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Garg S
Baveja S
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Year : 2014 | Volume : 7 | Issue : 1 | Page : 18-23

Combination therapy in the management of atrophic acne scars

Garg S
Baveja S
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Shilpa Garg, Sukriti Baveja

Department of Dermatology, Base Hospital, Delhi Cantonment, Delhi, India
Click here for correspondence address and email
Date of Web
Publication

2-Apr-2014

Abstract
Background: Atrophic acne scars are diicult to treat. The demand for less invasive but
highly eective treatment for scars is growing. Objective: To assess the eicacy of
combination therapy using subcision, microneedling and 15% trichloroacetic acid (TCA)
peel in the management of atrophic scars. Materials and Methods: Fifty patients with
atrophic acne scars were graded using Goodman and Baron Qualitative grading. After
subcision, dermaroller and 15% TCA peel were performed alternatively at 2-weeks
interval for a total of 6 sessions of each. Grading of acne scar photographs was done
pretreatment and 1 month after last procedure. Patients own evaluation of improvement
was assessed. Results: Out of 16 patients with Grade 4 scars, 10 (62.5%) patients
improved to Grade 2 and 6 (37.5%) patients improved to Grade 3 scars. Out of 22
patients with Grade 3 scars, 5 (22.7%) patients were left with no scars, 2 (9.1%) patients
improved to Grade 1and 15 (68.2%) patients improved to Grade 2. All 11 (100%) patients
with Grade 2 scars were left with no scars. There was high level of patient satisfaction.
Conclusion: This combination has shown good results in treating not only Grade 2 but
also severe Grade 4 and 3 scars.

Ablative laser for scars

dermaroller for scars
subcision
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Keywords:Ablative laser for scars, dermaroller for scars, subcision

How to cite this article:
Garg S, Baveja S. Combination therapy in the management of atrophic acne scars. J
Cutan Aesthet Surg 2014;7:18-23
How to cite this URL:
Garg S, Baveja S. Combination therapy in the management of atrophic acne scars. J
Cutan Aesthet Surg [serial online] 2014 [cited2016 Aug 19];7:18-23. Available
from:http://www.jcasonline.com/text.asp?2014/7/1/18/129964

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Introduction

Acne is prevalent in over 90% adolescents and it persists into adulthood in approximately

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12%-14% of cases with psychological and social implications. [1],[2],[3] In some patients
with acne, the inammatory response results in permanent, disguring scars from either
increased tissue formation or due to loss or damage of tissue. Hypertrophic scars and
keloids are examples of scars that result from increased tissue formation. Scars with loss
or damage of tissue can be classied into icepick, rolling and boxcar scars. [4] There is no
standard treatment option for the treatment of acne scars. Medical management of
atrophic scars can be done by using topical retinoids. Surgical management can be done
using punch excision, elliptical excision, punch elevation, skin grafting and subcision
depending on the type of scar. Procedural management includes microdermabrasion,
chemical peels, percutaneous collagen induction by microneedling and dermabrasion.
Tissue augmentation can be done using xenografts, autografts and homografts. Various
ablative and non-ablative lasers and light energies are also available for treatment of
atrophic acne scars. [5] Out of these multiple treatment options, treatment has to be
tailored to patient's needs, tolerance, and goals along with the physician's assessment,
skills and expectation. Patient should be counselled that the ultimate goal of any
intervention is to improve the scars and no currently available treatment will attain total
cure or perfection.
In 1995, Orentreich and Orentreich described subcision as a method of subcuticular
undermining of scars using a tri-beveled hypodermic needle. This results in lifting the
scar by releasing the papillary dermis from the binding connections of the deeper tissues
and by the formation of connective tissue that results from the course of normal wound
healing. [6] It is mainly used for the treatment of rolling type of atrophic scars. [4]
The mechanism hypothesised for action of percutaneous collagen induction using
dermaroller is that it creates thousands of microclefts through the epidermis into the
papillary dermis. These wounds create a conuent zone of supercial injury which
initiates the normal process of wound healing [7] with release of several growth factors.
This stimulates the migration and proliferation of broblasts resulting in collagen
deposition [8] which continues for months after the injury. [9] Another hypotheses states
that on penetration of skin with the microneedles, the cells react with a demarcation
current which in addition to the needles own electrical potential results in release of
various growth factors. This cuts short the healing process and stimulates the healing
phase. [10] Dermaroller also opens pores in upper layers of epidermis and allows creams
to be absorbed more eectively by the skin.
Fifteen percent tricholoroacetic acid (TCA) peel is supercial peeling agent. It causes
exfoliation, improves the skin texture and induces collagen synthesis. [11]
The aim of our study was assessment of combination therapy using subcision,
dermaroller and 15% TCA peel for the management of atrophic acne scars. The rationale
for combining these three minimally invasive procedures was their additive action on
acne scars. Subcision releases the scars from the underlying adhesions which should be
the rst step for any treatment for acne scars. Microneedling with dermaroller causes
collagen induction along with enhancing absorption of tretinoin cream. Fifteen percent
TCA peel causes improvement in skin texture as well as collagen induction. Hence by
combining these three minimally invasive modalities one can release the scars, enhance
collagen induction, increased penetration of topical agents and resurface the skin.

