Rivera AE. Acne scarring: A review and current treatment modalities. Journal of the American ...

18 Pages·2012·0.27 MB·English

Acne scarring: A review and current
treatment modalities
Albert E. Rivera, DO
Kirksville, Missouri
Acneisaprevalentconditioninsocietyandoftenresultsinsecondarydamageintheformofscarring.Of
course, prevention is the optimal method to avoid having to correct the physically or emotionally
troublesome scars. However, even with the best efforts, scars will certainly arise. This article attempts to
give a broad overview of multiple management options, whether medically, surgically, or procedurally
based. The hope is that a general knowledge of the current available alternatives will be of value to the
physician when confronted with the difficult task of developing a treatment plan for acne-scarred
individuals, even in challenging cases. (J Am Acad Dermatol 2008;59:659-76.)
ACNE
Abbreviationsused:
Acne is caused and characterized by multiple
factors,including:Propionibacteriumacnesactivity; Er:YAG: erbium:yttrium-aluminum-garnet
FDA: FoodandDrugAdministration
increased sebum production; androgenic stimula-
HA: hyaluronicacid
tion;follicularhypercornification;lymphocyte,mac- IPL: intensepulsedlight(notlisted)
rophage, and neutrophil inflammatory response; Nd:YAG: neodymium:yttrium-aluminum-garnet
PDL: pulseddyelaser
and cytokine activation. Multiple surveys and stud-
TCA: trichloroaceticacid
ies have attempted to determine the prevalence of
acne within various groups. None of these are
without shortcoming but all have done well with
girls.Cysticacnewaspresentin1.9per1000forboth
targeted,representativegroups.Agood review,too
sexes,3.3per1000inmenandboysand0.6per1000
extensive to be included in this work, containing
in women and girls. The common complication of
tables (consisting of 15 general population or
acne scarring was found in 1.7 per 1000 for both
schoolchildren-based cross-sectional surveys along
sexes,2.0per1000inmenandboysand1.3per1000
with 3 separate case-control studies) and discus-
inwomenandgirls.Approximately80%ofgirlsand
sions of several of these publications has been
90%ofboysdevelopacneintheiradolescentyears.
compiled and published by a group of Australian
Thepeakincidenceforgirlsisage14to17yearsand
authors.1
age16to19yearsforboysandmen.Furthermore,of
In 1978, the most comprehensive study to date,
individuals aged 11 to 30 years, 80% have some
HANES-1,2 established the prevalence of acne vul-
degreeofactiveacne.
garis within 20,749 US citizens aged 1 to 74 years
More recently, a community-based study, using
(excluding those hospitalized for another dermato- theLeedsgradingtechniqueforacne3andincluding
logicconditionandthosewith thediseaseinremis-
749 patients, all older than 25 years (range 25-58
sion)tobe68per1000forbothsexes,70.4per1000
years,meanage39.5years),was usedtodetermine
formenandboysand65.8per1000forwomenand
overall acne prevalence as 58% of women and 40%
of men. ‘‘Clinical’’ ([0.75 on the Leeds scale) acne
was present in 3% of men and 12% of women. The
Fromthe Department of Dermatology, NortheastRegionalMed-
icalCenter. prevalence of clinical acne decreased significantly
Fundingsources:None. only after age 45 years. Their definition of scarring
Conflictsofinterest:Nonedeclared. wasnotedin14%ofthewomenand11%ofthemen
Please see the Appendix for a listing of the manufacturers of in the study.4 However, even in the two examples
brandnamedrugsmentionedinthisarticle.
above, statistics are often inaccurate because most
Reprintrequests:AlbertE.Rivera,DO,DepartmentofDermatology,
NortheastRegionalMedicalCenter,700WJeffersonSt,Kirksville, estimations are based on patients who seek treat-
MO63501.E-mail:[email protected]. ment, physician diagnoses, hospital records, com-
PublishedonlineJuly28,2008. pensation claims, medication purchases, or various
0190-9622/$34.00
exclusion or inclusion criteria, rather than a full
ª2008bytheAmericanAcademyofDermatology,Inc.
cross-populationsample.5
doi:10.1016/j.jaad.2008.05.029
659
660 Rivera JAMACADDERMATOL
OCTOBER2008
Even though this condition is widespread, pa- transient erythema or pigmentary changes and not
tientsdonotalwayspresenttophysiciansforprompt truescarsasdefinedabove.
diagnosis and treatment. Of those with acne, only In one study of 185 patients (101 female and 84
approximately 16% seek appropriate medical treat- malewithvariousquantity,morphology,andsever-
ment: 74% wait greater than 1 year before seeking ityof acneof theface,chest, or back),it was found
evaluation,12%wait6to12months,6%wait3to6 that facial scarring affected 95% of both sexes to
months,andonly7%waitedlessthan3monthstobe some degree. The truncal region of male patients
seen.6Thisisattributedtomultiplefactorsthatcould showed significantly more total, hypertrophic, and
include financial limitations, physician access, and keloidal scarring than the same region of female
patientdelay,amongothers.Thedelayintreatment, patients. The correlation with scar formation was
though, increases the probability of secondary se- relatedtothoseacnelesionswithatimedelayofup
quelae such as scarring. Educational efforts should to 3 years between initial onset and sufficient treat-
beundertakentoinformthepublicandphysiciansas mentregardlessofsexorlocation.13
to the importance of preventative measures and AverytouchingandenlighteningarticlebyKoo14
urgency of early management. A good review of discussed psychosocial effects primarily in regard
such treatments, including topical or systemic med- to acne but it also applies to scars. They may both
icationandlasers,wasauthoredfairlyrecently.7 lead to emotional debilitation, embarrassment, poor
self-esteem, social isolation, preoccupation, low
BACKGROUND confidence, altered social interactions, body image
Ithasbeenwrittenthat‘‘thereisnosingledisease alterations, identity difficulties, anger, frustration,
which causes more psychic trauma, more malad- confusion, unemployment, lowered academic per-
justmentbetweenparentandchildren,moregeneral formance, exacerbation of psychiatric disease, anxi-
insecurity and feelings of inferiority and greater ety,ordepression.Althoughtheseeffectsaredifficult
sumsofpsychicsufferingthandoesacnevulgaris.’’8 toquantifyinpatientterms,healthcareeffect,orsocial
So too, and possibly more so through its perma- expense,thescarringthatresultsfromtissuedamage
nence, is the effect of the resulting damage in the and inflammation is a significant issue that requires
formofaphysicalscar.‘‘Scar,’’asanoun,isdefined attention and will be expanded. Now the focus will
as ‘‘the fibrous tissue that replaces normal tissue turntothescarsthemselves;initially,thescartypesare
destroyed by injury or disease’’ by the American covered and then several of the treatment options
Heritage Stedman’s Medical Dictionary.9 currentlyavailablearediscussed.
