This is a short review of a new study by a group of Indian reserchers:
Kubba R, Bajaj AK, Thappa DM, Sharma R, Vedamurthy M, Dhar S, Criton S, Fernandez R, Kanwar AJ, Khopkar U, Kohli M, Kuriyipe VP, Lahiri K, Madnani N, Parikh D, Pujara S, Rajababu KK, Sacchidanand S, Sharma VK, Thomas J. Acne in India: Guidelines for management – IAA Consensus Document: Acne scars. Indian J Dermatol Venereol Leprol 2009;75(Suppl 1):S52-S3. Available from: . reviewed the part of the study that directly pertains to our focus on the use of lasers.

Acne scars are classified as atrophic and hypertrophic. Atrophic acne scars are further classified as ice-pick, rolling, and boxcar. The European acne group (ECCA) has renamed the atrophic acne scars as V-shaped (ice-pick), U-shaped (boxcar), and W-shaped (rolling). Scar characteristics can be further assessed with specialized techniques such as silicon elastomer mold which is then examined under a light microscope. Proper classification of acne scars is essential to assess the severity of cosmetic disfigurement and to choose the appropriate therapeutic intervention.

Resurfacing techniques

These include TCA peeling, phenol peeling, microdermabrasion, laser abrasion, selective thermolysis with Fraxel laser, and resurfacing by radiofrequency and electrosurgery.

The objective of any of the skin/scar resurfacing treatments is to restore skin contour by inducing neocollagenosis (new collagen growth). Resurfacing is indicated in U and W scars. The main complication is erythema which persists for weeks. There is also risk of pigmentation.

Spot TCA peeling is a good technique for V and deep U scars. A sharp stick (toothpick) soaked in 62% or 100% TCA is brought in contact with the target and the contact is maintained till whitening appears. It is a painful procedure and multiple sessions are required.

Microdermabrasion involves planing of the skin by mechanized means utilizing the projection of micromarbles consisting of aluminum oxide on scars. Six to seven sessions, at two week intervals are needed. In one session, twenty passes are made on each area until superficial bleeding appears. Six to seven session microdermabrasion has low efficacy and may be useful in superficial U scars. Chemabrasion is when microdermabrasion is combined with a peeling agent.

Lasers are increasingly being used to treat acne scars. Intense Pulse Light (IPL) acts by heating the dermis and stimulating neocollagenosis. It has weak activity and may be helpful in red, hypertrophic scars. Light-Emitting Diode (LED) does not warm but acts by photomodulation. It is a safe and painless procedure but the efficacy is low. It is being used for superficial U scars, erythema (acne macules), and pigmentation. Ablative laser resurfacing, although effective, is associated with excessive tissue reaction as erythema and edema, and complications such as pigmentation and scarring. It is less suited for skin types V-VI. Fractional photothermolysis, a new concept, using 1,550-nm erbium-doped fiber laser (Fraxel® ) appears to be very promising. Fractional photothermolysis creates microscopic thermal wounds to achieve skin rejuvenation without significant side effects. In a study from USA, 53 patients (skin types I-V) with mild to moderate atrophic facial scars were treated with three treatment sessions at monthly intervals. Clinical improvement averaged 51-75% in nearly 90% of patients. Clinical response rates were independent of age, gender, or skin type. Side effects included transient erythema and edema in most patients, but no dyspigmentation, ulceration, or scarring. It was concluded that atrophic scars can be effectively and safely reduced with 1,550-nm erbium-doped fiber laser. Fractional thermolysis is an expensive treatment, and typically 4-8 sittings are required depending on the depth of scars. A single treatment with Fraxel® in the U.S. may cost $1,500.

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