
Atrophic Acne Scar Treatment Using Triple Combination Therapy: Dot Peeling, Subcision and Fractional Laser
Dr. Kim's Skin & Laser Clinic, Suwon, Korea
Jie Hoon Kim, M.D.
J Cosmet Laser Ther. 2009 Aug 17:1-4
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Abstract
Atrophic scars are a common complication of acne. Many modalities are proposed but each does not yield satisfactory clinical outcomes. Thus a new combination therapy is suggested that incorporates 1) dot peeling, the focal application and tattooing of higher trichloroacetic acid concentrations; 2) subcision, the process by which there is separation of the acne scar from the underlying skin; and 3) fractional laser irradiation. In this study the efficacy and safety of this method was investigated for the treatment of acne scar. Ten patients received this therapy for a year. Dot peeling and subcision were repeatedly performed every 2-3 months and fractional laser irradiation was performed every 3-4 weeks. Outcomes were assessed using scar severity score and patient¡¯s subjective ratings. Acne scarring improved in all of the patients completing this study. Scar severity scores decreased by a mean of 55.3. Eighty percent of the patients felt significant or marked improvement. There were no significant complications at the treatment sites. Therefore, triple combination therapy is a safe and very effective combination treatment modality for a variety of atrophic acne scars.
Key words : acne, atrophic scar; dot peeling; subcision; fractional photothermolysis;
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¡®Triple Combination Treatment (ÀÌÇÏ TCT)¡¯´Â ¡®Dot Peeling¡¯, ¡®Subcision¡¯, ¡®Fractional Laser¡¯, ÀÌ ¼¼°¡Áö Ä¡·á ¹æ¹ýÀ» º´ÇàÇÏ¿© Ä¡·áÇÏ´Â ¹æ¹ýÀÌ´Ù. ¿¬ÀÚ´Â ÀÌ ¼¼°¡Áö ¹æ¹ýÀ» º´ÇàÇÏ¿© Ä¡·áÇÏ¿´À» ¶§ ÁÁÀº °æ°ú¸¦ °æÇèÇϰí, 2009³âµµ¿¡ À̸¦ ¹ßÇ¥ÇÑ ¹Ù ÀÖ´Ù(J Cosmet Laser Ther. 2009; 17: 1-4).
ÀÌ ¼¼ °¡Áö Ä¡·á ¹æ¹ýÀÇ °³¿ä´Â ´ÙÀ½°ú °°´Ù
1) Dot peeling (focal application and tattooing of high concentration TCA)
¡®High concentrationÀÇ TCA ¿ë¾×(Åë»ó 100%)¡®À» atrophic scarÀÇ base¿¡ ºÎºÐÀûÀ¸·Î Âï¾î ¹ß¶ó¼ ÈäÅͰ¡ Â÷¿À¸£µµ·Ï À¯µµÇÏ´Â ¹æ¹ýÀÌ´Ù. ±âÁ¸¿¡ wooden applicator·Î TCA¸¦ Âï¾î ¹Ù¸£´Â ¹æ½Ä°ú´Â ´Þ¸® ¡¯1cc insuline syringe (29 gauge)¡¯¿¡ 100% TCA¸¦ ä¿ì°í, ¸¶Ä¡ ¸¸³âÇÊÀ» »ç¿ëÇÏ´Â °Í °°ÀÌ ½Ã¼úÇÏ´Â ¹æ¹ýÀÌ´Ù(Figure ).
ÀÌ ¹æ¹ýÀº ƯÈ÷ icepick scar³ª boxcar scar¿Í °°ÀÌ ³Ð°í ±íÀº ÇüŸ¦ºÎºÐÀûÀ¸·Î Ä¡·áÇϴµ¥ ¸Å¿ì È¿°úÀûÀÎ ¹æ¹ýÀÌ´Ù.