Materials and Methods

Fifty patients with atrophic acne scars were enrolled in this study. Exclusion criteria
were patients with active acne, active herpes labialis, patients on systemic retinoids,
evidence or history of keloid scars, pregnancy or lactation, history of any facial surgery
or procedure for scars and patients with unrealistic expectations. All the patients were
counselled for surgical intervention and written informed consent was taken. The
atrophic acne scars were graded by a single non-treating physician using Goodman and
Baron Qualitative scar grading system [Table 1]. [12]

Table 1: Goodman and Baron Qualitative scar grading system

Click here to view

Patient's skin was primed using topical tretinoin cream 0.05% at night along with
sunscreen with a minimum SPF of 30 during the day for 2 weeks prior to starting the
treatment. At the start of treatment, subcision was performed only once using a 24G
needle. One day after the subcision, patient was called for the rst sitting of

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microneedling with dermaroller containing 192 needles of needle size 1.5 mm. Eutectic
mixture of lignocaine 2% and prilocaine 2% cream was applied under occlusion for 1
hour to the aected areas which was removed using gauze. Thereafter topical tretinoin
cream 0.05% was applied to the aected area. Treatment was performed by rolling the
dermaroller in vertical, horizontal and diagonal directions in the aected area until
appearance of uniform ne pinpoint bleeding. Then the area was wiped with saline
soaked gauze and tretinoin cream 0.05% was applied and washed o after 30 minutes.
Two weeks after dermaroller, patient was called for 15% TCA peel. Whole face was
cleansed using spirit and degreased using acetone. Fifteen percent TCA peel was applied
with cotton tipped applicator on full face. Appearance of speckled white frosting was the
end point of treatment with peel. After using dermaroller and 15% TCA peel, patient was
instructed to apply sunscreen in the morning and mometasone furoate cream 0.1% twice
daily for 5 days after which sunscreen was continued in the morning with tretinoin cream
0.05% applied at night time. Patient was asked to discontinue topical tretinoin cream
application 2 days prior to TCA peel. Thereafter, dermaroller and 15% TCA peel were
repeated alternately after every 2 weeks for six sessions of each and this was taken as
the end point of our study. In some patients who developed inammatory lesions of acne
during treatment, capsule doxycycline or topical clindamycin cream 1% was given as and
when required. Any adverse eects and interference in daily activities post-treatment
were noted. Patients were evaluated for results 1 month after the last procedure was
performed. Post-treatment scars were graded again by the same physician using
Goodman and Baron Scale. Patient graded their response to treatment as poor, good,
very good or excellent with 0-24%, 25-49%, 50-74% and 75-100% improvement,
respectively, in their acne scars. The patients were followed up for 1 year at two monthly
intervals to observe the sustenance of improvement in scars. Digital colour facial
photographs were taken before treatment, during each visit of treatment, at 1 month
after the last procedure and at 2 monthly intervals for 1 year after the last procedure.
Patients were instructed to continue application of topical tretinoin cream 0.05% for 1
year after the last procedure.
Statistical analysis
Descriptive statistics such as mean and standard deviation are calculated. Data is
presented in frequencies and their respective percentages. Data was entered and
analysed using SPSS version 18.