An impressive study involving the histology, pa-
thology, and immunology of acne scarring found ACNE SCARS
that‘‘thecellularinfiltratewaslargeandactivewitha The two causes of acne scar formation can be
greaternonspecificresponse(fewmemoryTcells)in broadly categorized as either a result of increased
early lesions of NS [not prone to develop scarring] tissueformationor,themorecommoncause,lossor
patients,whichsubsidedinresolution.Incontrast,a damage of tissue. Two examples of excess tissue
predominately specific immune response was pre- presence are hypertrophic scars and keloids.
sentinS[pronetodevelopscarring]patients,which Hypertrophic scars are confined within the margins
was initially smaller and ineffective, but was in- oftheoriginalinjury.Thesescarsaremostprevalent
creased and activated in resolving lesions. Such withinthefirstcoupleofmonthspostinjury,andthen,
excessive inflammation in healing tissue is condu- incontrast tokeloids,tendtonormally mature with
civetoscarring....’’10 occasionalspontaneousregression.However,some
Collagen and other tissue damage from the in- do also worsen. These scars are most often less
flammationofacneleadstopermanentskintexture bothersomeandtreatmentmayormaynotbeneeded
changes and fibrosis. Scars normally proceed based on severity. Keloids are a human-specific
through the specific phases of the wound-healing phenomenonthatischaracterizedbydisproportion-
cascade:inflammation,granulation,andremodeling. ate creation and deposition of collagen with an
However, even normal scars never reach the same excess outside of the original injury margins. They
level of strength as original skin, only about 80% at arecommonly found onthe chest, back,shoulders,
best.11 Dermal damage is more long lasting and and ears. These lesions are very persistent and are
resultsinanincreaseordecreaseoftissueandoften found almost equally among male and female pa-
worsensinappearancewithageasaresultofnormal tients,lesscommonlyintheveryyoungorold.There
skin changes. In contrast, damage limited to the arefamilialandgeneticinfluenceswithbothautoso-
epidermis or papillary dermis can heal without scar mal dominant and recessive traits. Clinically, there
formation.12 Epidermal damage results in more may be pain, itching, burning, or limited range of
JAMACADDERMATOL Rivera 661
VOLUME59,NUMBER4
motion. Surgery is sometimes done for debulking sloped edges that merge with normal-appearing
and multiple modality treatment is recommended skin. There may be dermal or subdermal tethering,
because of the high recurrence with surgery alone; so treatment is commonly by subcision, which will
aggressivescarshavearegrowthof50%to100%. bediscussedlater.Anadditional,sometimescatego-
Histologically, normal-appearing dermis demon- rizedclass,atrophicscars,exhibitaslightlywrinkled
strates relaxed, randomly aligned collagen. Both textureandmaybesomewhatpigmentedbecauseof
hypertrophicscarsandkeloidsdemonstratethicker, the underlying vasculature. Treatment is most often
moreabundantcollagenthatisstretchedandaligned with abrasion, excision, or augmentation but occa-
inthesameplaneastheepidermis.Morespecifically, sionally with creams or peels that have generally
hypertrophic scars have islands of dermal collagen poorresults.
fibers, small vasculature, and fibroblasts through- Objectiveevaluationofthescarsisanecessityfor
out.15 Suggested pathophysiology includes trans- discussion,treatment,andresearch.Therearegrad-
forming growth factor-beta-I, platelet-derived ing devices that focus on 3-dimensional grid-based
growth factor, matrix metalloproteinases, interleu- mapping of lesions and molded skin replicas for
kin-I-alpha, fibroblasts themselves, altered micro- comparison examination.22 However, these are not
vascular regeneration, histamine, carboxypeptidase as applicable in practical, daily use by the average
A,prostaglandinD2,andtryptase.16Keloids,onthe physician. There are grading scales for acne scars
other hand, reveal regions of reticular dermal acel- that are more practical for day-to-day implementa-
lularnodelikestructuresandaremoreacellularasa tion.In1999,theECLA(echelled’evaluationclinique
wholecomparedwithhypertrophicscars. des lesions d’acne)23 was introduced, followed by
Both keloids and hypertrophic scars have an the ECCA (echelle d’evaluation clinique des cicatri-
incidence 5to15times higherinAfrican Americans cesd’acne)24in2006.Usingthisscale,thequalitative
and 3 to 5 times higher in Asians compared with aspectsofscarsdefinethetypeofscar,whichisthen
Caucasians.17Itisestimatedthattheyaffectboththe associatedwithaquantitativescore(0-4)determined
AfricanAmericanandHispanicpopulationsbetween semiquantitatively and multiplied by a weighting
4.5% to 16%.18 As briefly noted above, both are factor(15-50)ofclinicalseverity,leadingtopossible
treatedeithersinglyorincombinationwithmultiple totals of 0 to 540. It was found to have good
therapiessuchasexcision,abrasion,lasertreatment interinvestigator reliability although it did not focus
and medication, among others. As an outside refer- on icepick, rolling, or boxcar specifically but rather
ence,AlsterandWest19authoredanexcellent,thor- variations of atrophic and hypertrophic. Goodman
oughreviewonhypertrophicandkeloidscarsalong andBaron25describedaquantitativegradingsystem
withatrophicscars. based on counting (1-10, 11-20, [20) of scar type
Theothercauseofscars,lossordamageoftissue, (atrophic, macular, boxcar, hypertrophic, keloidal)
is demonstrated by the 3 primary acne scars as and severity (mild, moderate, severe). Points are
described by Jacob et al20: icepick, rolling, and assigned to each respective category and totaled
boxcar. The icepick scars are usually smaller in withintherangeofaminimumof0toamaximumof
diameter (\2 mm) and deep with tracts to the 84. This was found to be reasonably accurate and
dermis or subcutaneous tissue possible. Although reproducible with good interinvestigator reliability.
