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Acne Scars: Pathogenesis, Classification and Treatment
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Aromatherapy for Acne Treatment. Miriam Kinai. Cheryl Davidson. These scars tend to be wider at the surface than an icepick scar and do not have the tapering V shape. Boxcar scars can be shallow or deep Figure 3. Sometimes the 3 different types of atrophic scars can be observed in the same patients and it can be very difficult to differentiate between them. For this reason several classifications and scales have been proposed by other authors. Goodman and Baron proposed a qualitative scale and then presented a quantitative scale [ 21 , 22 ].
Dreno et al. The qualitative scarring grading system proposed by Goodman and Baron [ 9 ] is simple and universally applicable. According to this classification, four different grades can be used to identify an acne scar, as shown in Table 2. Often especially in those affected with mild acne the pattern and grading is easy to achieve but, in the observation of severe cases, different patterns are simultaneously present and may be difficult to differentiate.
The standard approach adopted by Goodman and Baron describes a grading pattern and they developed a quantitative global acne scarring assessment tool [ 22 ] based on the type of scar and the number of scars. This system assigns fewer points to macular and mild atrophic scores than to moderate and severe atrophic scores macular or mildly atrophic: 1 point; moderately atrophic: 2 points; punched out or linear-troughed severe scars: 3 points; hyperplastic papular scars: 4 points. The multiplication factor for these lesion types is based on the numerical range whereby, for one to ten scars, the multiplier is 1; for 11—20 it is 2; for more than 20 it is 3.
Qualitative scarring grading system adapted from [ 21 ]. Scar types considered to be more visibly disfiguring were weighted more heavily. A semiquantitative assessment of the number of each of these scar types was then determined with a four-point scale, in which 0 indicates no scars, 1 indicates less than five scars, 2 indicates between five and 20 scars, and 3 indicates more than 20 scars. With this method, the relative extent of scarring for each scar type was calculated. The total score can vary from 0 to In recent studies on the reliability of this scale, seven dermatologists underwent a min training session prior to the evaluation of ten acne patients.
There was no statistical difference in score grading between participating dermatologists. The global scores, however, varied from a minimum of 15 to a maximum of Unfortunately, a statistical estimate of reliability within and between raters was not provided. The potential advantages of this system include independent accounting of specific scar types, thereby providing for separate atrophic and hypertrophic subscores in addition to total scores.
Potential shortcomings include restriction to facial involvement, time intensity, and undetermined clinical relevance of score ranges [ 21 ].
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Hypertrophic and keloidal scars are associated with excess collagen deposition and decreased collagenase activity. Hypertrophic scars are typically pink, raised, and firm, with thick hyalinized collagen bundles that remain within the borders of the original site of injury. The histology of hypertrophic scars is similar to that of other dermal scars. In contrast, keloids form as reddish-purple papules and nodules that proliferate beyond the borders of the original wound; histologically, they are characterized by thick bundles of hyalinized acellular collagen arranged in whorls.
Hypertrophic and keloidal scars are more common in darker-skinned individuals and occur predominantly on the trunk. New acquisitions by the literature have showed that prevention is the main step in avoiding the appearance of post-acne scars. Genetic factors and the capacity to respond to trauma are the main factors influencing scar formation [ 24 ].
A number of treatments are available to reduce the appearance of scars. First, it is important to reduce as far as possible the duration and intensity of the inflammation, thus stressing the importance of the acne treatment. The use of topical retinoids is useful in the prevention of acne scars but more than any other measure, the use of silicone gel has a proven efficacy in the prevention of scars, especially for hypertrophic scars and keloids.
By chemical peeling we mean the process of applying chemicals to the skin to destroy the outer damaged layers and accelerate the repair process [ 25 ]. Chemical peeling is used for the reversal of signs of skin aging and for the treatment of skin lesions as well as scars, particularly acne scars. Dyschromias, wrinkles, and acne scars are the major clinical indications for facial chemical peeling [ 26 , 27 ].
As regards acne scars, the best results are achieved in macular scars. Icepick and rolling scars cannot disappear completely and need sequential peelings together with homecare treatment with topical retinoids and alpha hydroxy acids [ 28 , 29 ]. The level of improvement expected is extremely variable in different diseases and patients. For example, ice pick acne scars in a patient with hyperkeratotic skin are only mildly improved even if skin texture is remodeled.
