The Role of Topical Retinoids in Prevention and Treatment of Atrophic Acne Scarring: Understanding the Importance of Early Effective Treatment
March 2019 | Volume 18 | Issue 3 | Original Article | 255 | Copyright © 2019
Jerry Tan MD,a Emil Tanghetti MD,b Hilary Baldwin MD,c Linda Stein Gold MD,d Edward Lain MDe
aUniversity of Western Ontario, London, Ontario; Windsor Clinical Research Inc, Windsor, Ontario, Canada bCenter for Dermatology & Laser Surgery, Sacramento, CA cThe Acne Treatment and Research Center, Morristown, NJ; Rutgers Robert Wood Johnson Medical Center, Newark, NJ DHenry Ford Medical Center, Department of Dermatology, Detroit, MI EAustin Institute for Clinical Research, Pflugerville, TX
Atrophic acne scarring is a frequent occurrence among acne patients. These facial marks are often very emotionally distressing for the patient and can result in adverse impact to quality of life. While most clinicians consider scarring as a sequela of moderate to severe acne, recent studies have found that scars are also associated with mild acne. Risk factors include time to effective treatment, severity of acne, family history, and excoriations. New data shows that early and effective acne treatment can reduce the development of new scars, confirming the widespread perception of this approach in prevention. It is also becoming clear that the inflammatory process drives both the development of acne lesions and atrophic scars. This implies that inhibiting activation of inflammatory pathways early is key to preventing scars. Data also suggests a useful role for adapalene for the treatment of well-established acne scars with scar remodeling accompanied by the production of new collagen and elastic tissue. Acne guidelines and recommendations continue to highlight the central role of retinoids, with fixed-dose combination retinoids being particularly important due to targeting of multiple inflammatory pathophysiologic factors and for patient convenience. Higher concentrations of retinoids such as adapalene 0.3%/benzoyl peroxide 2.5% (A0.3/BPO2.5) have shown increased efficacy, particularly among patients with moderately severe and severe acne – a population at high risk for scarring. Further, controlled study of A0.3/BPO2.5 in patients with moderate acne (mean, 40 acne lesions per half face) and mild-moderate scarring demonstrated A0.3/BPO2.5 was significantly superior to vehicle in reducing scar counts from baseline over 24 weeks. While scar counts lessened on the A0.3/BPO2.5 side, counts increased on the vehicle side during the study. This occurred in the setting of active acne, where the efficacy of A/BPO is well known, emphasizing the dual actions of A0.3/BPO2.5 in both treatment and prevention.
J Drugs Dermatol. 2019;18(3):255-260.
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Atrophic acne scars are common and frequently distressing to those with acne.1-3 Acne scarring often profoundly affects an individual's self-esteem and has a negative impact on patients’ quality of life. It is common for many patients with acne to seek treatments that restore a smoother skin texture.4, 5 Decreased self-confidence, increased embarrassment, and a lower potential to be employed have been reported to accompany acne scarring.6 In a 2016 survey of images with and without digitally superimposed acne scars, images of those with acne scars were perceived more negatively and considered to be insecure, shy, less successful, less healthy, less happy and less confident.7While treatments for pre-existing acne scars such as fillers, dermabrasion, microneedling with and without radiofrequency, and fractional ablative and non-ablative laser resurfacing continue to advance, none resolve acne scars completely.8 Even in the best of circumstances only partial correction can be achieved. As an example, Elcin et al evaluated the efficacy and safety of fractional carbon dioxide laser in 31 subjects with acne scars, reporting that 22.6% had no improvement; in subjects with improvement, the change was mild in 35.5%, moderate in 29%, and significant in just 12.9%.9 Brauer et al10 and Bern-stein et al11 both evaluated fractional picosecond devices at 755nm, 523nm and 1064nm to treat acne scarring. They observed only modest changes with less than 30% improvement in their patients.11 With current technology, treatment of scars is expensive and has limited efficacy; thus, prevention and early, effective treatment of acne continue to be primary strategies to minimize acne scarring.12 We discuss in this article emerging evidence supporting the role of topical retinoids, such as adapalene 0.3%/benzoyl peroxide 2.5% (A0.3/BPO2.5), in treatment of acne, acne scars, and prevention of scarring.