theorificeissmallerandsteep-sided,theremaybea The same physicians also outlined a qualitative
widebasethatcouldevolveintoadepressed,boxcar (rather than quantitative) grading system26 that is
scar. Commonly these are seen on the cheeks. simplerforquick,dailyuse.Itdistinguished4grades
Treatment is frequently done by punch excision for level of disease: (1) macular, (2) mild, (3)
with closure by small suture along relaxed skin moderate, and (4) severe. Subdivisions of macular
tension lines. Nonabsorbable suture is preferred disease are erythematous, hyperpigmented, or hy-
because of the predisposition of the skin to scar popigmentedandthoseofmildtoseverediseaseare
and the inflammatory response seen with absorb- atrophic and hypertrophic. Further specification in-
ables.21 Depressed or boxcar scars are described as cludesthenumberofcosmeticunitsinvolved:Afor
shallow(\0.5mm)ordeep([0.5mm)andareoften focaloronelesionandBfordiscreteor2to3lesions.
1.5to4mmindiameter.Theyhavesharplydefined As the reader can appreciate, these systems and
edgeswithsteep,almostverticalwalls.Shallowscar variationthereincanbecomequiteconfusing.Inthe
treatmentcanbewithresurfacingorpossiblypunch literature,thereisoneattemptatcreatingacompre-
elevationwhereasdeepscartreatmentismostoften hensiveclassificationsystembasedonseveralother
donebypunchexcision, elevation,orother modal- systems.27 However, the lack of a true consensus
ity. Soft rolling scars can be circular or linear, are scalehindersstandardizationofdiagnosisandtreat-
oftengreaterthan4mmindiameter,andhavegently mentofacnescarring.
662 Rivera JAMACADDERMATOL
OCTOBER2008
Table I. Medical management orsponsorship/fundingbias.Thefollowingsections,
although not totally comprehensive, will attempt to
Retinoids
cover a majority of the medical, procedural, and
Topical/injectable steroids
surgicaloptions.Itislessoftenthatacnelesionslead
Siliconedressing
to hypertrophic scars or keloids, however, it is a
Various othertopicalorinjectable substances
possibilityandcertainlyisasideeffectconsideration
with treatments for other types of scars, so will
thereforebeincludedinthesediscussions.Therewill
Somelesionsarecalled‘‘scars’’butarenottrulyso
be an attempt to mention basic information or
bydefinitionbut,rather,arechangesinskincolor.A
pertinent advantages or disadvantages for each of
firstispostinflammatoryerythema.Theresolvingacne
the options from review of literature that is as fairly
site’sinitialpresentationmaybepinkorredbutusually
contemporaryaspossible.
improves. Persistent redness can be addressed with
laser or other therapy. Postinflammatory hyperpig-
MEDICAL MANAGEMENT
mentationisaverycommonlyseenvariant.Itisablack
Therearenumerousmedicaloptionsavailablefor
or brown residual discoloration in the location of
treatmentofacnescars.Hypertrophicscars,keloids,
previousacneorotherinflammatoryreaction.These
and pigmentary changes are the usual focus of
lesionsaremorecommoninthosewithdarkerskinor
medical management whereas the other types re-
thosewhotan.Fadingmayoccurbutquitefrequently
quireotherformsofintervention.Onlyafewofthe
takesaprolongedtimeperiod,sometimesuptoayear.
more commonly used or proven selections will be
Chemicalpeels,lasers,orbleachingagentsareusually
mentionedhere(TableI).Ofcourse,ifdesired,more
thefirst-linetherapies.Hypopigmentationisalossof
information can be researched for such topicals or
pigment in the area of the lesion. It can range from
injectables as vitamin A, vitamin E, vitamin C, zinc,
lighteningtototalwhiteningoftheskin. Oftenthese
colchicine, hyaluronidase, cyclosporine, honey,
areasdonotregainthelevelofpreviouspigmentation
onion extract, 5-fluorouracil, bleomycin, retinoids,
and only late if so. Multiple treatments can be con-
verapamil, pepsin, hydrochloric acid, formalin, and
sidered for all of these pigmentary lesions after the
almostunlimitedothers.Retinoids,specifically,have
acneisadequatelyaddressed.Includedarehydroqui-
supporting sparse reports of treatment to keloids,
none, tretinoin, cortisone, azelaic acid, camouflage,
hypertrophicscars,andverysuperficialscars.32The
combination creams (primary choice is retinoid plus
benefit is attributed to an increase in elasticity with
hydroquinone),superficialchemicalpeels,microder-
dermalcollagendepositionandalignment.33
mabrasion, laser therapy, or ultraviolet A/B sun-
One of the more popular choices for medical
screens.28 The one agreed-on facet is that the most
therapy, again, mostly for hypertrophic scars and
effectivetreatmentforboththetruescarsandpigmen-
keloids, is the use of the generically termed ‘‘ste-
tarychangesistopreventandcontroltheacnelesions
roids.’’ These are substances that are based on 4
themselvestolimitinflammationandothersequelae.