Glycolic acid is an alpha-hydroxy acid, soluble in alcohol, derived from fruit and milk sugars. Glycolic acid acts by thinning the stratum corneum, promoting epidermolysis and dispersing basal layer melanin. It increases dermal hyaluronic acid and collagen gene expression by increasing secretion of IL-6 [ 30 ]. The procedure is well tolerated and patient compliance is excellent, but glycolic acid peels are contraindicated in contact dermatitis, pregnancy, and in patients with glycolate hypersensitivity.
Side effects, such as temporary hyperpigmentation or irritation, are not very significant [ 31 ]. Some studies showed that the level of skin damage with glycolic acid peel increases in a dose- and time-dependent manner. An increase in the transmembrane permeability coefficient is observed with a decrease in pH, providing a possible explanation for the effectiveness of glycolic acid in skin treatment [ 32 ].
Formulated by Dr. Resorcinol is structurally and chemically similar to phenol. It disrupts the weak hydrogen bonds of keratin and enhances-penetration of other agents [ 33 ]. Lactic acid is an alpha hydroxy acid which causes corneocyte detachment and subsequent desquamation of the stratum corneum [ 34 ]. As with other superficial peeling agents, Jessner's peels are well tolerated.
General contraindications include active inflammation, dermatitis or infection of the area to be treated, isotretinoin therapy within 6 months of peeling and delayed or abnormal wound healing. Allergic contact dermatitis and systemic allergic reactions to resorcinol are rare and need to be considered as absolute contraindications [ 35 , 36 ]. Pyruvic acid is an alpha-ketoacid and an effective peeling agent [ 37 ].
It presents keratolytic, antimicrobial and sebostatic properties as well as the ability to stimulate new collagen production and the formation of elastic fibers [ 38 ]. Side effects include desquamation, crusting in areas of thinner skin, intense stinging, and a burning sensation during treatment. Pyruvic acid has stinging and irritating vapors for the upper respiratory mucosa, and it is advisable to ensure adequate ventilation during application.
Salicylic acid is one of the best peeling agents for the treatment of acne scars [ 41 ]. It is a beta hydroxy acid agent which removes intercellular lipids that are covalently linked to the cornified envelope surrounding cornified epithelioid cells. The side effects of salicylic acid peeling are mild and transient.
These include erythema and dryness. Persistent postinflammatory hyperpigmentation or scarring are very rare and for this reason it is used to treat dark skin [ 45 ]. Rapid breathing, tinnitus, hearing loss, dizziness, abdominal cramps, and central nervous system symptoms characterize salicylism or salicylic acid toxicity. The use of trichloroacetic acid TCA as a peeling agent was first described by P. Unna, a German dermatologist, in TCA application to the skin causes protein denaturation, the so-called keratocoagulation, resulting in a readily observed white frost [ 48 ].
The degree of tissue penetration and injury by a TCA solution is dependent on several factors, including percentage of TCA used, anatomic site, and skin preparation. Selection of appropriate TCA-concentrated solutions is critical when performing a peel. When performed properly, peeling with TCA can be one of the most satisfying procedures in acne scar treatment but it is not indicated for dark skin because of the high risk of hyperpigmentation [ 50 ]. CROSS stands for chemical reconstruction of skin scars method and involves local serial application of high concentration TCA to skin scars with wooden applicators sized via a number 10 blade to a dull point to approximate the shape of the scar.
No local anesthesia or sedation is needed to perform this technique [ 51 ]. TCA is applied for a few seconds until the scar displays a white frosting. Emollients then needs to be prescribed for the following 7 days and high photoprotection is required. The procedure should be repeated at 4-week intervals, and each patient receives a total of three treatments. Dermabrasion and microdermabrasion are facial resurfacing techniques that mechanically ablate damaged skin in order to promote reepithelialisation.
Although the act of physical abrasion of the skin is common to both procedures, dermabrasion, and microdermabrasion employ different instruments with a different technical execution [ 54 ]. Dermabrasion completely removes the epidermis and penetrates to the level of the papillary or reticular dermis, inducing remodeling of the skin's structural proteins. Microdermabrasion, a more superficial variation of dermabrasion, only removes the outer layer of the epidermis, accelerating the natural process of exfoliation [ 55 , 56 ].
Both techniques are particularly effective in the treatment of scars and produce clinically significant improvements in skin appearance.
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Dermabrasion is performed under local or general anaesthesia. A motorized hand piece rotates a wire brush or a diamond fraise. Several decades ago, the hand piece was made of aluminum oxide or sodium bicarbonate crystals, whereas now diamond tips have replaced these hand pieces to increase accuracy and decrease irritation. There is often a small pinpoint bleeding of the raw wound that subsides with appropriate wound care. Patients with darker skin may experience permanent skin discoloration or blotchiness.
