The considered to be deep are often phenol (carbolic acid) or croton oil based. These can certainly be more effective but carry an even greater potential for side effects including acne, milia, dermatitis, pigmentary alteration, secondary infection, atrophy, or scarring. Both the positive and negative results of the peel are based on the concentration, duration, skin type, prior medical or surgical intervention, location, sun exposure preprocedure and postprocedure, concomitant medications, and other factors.
One specific fact of great physician and patient importance is that phenol requires full cardiopulmonary monitoring and intravenous hydration because of direct cardiotoxicity that leads to decreased myocardial contraction and electrical activity.43
Two other management options that use a direct mechanical means of skin removal are microdermabrasion and the more invasive dermabrasion. Microdermabrasion is a usually painless, superficial treatment with more texture benefit than permanent surface change. There are variable results seen and multiple sessions are frequently required. The most improvement is achieved with fine wrinkles and postinflammatory hyperpigmentation, although superficial acne scars may benefit from deeper, more aggressive settings. Most often, aluminum oxide crystals used with a pressurized application and vacuum removal system or, sometimes, crystal-free diamond-tipped abrasive devices, are chosen. Occasionally, sodium chloride, sodium bicarbonate, or magnesium oxide crystals are used. Although cheaper, these crystal alternatives are not as abrasive and are less efficacious.44 Side effects typically include temporary striping of the treatment area, bruising, burning or stinging sensation, photosensitivity, and occasional pain. There is no wounding expected with the force, suction, and speed determining the ultimate depth attained. If using isotretinoin, it is common to wait up to 6 months after the last application to minimize probability of side effects.
Arguably one of the most effective but operatordependent therapies is dermabrasion. Its benefits include removal of the skin surface and refined contouring of scars. The sharp edges of some acne scars cast a shadow that emphasizes the lesions; contouring reduces these contrasts, lessening their visible impact. Essential removal of superficial scars can be achieved along with a reduction of deeper scars. In addition, it may be used as an adjunct to the surgical procedures as previously mentioned.
Dermabrasion is accomplished by use of a highspeed brush, diamond cylinder, fraise, or manual silicone carbide sandpaper. Superficial treatment eliminates the epidermis and deep treatment removes the epidermis and partial dermis. Once complete, re-epithelialization by migration of cells to the healing surface stems from the adnexal structures including hair follicles, sebaceous glands, and sweat ducts. Thus, neck, chest, and back are not ideally suited for treatment because of paucity of adnexal structures.45 In addition, in similar fashion, burns and hypertrophic scars, or more commonly keloids, have a poor response because of their lack of adnexa.46 Meticulous wound care should be emphasized throughout the entire postoperative course. After healing is complete, improvements may continue to be seen for months. If active, inflammatory acne lesions are present these must be controlled with corticosteroids, antibiotics, or retinoids first. If infection or a history of significant scarring is encountered, then treatment should be postponed or avoided. Many practitioners advocate testing for HIV, hepatitis, or other blood-borne diseases prior. Others suggest prophylactic treatment with antibiotics and antivirals.
The aggressiveness of this procedure correlates with its side-effect profile. Included are prolonged erythema and healing time, eczema, milia, bacterial or viral infection, hypertrophic or keloidal scarring, unroofing of unapparent wide-based scars, telangiectases, sun-sensitivity, treatment demarcation lines, and prolonged or permanent hyperpigmentation or hypopigmentation.47 As always, pigmentary concerns are greater for darker-skinned individuals. Hyperpigmentation typically slowly resolves during several months but initiation of pigmentary return in hypopigmentation begins at approximately 4 to 6 weeks, if at all, with full results at up to 1 year. The procedure is painful so at least local anesthesia or regional blocks plus anxiolytics and anti-inflammatories are used, but often light or occasionally general sedation are chosen.
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