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Acne Scar Treatment in Edmonton

Acne is one of the most prevalent and difficult inflammatory skin illnesses doctors face. The disease commonly manifests at puberty, affecting 95%–100% of teenage males and 83%–85% of adolescent girls, and continues into adulthood in around 12%–14% of instances. Scarring is one of the most unpleasant and long-lasting outcomes of acne, affecting up to 95% of patients, with 30% experiencing severe scarring. Three, four are acne scars unsightly, but they may also impose a major social and societal cost. They have been identified as a risk factor for several psychological outcomes, including suicide, depression, anxiety, low self-esteem, social impairment, poor academic achievement, and unemployment. 4,5,6 Acne scar formation is caused by an abnormal wound healing response triggered by epidermal inflammation, resulting in an imbalance in matrix breakdown and collagen production. The final severity of acne is connected to the acne grade and the length of time between active disease treatment. 8 The ultimate consequence is either an overabundance of collagen resulting in hypertrophic/keloid scars or, more typically, reduced collagen deposition resulting in atrophic acne scars in 80 to 90% of instances.

 

Atrophic Scars

Jacob and colleagues defined three fundamental forms of atrophic acne scars:

Among atrophic scars, the ice pick type accounts for 60%–70%; the boxcar type accounts for 20%–30%; and the rolling type accounts for 15%–25%. According to Goodman and Baron’s qualitative scarring grading system, a macular acne scar type exists, which manifests clinically as erythematous, hyperpigmented, or hypopigmented flat scars. These three scar forms are often found in the same individual, making differentiation difficult. On the one hand, this categorization system facilitated the adoption of a uniform and standardized definition of acne scars in clinical research and assisted in developing treatment regimens. On the other hand, clinical evaluation of scars indicates substantial heterogeneity amongst assessors, and the absence of a globally acknowledged quantitative or qualitative rating method makes it impossible to compare scarring therapies.

 

Acne Scar Treatment methods

Numerous characteristics, including color, depth, and shape, might influence the therapy option for every given scar, and a mixed modality strategy may result in more improvement than a single modality method. While significant progress has been made in developing novel therapeutic technologies and applications over the past decade, a shortage of high-quality clinical trials supporting many of these medicines and combinations exists. A 2016 Cochrane review concluded that there was insufficient evidence to justify the first-line use of any strategy for acne scar therapy. Additionally, the relative safety of the various methods as monotherapies or in combination had not been established properly, and there were no randomized controlled trials (RCTs) to identify the standard gold therapy against which the other techniques should be assessed.

 

energy-based devices and Lasers

Given these obstacles, a multidisciplinary panel of worldwide scar management specialists was convened to produce therapy recommendations based on existing research and expert opinion. In 2020, the same group will conduct a similar endeavor for traumatic scars.

 

METHODS of investigating Acne Scar treatment

An international panel of 24 dermatologists and plastic surgeons was self-assembled to update consensus guidelines for treating acne scars. Panelists from 12 different nations offered a diverse spectrum of expertise in academic, private practice, and hospital-based settings. Four authors selected the first clinical questions based on panel feedback and literature research. Between March 2020 and February 2021, a two-step modified Delphi technique was developed. The Delphi method is an iterative technique for achieving agreement on a specific clinical issue when published data is few or contradictory and expert opinions are essential. Our modified Delphi approach included two rounds of email surveys that focused on the following topics:

  1. The role of the Laser in preventing and treating acne scarring in an active acne patient.
  2. The use of various lasers in treating distinct forms of acne scars.
  3. Combinations of treatments, including lasers.
  4. Considerations for those with darker skin.

The last section of the questionnaire included ten photographs of real-life clinical situations. Each panelist recommended a treatment strategy to attain the greatest cosmetic result.