Figure 3. Schematic View of 'Dot peeling'
A. Application of 100% TCA on atrophic scar
B. Tattooing the TCA with sharp needle tip on 1cc insulin syringe
C. Proposed schematic view of deep penetration and delivery of TCA
2) Subcision (subcutaneous incision)
Fibrotic band·Î retractionÀÌ ½ÉÇÑ ÈäÅ͸¦ Ä¡·áÇÏ´Â °í½ÄÀûÀÎ ÇǺοܰúÀûÀÎ ¹æ¹ýÀÌ´Ù. Atrophic scar Áß¿¡¼µµ ƯÈ÷ ¡®Rolling scar¡¯¸¦ Ä¡·áÇÏ´Â µ¥ ¸Å¿ì È¿°úÀûÀÌ´Ù. ¹Ù´Ã(Nokor needle)À̳ª blade¸¦ ÀÌ¿ëÇÏ¿© ÁøÇÇÀÇ fibrotic band¸¦ ²÷¾î ÁÖ¾î ÈäÅ͸¦ ±³Á¤ÇÏ´Â ¿ø¸®ÀÌ´Ù(Figure ).
Figure . SubcisionÀÇ ÈäÅÍ ±³Á¤ ¿ø¸®. DermisÀÇ fibrotic band¸¦ ²÷¾î ÁÖ¾î 'retracted scar'¸¦ ±³Á¤ÇÏ´Â ¹æ¹ýÀÌ´Ù.
3) Fractional laser: 1,550 nm Erbium Glass Fractional laser
Fractional photothermolysis´Â ±âÁ¸ÀÇ laser resurfacing¿¡ ºñÇÏ¿© ¿©·¯ °¡Áö ÀåÁ¡ÀÌ ¸¹¾Æ, ÃÖ±Ù ÈäÅÍ Ä¡·á¿¡ °¢±¤À» ¹Þ´Â ¹æ¹ýÀÌ´Ù.
ÇǺΠÀüü¿¡ laser¸¦ Á¶»çÇÏ´Â °ÍÀÌ ¾Æ´Ï¶ó, ÀϺο¡¸¸ Á¶»çÇÏ¿©(fraction) À̶§ ÁÖº¯ Á¤»óÁ¶Á÷À» ÅëÇÏ¿© ÇǺΰ¡ regenerationµÇ´Â ¹æ½ÄÀÌ´Ù. ÀÌ¿Í °°ÀÌ Çü¼ºµÈ microscopic thermal wound¸¦ ÅëÇÏ¿© ºÎÀÛ¿ëÀ» ÃÖ¼ÒÈ ÇÏ¸é¼ skin rejuvenationÀ̳ª ÈäÅÍ Ä¡·á¸¦ ÇÒ ¼ö ÀÖ´Â °³³äÀÌ´Ù. Laser¸¦ ÀüüÀûÀ¸·Î Á¶»çÇÏ´Â °ÍÀÌ ¾Æ´Ï¶ó low pulse energy¸¦ ÀÏÁ¤ °£°ÝÀ» µÎ°í ºÎºÐÀûÀ¸·Î(fraction) Á¶»çÇϸé, bulk thermal damage¸¦ ÁÖÁö ¾Ê´Â´Ù. À̶§ FractionsÀ» ¡®Microscopic Thermal Zones (MTZs)¡®À̶ó°í Ç¥ÇöÇÑ´Ù. À̶§ ¼Õ»óµÇÁö ¾ÊÀº ÁÖº¯ Á¤»ó Á¶Á÷À¸·ÎºÎÅÍ 24½Ã°£ À̳»¿¡ ½Å¼ÓÇÏ°Ô ¡¯re-epithelialization¡¯ÀÌ Çü¼ºµÈ´Ù. ÁÖº¯ Á¤»ó keratinocyte°¡ ½Å¼ÓÇÏ°Ô ¼Õ»óºÎÀ§·Î À̵¿Çϱ⠶§¹®¿¡ ÈÀåÀ̳ª ¼¼¾È µîÀÌ °¡´ÉÇϱ⠶§¹®¿¡ downtimeÀÌ ¸Å¿ì ÀûÀº ¹æ¹ýÀÌ´Ù.