fused carbon rings that derive from the cholesterol
molecule. The glucocorticoids (eg, triamcinolone,
ACNE SCAR TREATMENT hydrocortisone,methylprednisone,anddexametha-
Treatment of the true scars resulting from acne sone), in the corticosteroid family, have immuno-
mustreflectseveralconsiderationsbythephysician. modulatory and anti-inflammatory properties. They
Cost of treatment, severity of lesions, physician reduce the expression of cytokines, cellular adhe-
goals,patientexpectations,side-effectprofiles,psy- sion molecules, and other enzymes related to the
chological or emotional effect to the patient, and inflammatory process.34 The exact mechanism is
prevention measures should all play a role. The unknown but it is thought to related directly to the
ultimategoalofanyinterventionisforimprovement, anti-inflammatoryproperties,reductionofcollagen,
not for a total cure or perfection. Single treatment, glycosaminoglycans, and fibroblasts, along with
multipletreatments,orcombinationtherapymaybe overalllesion growth retardation. Used asatopical,
required. An excellent review and discussion by both with and without occlusion, there is a wide
Goodman29 on postacne scarring treatments was range of clinical response. Steroids used in high
recentlypublishedasanupdatetoasimilarprevious doses, typically intravenously, may lead to multiple
study by Goodman and Baron.30 Another in-depth systemicsideeffectsbutthesearehighlyunlikelyin
article by Tsau et al31 examined the procedural the topical doses used in scar treatment. However,
techniques available. Studies to evaluate these cutaneous use does include side effects that might
methods areoftendifficultbecauseofsamplesizes, include telangiectases, bruising, atrophy, pain, or
lackofcontrols,objectivegradingscales,follow-up, pigmentary change. The other route, some say the
JAMACADDERMATOL Rivera 663
VOLUME59,NUMBER4
first-linetreatment,commonlyusedforhypertrophic Table II. Surgicalmanagement
scar and keloid treatment is intralesional injection
Punchexcision
becausesurgeryisoftendebatablefortheselesions.
Elliptical excision
Often, multiple injections spaced one or several
Punchelevation
months apart are required to determine the final
Skin graft
result and prevent excess atrophy. If a permanent
‘‘Subcision’’
filler for augmentation is used and there is overcor- Debulking
rection,atrophyoftheareamaybeadesiredeffectto
balance the contours. Other side effects of injected
steroidsincludeintolerance,necrosis,allergy,bruis-
ing,hyperpigmentationorhypopigmentation,injec- base should appear normal because it will be
tionpain,andtelangiectases. elevated to the skin surface. After the punch is
Another treatment modality used that focuses on done and the base elevated, it is sutured flush with
hypertrophic scars and, although less effective, ke- the normal-appearing skin and allowed to heal in
loidsissiliconedressing.Thereisvariablesupportto place. Finally, the surgical choice for rolling or
thesiliconeitself,withresultsmorelikelyattributable depressedscars(definitelynotforicepickoratrophic
to occlusion or hydration. Pressure was also one scarsorinfected areas)is‘‘subcision.’’Thiswasfirst
supported mechanism along with other rationales describedbyOrentreichandOrentreich37in1995as
thatincludetemperature,increasedoxygentension, an original word created from ‘‘subcutaneous inci-
electrostatic properties, or immunologic effects. sionless.’’ A tri-bevel needle is probed under the
There are conflicting reports as to its efficacy. One lesion through the needle’s puncture so it is not a
study noted improved pruritus, pain, and pliability trueincision.Thismovementresultsinthereleasing
butfoundnoimprovementinpigmentation,average ofpapillaryskinfromthebindingconnectionsofthe
elevation, or minimum elevation of scars.35 A sepa- deeper tissues and creates controlled trauma that
ratereviewofeffects,efficacy,andsafetydetermined leads to wound healing and associated additional
that ‘‘although the mechanism of action of silicone connectivetissueformationinthetreatedlocation.It
elastomer sheeting has not been completely eluci- may be necessary to perform variable depths of
dated...it appears to be an effective means of sweeping, fanning, or lancingto disruptthe fibrous
treating and preventing hypertrophic and keloid connections and multiple attempts or sessions may
scars and can be used with little risk of serious be required. Although uncommon, there is the
adverseeffects.’’Theincludedcommentarypointed potential for bruising, hypertrophy, cysts from pilo-
outthat‘‘theyworkclinicallyandaresafeandquite sebaceousunitdisruption,infection,additionalscar,
frankly should be part of all hypertrophic scar and orworseningofthescar.
keloid therapy.’’36 Rarely,side effects include pruri- Intervention for hypertrophic scars or keloids
tus,contactdermatitis,maceration,skinbreakdown, mustbedonewithcarebecausethepatientisknown
xerosis,andodors. tohaveapropensityforthattypeofresponse.There
isargumentregardingtheappropriatenessofsurgery
SURGICAL MANAGEMENT withbothtypesofscarsbutmoresowithkeloids.If
Surgical management is an essential tool in the undertaken, some say that the incision must be
armamentarium against acne scarring. The icepick, within the lesion boundaries to prevent further
boxcar,androllingscarsarefrequentlyaddressedby extension. In addition, steroids are commonly ad-
surgery(TableII).Punchorellipticalexcisiontothe ministered locally. Therefore, the goal would be
subcutaneous level is preferred for icepick scars. A more to reduce overall size or debulk rather than
scar ‘‘requiring a punch larger than 3.5 mm is completelyexcise.
repaired by elliptical excision or punch elevation Secondary,refiningproceduresmayalsobeused
becausetheselargerdefectslendto‘dogear’forma- in the areas if desired or needed. It was found in a
tion on the face.’’19 The goal is to trade a larger, study of 21 patients (10 male, 11 female; age 17-59
deeper scar for a smaller, linear closure that will years, mean age 35.52 years; Fitzpatrick skin I-III)
hopefully be less noticeable and possibly fade with that there was good improvement, as rated by both
time.Rarely,askingraftmayberequiredratherthan independent assessors and patients, when laser
primary closure. This usually only applies if a sinus resurfacingwasdoneafterpunchexcisionofscars.38
tract or wide-based lesion is unroofed. A second Thenotedadvantagewasthatpunchexcisionelim-
alternative, punch elevation, is a method of treat- inates the deeper components and allows for only
ment for depressed boxcar scars. The biopsy tool superficial laser treatment with fewer passes. So, if
shouldmatchtheinnerdiameterofthelesionandthe surgery is done, laser resurfacing may also be a
664 Rivera JAMACADDERMATOL
OCTOBER2008
Table III. Procedural management to prevent a recurrence rather than a stand-alone
treatment.AJapanesestudyof38keloids(ear,neck,
Cryosurgery
and upper lip) treated with surgical excision and
Electrodessication
postoperative irradiation on average day 4.0 6 4.9,
Radiation treatment
withfollow-upatameanof4.462.5years,showed
Chemicalpeels
significant improvement of pigmentation, pliability,
Microdermabrasion
Dermabrasion height, vascularity, and hardness. Recurrence rate
was 21.2% overall with none observed in the crani-
ofacial area. Thus, it was concluded that surgical
consideration because the chance of unwanted excisionpluselectronbeamradiationstartedwithin
side effects could be reduced. Medical, additional a few days is beneficial in both controlling scar
surgical, or other procedural interventions are also qualityandpreventingrecurrence.40Acontroversial
availableafteranysurgicalmanagementandmaybe risk-to-benefitratioissometimescitedasadeterrent
appropriate. to selection of radiation. These risks include hyper-
pigmentation or hypopigmentation, prolonged ery-
PROCEDURAL MANAGEMENT thema, telangiectases, atrophy, and questionable
Procedures will be addressed distinct from sur- increaseinmalignancies.
