An Overview on the Management of Atrophic Acne Scars: The Role of Trifarotene as an Adjunct.

Acne vulgaris is a common, often chronic inflammatory disease that can affect all ages and skin tones. Beyond acute lesions, the sequelae of acne - specifically scarring and dyspigmentation - can be long-lasting, challenging to treat and have substantial psychosocial impact on affected individuals. For acne scarring, treatment modalities include topical, physical, and laser and light therapies, with combination approaches typically yielding optimal outcomes. Trifarotene is a novel fourth generation retinoid with targeted action towards retinoid acid receptor gamma (RAR-γ), the most common isotype found in the epidermis, that has previously been approved for the management of moderate-to-severe facial and truncal acne in individuals over the age of 12 years. Recently, data on trifarotene supports its application in acne scarring. Herein, we provide a succinct review on various treatments for acne scarring and explore how trifarotene and its mechanism of action present an additional topical approach to target atrophic acne scarring.

Fractional picosecond laser treatment of non-acne atrophic scars and scar erythema in Chinese patients.

BACKGROUND: Fractional picosecond lasers (FPL) are reported to be effective and safe for atrophic acne scars and post-acne erythema. However, there is no evidence regarding the effectiveness and safety of FPL treatment for non-acne atrophic scars and scar erythema among Chinese patients. METHODS: In this retrospective study, 12 Chinese patients with non-acne atrophic scars, including nine with scar erythema, were treated with one to three sessions of 1064 nm FPL treatment. Clinical improvement was objectively assessed through blinded evaluations by external physicians. A modified Manchester Scar Scale (mMSS) and the Clinician Erythema Assessment Scale (CEAS) were individually used to evaluate atrophic scars and scar erythema based on photographs. Physician-assessed and subject-assessed Global Aesthetic Improvement Scale (GAIS) were used to assess changes before and after FPL treatment. Patient satisfaction and adverse events were also documented. RESULTS: Total mMSS scores, as well as three parameters (color, distortion, and texture), were significantly decreased after FPL treatment, with a mean reduction of 3.18 ± 1.60 in total scores (p < 0.05). The CEAS scores were significantly reduced from 2.41 ± 0.98 before treatment to 0.41 ± 0.40 at the final visit (p < 0.05). Based on physician-assessed and subject-assessed GAIS scores, 11 (91.7%) patients were improved after FPL treatment. 33.3% of patients were very satisfied, and 41.7% were satisfied. No serious, prolonged (> 3 weeks) adverse events were observed. CONCLUSION: Our study suggests that 1064 nm FPL treatment may be a promising option for non-acne atrophic scars, especially with scar erythema. Further studies are needed to confirm our results.

Evaluation and comparison of the efficacy and safety of the combination of topical phenytoin and microneedling with microneedling alone in the treatment of atrophic acne scars: A controlled blinded randomized clinical trial.

INTRODUCTION: Severe acne breakouts often lead to atrophic acne scars, which affect millions of people worldwide and can significantly affect a person's self-confidence and self-image. Given the difficulty in treating atrophic acne scars, this study aims to investigate the efficacy of topical phenytoin in the treatment of atrophic acne scars. METHOD: This split face clinical trial on 25 patients between the ages of 18 and 40 involved the application of microneedling on one side of the face, with three sessions taking place over the course of a month. On the other side, a 1% phenytoin cream was administered three times daily for 1 week following the microneedling procedure. Baseline information was collected for all patients, and follow-up assessments were conducted during the treatment sessions and 2 months after the last session. The assessments included evaluating the number and area of pores and spots, determining scar severity, assessing patient satisfaction, and recording any potential complications. RESULTS: Among patients, 20 individuals (80%) were females, and the average age of the participants was 35.96 ± 9.23. In terms of the fine pore area, despite the fine pore count, both groups showed improvement over time (p: 0.03 vs. 0.06). Also, regarding large pore count and area, and the count and area of spots, both groups showed improvement over time (p: 0.001). However, there were no significant differences between the two groups (p > 0.05). On the other hand, when it comes to acne scar grade and patients' satisfaction, the phenytoin group outperformed the control group in all follow-up sessions and this difference was found to be significant (p: 0.001). It is worth noting that no complications were observed among any of the patients. CONCLUSION: It appears that combining phenytoin cream with microneedling has a more effective therapeutic outcome in enhancing atrophic acne scars, when compared to microneedling alone, and this method can be regarded as a viable alternative in treating these types of scars.