¶ÇÇÑ Áö¼ÓÀûÀ¸·Î collagen regenerationÀ» ÀÚ±ØÇϱ⠶§¹®¿¡ ½Ã¼ú ÀÌÈÄ¿¡µµ Áö¼ÓÀûÀ¸·Î ÈäÅͰ¡ °³¼±µÇ¸ç, skin texture ¶ÇÇÑ °³¼±µÈ´Ù.
ÇÏÁö¸¸, icepick scar³ª boxcar scar °°ÀÌ ³Ð°í ±íÀº ÈäÅ͸¦ ±³Á¤ÇÏ´Â µ¥´Â ÇѰ谡 ÀÖ´Ù.
À§ÀÇ ¼¼ °¡Áö ¹æ¹ý Áß, dot peeling°ú subcisionÀº 2~3°³¿ù °£°ÝÀ¸·Î, fractional laser´Â 3~4ÁÖ °£°ÝÀ¸·Î º´ÇàÇÏ¿© ½Ã¼úÇÏ¿´À» ¶§, °¢°¢ÀÇ Ä¡·á¿¡ ºñÇÏ¿© ÁÁÀº Ä¡·á °á°ú¸¦ °æÇèÇÒ ¼ö ÀÖ¾ú´Ù(Figure ).
Figure . TCT¸¦ ÀÌ¿ëÇÏ¿© atrophic scar¸¦ Ä¡·áÇÑ ÀÓ»ó»çÁø
ƯÈ÷ ÀÌ ¼¼ °¡Áö ¹æ¹ýÀ» ÀûÀýÈ÷ Á¶ÇÕÇÏ¿© ½Ã¼úÇÏ¿´À» ¶§ °¢°¢ÀÇ ÀåÁ¡À» ±Ø´ëÈ ÇÒ ¼ö ÀÖ°í ¾ÈÀüÇÏ°í ºÎÀÛ¿ë ¾øÀÌ atrophic scar¸¦ Ä¡·áÇÒ ¼ö ÀÖ¾ú´Ù.
ÇÊÀÚ´Â TCT¾ß ¸»·Î downtime°ú ºÎÀÛ¿ëÀ» ÃÖ¼ÒÈÇϸé¼, ¸Å¿ì È¿°úÀûÀÌ°í ¾ÈÀüÇÏ°Ô atrophic acne scar¸¦ Ä¡·áÇÏ´Â ¹æ¹ýÀ̶ó°í Á¦¾ÈÇÑ´Ù.
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INTRODUCTION
Acne vulgaris is one of the most common diseases treated by both dermatologists and plastic surgeons. The psychological impact of acne, from inflammatory eruptions to post-inflammatory acne scars, can be devastating. Multiple treatment modalities have attempted to remove, to replace, and even to raise acne scars and in turn to resurface the cutaneous surface and reduce shadows. These modalities include techniques such as punch grafts, punch excisions, dermabrasion, laser resurfacing, chemical peels, subcision, and the use of dermal fillers.
Focal application of high concentrations of trichloroacetic acid (TCA) is known as chemical reconstruction of skin scars, which is achieved by firmly pressing on the entire depressed area of atrophic acne scars with a sharpened wooden applicator1. Clinical examination revealed apparent cosmetic improvement in both depth and appearance of atrophic acne scars. This highly focused technique inspired the name and is the method referred to as "dot peeling."
Subcision is a method for subdermal undermining of depressed areas2. It is a relatively safe method that can provide significant long-term improvements in ¡®¡®rolling scars¡¯¡¯ found in many patients. When such scars do not completely resolve, combining subcision with other scar revision procedures or repetitive subcision can be beneficial3.
The fractional photothermolysis system is a recent novelty in skin treatments with many advantages and benefits similar to conventional laser resurfacing4. Ablative laser resurfacing is an effective treatment for acne scars. However, edema and prolonged erythema are common side effects that are equally unwanted and inconvenient. Thus the new trend for fractional photothermolysis has been designed to create microscopic thermal wounds that achieve skin rejuvenation without significant side-effects5.
In this clinical trial, beneficial results from combination therapy were observed with dot peeling (focal application and tattooing of high concentration TCA), subcision and fractional photothermolysis. The described combination therapy of this study is proposed as a triple combination therapy for atrophic acne scars.
