Cosmetic Dermatology

Update on Acne Scar Treatment

Cutis. 2018 July;102(1):21-25, 47-48

Yssra S. Soliman, BA

Rebecca Horowitz

Peter W. Hashim, MD, MHS

John K. Nia, MD

Aaron S. Farberg, MD

Gary Goldenberg, MD

Acne vulgaris and postacne scarring are common in the general population. Even after lesions have resolved, scarring can lead to detrimental psychologic effects and can negatively impact patients’ quality of life. Fortunately, there have been several recent advances in therapeutic options to treat acne scarring. This article discusses these treatments with a focus on microneedling, lasers, chemical peels, and dermal fillers.

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Practice Points

Acne scarring affects millions of Americans and can lead to poor psychological sequelae such as low self-esteem.
Multiple modalities for acne scarring treatment exist including microneedling, lasers, chemical peels, and dermal fillers.
Consider patient-desired outcome, cost, and adverse events when choosing a specific treatment modality.

References

White GM. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol. 1998;39(2, pt 3):S34-S37.
Yazici K, Baz K, Yazici AE, et al. Disease-specific quality of life is associated with anxiety and depression in patients with acne. J Eur Acad Dermatol Venereol. 2004;18:435-439.
Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg. 1995;21:543-549.
Fabbrocini G, De Padova M, De Vita V, et al. Periorbital wrinkles treatment using collagen induction therapy. Surg Cosmet Dermatol. 2009;1:106-111.
Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J Dermatol Treat. 2012;23:144-152.
Fabbrocini G, De Vita V, Di Costanzo L, et al. Skin needling in the treatment of the aging neck. Skinmed. 2011;9:347-351.
El-Domyati M, Barakat M, Awad S, et al. Microneedling therapy for atrophic acne scars: an objective evaluation. J Clin Aesthet Dermatol. 2015;8:36-42.
Fabbrocini G, Fardella N, Monfrecola A, et al. Acne scarring treatment using skin needling. Clin Exp Dermatol. 2009;34:874-879.
Alam M, Han S, Pongprutthipan M, et al. Efficacy of a needling device for the treatment of acne scars: a randomized clinical trial. JAMA Dermatol. 2014;150:844-849.
Dhurat R, Sukesh M, Avhad G, et al. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013;5:6-11.
Dhurat R, Mathapati S. Response to microneedling treatment in men with androgenetic alopecia who failed to respond to conventional therapy. Indian J Dermatol. 2015;60:260-263.
Fabbrocini G, De Vita V, Fardella N, et al. Skin needling to enhance depigmenting serum penetration in the treatment of melasma [published online April 7, 2011]. Plast Surg Int. 2011;2011:158241.
Bariya SH, Gohel MC, Mehta TA, et al. Microneedles: an emerging transdermal drug delivery system. J Pharm Pharmacol. 2012;64:11-29.
Fabbrocini G, De Vita V, Izzo R, et al. The use of skin needling for the delivery of a eutectic mixture of local anesthetics. G Ital Dermatol Venereol. 2014;149:581-585.
De Vita V. How to choose among the multiple options to enhance the penetration of topically applied methyl aminolevulinate prior to photodynamic therapy [published online February 22, 2018]. Photodiagnosis Photodyn Ther. doi:10.1016/j.pdpdt.2018.02.014.
Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac Surg Clin North Am. 2005;17:51-63.
Goodman GJ, Baron JA. Postacne scarring—a quantitative global scarring grading system. J Cosmet Dermatol. 2006;5:48-52.
Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J Cutan Aesthet Surg. 2009;2:26-30.
Dogra S, Yadav S, Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J Cosmet Dermatol. 2014;13:180-187.
Fabbrocini G, De Vita V, Monfrecola A, et al. Percutaneous collagen induction: an effective and safe treatment for post-acne scarring in different skin phototypes. J Dermatol Treat. 2014;25:147-152.
Hashim PW, Levy Z, Cohen JL, et al. Microneedling therapy with and without platelet-rich plasma. Cutis. 2017;99:239-242.
Wang HL, Avila G. Platelet rich plasma: myth or reality? Eur J Dent. 2007;1:192-194.
Marx RE. Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg. 2004;62:489-496.
Fabbrocini G, De Vita V, Pastore F, et al. Combined use of skin needling and platelet-rich plasma in acne scarring treatment. Cosmet Dermatol. 2011;24:177-183.
Chawla S. Split face comparative study of microneedling with PRP versus microneedling with vitamin C in treating atrophic post acne scars. J Cutan Aesthet Surg. 2014;7:209-212.