Practical Aspects of Acne Scar Management: ASAP 2024.

Acne scars are one of the most common complications of acne. They can significantly affect the patient's quality of life. Often, several types of atrophic acne scars are observed simultaneously; therefore, consideration must be given to the type of scar while choosing the treatment modality. Effective treatment is not only important to prevent and improve acne scars but also crucial in preventing psychosocial effects. Treatment of acne scars requires an algorithmic approach that targets each component of the scars, and combination therapy on a patient-specific basis may offer the best chance for significant improvement. The goal of the current article is to discuss the practical aspects of management of atrophic acne scars using the vast modalities of treatment available. The panel of dermatologists and plastic surgeons, each one with at least 20 years of experience in acne scar treatment, participated in a series of 'Practical Aspects of Acne Scar Management' (ASAP) meetings: ASAP 2024. ASAP meetings were organized by "Scar Forum India" from March 2023 to July 2023 in four Indian cities (Mumbai, Delhi, Bengaluru, and Kolkata), each one for a duration of at least three hours. During these meetings and discussions, panelists reviewed and discussed the acne scar-related literature, their clinical experience in its management, available treatment options, along with recent advances. Consequently, a summary of the discussion and practical approach for the management of acne scars is developed. It was concluded that, though there is no specific guideline available to optimize acne scar management despite the multitude of treatment options, the best results can be achieved through the synergy of multiple treatment modalities and using the algorithmic approach.

Efficacy and safety of 1064-nm fractional picosecond laser for the treatment of postmastectomy scars in transgender men: A randomized controlled trial.

OBJECTIVES: Subcutaneous mastectomy is a crucial component of gender affirmation therapy for transgender men (TM), but the scars that result from this procedure can frequently impair their quality of life. This study aimed to assess the efficacy and safety of 1064-nm fractional picosecond laser (FxPico) treatment for hypertrophic and atrophic postmastectomy scars in TM. METHODS: Twenty-two patients with a total of 35 pairs of bilateral symmetric mastectomy scars were enrolled. One of each pair of symmetric scars was randomly assigned to receive four FxPico treatments at 4-week intervals. All scars were evaluated using the modified Vancouver Scar Scale (mVSS) and three-dimensional imaging for scar roughness, melanin index, and hemoglobin index before each treatment session and at 1, 3, and 6 months following the last treatment. Additionally, participant-rated scar satisfaction (PSS) and scar improvement (Global Assessment Score, GAS), as well as adverse events were recorded. RESULTS: During the 6-month follow-up period after the end of laser treatment sessions, the treated scars showed significant reductions in the mVSS compared to the untreated controls (p < 0.001), whereas the melanin index and hemoglobin index were not significantly different. Subgroup analysis of hypertrophic scars demonstrated statistically significant reductions in mVSS at 1 (p = 0.003) and 3 months (p = 0.041) after the end of laser treatments. PSS was significantly higher on the laser-treated scars than the controls (p = 0.008), and a participant-rated GAS of 2.95 ± 0.65 was found. There were no serious adverse events reported. CONCLUSIONS: 1064-nm FxPico could be utilized to treat mastectomy scars among TM, particularly the hypertrophic type.

Evaluation and comparison of the efficacy and safety of cross-linked and non-cross-linked hyaluronic acid in combination with botulinum toxin type A in the treatment of atrophic acne scars: A double-blind randomized clinical trial.