As regards the technique of microdermabrasion, a variety of microdermabraders are available. All microdermabraders include a pump that generates a stream of aluminum oxide or salt crystals with a hand piece and vacuum to remove the crystals and exfoliate the skin [ 57 ]. Unlike dermabrasion, microdermabrasion can be repeated at short intervals, is painless, does not require anesthesia and is associated with less severe and rare complications, but it also has a lesser effect and does not treat deep scars [ 58 , 59 ].
It is essential to conduct a thorough investigation of the patient's pharmacological history to ensure that the patient has not taken isotretinoin in the previous 6—12 months. As noted by some studies [ 60 ], the use of tretinoin causes delayed reepithelialization and development of hypertrophic scars. All patients with box-car scars superficial or deep or rolling scars are candidates for laser treatment.
Different types of laser, including the nonablative and ablative lasers are very useful in treating acne scars. Ablative lasers achieve removal of the damaged scar tissue through melting, evaporation, or vaporization.
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Carbon dioxide laser and Erbium YAG laser are the most commonly used ablative lasers for the treatment of acne scars. These abrade the surface and also help tighten the collagen fibers beneath. Nonablative lasers do not remove the tissue, but stimulate new collagen formation and cause tightening of the skin resulting in the scar being raised to the surface. The ablative lasers are technologies with a high selectivity for water. Therefore, their action takes place mainly on the surface but the depth of action is certainly to be correlated to the intensity of the emitted energy and the diameter of the spot used.
Among the ablative lasers, Erbium technologies are so selective for water that their action is almost exclusively ablative. CO 2 lasers, which present lower selectivity for water, besides causing ablation are also capable of determining a denaturation in the tissues surrounding the ablation and a thermal stimulus not coagulated for dermal protein. CO 2 lasers have a double effect: they promote the wound healing process and arouse an amplified production of myofibroblasts and matrix proteins such as hyaluronic acid [ 62 ]. The differences in results reported with apparently similar laser techniques may be due to variations in the types of scar treated.
Candidates must present a skin disease with acne off for at least 1 year; they should have stopped taking oral isotretinoin for at least 1 year; they should not have presented skin infections by herpes virus during the six months prior to treatment; they must not have a history of keloids or hypertrophic scarring.
Patients with a high skin type phototype are exposed to a higher risk of hyperpigmentation after treatment than patients with low phototype. All ablative lasers showed high risk of complications and side effects. Adverse reactions to the first generation of ablative lasers can be classified into short-term bacterial, herpetic or fungal infections and long-term persistent erythema, hyperpigmentation, scarring [ 63 , 64 ]. In particular, scarring after CO 2 laser therapy may be due to the over treatment of the areas including excessive energy, density, or both , lack of technical aspects, infection, or idiopathic.
It is necessary to take into account these aspects when sensitive areas such as the eyelids, upper neck, and especially the lower neck and chest are treated [ 65 , 66 ]. Nonablative skin remodeling systems have become increasingly popular for the treatment of facial rhytides and acne scars because they decrease the risk of side effects and the need for postoperative care. Nonablative technology using long-pulse infrared 1. Although improvement was noted with these nonablative lasers, the results obtained were not as impressive as the results from those using laser resurfacing [ 71 ].
For this reason, a new concept in skin laser therapy, called fractional photothermolysis, has been designed to create microscopic thermal wounds to achieve homogeneous thermal damage at a particular depth within the skin, a method that differs from chemical peeling and laser resurfacing. Prior studies using fractional photothermolysis have demonstrated its effectiveness in the treatment of acne scars [ 73 ] with particular attention for dark skin to avoid postinflammatory hyperpigmentation [ 74 ].
Newer modalities using the principles of fractional photothermolysis devices FP to create patterns of tiny microscopic wounds surrounded by undamaged tissues are new devices that are preferred for these treatments. These devices produce more modest results in many cases than traditional carbon dioxide lasers but have few side effects and short recovery periods [ 75 ].
Many fractional lasers are available with different types of source. By depositing a pixilated pattern of microscopic ablative wounds surrounded by healthy tissue in a manner similar to that of FP [ 76 ], AFR combines the increased efficacy of ablative techniques with the safety and reduced downtime associated with FP. The different experiences of numerous authors in this field have shown that, by combining ablative technology with FP, AFR treatments constitute a safe and effective treatment modality for acneiform scarring.
Compared to conventional ablative CO 2 devices the side effects profile is greatly improved and, as with FP, rapid reepithelization from surrounding undamaged tissue is believed to be responsible for the comparatively rapid recovery and reduced downtime noted with AFR [ 78 — 80 ].
