Acne Scarring and The Top 6 Procedural Managements see the table at the top.
J AM ACAD DERMATOL
Table III. Procedural management
Procedures will be addressed distinct from surgeries for the purposes of this article. Initially, several procedural options will be covered within this section (Table III).
Then following, although they are technically also procedures, there will be dedicated discussions of augmentation and light, laser, and energy treatments because these topics require more review than some of the others as a result of the diversity within those categories.
Two simple procedural treatment options include cryosurgery and electrodessication. Cryosurgery involves the use of liquid nitrogen spray, or historically solid carbon dioxide, locally. Its use is primarily for hypertrophic scars and keloids, although it is fairly ineffective for the latter. The mechanism is through direct physical damage by thrombosis, cell damage, or other changes. Side effects include possible atrophy or hypopigmentation, which is quite often long lasting or permanent. Electrodessication involves the use of electrical probes or elements that heat the tissues to destruction and coagulation. This is a rarely used technique typically indicated for shaping or reducing the sharp edges of boxcar scars. If used, this is not isolated treatment but usually with adjunctive therapies as well. There are multiple obvious side effects that may arise, most importantly the creation of new scar.
Radiation is another possible intervention also focused on hypertrophic scars and keloids that is available to the physician. Its use is derived from the destruction of fibroblast vasculature, decrease of fibroblast activity, and local cellular apoptosis. It has been found that the regrowth of keloids is proportional to the total dose of irradiation given and that 900 cGy is the minimal effective dose recommended. Initiation of treatment, size of the largest fraction given, fractionation of doses, duration of treatment, or location of lesion are less important.39 This modality is used more as an adjunct to prevent a recurrence rather than a stand-alone treatment.
A Japanese study of 38 keloids (ear, neck, and upper lip) treated with surgical excision and postoperative irradiation on average day 4.0 6 4.9, with follow-up at a mean of 4.4 6 2.5 years, showed significant improvement of pigmentation, pliability, height, vascularity, and hardness. Recurrence rate was 21.2% overall with none observed in the craniofacial area. Thus, it was concluded that surgical excision plus electron beam radiation started within a few days is beneficial in both controlling scar quality and preventing recurrence.40 A controversial risk-to-benefit ratio is sometimes cited as a deterrent to selection of radiation. These risks include hyperpigmentation or hypopigmentation, prolonged erythema, telangiectases, atrophy, and questionable increase in malignancies.
Topically, chemical peels are another prospect for addressing the scarring left from acne lesions. These can be from superficial to deep effect and, unless the very deep peels are used, are generally considered for milder acne scarring and certainly not icepick or keloid scars. Usually multiple treatments are necessary for efficacy, although some secondary benefit is seen with acne lesions in earlier sessions. The expected result is a mild blister and/or desquamation with normal skin regeneration. Light or superficial peels include alpha hydroxy acid (glycolic, lactic, citric) or beta hydroxy acid (salicylic), Jessner’s solution, modified Jessner’s solution, resorcinol, and low-strength (concentration \\ 10%) trichloroacetic acid (TCA). Beta hydroxy acids inhibit the arachidonic pathway and, therefore, decrease inflammation and may be better for sensitive skin. They do not require neutralization and are contraindicated in pregnancy or breast-feeding.41 If resorcinol is used, awareness of pigmentary changes or direct toxicity must be kept in mind. A Jessner’s solution contains salicylic acid, resorcinol, lactic acid, and ethanol. Its primary risk is of hyperpigmentation and to a lesser degree the toxicity of resorcinol. That solution becomes ‘‘modified’’ with the addition of hydroquinone and kojic acid to lower the risk of hyperpigmentation. TCA causes epidermal coagulative necrosis and protein precipitation along with dermal collagen necrosis and regeneration. This mechanism may lead to scarring or pigmentary changes but not as frequently when used at lower concentrations. The medium-depth peels are primarily considered to be the 10% to 40% TCA solutions. The risks just mentioned increase as the concentration increases. However, used with caution, they may be very beneficial. A study introducing the CROSS (chemical reconstruction of skin scars) method described the focal application of TCA at high concentrations directly to scars. After 3 to 6 treatments, 90% of patients showed good (50%-70%) improvement by blinded physician assessment. Within the 65% TCA group, 82% were satisfied with results compared with 94% satisfaction in the 100% TCA group. They found the technique to be safe, with the 100% TCA treatments of atrophic scars more effective than the 65% TCA treatments.
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