INTRODUCTION: Acne vulgaris is a common skin condition that affects a significant percentage of adolescents, with scarring being one of its permanent complications. This study aims to compare the efficacy and safety of using botulinum toxin type A (BTA) in combination with cross-linked and non-cross-linked hyaluronic acid (HA) for the treatment of atrophic acne scars. METHOD: Our study is a randomized, double-blind clinical trial conducted on 16 patients with atrophic acne scars. The patients were randomly assigned to one of two groups: one group received a single session of BTA and crossed link HA combination, while the other group received two sessions of BTA and non-crossed link HA, 1 month apart. The patients were followed up at 3 and 6 months after baseline to evaluate the number and area of fine and large pores and spots, scar grading, patient satisfaction, and complications. RESULTS: The mean age of individuals in both the cross-linked HA and non-cross-linked HA groups was 32.75 ± 4.26 and 31.50 ± 8.48 years, respectively (p = 0.71). In terms of gender, three (37.5%) and seven (87.5%) individuals in the cross-linked and non-cross-linked HA groups were female, respectively (p = 0.11). There were no significant differences in the count and area of fine and large pores and spots between the two groups at baseline and the first follow-up session. However, in the second follow-up session, the non-cross-linked HA group had significantly better results than the cross-linked HA group in terms of large pores count and area (p = 0.01). In terms of changes over time, the non-cross-linked HA group showed significantly better improvements in the count and area of large pores compared to the cross-linked HA group (p = 0.03). Additionally, both groups experienced a significant decrease in the count and area of fine pores over time (p = 0.001), but the amount of changes was not statistically significant between the two groups (p = 0.06). Concerning acne grade, initially, 62.5% and 12.5% of cases in the cross-linked HA and non-cross-linked HA groups, respectively, had severe grades. However, in the last session, these percentages significantly decreased to 0% for both groups (p = 0.002 and 0.005, respectively). In terms of treatment complications, none of the patients experienced any adverse effects. CONCLUSION: The study demonstrated that both cross-linked HA and non-cross-linked HA were effective in reducing acne severity and improving the appearance of pores and spots. The treatments had similar effects on fine pores, spots, and overall acne severity. However, non-cross-linked HA appeared to have a better result on large pores compared to cross-linked HA.

Trifarotene Reduces Risk for Atrophic Acne Scars: Results from A Phase 4 Controlled Study.

BACKGROUND: Atrophic acne scarring often accompanies acne vulgaris. The efficacy of topical retinoids for treatment of acne is well documented; however, evidence for use in atrophic acne scars is limited. METHODS: In this randomized, split-face, double-blind study, subjects (age: 17-34 years, N = 121) with moderate-to-severe facial acne, with acne scars present, were treated with either trifarotene 50 µg/g or vehicle once daily for 24 weeks. Efficacy was assessed by absolute and percent change from baseline in atrophic acne scar counts, Scar Global assessment (SGA), and IGA success rates as well as acne lesion counts. RESULTS: At week 24, a statistically significantly greater reduction in the mean absolute change from baseline in the total atrophic scar count was noted in the trifarotene- vs vehicle-treated area (- 5.9 vs - 2.7; p < 0.0001) with differences between sides noted as early as week 2 (- 1.5 vs - 0.7; p = 0.0072). The SGA success rate was higher in the trifarotene side at week 12 (14.9% vs 5.0%, P < 0.05) and improved through week 24 (31.3% vs 8.1%, P < 0.001). Similarly, at week 24, the IGA success rate was higher with trifarotene (63.6% vs 31.3%, P < 0.0001) along with reductions in total (70% vs 45%) and inflammatory (76% vs 48%) lesion counts. The incidence of treatment-emergent adverse events was 5.8% (trifarotene) and 2.5% (vehicle); most common (> 1%) was skin tightness (1.7% vs 0.8%), and all events were mild to moderate in severity. CONCLUSIONS: Trifarotene was effective and well tolerated in treating moderate-to-severe facial acne and reducing atrophic acne scars, with reduction of total atrophic scar count as early as week 2. TRIAL REGISTRATION: Clinicaltrials.gov NCT04856904.

Self-assembled adipose-derived mesenchymal stem cells as an extracellular matrix component- and growth factor-enriched filler.

The clinical application of mesenchymal stem cells (MSCs) is attracting attention due to their excellent safety, convenient acquisition, multipotency, and trophic activity. The clinical effectiveness of transplanted MSCs is well-known in regenerative and immunomodulatory medicine, but there is a demand for their improved viability and regenerative function after transplantation. In this study, we isolated MSCs from adipose tissue from three human donors and generated uniformly sized MSC spheroids (∼100 µm in diameter) called microblocks (MiBs) for dermal reconstitution. The viability and MSC marker expression of MSCs in MiBs were similar to those of monolayer MSCs. Compared with monolayer MSCs, MiBs produced more extracellular matrix (ECM) components, including type I collagen, fibronectin, and hyaluronic acid, and growth factors such as vascular endothelial growth factor and hepatocyte growth factor. Subcutaneously injected MiBs showed skin volume retaining capacity in mice. These results indicate that MiBs could be applied as regenerative medicine for skin conditions such as atrophic scar by having high ECM and bioactive factor expression.

