J AM ACAD DERMATOL
VOLUME 59, NUMBER 4
Efficient absorption is seen by water but minimally by melanin when using the 1540 Er:glass laser. The primary depth is within the papillary dermis where collagen tightening and neocollagenesis are achieved. A review of several articles noted progressive improvement and long-term benefit after treatment with this modality.91 It states that outcomes are often gradual with increased dermal collagen seen in approximately 6 months after 4 successive treatments and continued improvement occurs several months after the session. The following included commentary on the study points out that typical responders show 20% to 30% improvement. Although less than some other interventions, this may be an acceptable goal for some patients.
The next few therapies are not true lasers by definition but are more reliant on different energy forms to achieve their effect. The first is intense pulsed light (IPL). Thesemachines emit a wide range of wavelengths from their source that can be precisely narrowed using wavelength filters. Other parameters such as pulse length, pulse delay, and joules can be adjusted also. All of these options, in combination, allow for tailoring therapy to a defined goal. One study done by Goldberg,92 focusing on rhytides, examined 5 women (age 40-55 years and Fitzpatrick I-II). Punch biopsy specimens before intervention and 6 months after treatment with 4 IPL sessions were examined by an independent dermatopathologist. These biopsy specimens revealed an increase in superficial papillary dermal fibrosis and evidence of increased numbers of fibroblasts throughout the dermis. Both of these findings prove beneficial for superficial acne scarring and the rhytides studied. In comparison with atrophic or depressed scar benefit, some studies note the efficacy of IPL for reducing hypertrophic scars. One evaluated hypertrophic scars of 6 to 8 weeks’ duration on 20 patients (all female; 10 breast reduction, 10 abdominoplasty) after treatment with either 595- nm PDL or IPL. Two treatments with each device were performed 2 months apart for designated halves of the same scar of each patient. Single, nontreating physician assessment of the results was then done. Both sides were found to be significantly improved with the difference in effectiveness not statistically significant. The mean scar improvement for IPL was 45% after the first treatment and 65% after the second. The authors attribute this to targeted treatment of the vascular proliferation within the scars. They conclude ‘‘IPL offers a therapeutic alternative to the gold standard PDL [for the treatment of hypertrophic scars] since it minimizes the development of posttreatment purpura, although the tradeoff is greater discomfort.’’93 The discussion of effect on vasculature is similar to that already covered above for the PDL. Of course, it would be necessary to corroborate these findings to facial scars to determine the benefit in that setting.
Radiofrequency devices are another possible option for improving scars through stimulation of remodeling. A monopolar device uses a single contact location for the area of origin of the electric current. That current then diminishes as it flows to a remote grounding pad. A bipolar device has two local electrodes so there is not a path of current through the body.94 Physicians are able to treat variable skin types because this is electric energy use and not a chromophore-based intervention. It leads to tissue tightening and skin appearance improvement through dermal collagen denaturation with subsequent neocollagenesis and remodeling without the ablation and invasion of other treatments. One study investigating the use of nonablative radiofrequency for the treatment of moderate to severe acne (scar preventative treatment) noted, as an incidental result, that there was qualitative improvement in underlying scarring.95 Still, large studies that evaluate treatment of acne scarring with this technology need to be performed.
A newer form of energy treatment used in skin remodeling is plasma. Plasma pulses are created by passing ultrahigh radiofrequency energy through inert nitrogen gas, leading to stripping of electrons and formation of the ionized gas. The energy is then directed to the patient’s skin surface by the handpiece. No specific chromophore is targeted but the energy causes dermal collagen denaturation and stimulates neocollagenesis with minimal side effects. A short discussion of the technology involved can be reviewed if wished.96 A presentation at the American Society for Laser Medicine and Surgery meeting included 11 patients (1 male, 10 female; Fitzpatrick I-II; 4 with fine-line wrinkles, 8 with acne scarring, one patient had both wrinkles and scarring) treated with the plasma device. Acne scarring showed a 34% reduction in depth at 10 days, 26% at 3 months, 23% at 6 months, and no significant change in findings between 6 months and 2 years. There was no itchiness, weeping, exudates, lumpiness, pain, scarring, or hyperpigmentation or hypopigmentation recorded. The greatest reepithelialization time was 5 days and the most persistent erythema resolved by day 6. This article, although limited, concluded that plasma resurfacing was an effective long-term option with minimal side-effect profile.97
Acne Scarring Light, Laser, and Energy Therapy page 4
Acne Scarring A review and current treatment modalities BACKGROUND and ACNE SCARS ACNE SCARS page 2 ACNE SCAR TREATMENT and MEDICAL MANAGEMENT SURGICAL MANAGEMENT PROCEDURAL MANAGEMENT PROCEDURAL MANAGEMENT page 2 TISSUE AUGMENTATION TISSUE AUGMENTATION page 2 TISSUE AUGMENTATION page 3 TISSUE AUGMENTATION page 4 Light, laser, and energy therapy Light, laser, and energy therapy page 2 Light, laser, and energy therapy page 3 Light, laser, and energy therapy page 4 Conclusion and REFERENCES Manufacturers of brand name drugs mentioned in this article