Results

Out of 50 patients, 49 patients completed the treatment. Out of 49 patients 2 patients

were treated with capsule doxycycline during the treatment protocol due to active acne
eruptions. Out of 49 patients there were 30 females and 19 males with age group
between 18-39 years with mean age of 25.6 5.2 yrs. 9 patients (18.4%) had Type III
Fitzpatrick skin type, 32 (65.3%) type IV and 8 (16.3%) patients had type V Fitzpatrick
skin type. Pre treatment melasma was present in 3 (6%) patients.
Out of 49 patients who completed the treatment, 16 patients had Grade 4, 22 patients
had Grade 3 and 11 patients had Grade 2 scars before treatment. The physician's
assessment of response to treatment based on Goodman and Baron Qualitative scar
grading system is summarised in [Table 2]. In patients with Grade 4 scars, 10 patients
(62.5%) showed improvement by 2 grades i.e., their scars improved from Grade 4 to
Grade 2 of Goodman Baron Scale [Figure 1]a and b. Six patients (37.5%) with Grade 4
scars showed improvement by 1 grade [Figure 2]a and b with scars being obvious at
social distances of 50cm or greater. In 22 patients with Grade 3 scars, 5 patients (22.7%)
showed improvement by 3 grades i.e., they were left with no scars at all [Figure 3]a and
b, Two patients (9.1%) improved by 2 grades and as per Grade 1 they were left with only
hyper-pigmented at marks [Figure 4]a and b and 15 patients (68.2%) showed
improvement by 1 grade by moving to Grade 2 [Figure 5]a and b as per Grade 2 their
scars were not obvious at social distances of 50cm or greater. All 11 patients (100%) who
had Grade 2 scars before treatment showed improvement by 2 grades in their scars and
were left with no scars [Figure 6]a-b and [Figure 7]a-b. Hence all 49 patients (100%) had
improvement in their scars by some grade with no failure rate. In patients with Grade 4
scars [Table 3], 12 patients (75%) graded their response to treatment as very good with
50-74% improvement in their acne scars after treatment and 4 patients (25%) had good
improvement in their scars with 25-29% improvement. In patients with Grade 3 scars, 8
patients (36.4%) graded their response to treatment as excellent with 75-100%
improvement in their scars and 14 patients (63.6%) reported the response as very good
with improvement between 50 and 74%. All 11 patients (100%) with Grade 2 scars
graded their response after treatment as excellent with improvement between 75 and
100%. Poor response with 0-24% improvement in scars was reported by none of the
patients. Improvement in scars was rst noted in majority of the patients after
completing two sitting of dermaroller and peel. At the end of 1-year of follow-up, it was
observed that all the 49 patients sustained the level of improvement in their grade of
scars which was attained at the end of the last procedure [Figure 8]a-c. Although

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improvement in the scars as noticed by the patient and the physician continued in the
follow up period of 1 year, there was no further shift in the grade of scars.
Figure 1: (a) Grade 4 acne scars; (b) Improvement in acne
scars from Grade 4 to Grade 2 after treatment
Click here to view
Figure 2: (a) Grade 4 acne scars; (b): Improvement in acne
scars from Grade 4 to Grade 3 after treatment
Click here to view
Figure 3: (a) Grade 3 acne scars; (b) Post-treatment patient
had no scars
Click here to view
Figure 4: (a) Grade 3 acne scars; (b) Improvement in acne
scars from Grade 3 to Grade 1 after treatment
Click here to view
Figure 5: (a) Grade 3 acne scars; (b) Improvement in acne
scars from Grade 3 to Grade 2 after treatment
Click here to view
Figure 6: (a) Grade 2 acne scars; (b) Post-treatment patient
had no scars
Click here to view
Figure 7: (a) Grade 2 acne scars; (b) Post-treatment patient
had no scars
Click here to view
Figure 8: (a) Grade 4 acne scars; (b) Improvement in acne
scars from Grade 4 to Grade 2 after treatment; (c): Sustenance
of improvement in acne scars from Grade 4 to Grade 2 at 1
year of follow-up
Click here to view
Table 2: Physician's assessment of response to treatment based
on Goodman and Baron Qualitative scar grading system
Click here to view
Table 3: Patient's assessment of response to treatment
Click here to view