Osteopathic Approach for Keloids and Hypertrophic Scars.

The skin is a complex organ, a system that influences and is influenced by the body system, with different skin layers always mechano-biologically active. In the presence of a lesion that damages the dermis, the skin undergoes sensory, morphological, and functional alterations. The subsequent adaptation is the formation of scar tissue, following distinct and overlapping biological phases. For reasons not yet fully elucidated, some healing processes lead to pathological scars, from which symptoms such as pain, itching, and functional limitations are derived. Currently, there is no gold standard treatment that fully meets the needs of different scars and can eliminate any symptoms that the patient suffers. One such treatment is manual medicine, which involves direct manual approaches to the site of injury. Reviewing the phases that allow the skin to be remodeled following an injury, this article reflects on the usefulness of resorting to these procedures, highlighting erroneous concepts on which the manual approach is based, compared to what the current literature highlights the cicatricial processes. Considering pathological scar adaptations, it would be better to follow a gentle manual approach.

"Multiple Mode Procedures" of Ultra-Pulse Fractional CO2 Laser: A Novel Treatment Modality of Facial Atrophic Acne Scars.

BACKGROUND AND AIM: Fractional CO2 laser is therapeutic for acne atrophic scar, but its effect usually is limited after multiple sessions, with occasional adverse reactions. This study aimed to evaluate the efficacy and safety of a new modality combining ultra-pulse CO2 laser and fractional CO2 laser (multiple mode procedures [MMP]) in the treatment of acne atrophic scars. METHOD: From December 2017 to January 2023, a total of 103 patients with facial acne atrophic scars treated with MMP technique were retrospectively analyzed. MMP was performed for 1-4 sessions with an interval of approximately three months. Based on photographs taken before and after treatment, overall atrophic scar improvement was assessed according to the ECCA grading scale, the modified Manchester Scar Scale and the 4-point Global Assessment Scale (GAS). The safety was evaluated by the degree of pain during treatment and postoperative adverse reactions. RESULTS: All the 103 patients received treatment and completed follow-up, with an average of two sessions. The mean ECCA score decreased from 162.7 to 93.1 with statistically significant difference (p < 0.001). The mean GAS score increased by an average of 2.3 ± 0.9. The GAS improvement more evident for "boxcar" atrophic scars (2.7 ± 0.8) than for "rolling" (2.3 ± 0.8) and "icepick" scars (1.7 ± 0.8) (p < 0.001). The average improvement scores for color, distortion and texture were 2.0 ± 0.9, 2.2 ± 0.9 and 2.3 ± 0.8, respectively. The mean pain score during treatment was 3.9 ± 0.8, and the mean duration of erythema was 30.7 ± 3.5 days. Only three patients developed hyperpigmentation at the treated site within a few months. DISCUSSION: Ultra-pulse CO2 fractional laser MMP technique can effectively improve the condition of facial atrophic acne scars with limited adverse reactions.

Efficacy of fibroblast transplantation in the healing of cutaneous leishmaniasis scar: A case report.

Autologous fibroblast transplantation has been proven to be a promising method in wound healing with no side effects. This is the first study aimed to determine the efficacy and safety of autologous fibroblast cell injection to the atrophic scar caused by cutaneous leishmaniasis as an endemic disease in many middle-eastern countries. It causes chronic skin lesions and permanently disfiguring scars. Autologous fibroblasts were obtained from the patient's ear skin and were injected intradermally twice at 2-month intervals. Outcomes were measured using ultrasonography, VisioFace, and Cutometer. No adverse reaction was observed. The results showed improvements in epidermal thickness and density, melanin level, and skin lightening. Moreover, the skin elasticity in the scar area increased after the second transplantation. No improvement was observed in dermal thickness and density. A longer follow-up with more patients is recommended to investigate the effectiveness of fibroblast transplantation better.

Clinical evaluation of needle-free electronic pneumatic hyaluronic acid injection treatment for facial atrophic acne scars: A prospective, randomized comparative trial.