MATERIALS AND METHODS
Patient selection
From May 2006 to December 2007, 35 patients were recruited. The age of the patients ranged from 22 to 38 years-old (the mean age of 31). Twenty-six patients were females and 9 were males. All patients had either Fitzpatrick¡¯s skin type IV or V. Patients were evaluated carefully before treatments. Exclusion criteria included concomitant treatments to involved skin areas, propensity for keloid scarring, pregnancy, immunosuppression, herpes simplex infection, isotretinoin use, and filler injections or ablative/nonablative laser skin resurfacing procedures within the preceding 6-12 months. The patients were offered local anesthesia with 9% lidocaine cream.
Triple combination therapy
A 29 gauge ultra-fine needle (Becton, Dickinson and Company, Franklin Lakes, NJ, USA) was introduced just under the dermis. Advancement and retraction of the needle were subsequently performed to release fibrous attachments tethering the epidermis and dermis to the subcutis. This action was repeated in a fan-shaped pattern to treat the entire lesion
A concentration of 100% TCA was dropped within atrophic scars, and the scar was pricked with a sharp 29 gauge needle that was placed on the tip of the 1cc insulin syringe to facilitate deeper penetration.
One treatment consisted of four passes of the fractional laser irradiation (MOSAICTM , Lutronic Corp. South Korea) to attain a final microscopic treatment zone with thermal injury density of 350-800 spots/cm2. Two successive passes were performed in one direction and the remaining two were performed perpendicular to that direction. The pulse energy was set to 25 mJ per microscopic treatment zone.
Dot peeling and subcision were repeatedly performed every 2-3 months and fractional laser irradiation was performed every 3-4 weeks. The condition of each individual patient was evaluated to determine the interval length of each of the procedures.
Efficacy evaluation
For an objective independent clinical assessment the photographs were taken before the treatments and 3 months after the completion of the treatments were evaluated by a plastic surgeon and a dermatologist. The acne severity scales as described by Lipper et. al6 were used as the measurement. The number of each type of acne scar was counted using weighted scale (where 1 point was assigned for rolling-superficial, 2 points were assigned for boxcar-shallow, 3 points were assigned for ice pick-deep scars), to yield the overall score.
The subjective patient satisfaction rates were recorded from interviews conducted 3 months after the last treatment. A 4-point scale was used: 0 = no or minimal improvement (0%-10%); 1 = light improvement (11%-25%); 2 = significant improvement (51%-75%); and 3 = marked improvement (>75%).
RESULTS
Among the 35 patients, 10 patients completed 1 year of treatment session. Acne scarring improved in all of the 10 patients. The mean scar severity scores decreased to 34.8 as compared to 80.0 before the treatment (Table 1). The patients improved by a mean of 55.3%. The mean patients¡¯ subjective scores was recorded as 2, which represents significant improvement (51%-75%). There were no cases of significant complication at the treatment sites. This includes instances of persistent erythema, permanent hyperpigmentation, hypopigmentation, herpes simplex flare-up, scarring, or keloids. The results of the evaluation are presented in Figures 1 and2.
DISCUSSION
Acne scars are not a single but a variable morphologic feature. The treatment of acne scars are multiple procedures depending on scar types. Among them, laser resurfacing such as pulsed and scanned carbon dioxide (CO2) and erbium: yttrium–aluminum–garnet (Er:YAG) lasers are now the mainstays of laser treatments. A pulsed CO2 laser is the most effective laser device and employs ablative skin resurfacing. Edema and prolonged erythema are common byproducts of such ablative methods. Scarring and hyperpigmentation are also easily induced6,7,8.
Among the many trials of atrophic acne scar treatments, dot peeling, subcision and fractional photothermolysis were chosen. Dot peeling and subcision are bloodless, simple, and convenient and time effective compared to punch excision and punch grafting. The efficacies of focal application of high concentration of TCA with wooden tip were reported1. Sharpened wooden tip has advantages in bloodless surgery; but it was found to be time-consuming when the procedures are done repeatedly. One cc insulin syringe has more advantages in fine and accurate focal application of TCA. After filling the syringe with TCA, only a single droplet of TCA was applied and tattooed with a sharp needle that is placed on the tip of the 1cc insulin syringe. So TCA can penetrate more deeply compared to the wooden applicator (Figure 3). Additionally procedure time is shorter when using a 1cc insulin syringe applicator.