Asif M, Kanodia S, Singh K. Combined autologous platelet-rich plasma with microneedling verses microneedling with distilled water in the treatment of atrophic acne scars: a concurrent split-face study. J Cosmet Dermatol. 2016;15:434-443.
Ibrahim MK, Ibrahim SM, Salem AM. Skin microneedling plus platelet-rich plasma versus skin microneedling alone in the treatment of atrophic post acne scars: a split face comparative study. J Dermatolog Treat. 2018;29:281-286.
Goodman GJ, Baron JA. Postacne scarring: a qualitative global scarring grading system. Dermatol Surg. 2006;32:1458-1466.
You H, Kim D, Yoon E, et al. Comparison of four different lasers for acne scars: resurfacing and fractional lasers. J Plast Reconstr Aesthet Surg. 2016;69:E87-E95.
Osman MA, Shokeir HA, Fawzy MM. Fractional erbium-doped yttrium aluminum garnet laser versus microneedling in treatment of atrophic acne scars: a randomized split-face clinical study. Dermatol Surg. 2017;43(suppl 1):S47-S56.
Lee JW, Kim BJ, Kim MN, et al. The efficacy of autologous platelet rich plasma combined with ablative carbon dioxide fractional resurfacing for acne scars: a simultaneous split-face trial. Dermatol Surg. 2011;37:931-938.
Gawdat HI, Hegazy RA, Fawzy MM, et al. Autologous platelet rich plasma: topical versus intradermal after fractional ablative carbon dioxide laser treatment of atrophic acne scars. Dermatol Surg. 2014;40:152-161.
Abdel Aal AM, Ibrahim IM, Sami NA, et al. Evaluation of autologous platelet rich plasma plus ablative carbon dioxide fractional laser in the treatment of acne scars. J Cosmet Laser Ther. 2018;20:106-113.
Min S, Yoon JY, Park SY, et al. Combination of platelet rich plasma in fractional carbon dioxide laser treatment increased clinical efficacy of for acne scar by enhancement of collagen production and modulation of laser-induced inflammation. Lasers Surg Med. 2018;50:302-310.
Roberts AB, Sporn MB, Assoian RK, et al. Transforming growth factor type beta: rapid induction of fibrosis and angiogenesis in vivo and stimulation of collagen formation in vitro. Proc Natl Acad Sci U S A. 1986;83:4167-4171.
Schmidt EV. The role of c-myc in cellular growth control. Oncogene. 1999;18:2988-2996.
Varga J, Rosenbloom J, Jimenez SA. Transforming growth factor beta (TGF beta) causes a persistent increase in steady-state amounts of type I and type III collagen and fibronectin mRNAs in normal human dermal fibroblasts. Biochem J. 1987;247:597-604.
Chen J, Somanath PR, Razorenova O, et al. Akt1 regulates pathological angiogenesis, vascular maturation and permeability in vivo. Nat Med. 2005;11:1188-1196.
Repertinger SK, Campagnaro E, Fuhrman J, et al. EGFR enhances early healing after cutaneous incisional wounding. J Invest Dermatol. 2004;123:982-989.
Landau M. Chemical peels. Clin Dermatol. 2008;26:200-208.
Drake LA, Dinehart SM, Goltz RW, et al. Guidelines of care for chemical peeling. J Am Acad Dermatol. 1995;33:497-503.
Meaike JD, Agrawal N, Chang D, et al. Noninvasive facial rejuvenation. part 3: physician-directed-lasers, chemical peels, and other noninvasive modalities. Semin Plast Surg. 2016;30:143-150.
Leheta TM, Abdel Hay RM, El Garem YF. Deep peeling using phenol versus percutaneous collagen induction combined with trichloroacetic acid 20% in atrophic post-acne scars; a randomized controlled trial.J Dermatol Treat. 2014;25:130-136.
El-Domyati M, Abdel-Wahab H, Hossam A. Microneedling combined with platelet-rich plasma or trichloroacetic acid peeling for management of acne scarring: a split-face clinical and histologic comparison.J Cosmet Dermatol. 2018;17:73-83.
Hession MT, Graber EM. Atrophic acne scarring: a review of treatment options. J Clin Aesthet Dermatol. 2015;8:50-58.
Dayan SH, Bassichis BA. Facial dermal fillers: selection of appropriate products and techniques. Aesthet Surg J. 2008;28:335-347.
Munavalli GS, Smith S, Maslowski JM, et al. Successful treatment of depressed, distensible acne scars using autologous fibroblasts: a multi-site, prospective, double blind, placebo-controlled clinical trial. Dermatol Surg. 2013;39:1226-1236.

Acne vulgaris is prevalent in the general population, with 40 to 50 million affected individuals in the United States.¹ Severe inflammation and injury can lead to disfiguring scarring, which has a considerable impact on quality of life.² Numerous therapeutic options for acne scarring are available, including microneedling with and without platelet-rich plasma (PRP), lasers, chemical peels, and dermal fillers, with different modalities suited to individual patients and scar characteristics. This article reviews updates in treatment options for acne scarring.