There was improvement in rolling, boxcar and linear tunnel type of scars with little or no
improvement in ice pick scars. All patients tolerated the procedure well. Side eects
were mild and transient. Post-dermaroller transient erythema and oedema lasted for 1-4
days with a mean of 2.4 0.7 days. Post-peel exfoliation of skin was present from 2 to 7
days with a mean of 4.4 1 day. Only three patients (6%) developed post-inammatory
hyper-pigmentation (PIH) which was treated with sunscreen in the morning and triple
combination of tretinoin, hydroquinone and mometasone at night time. The PIH subsided
after 5 months of topical treatment. One patient (2%) developed mildly tender cervical
lymphadenopathy each time after dermaroller which lasted for around 3 weeks and
subsided on its own. There was no interference in daily activity with no loss of days at
work.

Discussion

This study has shown good results in patients with severe Grade 4 and 3 acne scars with
10 (62.5%) patients with Grade 4 scars moving to Grade 2 and 5 (22.7%) patients with
Grade 3 scars improving to have no scars at the end of treatment. In Grade 2 scars all
the 11 patients (100%) showed improvement by 2 grades and were left with no scars.
Hence, all 49 (100%) patients showed improvement in their scars by some grade with no
failure rate. The physician's analysis also correlated with the patient's assessment of
improvement in scars with 12 (75%) patients with Grade 4 scars reporting improvement
as very good, 8 (36.4%) patients with Grade 3 scars as excellent and 11 (100%) patients

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with Grade 2 scars as excellent with poor response reported by none of the patients. The
procedure was well tolerated by all the patients. Post-procedure there was no loss of
work days and side eects were mild and transient. In spite of patients being of Type III,
IV and V Fitzpatrick skin type, only three patients (6%) developed PIH during the
treatment, which subsided within 5 months of topical therapy. It has the advantage of
being an oice procedure and in being cost-eective. Topical tretinoin 0.05% favours the
development of a regenerative lattice-patterned collagen network rather than the parallel
deposition of scar collagen found with cicatrisation. Since dermaroller opens pores in the
upper layer of epidermis and allows creams to be absorbed more eectively, it is for this
reason that topical tretinoin was applied during dermaroller and kept for 30 minutes
post-procedure to maximise its absorption in skin. Also the improvement in the grade of
scars was sustained in the follow-up period of 1 year.
Although ablative laser resurfacing is generally considered to be the most eective
option for scar resurfacing, it is associated with signicant damage to the epidermis and
basal membrane with associated inammation which causes erythema, scarring and
pigmentation problems. [13],[14],[15] It also has a long downtime. In comparison,
percutaneous collagen induction does not induce post-operative dyspigmentation as the
epidermis and basal membrane are left intact. [16]

Conclusions

As the demand for less invasive, highly eective cosmetic procedures is growing, this
combination of treatment for acne scars has shown good results not only in Grade 2 but
also in severe Grade 4 and 3 acne scars. The treatment is well tolerated in Fitzpatrick
skin types III, IV and V with no failure rates or loss of days at work. There is a high level
of patient satisfaction, minimal downtime and the treatment is cost-eective to the
patient. To our knowledge, this is the rst study using this combination of therapy in the
management of atrophic acne scars and the rst in which topical tretinoin cream was
applied both during and immediately after doing dermaroller.

References
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14. Ross EV, Naseef GS, McKinlay JR, Barnette DJ, Skrobal M, Grevelink J, et al.
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15. Bernstein LJ, Kauvar AN, Grossman MC, Geronemus RG. The short- and long-term
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Correspondence Address:
Shilpa Garg
22/11 Geeta Mandir Marg, New Rajinder Nagar, New Delhi - 110 060
India
Source of Support: None, Conict of Interest: None

DOI:10.4103/0974-2077.129964

Figures
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure
8]

Tables
[Table 1], [Table 2], [Table 3]

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