Acne scars are common but difficult to treat, and an effective new treatment strategy is desired. This prospective, split-face randomized controlled trial was designed to compare the safety and efficacy of needle-free electronic pneumatic hyaluronic acid injection (EPI-HA) treatment for acne scars. Thirty Japanese subjects with moderate to severe facial atrophic acne scars underwent EPI-HA treatment on a randomized side of their face. Three treatment sessions were carried out at 1-month intervals, and the subjects were followed-up for 3 months after the final treatment. Three months after the final treatment, 48.3% of treated sides met the criteria for success, compared with 0% for the control sides (P < 0.0001). Rolling type scars were much improved compared with boxcar types and icepick types. Satisfaction (or better) was reported by 55.2% of subjects at the 3-month follow-up after the final treatment, which was similar to the physicians' assessment. Three-dimensional in vivo imaging analysis detected significant difference in scar reductions between the treated and control sides in the mean scar area, scar depth, and maximum depth of the biggest scar at 1 and 3 months after the final treatment (all P < 0.05). In conclusion, EPI-HA treatment significantly improved rolling facial atrophic acne scars in our Japanese subjects, with minimal side effects.

Efficacy and safety of fractional 1064-nm picosecond laser for atrophic traumatic and surgical scars: A randomized, single-blinded, split-scar-controlled study.

OBJECTIVE: A fractional 1064-nm picosecond laser is an efficient and safe treatment for atrophic acne scars. However, evidence of using a picosecond laser for atrophic posttraumatic and surgical scar therapy is lacking. This study aimed to evaluate the efficacy and safety of using a 1064-nm picosecond laser with a microlens array (MLA) for the treatment of atrophic posttraumatic and surgical scars. METHODS: This was a prospective, intraindividual, single-blinded, randomized split-lesion-controlled trial. Twenty-five subjects with atrophic traumatic or surgical scars that existed for more than 1 year were enrolled. All atrophic scars were divided at the midline into two halves and randomly assigned to a treatment or control side. The treatment group was treated with a 1064-nm picosecond laser with an MLA handpiece (spot size: 6-8 mm, fluence: 1.0-1.2 J/cm2 , repetition rate: 5 Hz, three passes) for 3 monthly sessions. The scar volumes were objectively measured using a three-dimensional (3D) photograph at baseline, 1 month after the first and second treatments, and 3 and 6 months after the final treatment. Subjective assessments were conducted by a blinded dermatologist and patients' self-assessment to evaluate improvements at 3 months after the final treatment. RESULTS: The treated sides exhibited a significant volume reduction, with statistically significant improvements over the control group at 1 month after the first and second treatments and at 3 months after the final treatment (p = 0.024, 0.005, and 0.019, respectively). At 3 months after the final treatment, a blinded dermatologist correctly identified the treated side in 24 of 25 patients (96%). The patients rated the improvements as excellent (>75%) and marked (50%-75%) in 36% and 48% of patients, respectively. CONCLUSION: At 3 months, the 1064-nm picosecond laser with a fractionated MLA can significantly reduce the posttraumatic and postsurgical atrophic scar volume in patients with Fitzpatrick skin types III-V. Insufficient data preclude inferences regarding efficacy at 6 months.

A systematic review of the comparison between needling (RF-needling, meso-needling, and micro-needling) and ablative fractional lasers (CO2, erbium YAG) in the treatment of atrophic and hypertrophic scars.

The aim of this study is to compare needling (RF-needling, meso-needling, micro-needling) and ablative fractional lasers (CO2, erbium-YAG) in the treatment of atrophic and hypertrophic scars in a systematic review. The database was searched, and 10 articles were selected that were relevant in terms of content, topic, and purpose and met the inclusion criteria. Of all the articles reviewed in this study, there were 2 randomized split-face trials (20%), 1 controlled nonrandomized trial (10%), 1 controlled randomized phase III clinical trial (10%), 1 prospective trial (10%), 1 prospective nonrandomized open-label trial (10%), and 1 randomized comparative trial (10%), with the type of study not reported in 3 articles. We used Endnote X8 to review the articles and extract data. After review, the studies were analyzed and categorized. No statistically significant difference was found between the two methods, laser and micro-needling, in the treatment of atrophic and hypertrophic scars in 60% of the articles studied, and both showed significant improvement (70% or more improvement to complete response). Significant improvement was noted in 20% of the studies reviewed for the laser and micro-needling treatment methods. The results of this study show that needling and ablative fractional lasers are tolerable and safe procedures with no significant difference in the treatment of skin scars in sixty percent of the studies.

