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Atrophic Acne Scar Treatment Using Triple Combination Therapy

글쓴이 : 관리자 날짜 : 2013-03-05 (화) 17:21 조회 : 11453

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
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;
‘Triple Combination Treatment (이하 TCT)’는 ‘Dot Peeling’, ‘Subcision’, ‘Fractional Laser’, 이 세가지 치료 방법을 병행하여 치료하는 방법이다. 연자는 이 세가지 방법을 병행하여 치료하였을 때 좋은 경과를 경험하고, 2009년도에 이를 발표한 바 있다(J Cosmet Laser Ther. 2009; 17: 1-4).
이 세 가지 치료 방법의 개요는 다음과 같다
1) Dot peeling (focal application and tattooing of high concentration TCA)
‘High concentration의 TCA 용액(통상 100%)‘을 atrophic scar의 base에 부분적으로 찍어 발라서 흉터가 차오르도록 유도하는 방법이다. 기존에 wooden applicator로 TCA를 찍어 바르는 방식과는 달리 ’1cc insuline syringe (29 gauge)’에 100% TCA를 채우고, 마치 만년필을 사용하는 것 같이 시술하는 방법이다(Figure ).
이 방법은 특히 icepick scar나 boxcar scar와 같이 넓고 깊은 형태를부분적으로 치료하는데 매우 효과적인 방법이다.

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 band로 retraction이 심한 흉터를 치료하는 고식적인 피부외과적인 방법이다. Atrophic scar 중에서도 특히 ‘Rolling scar’를 치료하는 데 매우 효과적이다. 바늘(Nokor needle)이나 blade를 이용하여 진피의 fibrotic band를 끊어 주어 흉터를 교정하는 원리이다(Figure ).

Figure . Subcision의 흉터 교정 원리. Dermis의 fibrotic band를 끊어 주어 'retracted scar'를 교정하는 방법이다.
3) Fractional laser: 1,550 nm Erbium Glass Fractional laser
Fractional photothermolysis는 기존의 laser resurfacing에 비하여 여러 가지 장점이 많아, 최근 흉터 치료에 각광을 받는 방법이다.
피부 전체에 laser를 조사하는 것이 아니라, 일부에만 조사하여(fraction) 이때 주변 정상조직을 통하여 피부가 regeneration되는 방식이다. 이와 같이 형성된 microscopic thermal wound를 통하여 부작용을 최소화 하면서 skin rejuvenation이나 흉터 치료를 할 수 있는 개념이다. Laser를 전체적으로 조사하는 것이 아니라 low pulse energy를 일정 간격을 두고 부분적으로(fraction) 조사하면, bulk thermal damage를 주지 않는다. 이때 Fractions을 ‘Microscopic Thermal Zones (MTZs)‘이라고 표현한다. 이때 손상되지 않은 주변 정상 조직으로부터 24시간 이내에 신속하게 ’re-epithelialization’이 형성된다. 주변 정상 keratinocyte가 신속하게 손상부위로 이동하기 때문에 화장이나 세안 등이 가능하기 때문에 downtime이 매우 적은 방법이다.
또한 지속적으로 collagen regeneration을 자극하기 때문에 시술 이후에도 지속적으로 흉터가 개선되며, skin texture 또한 개선된다.
하지만, icepick scar나 boxcar scar 같이 넓고 깊은 흉터를 교정하는 데는 한계가 있다.
위의 세 가지 방법 중, dot peeling과 subcision은 2~3개월 간격으로, fractional laser는 3~4주 간격으로 병행하여 시술하였을 때, 각각의 치료에 비하여 좋은 치료 결과를 경험할 수 있었다(Figure ).

Figure . TCT를 이용하여 atrophic scar를 치료한 임상사진
특히 이 세 가지 방법을 적절히 조합하여 시술하였을 때 각각의 장점을 극대화 할 수 있고 안전하고 부작용 없이 atrophic scar를 치료할 수 있었다.
필자는 TCT야 말로 downtime과 부작용을 최소화하면서, 매우 효과적이고 안전하게 atrophic acne scar를 치료하는 방법이라고 제안한다.
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.
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%).
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. 

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.
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 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