Pigmentation abnormalities following laser treatment is always a concern. The treatment strategy is linked to establishing the optimal energy, the interval between sessions, and a longer follow-up period to optimize treatment parameters. Atrophic scarring is the more common type of scarring encountered after acne. Autologous and nonautologous tissue augmentation, and the use of punch replacement techniques has added more precision and efficacy to the treatment of these scars [ 82 ]. The laser punch-out method is better than even depth resurfacing for improving deep acne scars and can be combined with the shoulder technique or even depth resurfacing according to the type of acne scar [ 83 ].
Laser skin resurfacing with the concurrent use of punch excision improves facial acne scarring [ 84 ]. The useful modalities available are dermal punch grafting, excision, and facelifting. The selection of these techniques is dependent on the above classification and the patient's desire for improvement [ 86 ]. The technique is useful in repairing unstable scars from chronic leg ulcers or X-ray scars.
It can also camouflage acne scars, extensive nevi pigmentosus, and tattoos [ 87 , 88 ]. It is prepackaged dermal graft material that is easy to use, safe, and effective [ 89 ]. Fat transplantation. Fat is easily available and it has low incidence of side effects [ 90 ]. The technique consists of two phases: procurement of the graft and placement of the graft. The injection phase with small parcels of fat implanted in multiple tunnels allows the fat graft maximal access to its available bloody supply. The fat injected will normalize the contour excepted where residual scar attachments impede this.
There are many new and older autologous, nonautologous biologic, and nonbiologic tissue augmentation agents that have been used in the past for atrophic scars, such as autologous collagen, bovine collagen, isolagen, alloderm, hyaluronic acid, fibrel, artecoll, and silicon, but nowadays, because of the high incidence of side effects, the recommended material to use is hyaluronic acid [ 91 ]. Skin needling is a recently proposed technique that involves using a sterile roller comprised of a series of fine, sharp needles to puncture the skin.
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At first, facial skin must be disinfected, then a topical anesthetic is applied, left for 60 minutes. The skin needling procedure is achieved by rolling a performed tool on the cutaneous areas affected by acne scars Figure 6 , backward and forward with some pressure in various directions. The needles penetrate about 1. As expected, the skin bleeds for a short time, but that soon stops. The skin develops multiple microbruises in the dermis that initiate the complex cascade of growth factors that finally results in collagen production.
Histology shows thickening of skin and a dramatic increase in new collagen and elastin fibers. Results generally start to be seen after about 6 weeks but the full effects can take at least three months to occur and, as the deposition of new collagen takes place slowly, the skin texture will continue to improve over a 12 month period. The number of treatments required varies depending on the individual collagen response, on the condition of the tissue and on the desired results.
Most patients require around 3 treatments approximately 4 weeks apart. Skin needling can be safely performed on all skin colours and types: there is a lower risk of postinflammatory hyperpigmentation than other procedures, such as dermabrasion, chemical peelings, and laser resurfacing. Skin needling is contraindicated in the presence of anticoagulant therapies, active skin infections, collagen injections, and other injectable fillers in the previous six months, personal or familiar history of hypertrophic and keloidal scars [ 92 , 93 ].
There is a new combination therapy for the treatment of acne scars. The first therapy consists of peeling with trichloroacetic acid, then followed by subcision, the process by which there is separation of the acne scar from the underlying skin and in the end fractional laser irradiation. The efficacy and safety of this method was investigated for the treatment of acne scars.
The duration of this therapy is 12 months. Dot peeling and subcision were performed twice months apart and fractional laser irradiation was performed every weeks. There were no significant complications at the treatment sites. It would appear that triple combination therapy is a safe and very effective combination treatment modality for a variety of atrophic acne scars [ 94 ]. Silicone-based products represent one of the most common and effective solutions in preventing and also in the treatment of hypertrophic acne scars.
The silicone gel was introduced in the treatment of hypertrophic acne scars to overcome the difficulties in the management of silicone sheets. Indeed, the silicone gel has several advantages: it is transparent, quick drying, nonirritating and does not induce skin maceration, it can be used to treat extensive scars and uneven areas of skin. The mechanism of action is not fully understood but several hypotheses [ 95 ] have been advanced: 1 the increase in hydration; 2 the increase in temperature; 3 protection of the scar; 4 increased tension of O2; 5 action on the immune system.
There is, currently, only one observational open label study, conducted on 57 patients. As regards the treatment of already formed hypertrophic scars, the gel should be applied in small amounts, twice daily for at least 8 weeks to achieve a satisfactory aesthetic result.
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