of the
1540 nm device
Nonablative therapy can also be performed with RFdevices, including those using monopolar and bipolartechnologies RF energy, in cadaver skin, can shrink thefibrous septae,20and may also have collagen-remodelingeffects.While it is typically used for tightening saggingfacial or body skin rather than for rectification of acnescars, RF treatment, like treatment with broadbandinfrared light, may ameliorate acne scars
When acne scars are mild, textural abnormalitymay be minimal, and the primary visual feature may be ahalo of erythema that highlights the scar Such rednesscan be removed by a series of treatments with vascular-selective lasers or light sources,21such as the pulsed-dyelaser, the KTP laser, and the intense-pulsed light device
Trang 10Post-treatment effects are minimal erythema and
edema, which resolve within a few hours to a day Such
treatments may be also appropriate for patients who
desire a very minimal intervention, and can tolerate
little or no downtime Acne excoriée, which may be
associated with erythematous macules, has also been
successfully treated with vascular laser and
psychother-apy.22 It is believed that erythematous acne scars can be
treated even when they are immature, by pulsed-dye
laser immediately after suture removal.23Unlike
erythe-matous macules, hyperpigmented and hypopigmented
macules are better managed passively Q-switched lasers
for pigment and tattoos are minimally effective in
reduc-ing post-inflammatory hyperpigmentation, and may
even exacerabate such pigmentation at high fluences;24,25
gentle nonablative glycolic acid, salicylic acid, Jessner’s
solution, and retinoic acid peels may be less prone to
aggravate brown areas.26,27In general, pigmentation of
scars in olive-skinned patients will fade gradually over
3–18 months, if strict sun avoidance and sun protection
are practiced in association with a topical preparation,
such as hydroquinone, kojic acid, and azelaic acid.28,29
White macules may be very difficult to treat, and may
only be transiently repigmented with repeated
treat-ments with the 308-nm excimer laser, phototherapy, or
application of autologous cultured melanocytes
Microdermabrasion, a topical therapy that entails
spraying of aluminum oxide crystals on the epidermis,
is popular and frequently touted as beneficial for acne
scarring.30However, objective evidence of the efficacy
of microdermabrasion for treatment of acne scarring
is minimal What little improvement can be achieved
appears to require repeated, intense sessions and the
elicitation of pinpoint bleeding, which is seldom
induced Microdermabrasion should not be confused
with dermabrasion, a highly effective ablative therapy
for acne scars
ACNE SCAR TREATMENT BY
PARTIALLY ABLATIVE THERAPY
For treatment of acne scars, resurfacing provides
max-imal improvement and nonablative therapy offers the
promise of convenience and safety To wed these two
desirable outcomes in a single therapy, so-called
‘par-tially ablative’ treatments have been devised These
methods are used to resurface only a portion of theskin area treated, thus allowing maintenance of skinintegrity, fewer side-effects, and more rapid healing.One pioneering method of partially ablative therapy
is fractional resurfacing Using a diode-pumped 1550 nmerbium laser, fractional resurfacing (Fraxel, ReliantTechnologies, Mountain View, CA) creates a gridpattern of microthermal zones of tissue coagulationbut an intact stratum corneum.31,32 Over a period ofdays after treatment, microscopic epidermal and der-mal necrotic debris is expelled, and collagen remodel-ing occurs at the affected areas A series of treatmentscan resurface virtually the entire surface area, but byfractionating treatments, downtime is minimized andthe serous crusting of typical resurfacing is avoided Ithas been shown that high-energy treatments are moreeffective for the treatment of acne scarring; such treat-ments do not ablate more surface area, but provide agreater volume of thermal injury
A simpler, less precise approach to partially ablativetherapy is skin rolling or needling These procedurespurport to achieve on a macroscopic level what frac-tional resurfacing can do on a microscopic level Inneedling,11a fine 30-gauge needle held by a hemostat
is used to serially puncture a 2–3 mm deep grid tern on the skin, including epidermis and dermis.Fibrous bands holding down acne scars are released,and the coagulum resulting from the pinpoint intra-dermal bleeding can raise depressed scars and instigategranulation tissue For larger scars, a tattoo gun with-out pigment11or a rolling pin may be used Rolling isperformed with a needle-studded rolling pin33 – ametal cylinder implanted with needle-like protrusions– that is pressed against the facial or extrafacial skinand rotated around the long axis to make an array ofmicroperforations until some bruising is observed Inboth rolling and needling, pinpoint bleeding occursand is managed by application of pressure Epidermalhealing occurs with minimal crusting in a few days,and dermal trauma culminates in collagen remodeling.This process, also referred to as ‘collagen inductiontherapy’ can be repeated a few weeks later.Anatomicalareas that respond poorly to this treatment include thenose and periorbital regions Synergies may accrue ifrolling is used in combination with other treatments,such as nonablative laser, vascular laser, subcision, orblood transfer
Trang 11pat-ACNE SCAR TREATMENT BY
INCISIONAL SURGERY
Apart from ablative, partially ablative, and nonablative