A limited experienced clinician may induce pin-point bleeding while tattooing. Therefore, precautions are required to control the power of tattooing forces and to monitor the possible overflow of TCA. This is to prevent any unwanted injury to the site. A delicate and gentle power is recommended during procedure.
Fractional photothermolysis is a new approach to nonablative laser therapy in which an array of microscopic thermal wounds are created in the dermis at controllable depths. The technique coagulates both the epidermis and dermis without affecting the normal adjacent stratum corneum, which acts as a natural bandage that protects the tiny wounds during healing. Treated zones are completely healed within 24 hours compared to 2 weeks for ablative laser resurfacing4,5. The fractional laser of this study is a latest erbium glass laser with 1550 nm of wavelength and 4-40 mJ of the energy range. The diameter of thermal wound is between 100-200 µm. Thermal stimulation with low pulse energy and selective spacing avoids bulk thermal damage. The uninjured tissue surrounding the microscopic thermal wound allows rapid re-epithelialization within 24 hours of treatment. This immediate migration of lateral keratinocytes decreases downtime (shaving or make-up application can be performed immediately) (Figure 4).
Continued regenerative signaling in the dermis provides long-term collagen remodeling. Dot peeling is an effective method for single atrophic acne scar, but has limitations in improving the texture of the skin. Fractional lasers have the advantages to improve skin texture and treat shallow and small atrophic scars, but have limitations in affecting icepick and boxcar scars. Subcision effectively treats wide depressed boxcar or rolling scars3.
In this study, the additional effect of fractional laser for dot peeling was demonstrated. Fractional photothermolysis of the bottom of the scar may stimulate collagen regeneration with little influence to the normal adjacent structures. It is concluded that the triple combination therapy presented in this study is a safe and very effective combination modality for the treatment of atrophic acne scars with little down time and no significant complications.
REFERENCES
1. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatol Surg 2002; 28: 1017–21.
2. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg 1995; 21: 543–9.
3. Alam M, Omura N, Kaminer MS. Subcision for Acne Scarring: Technique and outcomes in 40 patients. Dermatol Surg 2005; 31: 310–317.
4. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Laser Surg Med 2004; 34: 426–438.
5. Hasegawa T, Matsumira T, Mizuno Y, Suga Y, Ogawa H, Ikeda S. Clinical trial of a laser device called fractional photothermolysis system for acne scars. J Dermatol 2006; 33: 623–627.
6. Lipper GM, Perez M. Nonablative acne scar reduction after a series of treatments with a short-pulsed 1,064-nm Neodymium:YAG laser. Dermatol Surg 2006; 32: 998–1006
7. Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing. An evaluation of 500 patients. Dermatol Surg 1998; 24; 315–320.
8. Ratner D, Tse Y, Marchell N, Goldman MP, Fitzpatrick RE, Fader DJ. Cutaneous laser resurfacing. J Am Acad Dermatol 1999; 41: 365–389.
9. Bernstein LJ, Kauvar ANB, Grossman MC, Geronemus RG. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997; 23: 519–525.
Table 1. Evaluation of treatment using fractional photothermolysis system (4 weeks post treatment completion)
FIGURE LEGENDS
Figure 1. Pretreatment and post-treatment photographs of case 3
Figure 2. Pretreatment and post-treatment photographs of case 8.
Figure 3. Schematic View of 'Dot peeling' A. Application of 100% TCA on atrophic scar; B. Tattooing the TCA with sharp needle tip on 1cc insulin syringe; C. Proposed schematic view of deep penetration and delivery of TCA
Figure 4. Proposed Mechanism of Fractional Photothermolysis A. Fractional photothermolysis creates microscopic thermal wound; B. re-epithelialization and dermal collagen remodeling contribute to the improvement of atrophic acne scar