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: http://www.ijdvl.com/text.asp?2009/75/7/52/45487 .
LaserOffers.com 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.
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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The early 1980s brought about a revolution in dermatologic laser treatment with Anderson and Parrish’s1 publication detailing the theory of selective photothermolysis. Selective photothermolysis describes the use of specific absorptions of laser energy to achieve temperature-mediated localized injury in a target. This theory led to the invention of pulsed lasers that are target-specific and highly selective. Increased selectivity decreased the amount of thermal damage to healthy tissue, thereby decreasing scarring and other adverse effects.
The first laser used in the treatment of hypertrophic scars and keloids was a continuous-wave argon laser. While initial reports were encouraging, subsequent studies did not confirm its efficacy. Similarly, use of the continuous wave neodymium:yttrium-aluminum-garnet (Nd:YAG) laser (1064 nm), which selectively inhibits collagen production by a direct photobiologic effect and creates tissue infarction with subsequent charring and sloughing of the treated area, also showed initial clinical improvement. Results, however, were transient and scar recurrences were common. Similar recurrences were observed when hypertrophic scars and keloids were excised or vaporized with a continuous-wave carbon dioxide laser (CO2). When treated with the carbon dioxide laser, scars universally recurred within 1 year.
By the early 1990s, the effectiveness of the vascular-specific 585-nm pulsed dye laser (PDL) in treating a variety of vascular lesions (eg, port-wine stain, telangiectasia) was widely known. The first series of studies on the successful use of the 585-nm flashlamp-pumped PDL in the treatment of hypertrophic scars and keloids had been published. In 1993, Dr. Alster and colleagues reported prolonged improvement in argon laser–induced port-wine stain scars treated with PDL irradiation. Skin surface texture analysis performed by optical profilometry with accompanying clinical assessment revealed that laser-irradiated scars approximated normal skin characteristics. No scar recurrences were noted 4 years following treatment.
In 1994, Alster reported clinical and textural improvement in long-standing erythematous and hypertrophic scars. An improvement rate ranging from 57-83% was observed following 1-2 PDL treatments, respectively. Dierickx and colleagues corroborated these findings the following year; they reported an average scar improvement of 77% after 1.8 laser treatments. Not surprisingly, in 1995, Alster and Williams compared the clinical, textural, histologic, and symptomatic responses of irradiated scar halves with untreated control halves. Significant improvement was observed for all clinical parameters. Histologic evaluation revealed increased numbers of regional mast cells. Because mast cells also elaborate a variety of cytokines, the presence of mast cells following laser irradiation and accompanying tissue revascularization may provide an explanation for the therapeutic outcome following microvasculature destruction in terms of stimulating collagen remodeling.
Subsequent studies also showed improvement in keloid scars following PDL treatment. In 1996, Alster and McMeekin also reported improvement in erythematous and hypertrophic facial acne scars following 585-nm pulsed dye irradiation.
Improvement in nonerythematous, minimally hypertrophic scars was also achieved following combination treatment involving pulsed dye technology and carbon dioxide laser vaporization. In 1998, Alster and Lewis treated selected scars by performing carbon dioxide laser de-epithelialization followed by PDL irradiation. Significant and prolonged clinical and textural improvement was observed in all treatment areas. In a 1995 report, Goldman and Fitzpatrick also described a combination approach to scar management. They used intralesional corticosteroids concomitantly with 585-nm PDL irradiation in 11 of 37 patients with hypertrophic scars.
No consensus exists regarding the mechanism by which PDLs achieve these additional clinical effects. Plausible explanations include laser-induced tissue hypoxia (leading to collagenesis from decreased microvascular perfusion), collagen fiber heating with dissociation of disulfide bonds and subsequent collagen realignment, selective photothermolysis of vasculature, suppression of TGF-β1 expression, and mast cell factors (eg, histamine, interleukins, various immunofactors) that may affect collagen metabolism.
In 1996, McDaniel and colleagues reported using the same 585-nm PDL to effect an improvement in the appearance of striae. They observed an improvement not only in skin surface appearance, but also in increased dermal elastin after low-fluence laser irradiation. In a 1998 report, Alster and colleagues7 also found that low-fluence PDL irradiation was superior compared with pulsed dye treatment at regular (scar) fluences and pulsed carbon dioxide vaporization. Both groups postulate that the improvement may be due to laser-induced effects on elastin, collagen, or other undiscovered factors.
In 2003, Nouri and colleagues showed that the 585-nm PDL can improve the quality and appearances of surgical scars when used as early as the day of suture removal. Scars were treated 3 times at monthly intervals and were significantly more improved compared with controls in overall Vancouver Burn Scar Scale (ie, vascularity, pliability, height, and cosmetic appearance) comparisons.
More in Laser Revision of Scars (April 2008)
Many patients who undergo cosmetic and plastic surgery procedures experience significant scarring from the incisions. Procedures such as the tummy tuck, breast augmentation and facelift surgery typically leave behind large, noticeable scars that are difficult to cover up with makeup. Scars can take weeks, months and even years to heal completely and there are a number of topical scar gels and creams available to reduce the appearance of the traumatized skin.
However, results from a recent study completed at the Cosmetic Surgery and Skin Health Center at the University of Pittsburgh Medical Center (UPMC) in Pittsburgh indicate that laser therapy may be used as an early intervention plan for scar formation. Lasers can be used to stop the growth of scars by delivering high-energy waves to the skin and lightening any discoloration on the traumatized skin. Pulse-dyed lasers and fractionated lasers have been the most effective at reducing the appearance of scars after surgery so far, and lasers such as Fraxel may even help reduce the appearance of mature scars
Dr. Suzan Obagi, assistant clinical profesor of dermatology at UPMC explains that the best time to treat scars with this type of therpay is right when the sutures are removed. This helps reduce the risk of dark scar formation, and may also speed up the body’s natural healing process. Increasing collagen and elastin production helps the skin recover rapidly and restore itself to its natural state.
Younger patients tend to heal faster than older patients regardless of the type of treatment used, and overall health and diet also play a role in wound healing and scar development. Individuals who are deficient in vitamins and proteins may not be able to heal as fast or as effectively; however, laser therapy may help to reduce the risk of deep scar formation and improve the healing process overall. (Source: ModernMedicine.com)