Microneedling

Microneedling, also known as percutaneous collagen induction or collagen induction therapy, has been utilized for more than 2 decades.³ Dermatologic indications for microneedling include skin rejuvenation,^4-6 atrophic acne scarring,^7-9 and androgenic alopecia.^10,11 Microneedling also has been used to enhance skin penetration of topically applied drugs.^12-15 Fernandes¹⁶ described percutaneous collagen induction as the skin’s natural response to injury. Microneedling creates small wounds as fine needles puncture the epidermis and dermis, resulting in a cascade of growth factors that lead to tissue proliferation, regeneration, and a collagen remodeling phase that can last for several months.^8,16

Microneedling has gained popularity in the treatment of acne scarring.⁷ Alam et al⁹ conducted a split-face randomized clinical trial (RCT) to evaluate acne scarring after 3 microneedling sessions performed at 2-week intervals. Twenty participants with acne scarring on both sides of the face were enrolled in the study and one side of the face was randomized for treatment. Participants had at least two 5×5-cm areas of acne scarring graded as 2 (moderately atrophic scars) to 4 (hyperplastic or papular scars) on the quantitative Global Acne Scarring Classification system. A roller device with a 1.0-mm depth was used on participants with fine, less sebaceous skin and a 2.0-mm device for all others. Two blinded investigators assessed acne scars at baseline and at 3 and 6 months after treatment. Scar improvement was measured using the quantitative Goodman and Baron scale, which provides a score according to type and number of scars.¹⁷ Mean scar scores were significantly reduced at 6 months compared to baseline on the treatment side (P=.03) but not the control side. Participants experienced minimal pain associated with microneedling therapy, rated 1.08 of 10, and adverse effects were limited to mild transient erythema and edema.⁹ Several other clinical trials have demonstrated clinical improvements with microneedling.^18-2⁰

The benefits of microneedling also have been observed on a histologic level. One group of investigators explored the effects of microneedling on dermal collagen in the treatment of various atrophic acne scars in 10 participants.⁷ After 6 treatment sessions performed at 2-week intervals, dermal collagen was assessed via punch biopsy. A roller device with a needle depth of 1.5 mm was used for all patients. At 1 month after treatment compared to baseline, mean (SD) levels of type I collagen were significantly increased (67.1% [4.2%] vs 70.4% [5.4%]; P=.01) as well as at 3 months after treatment compared to baseline for type III collagen (61.4% [3.6%] vs 74.3% [7.4%]; P=.01), type VII collagen (15.2% [2.1%] vs 21.3% [1.2%]; P=.03), and newly synthesized collagen (14.5% [5.8%] vs 19.5% [3.2%]; P=.02). Total elastin levels were significantly decreased at 3 months after treatment compared to baseline (51.3% [6.7%] vs 46.9% [4.3%]; P=.04). Adverse effects were limited to transient erythema and edema.⁷

Microneedling With Platelet-Rich Plasma

Microneedling has been combined with platelet-rich plasma (PRP) in the treatment of atrophic acne scars.²¹ In addition to inducing new collagen synthesis, microneedling aids in the absorption of PRP, an autologous concentrate of platelets that is obtained through peripheral venipuncture. The concentrate is centrifuged into 3 layers: (1) platelet-poor plasma, (2) PRP, and (3) erythrocytes.²² Platelet-rich plasma contains growth factors such as platelet-derived growth factor, transforming growth factor (TGF), and vascular endothelial growth factor, as well as cell adhesion molecules.^22,23 The application of PRP is thought to result in upregulated protein synthesis, greater collagen remodeling, and accelerated wound healing.²¹

Several studies have shown that the addition of PRP to microneedling can improve treatment outcome (Table 1).^24-27 Severity of acne scarring can be improved, such as reduced scar depth, by using both modalities synergistically (Figure).²⁴ Asif et al²⁶ compared microneedling with PRP to microneedling with distilled water in the treatment of 50 patients with atrophic acne scars graded 2 to 4 (mild to severe acne scarring) on the Goodman’s Qualitative classification and equal Goodman’s Qualitative and Quantitative scores on both halves of the face.^17,28 The right side of the face was treated with a 1.5-mm microneedling roller with intradermal and topical PRP, while the left side was treated with distilled water (placebo) delivered intradermally. Patients underwent 3 treatment sessions at 1-month intervals. The area treated with microneedling and PRP showed a 62.20% improvement from baseline after 3 treatments, while the placebo-treated area showed a 45.84% improvement on the Goodman and Baron quantitative scale.²⁶

Right side of the patient’s face before treatment with skin needling and platelet-rich plasma (A). Right side of the patient’s face after treatment with skin needling and platelet-rich plasma (B).

Chawla²⁵ compared microneedling with topical PRP to microneedling with topical vitamin C in a split-face study of 30 participants with atrophic acne scarring graded 2 to 4 on the Goodman and Baron scale. A 1.5-mm roller device was used. Patients underwent 4 treatment sessions at 1-month intervals, and treatment efficacy was evaluated using the qualitative Goodman and Baron scale.²⁸ Participants experienced positive outcomes overall with both treatments. Notably, 18.5% (5/27) on the microneedling with PRP side demonstrated excellent response compared to 7.4% (2/27) on the microneedling with vitamin C side.²⁵

Update on Acne Scar Treatment

References

Microneedling

Microneedling With Platelet-Rich Plasma

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