Combination Therapy for Acne Scarring: Personal Experience and Clinical Suggestions
November 2016 | Volume 15 | Issue 11 | Original Article | 1413 | Copyright © November 2016
Lucija Kroepfl MBChBa and Jason J. Emer MDb
aInstitut: Buljanovic-Kroepfl, Essen, Germany bJason J. Emer MD, Beverly Hills, CA
Acne is one of the most prevalent skin conditions seen by dermatologists. The cosmetic sequelae of severe acne, including scarring and pigmentation, have a profound psychological impact on those in icted. Topical (eg, retinoids, antibiotics, dapsone, hydroxyacids) and oral treatments (eg, antibiotics and/or spironolactone) are often bene cial to control acne or in the instance of oral isotretinoin use, rid the acne permanently; however, these treatments have very little affect on the ultimate cosmetic outcome of the acne scarring and skin texture that results. Given the variety of scar types that can form and the variability of responses seen in various skin types and textures, treatment options are vast without appropriate guidelines for pathways that dictate best timing, combinations, and options in given clinical scenarios. Current treatment options include solo or combina- tions of energy-based (eg, laser, radiofrequency), chemical-based (eg, peels, TCA cross), surgical-based options (eg, subcision, punch excision), microneedling, and llers and/or fat injections. Most recently, fractional radiofrequency-based treatments have been used to improve acne scarring with less reported downtime as compared to lasers or chemical peels and the ability to treat darker or sensitive skin types with less risk of scarring or hyperpigmentation. In severe cystic ares, scarring treatments are often postposed till the acne is under control and in many instances this can limit the dermatologists ability to affect future cosmetic treatments. Based on personal experience of various clinical scenarios in a busy laser practice that treats a signi cant number of patients with acne scarring, fractional radiofrequency is an excellent choice for treating all forms of acne scars with minimal risk to patients, even those on concurrent treatments such as isotretinoin. Additionally, fractional radiofrequency can be used in combination with all other treatment options to speed the time to clinical improvement appreciated by the patient. Here we present personal experiences of combination treatments for acne scarring, pigmentation and textural issues, and suggest that fractional radiofrequency be considered a “gold standard” treatment of acne scarring in those with dark or sensitive skin types or those on concurrent isotretinoin.J Drugs Dermatol. 2016;15(11):1413-1419.
Acne is one of the top 10 most prevalent skin diseases worldwide.1-3 It affects more than 50 million people in the US with a prevalence of over 90% among adolescents.1-3 Acne has a major psychological and social impact on the individual and 12-14% of the patients will still suffer from acute acne during adulthood.2 Furthermore a significant number of patients with acne develop scars due to an abnormal healing response following tissue injury. The epidemiology regarding the incidence of acne scarring is inconsistent with incidences between 0.17% and 90% being reported.4 Those of us with busy practices know the incidence of scarring and associated dyschromia and textural changes is extremely significant. Scarring and complexion issues can negatively influence the psychological and social wellbeing of those affected, especially younger patients. It is therefore of great importance not only to treat the acne aggressively, but also to manage the sequelae early on in order to have a more profound impact on a patient’s life by limiting the number of future cosmetic treatments necessary to improve the resultant scarring.Current treatment options include solo or combinations of energy-based (eg, laser, radiofrequency (RF)), chemical-based (eg, peels, TCA cross), surgical-based options (eg, subcision, punch excision), microneedling, and fillers and/or fat injections. Most recently, fractional RF-based treatments have been used to improve acne scarring with less reported downtime as compared to lasers or chemical peels and the ability to treat darker or sensitive skin types with less risk of scarring or hyperpigmentation.
Management of Acne Scars
There are two major types of scars including hypertrophic/keloid and atrophic scars. Atrophic scars occur more frequently than hypertrophic/keloid scars with a ratio 3:1.2 Both types of scars can occur simultaneously in one patient. From here further when describing scars, we will be describing atrophic scars characterized by a localized loss of collagen fibers developing from abnormal matrix remodeling after severe inflammation or picking (Table 1).2,4