external smoothening techniques, cutting surgery can
be used to treat acne scars One minimally invasive
surgical technique for rolling scars is subcision, which
is preceded by instillation at the site of scarring of
anesthesia – local for small areas and tumescent
for larger areas Developed by Norman and David
Orentreich,34,35 subcision (Figs 8.4 and 8.5) requires
insertion of an 18–26-gauge Nokor or similar needle,
or even a blunt canula, into the superficial subcutis
Depth of insertion is contingent on the degree of scar
indentation, with intradermal positioning more
appro-priate for shallow scars and deep dermal placement for
deeper scars The needle is then rotated so that the
spearlike tip is parallel to the skin, and the needle is
used to tent the skin Back-and-forth rasping
move-ment of the needle along the underside of the dermis
releases fibrous attachments holding down scars and
stimulates the growth of reactive fibrosis that gradually
fills the deadspace underlying newly loosened scars In
a manner similar to liposuction, fanning movement of
the needle and triangulation of each scar from
differ-ent differ-entry sites helps elevate scars Especially if
wide-spread treatment is being performed, intraoperative
bruising and bleeding is minimized by using tumescent
anesthesia, or copious quantities of a dilute 0.5% caine with 1:200 000 solution, and allowing the anes-thesia to sit for 20–30 minutes before commencing
lido-Fig 8.4 Rolling scars amenable to subcision can occur
periorally, on the upper and lower cheeks, and at the temples
Subcision can also be highly effective for nasal scars (not
shown)
Fig 8.5 (a) In subcision, the rasping needle is used torelease the fibrous bands connecting rolling scars to the deepskin structures (b) Simultaneous tenting of the skin with theneedle minimizes the risk of injury to neurovascularstructures
a
b
Trang 12needle insertion Postoperative ecchymoses and edema
can last 1–3 weeks.To avoid a flare of cystic acne after
treatment, susceptible patients with some active acne
may be treated with oral tetracyclines for several
weeks before and after subcision
Individual deep boxcar or ice-pick scars can be
resis-tant to nonsurgical treatment At times, the best
approach can be to cut these out A time-honored
tech-nique uses a biopsy punch to treat such scars If the
targeted scar fits precisely within the punch,
circumfer-ential cutting with the punch can cause elevation of the
scar as lateral and deep fibrous bands are severed and the
plug containing the scar spontaneously elevates This is
referred to as punch elevation Alternatively, if the scar
is very deep and well embedded, the central plug may
be removed, as in the case of a punch biopsy Then the
created defect may either be sewn end-to-end, to create
a slit-like scar (i.e., punch excision), or filled with a
sim-ilar shaped plug harvested from an uninvolved scar (i.e.,
punch grafting) At times, a series of deep scars may be
present in a linear or curvilinear array Such scars may
be revised by removal of a strip of epidermis and dermis
using the techniques of elliptical excision and bilayered
closure with eversion If a patient requires punch or
lin-ear excision as well as resurfacing for treatment of acne
scars, it is preferable to perform the excisions first, as
the re-epithelialization following the ablative procedure
will conceal the excision lines
Perifollicular hypopigmentation of acne scars,
espe-cially those of the trunk, remains highly resistant to
treatment If papular and facial, hypopigmented scars
may be treated with fine-needle diathermy, and ing procedures useful in vitiligo may also be consid-ered Minigrafting is limited in efficacy, since thespread in pigment from the graft sites to the surround-ing scars appears to be restricted,36,37 but epidermalsuspensions of cultured and noncultured cells arepromising new therapies Newly available automatedcommercial kits for trypsin epidermal separation (Re-Cell) may simplify the grafting process.37,38
graft-ACNE SCAR TREATMENT BY FILLERS
Filler injection is a minimally invasive method ofscar improvement that can be combined with othertreatments Also known as soft-tissue augmentationmaterials, fillers can be autologous, heterologous, orsynthetic; additionally, they can be prepackaged orharvested prior to use
Until the 21st century, the primary Food and DrugAdministration (FDA)-approved prepackaged aug-mentation material was bovine collagen Since then,human-derived collagen (Cosmoderm and Cosmoplast),hyaluronic acid derivatives (Restylane, Juvederm,Hylaform, Hylaform Plus, and Captique), calciumhydroxyapatite (Radiesse – pending FDA approval,used off-label), and liquid silicone (used off-label)39have been used frequently (Table 8.1) While bovinecollagen required skin testing to exclude allergy,none of the newer fillers do, although they shouldnot be used in patients with known sensitivity to their
Table 8.1 Common fillers for acne scarring (USA)
Filler type Filler name Method of use Persistence
Human-derived
Autologous Blood aspirate Can be injected deep or superficially Weeks to months
Fat Injected deep for rolling scars Weeks to months, portion of effect
may be permanent Heterologous Human collagen Fine superficial scars, or layering in 2–3 months
dermis Non-human-derived
Temporary Hyaluronic acid Versatile, for deep and medium injection 6–9 months
Calcium Deep, for rolling scars (off-label) 1 year hydroxyapatite
Permanent Liquid silicone Rolling scars (not FDA-approved) Many years