geriesforthepurposesofthisarticle.Initially,several Topically,chemicalpeelsareanotherprospectfor
procedural options will be covered within this sec- addressingthescarringleftfromacnelesions.These
tion (Table III). Then following, although they are canbefromsuperficialtodeepeffectand,unlessthe
technically also procedures, there will be dedicated very deep peels are used, are generally considered
discussions of augmentation and light, laser, and formilderacnescarringandcertainlynoticepickor
energytreatmentsbecausethesetopicsrequiremore keloid scars. Usually multiple treatments are neces-
review than some of the others as a result of the sary for efficacy, although some secondary benefit
diversitywithinthosecategories. is seen with acne lesions in earlier sessions. The
Twosimpleproceduraltreatmentoptionsinclude expectedresultisamildblisterand/ordesquamation
cryosurgery and electrodessication. Cryosurgery in- withnormalskinregeneration.
volvestheuseofliquidnitrogenspray,orhistorically Light or superficial peels include alpha hydroxy
solid carbon dioxide, locally. Its use is primarily for acid (glycolic, lactic, citric) or beta hydroxy acid
hypertrophic scars and keloids, although it is fairly (salicylic), Jessner’s solution, modified Jessner’s so-
ineffective for the latter. The mechanism is through lution, resorcinol, and low-strength (concentration
directphysicaldamagebythrombosis,celldamage, \ 10%) trichloroacetic acid (TCA). Beta hydroxy
orotherchanges.Sideeffectsincludepossibleatro- acidsinhibitthearachidonicpathwayand,therefore,
phyorhypopigmentation,whichisquiteoftenlong decrease inflammation and may be better for sensi-
lastingorpermanent.Electrodessicationinvolvesthe tiveskin.Theydonotrequireneutralizationandare
use of electrical probes or elements that heat the contraindicated in pregnancy or breast-feeding.41 If
tissuestodestructionandcoagulation.Thisisararely resorcinolisused,awarenessofpigmentarychanges
used technique typically indicated for shaping or or direct toxicity must be kept in mind. A Jessner’s
reducingthesharpedgesofboxcarscars.Ifused,this solution contains salicylic acid, resorcinol, lactic
isnotisolated treatmentbutusuallywithadjunctive acid, and ethanol. Its primary risk is of hyperpig-
therapies as well. There are multiple obvious side mentation and to a lesser degree the toxicity of
effectsthatmayarise,mostimportantlythecreation resorcinol. That solution becomes ‘‘modified’’ with
ofnewscar. theadditionofhydroquinoneandkojicacidtolower
Radiation is another possible intervention also the risk of hyperpigmentation. TCA causes epider-
focused on hypertrophic scars and keloids that is mal coagulative necrosis and protein precipitation
availabletothephysician.Itsuseisderivedfromthe along with dermal collagen necrosis and regenera-
destruction of fibroblast vasculature, decrease of tion. This mechanism may lead to scarring or pig-
fibroblast activity, and local cellular apoptosis. It mentarychangesbutnotasfrequentlywhenusedat
has been found that the regrowth of keloids is lowerconcentrations.
proportional to the total dose of irradiation given The medium-depth peels are primarily consid-
and that 900 cGy is the minimal effective dose ered to be the 10% to 40% TCA solutions. The risks
recommended. Initiation of treatment, size of the just mentioned increase as the concentration in-
largest fraction given, fractionation of doses, dura- creases. However, used with caution, they may be
tion of treatment, or location of lesion are less very beneficial. A study introducing the CROSS
important.39Thismodalityisusedmoreasanadjunct (chemical reconstruction of skin scars) method
JAMACADDERMATOL Rivera 665
VOLUME59,NUMBER4
described the focal application of TCA at high contouring reduces these contrasts, lessening their
concentrations directly to scars. After 3 to 6 treat- visible impact.Essentialremovalofsuperficialscars
ments, 90% of patients showed good (50%-70%) can be achieved along with a reduction of deeper
improvement by blinded physician assessment. scars.Inaddition,itmaybeusedasanadjuncttothe
Withinthe65%TCAgroup,82%weresatisfiedwith surgicalproceduresaspreviouslymentioned.