 

The role of EBD in preventing and treating acne scarring in an active acne patient

The coexistence of current inflammatory acne lesions with acne scars presents both a difficulty and an opportunity for effective scar care. The time interval between the development of acne and the first successful therapy has been identified as a risk factor for developing acne scars. While the majority of patients are treated solely with topical and systemic anti-acne medications, prior research has shown that a variety of lasers, including intense pulsed light (IPL), diode, 585/595 nm pulsed dye laser (PDL), 532 nm potassium titanyl phosphate (KTP) lasers, several infrared lasers, including the 1550 nm erbium glass, 1064 nm, and 1320 20-25 The postulated mechanism of action is via lowering Propionibacterium acnes (P. acnes) levels, interfering with sebum production, and decreasing inflammation. 25-27 When combined with medical treatment, laser therapies are anticipated to provide the most benefit to individuals with acne vulgaris,28 and the research on their effectiveness is developing quickly. Mounting data is demonstrating the efficacy of fractional radiofrequency (FRF) microneedling in the treatment of active acne, either alone or in conjunction with other lasers such as carbon dioxide (CO2) lasers. FRF was proven to help reduce acne lesions (inflammatory and noninflammatory) and sebum excretion.

 

Isotretinoin and Lasers

Patients with nodulocystic and severe acne who are currently on or have just discontinued isotretinoin are likewise very likely to benefit from lasers intervention to minimize scarring. Isotretinoin (13-cis-retinoic acid) is a vitamin A metabolite authorized by the FDA to treat severe acne, acne that is resistant to conventional therapies, and instances in which alternative treatments might leave scars or have a negative emotional impact. It is beneficial in individuals with severe acne, with multiple benefits, including involution of the pilosebaceous unit, reduction of acne lesions and associated scarring, and reduction of anxiety and depression-related symptoms.

For decades, dogma dictated that patients on isotretinoin, or within 6 to 12 months of completing a course, should avoid most cutaneous procedures due to a heightened risk of delayed wound healing and increased dermal (hypertrophic/keloid) scarring in the context of decreased healing potential due to pilosebaceous apparatus diminution. Surprisingly, this broad and enduring prescription was mostly based on a tiny number of case reports from the 1980s, including mechanical dermabrasion. This subject was revisited in 2017 with the publishing of two seminal consensus papers, one of which was sponsored by the American Society for Dermatologic Surgery (ASDS). Only three cases of aberrant scarring after laser operations within six months of starting isotretinoin were identified via a literature search, including one using an argon laser and one using a completely ablative Er: YAG, and one using a pulsed dye laser. The ASDS task force concluded that there was insufficient evidence in the literature to justify delaying treatment with hair removal devices and non-ablative fractional lasers, or fractional ablative lasers (AFL) in patients who are currently receiving or have recently received isotretinoin. Additionally, they suggested that completely ablative (i.e., non-fractionated) therapies be avoided for at least six months after the conclusion of isotretinoin.

The consensus panel that authored the JAMA Dermatology article reached a similar conclusion, indicating that delaying procedural intervention for 6–12 months following isotretinoin completion contradicts current trends toward early scar intervention and effectively delays treatment for a condition with significant physical and mental consequences.

 

Lasers for the prevention and treatment of acne scars in a patient with active acne

74% of panel participants felt that patients with active acne and acne scars should get Lasers in addition to topical or systemic medicines. The motivation for utilizing lasers was to alleviate the intensity and length of inflammation and the possibility of scarring (98 percent of panelists) and enhance the efficacy of topical or oral medicines (54 percent of the panelists).

 

The most compelling reasons for using Laser in the treatment of active acne were as follows:

  • Candidate for oral medicine who is not a good candidate (e.g., pregnancy, mental health difficulties, etc.) (94 percent of panelists).
  • Existing scars (75 percent ).
  • Scarring risk is increased in active inflammatory lesions (69 percent ).
  • Vascular lasers were the respondents’ favorite EBD for treating inflammatory acne (80%).
  • 75% of respondents utilize 595-nm PDL. Most panelists chose a pulse width of three to ten milliseconds (67 percent ). The recommended parameters for 595-nm PDL were 7–10 mm, 3–10 milliseconds, and 6.5–10 J/cm2, with a minority of respondents preferring pulse lengths of 5–10 mm, 0.45–1.5 milliseconds, and 5–9 J/cm2.
  • 50% of panelists utilize the 1064-nm Nd: YAG laser. This wavelength may be advantageous for patients with darker skin tones owing to lower melanin absorption or for individuals with hypertrophic scars due to increased penetration depth.
  • Additionally, panel members utilized AFL and NAFL (25 percent of panelists) and FRF to control inflammatory acne (20 percent ).
  • The majority (82 percent) of panel experts felt that concurrent therapy with vascular, AFL, or NAFL and oral antibiotics might have a beneficial synergistic impact on inflammatory acne.
  • Most panelists (82 percent) believe that lasers may be administered safely in conjunction with isotretinoin in suitable circumstances.
  • Thirty-three percent of panelists stated that combination therapy might synergize anti-inflammatory and anti-scarring impacts.

Most panelists (80%) said that vascular lasers were their preferred laser for individuals using isotretinoin. Approximately three-fourths of respondents indicated the necessity to change vascular laser parameters, including the pulse intensity and the number of passes, when isotretinoin was used.

Sixty-five percent and forty-five percent of panelists favored using NAFL and AFL during isotretinoin therapy. There was an equal split among those who would not use AFL while on isotretinoin between those who advocated waiting 1–5 months and those who advocated waiting six months or longer following discontinuation.

 

Conclusions and potential research directions

The panel members agree that some lasers, notably vascular lasers, may be used safely with isotretinoin therapy. It is critical to assess the continuum of cumulative thermal harm and anticipated relative dangers associated with devices ranging from vascular through NAFL, AFL, and eventually completely ablative “full-field” lasers. Given the negative effect of acne scarring on overall psychological well-being and quality of life, a more comprehensive treatment paradigm is necessary. Indeed, early intervention should be implemented for lasers, and informed consent should include a discussion of these choices. Additional study is necessary to establish the safety and effectiveness of each platform in the presence of isotretinoin and determine the existence or absence of a synergistic response.

 

The use of various lasers in the treatment of various kinds of acne scars

lasers, especially lasers and FRF, have emerged as a non-invasive alternative for treating acne scars in the recent decade. 45 Controlled thermal and non-thermal harm to the epidermis/dermis (e.g., Picosecond lasers) induces extracellular matrix remodeling, collagen, and elastin formation, depending on the laser wavelength used dyspigmentation, and erythema reduction. 46-48

 

Panel recommendations: selecting a device and its settings

The most important things to think about when choosing a laser were the type and location of acne scars (e.g., boxcar, ice pick, rolling) (77 percent of panelists). Fitzpatrick’s skin type and how many scars he had were not very important (56 percent and 43 percent, respectively). One reason might be that fractional devices are more tolerable for people with darker skin types because of the water chromophore (AFL, NAFL) and the amount of epidermal sparing (FRF).

A lot of people said that lasers should be used as the first-line treatment for the following types of scars: macular discoloration (95 percent), mild atrophic (rolling), and moderate atrophic scarring (73 percent) (95 percent ). A lot of people have superficial boxcar scars, 78 percent of the time

Panelists said that superficial boxcar scars (91%) were the scars that were most likely to respond to laser treatment for atrophic acne scars. People used AFL to get boxcar scars (62 percent ). The following table lists the platforms that were used for each type of acne scar.

In light of how much improvement is expected to be made at the end of a normal course of laser treatment:

  • AFL saw a 51%–70% increase in its score.
  • NAFL and R.F. devices got better by 31 percent to 70 percent.
  • Vascular devices got better by 31%–>70%. (erythema).

Most of the people who took part in the poll said that six months after the last treatment was the best time to look at the results of laser therapy for acne scars. Most people (95%) would keep laser therapy going if there were no contraindications and the disease kept getting better, rather than sticking to a set number of sessions.

after acne scars

Laser Resurfacing

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