An Atlas of Optical Coherence Tomography (OCT): Elucidating In Vivo Differences of Scar Types Using OCT in Order to Guide Laser Treatment Parameters.

Objective: When using laser therapy to effectively treat scars, the choice of treatment parameters depends on the knowledge accuracy of the underlying scar pathology, which is often difficult to judge by gross physical exam. As such, more quantitative measures are needed. In recent years, optical coherencetomography (OCT) has shown promise as a real-time imaging technolgoy of skin microstructure. A key step in developing a methodology for utilizing OCT to develop a comprehensive 'atlas' of OCT characteristics of a wide variety of scar types. This atlas may then be used as a tool for selecting the optimal treatment modality and parameters for each scar type. Methods: One hundred and fifty scars of a wide range of anatomical locations were imaged using OCT, capturing both vascular and structural data. A variety of scar etiologies (e.g. burn, surgical, traumatic) and types (e.g. hypertrophic, keloidal, atrophic) were included. Comparator scans were also taken from normal, unscarred skin. Results: OCT revealed morphological differences in the epidermis and dermis between scars and normal tissue, and between scar subtypes. Features affected by scar pathology included epidermal thickness, skin surface texture, dermal epidermal junction rugosity, blood vessel density, vessel shape and diameter, vessel direction and vascular network, dermis scattering intensity and non-uniformity. Each scar subtype showed consistent characteristics distinct from other scar subtypes. Limitations: This was a single-site study of a patient population in South Florida. Conclusion: OCT is a powerful new objective tool for the clinician to utilize in the pursuit of effective laser treatment parameters by enabling personalized treatment based on individual scar characteristics in order to maximize treatment capabilities.

Combination treatment of COVID-19 associated herpes zoster scar with 1540 nm and 755 nm picosecond lasers: a case report.

A 33-year-old female, Fitzpatrick IV phototype, developed varicella zoster eruption over the ophthalmic dermatome of the right trigeminal nerve, confirmed through Polymerase Chain Reaction, 4 weeks after recovering from COVID-19 disease. After the resolution of the acute manifestations, she developed significant atrophic scars on the forehead, about 2 mm deep, with marked post-inflammatory hyperpigmentation. She came to our clinic looking for treatment, as the scars caused significant psychological distress. We decided for a combination treatment with Erbium:glass 1540 nm non-ablative laser and 755 nm Alexandrite picosecond laser. After 16 weeks of starting treatment, significant improvement was observed, with complete resolution of the hyperpigmentation and overall improvement in the atrophic scar. No complications occurred during the treatment period. This strategy may be an effective and safe option to treat these lesions, which may be increasingly found in young individuals after COVID-19 disease or SARS-CoV-2 vaccination, even in darker skin phototypes.

Platelet-rich plasma in the treatment of scars, to suggest or not to suggest? A systematic review and meta-analysis.

Despite the rising trend for applying platelet-rich plasma (PRP) in the management of various types of scars, there is no convincing evidence supporting its use. This motivated us to review the randomized clinical trials that examine the effectiveness and safety of PRP, alone or in combination with other methods, for the management of atrophic or hypertrophic/keloidal scars. The Web of Science, Scopus, Google Scholar, and Cochrane Library databases were systematically searched until September 1st , 2020. Thirteen clinical trials were enrolled in the meta-analysis, and 10 more were reviewed for their results. The random effect meta-analysis method was used to assess the effect size of each outcome for each treatment type, and I2 was used to calculate the statistical heterogeneity between the studies. Patients treated with PRP experienced an overall response rate of 23%, comparable to the results seen with laser or micro-needling (22% and 23%, respectively) When used alone, moderate improvement was the most frequently observed degree of response with PRP (36%) whereas, when added to laser or micro-needling, most patients experienced marked (33%, 43%, respectively) or excellent (32% and 23%, respectively) results. Concerning the hypertrophic/keloid scars, the only study meeting the required criteria reported a better improvement and fewer adverse effects when PRP was added to the intralesional corticosteroids. Platelet-rich plasma appears to be a safe and effective treatment for various types of atrophic scars. In addition, when added to ablative lasers or micro-needling, it seems to considerably add to the efficacy of treatment and reduce the side effects.