results compared with 94% satisfaction in the 100% Dermabrasion is accomplished by use of a high-
TCA group. They found the technique to be safe, speed brush, diamond cylinder, fraise, or manual
withthe100%TCAtreatmentsofatrophicscarsmore silicone carbide sandpaper. Superficial treatment
effectivethanthe65%TCAtreatments.42 eliminates the epidermis and deep treatment re-
Thepeelsconsideredtobedeepareoftenphenol movestheepidermisandpartialdermis.Oncecom-
(carbolic acid) or croton oil based. These can cer- plete,re-epithelializationbymigrationofcellstothe
tainly be more effective but carry an even greater healing surface stems from the adnexal structures
potential for side effects including acne, milia, der- includinghairfollicles,sebaceousglands,andsweat
matitis, pigmentary alteration, secondary infection, ducts. Thus, neck, chest, and back are not ideally
atrophy, or scarring. Both the positive and negative suited for treatment because of paucity of adnexal
results of the peel are based on the concentration, structures.45Inaddition,insimilarfashion,burnsand
duration, skin type, prior medical or surgical inter- hypertrophicscars,ormorecommonlykeloids,have
vention, location, sun exposure preprocedure and a poor response because of their lack of adnexa.46
postprocedure,concomitantmedications,andother Meticulous wound care should be emphasized
factors. One specific fact of great physician and throughout the entire postoperative course. After
patientimportanceisthatphenolrequiresfullcardi- healingiscomplete,improvementsmaycontinueto
opulmonary monitoring and intravenous hydration be seen for months. If active, inflammatory acne
because of direct cardiotoxicity that leads to lesions are present these must be controlled with
decreased myocardial contraction and electrical corticosteroids,antibiotics,orretinoidsfirst.Ifinfec-
activity.43 tionorahistoryofsignificantscarringisencountered,
Twoother management options thatuse adirect then treatment should be postponed or avoided.
mechanical means of skin removal are microder- ManypractitionersadvocatetestingforHIV,hepatitis,
mabrasion and the more invasive dermabrasion. or other blood-borne diseasesprior.Otherssuggest
Microdermabrasion is a usually painless, superficial prophylactictreatmentwithantibioticsandantivirals.
treatmentwithmoretexturebenefitthanpermanent The aggressiveness of this procedure correlates
surface change. There are variable results seen and with its side-effect profile. Included are prolonged
multiple sessions are frequently required. The most erythema and healing time, eczema, milia, bacterial
improvement is achieved with fine wrinkles and or viral infection, hypertrophic or keloidal scarring,
postinflammatory hyperpigmentation, although unroofing of unapparent wide-based scars, telangi-
superficial acne scars may benefit from deeper, ectases,sun-sensitivity,treatmentdemarcationlines,
more aggressive settings. Most often, aluminumox- andprolongedorpermanenthyperpigmentationor
idecrystalsused with apressurizedapplication and hypopigmentation.47 As always, pigmentary con-
vacuum removal system or, sometimes, crystal-free cerns are greater for darker-skinned individuals.
diamond-tipped abrasive devices, are chosen. Hyperpigmentation typicallyslowlyresolves during
Occasionally,sodiumchloride,sodiumbicarbonate, severalmonthsbutinitiationofpigmentaryreturnin
or magnesium oxide crystals are used. Although hypopigmentation begins at approximately 4 to 6
cheaper,thesecrystalalternativesarenotasabrasive weeks, if at all, with full results at up to 1 year. The
and are less efficacious.44 Side effects typically in- procedure is painful so at least local anesthesia or
cludetemporarystripingofthetreatmentarea,bruis- regional blocks plus anxiolytics and anti-inflamma-
ing, burning or stinging sensation, photosensitivity, tories are used, but often light or occasionally gen-
andoccasionalpain.Thereisnowoundingexpected eralsedationarechosen.
with the force, suction, and speed determining the
ultimate depth attained. If using isotretinoin, it is TISSUE AUGMENTATION
common to wait up to 6 months after the last Augmentationisafurtheralternativeformanage-
applicationtominimizeprobabilityofsideeffects. mentofacnescarring.Thistopicincludesnumerous
Arguably one of the most effective but operator- variations and compositions of filler substances.
dependent therapies is dermabrasion. Its benefits Thosetobeaddressedmayormaynotbeavailable
include removal of the skin surface and refined in the United States and the list is certainly not
contouring of scars. The sharp edges of some acne comprehensive or detailed for each product men-
scars cast a shadow that emphasizes the lesions; tioned. In addition, some products, such as
666 Rivera JAMACADDERMATOL
OCTOBER2008
Table IV. Tissue augmentation
Xenografts Autografts Homografts
Zyderm (bovine) Autologen(not available) Dermalogen (notavailable)
Zyderm II(bovine) Isolagen (United Kingdomand Australia) Alloderm
Zyplast (bovine) Autologous fat Cymetra
Resoplast (bovine) Fascian
Endoplast-50 (bovine) Cosmoderm
Evolence (porcine) Cosmoplast
Autologen and Dermalogen, are mentioned for his- degradationsomaintenancesessionsarenecessary.
toricalinterest.However,thereisanexcellent,com- Usuallythereisabenefitat3togreaterthan6months
prehensive,in-depthreviewofmultiplefillingagents withsomeaccountsofuptoseveralyears.Common
published several years ago by Klein48; a recent toalloftheseproductscouldbediscomfort,inflam-
reviewofnon-FoodandDrugAdministration(FDA)- mation, bruising, allergy, erythema, discoloration,
approved fillers by Ellis and Segall49; and a very and correction defects. Hypertrophic scars, keloids,
complete,easy-to-usedermalfillerproductcompar- andicepickscarsarenotindicatedfortreatmentwith
isonchartinaseparatepublication.50Thesealterna- this method. In addition, those with autoimmune
tives may be xenografts (from a different species), diseaseshouldavoiditsusebecauseofthehigherrisk
autografts (obtained from the patient), homografts ofsensitizationorallergy.Doubleallergytestsover4
(same-speciesderived),orsynthetics. to6weeksareevenrequiredforthosewithnormal
An ideal filler material would be physiologic immune systems because of a delayed hypersensi-
(incorporatesintothebody’stissues),simpletoplace tivityinapproximately3%ofthepopulation(2%will
(injection), permanent (no degradation), and risk sensitize after the first skin test exposure).53 The
free (no complications or side effects).51 Potential followingparagraphsgointofurtherdepthforafew
superficial skin products may include collagen or collagen products and briefly mention multiple
hyaluronic acid and deep skin productsinclude fat, others(TablesIVandV).
synthetics, silicone, implants, and permanents. ThefirstinjectablefillerapprovedbytheFDAwas
Although close, none available meet all of these Zyderm. The other similar products are Zyderm II
criteria completely. Most of these are applicable to and Zyplast. These collagen products are derived
depressedscarssuchastheatrophicrollingvariantor from a closed US bovine herd. Even though this
sometimesothers.Potentialsideeffectsmayinclude helpstoensurequality,purity,andsafety,itsimmu-
pain, pigmentary changes, bruising, infection, aller- nologicbasisisnoteffected,therefore,skintestsare
gicreaction,hypertrophicscarringorkeloids,possi- still required.44 Type I collagen represents 95% to
ble granulomas, bleeding, migration of product, 99%andtypeIIIcollagenrepresents1%to5%ofthe
ulceration, tissue death, significant distortion, or product contained in prefilled syringes. Zyderm I
technical error on placement. If a permanent sub- wasapproved in1981.Itisa25%suspension(3.5%
stanceischosenandisplacedtoodeep,tooshallow, by weight) of collagen in saline and lidocaine solu-
or overcorrected, or if there is a persistent defect, tion.Itisusuallyforshallowscars,soisplacedinthe
minorsurgicalremoval,excision,electrodessication, papillarydermis.Overcorrectionisinitiallyrequired
orsteroidtreatmentcouldberequired. because of water loss after placement. Two to 3
The first FDA-approved fillers were collagen months of result are typically expected. Zyderm II
based. The reconstituted bovine class of collagen gainedapprovalin1983.Itisa50%suspension(6.5%
hasbeenavailablesincethelate1970stoearly1980s. by weight) of collagen. Larger scars are more often
However, there are various other derivations. addressed with this variant. Overcorrection is again
Collagen functions as a physical augmentation me- recommended and 4 to 6 months of effect can be
dium and a stimulus for scar base formation by expected.Zyplast,approvedin1985,isa35-mg/mL
connective tissue encapsulation. The placement solution of collagen cross-linked with 0.0075% glu-
should focus on mature scars rather than those that taraldehyde to slow reabsorption. Injection into the
arenewlycreatedbecausestatic,noninflamedscars mid dermis allows for contouring and larger scar
orthosewithnoongoingdiseasedemonstratelonger treatment. Overcorrection is not required and its
efficacy.52 Its use is very technique sensitive, which durationofeffectmaybeupto1year.
alsoaffectsthequalityanddurationofthetreatments. ArteFillorArtecollare20-volumepercentsuspen-
Placementshouldbesuperficiallyinthedermisand sions of 30 to 50 (cid:2)mediameter microspheres of
not in the subcutaneous tissue. There is fairly rapid polymethyl-methacrylate(alsoknownasPlexiglasor
JAMACADDERMATOL Rivera 667
VOLUME59,NUMBER4
Lucite) in atelocollagen (3.5% collagen solution), e
saline, and lidocaine.54 ArteFill (US) is the same mpatit se
cspohmepreossiatiroensaosmAertwechoaltls(mEuarlolepreaannddmCaonreadsay)mbmutetthrie- Calciudroxya Radies
y
cal. Polymethyl-methacrylate is used in bone ce- h
ments for joint replacements, cataracts surgeries,
d
dental procedures, and neurosurgical applications. acin,
Thepolymethyl-methacrylateispermanentlydepos- roicelatima)
siitrstieceosardnoerqrasbutnwieimdrhdeuie.dl5nel5ubcsBaetphfocueastnhuuclsratseeiteoemirntdvaiseswi.nfApiritnoshhgmynfsoibiactcreoabodlloulaaavsgbuitneoigsnemvseuseo,iesnusatkrafgcittnereioa.rtdneTinushtajaieennlrcldgye- psilon-aminocap(plusporcinegpatientplas Fibrel
E
maybeinitialinflammation,erythema,bruising,and
discomfort from the injection of these products. A e/ne
ne
2A0rt0e6Fiallrtuicseledraespaofritlilnegrfo4-rwtorin5-kyleealrinoesutecvoamlueastewdiitths ethylepropylymer ofill
srineaicfteeiatiyvleasdntudtdhylee)n,pgarthosdouufbcgetrffo(eoucfpt.2Oo51ff t6tho9etaw1l2ep8raeptiaertenieatsnsstisenswstehhdoe. Polyoxypolyoxypol Pr
Therewere6adverseeventsnotedwithin5patients s
e d
treated with 272 injections. Four (1.5%) were mild mid mi
(mlalubinmiaimpliafnoleltdsoss)nbaoinlnaditnetfrwlaalomlym()0.a.7Tto%hre)yswereeasrecevtieosrenevseeirnveet(nhntesodnwuaelsaorre-, Polyacryla OutlineEvolutionBio-AlacaAgriformAquamid
treatedwithintralesionalsteroidinjectionsandwere
rathedsedoioltvitohinneg,r psaoastmietehnwetshatahrttaictsultehrpewrrisaeissnugblltyes,iancigttuwpaulalybslainsphopeteedda.reIinnd Synthetics Polylacticacid NewfillSculptra
better at 5 years than at 3 months to 1 year. It was
taswoacesoqtobnfrrefanldeiA6prentcce%eo)nrlto.odussviItfdnsedneagtuurieirjnotcessicdidlsooapceiuzltrdtewahreehAnebd.laaasouclTtrsieatntovhiAonoagpenelrdnn-sor.ttatoegethSeuohFdreeaftfimeufnovlditlnccehltowtp(arpeoaa(gcear1plbiorosopsaeimuvuinrrtsisoaiesjLdteechled)enamchnuudwtttiic’imacevsoaaettvesenasselkanrnsyaodinioannbcwfdblortiwleaenetolshliercajananeeaafsggfeceturrreetdtodeesaynremqqbef.r5fiamuulto6ehvbsiimorreia4edeenri%rlddee2s-- Hyaluronicacid HylaformHylaformPlusRestylaneRestylaneFineLinesPerlaneCaptiqueJuvedermDermalive(plus40%acrylate)Dermadeep(plus40%acrylate)TeosylRevidermIntra(plusdextran)
was approximately 20% to 30% volume loss after
injection from fluid reabsorption.57 Dermalogen, ne
a
also unavailable, was similar to Autologen but it ox
wfseuicnbsarecees.eres.anSIleenloovdbaegdtfreaoadnirlniitcveiio,nidrnjase,tlcfe,srtrkobiioilmaninzcsetteedtsrios,itfasspulw,terhfie-uembrneaa3gnrn.ai5kloly%e,tdariennsqodtsauklucpiitrntreii.ocodnonIbltlepwafwgroeeearrsnees- mentation Silicone AdatosilSilikon1000BiopolimeroSilskinPolydimethylsilgel crylate.
g ha
rbeeqeunireddonoevewr titimheeaacnhd oavdemrcinoirsrteracttiioonn.shAoudludrahtaiovne ueau gen) gen) yl-met
hboacuafhnmIbinkeaetevrnndoeeddcsfo.uki5tlic8lneaa.gdrIoetnuimnnaudc1set93lb9lu2elt,aoimrAg6pllrloaamdfnteotedrndmetrhbisvyiseiwdnacafnirssoimoarelnlgotriugsalsetahunreeliycr- TissTableV. PMMA ArteFill(plusbovinecollaArtecoll(plusbovinecolla PMMA,Polymeth
668 Rivera JAMACADDERMATOL
OCTOBER2008
thaninjectedsoonlyalimitednumberofacnescars overcorrection must be done because a percentage
may benefit from its use. There is no skin testing of the injected material is initially or permanently
required and there is possible longer benefit as a nonviable.Thereabsorptionratevariesbylocation,
result of the method of placement. Cymetra is a amount injected, technique, or other factors.
micronized, injectable from of Alloderm. It is allo- Variable reports of 6 to 18 months’ duration may
genic acellular human collagen obtained from beseen.Onestudyofautologousfattransplantation
screened, standardized US skin and tissue banks. It included43patients(24women,19men;age22-69
isadriedproductthatrequiresresuspensionbefore years, mean 34.5 years), 23 specifically with acne
use. Again, no skin testing is necessary before scars,with3-to48-month(mean26months)follow-
injectionbutmultipleinjectionsovertimeandover- up to evaluate graft survival. It found that the
correctionarebothadvised.59 greatest resorption was in areas of fibrotic acne
Isolagen, available in the United Kingdom and scars and 65% remained at 3 months, 50% at 6
Australia, is an autologous isolation of fibroblasts months,40%at9months,and30%at12months.The
obtained by a punch biopsy specimen from the authors suggested that this was possibly because of
patient. The tissue is sent to a laboratory where the decreased vascularity and, thus, viability.63 It has
company cultures the fibroblasts and then places also been reported that including adipose-derived
them in an injectable suspension. That product is stemcellswiththeinjectedfatimprovesresults.At6
returned to the clinician for use within 1 day of months, fat with the stem cells weighed 2.5 times
receipt. There are few side effects because it is more than the fat-only group and demonstrated a
autologous,however,thecompanydoesstillsuggest greatervolume.Inaddition,thestemcellefreegrafts
skin testing for this product. This is another sub- appeared more fibrous at 6 months as compared
stance that loses volume initially so more than one with the adipocytes richeappearing grafts.64 This
injectionwithovercorrectionisusuallystandard. finding may improve long-term results or lead to
An available bovine collagen in 3.5% or 6.5% other valuable research. The benefit is direct aug-
solutionisResoplast.Becauseofitsderivation,askin mentation from the adipocytes if they are vascular-
test is required before use. Endoplast-50 consists of ized and can function normally or, some propose,
solubilized elastin peptides in bovine collagen. from their contribution to fibrosis and physical
Fascian was introduced in 1998 as allogenic human enhancementofthearea.Asstated,severalsessions
cadaver collagen from fascia lata or gastrocnemius arerequiredandbruising,erythema,ormildinflam-
fascia. There are 5 particle sizes: 0.1, 0.25, 0.5, 1.0, mation may occur with a report of unilateral blind-
and 2.0 mm. Neocollagenesis from the ingrowth of nessasaresultofintravascularinjectionevennoted.
fibroblasts occurs after injection of the product.60 Excess fat may be frozen for later use and there are
Cosmodermwascreatedin2003asahuman-derived noimmunologicconcernsbecauseitcomesfromthe
collagenproducedunderlaboratoryconditionswith patient.
extensive safety testing. On completion, it is mixed ‘‘Silicone,’’ a term consisting of polymers in the
into a solution of lidocaine for injection. No skin familyoftheelementsilicon,mostcommonlypoly-
testing is required and 3 to 7 months of benefit can dimethylsiloxane (silicon, oxygen, methane), is a
be expected. Cosmoplast is yet another laboratory- permanentinjectable.Itissafe,nonmutagenic,non-
createdhuman-derivedcollagen.Itisalsoputintoa carcinogenic, and nonteratogenic despite scattered
lidocainesolutionforuseanddoesnotrequireskin case reports of adverse events. The mechanism of
tests. This product, however, is cross-linked with action is from physical filling of connective tissue
glutaraldehyde to resist degradation and hopefully defects and possibleproduction of fibroticcollagen
prolong effect.61 A newer, porcine-derived product that encapsulates the injected material (a foreign
is Evolence. It contains ribose moieties that are body)preventingmigration.Finalresultscouldtake
cross-linked to the collagen. No skin testing is months while the collagen is deposited and re-
necessary and refrigeration of the injectable is not models. In addition, it is not altered, metabolized,
needed. There may be up to 1 year of effect after ordestroyedbythehumanbody.Consideringallof
placement.62 thesefacts,undercorrectionisoftenprudentinitially.
Autologousfatisanotheralternativeforaugmen- Side effects, including injection pain, mild inflam-
tation, first noted in 1893, to improve acne scars. mation,edema,hyperpigmentationorhypopigmen-
Thesecellsareobtainedfromthepatient’sownbody tation,andpoorplacement,arepossiblebutcanbe
so must be harvested by liposuction or other reduced with meticulous detail. Silicone is not a
methods. Injection is into the subcutaneous area, growthmediaforbacteriaorotherorganismsandno
althoughsomesuggestdermalapplicationisaccept- true allergies have been reported, so skin tests are
able as well. It is good for contour defects but notrequiredbeforeuse.