Subcision Versus 100% Trichloroacetic Acid in the Treatment of Rolling Acne Scars

Transcription

1 Subcision Versus 100% Trichloroacetic Acid in the Treatment of Rolling Acne Scars SHAHIRA ABD EL-RAHMAN RAMADAN, MD, MOHAMED HUSSEIN MEDHAT EL-KOMY, MD, DALIA AHMED BASSIOUNY, MD, AND SEHAM AHMED EL-TOBSHY, MSC y BACKGROUND Acne scarring is common but surprisingly difficult to treat. Newer techniques and modifications to older ones may make this refractory problem more manageable. The 100% trichloroacetic acid (TCA) chemical reconstruction of skin scars (CROSS) method is a safe and effective single modality for the treatment of atrophic acne scars, whereas subcision appears to be a safe technique that provides significant improvement for rolling acne scars. OBJECTIVE acne scars. To compare the effect of the 100% TCA CROSS method with subcision in treating rolling METHODS Twenty patients of skin types III and IV with bilateral rolling acne scars received one to three sessions of the 100% TCA CROSS technique for scars on the left side of the face and subcision for scars on the right side. RESULTS The mean decrease in size and depth of scars was significantly greater for the subcision side than the 100% TCA CROSS (po.001). More side effects in the form of pigmentary alteration were observed with the 100% TCA CROSS method. CONCLUSION For rolling acne scars in patients with Fitzpatrick skin types III and IV, subcision shows better results with fewer side effects than the 100% TCA CROSS technique, although further decrease in scar depth with time occurs more significantly after 100% TCA CROSS. The authors have indicated no significant interest with commercial supporters. Acne scarring originates from a deep inflammatory reaction and involves the destruction or loss of connective tissue with dermal atrophy and fibrosis. During the maturation phase, the scar contracts and pulls the surface layers, causing indentation of the skin, resulting in atrophic scars, the most common type of postacne scarring. 1 Acne scarring is common but surprisingly difficult to treat. 2 A high concentration of trichloroacetic acid (95 100% TCA) applied focally to atrophic acne scars has been histologically shown to increase collagen fibers in the dermis and to result in shallower depth of acne scars. 3 This is called the chemical reconstruction of skin scars (CROSS) method. 4 Subcision is a procedure that releases subcutaneous fibrotic strands that tether the overlying tissue. The controlled trauma creates new connective tissue formation under the defect for additional support. The technique severs the fibrous bands while initiating a reactive fibrosis that gradually, over several weeks, propels the depressed scar upward. 5 The aim of this work was to compare the efficacy of a high-concentration TCA CROSS method with subcision in the treatment of atrophic rolling acne scars. Patients and Methods Participants Twenty participants of both sexes of skin types III and IV with postacne scars were recruited from the Department of Dermatology, Faculty of Medicine and y Department of Dermatology, Students Hospital, Cairo University, EL-Manial, Cairo, Egypt & 2011 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: Dermatol Surg 2011;37: DOI: /j x 626

2 RAMADAN ET AL dermatology outpatient clinic of Kasr El-Aini Hospital after approval from the Dermatology Research Ethical Committee of the Faculty of Medicine, Cairo University. Inclusion criteria included the presence of bilateral rolling facial acne scars and age of 16 and older. Exclusion criteria included taking systemic retinoids or immunosuppressive drugs during or within 6 months before the study; other dermatologic diseases, coagulation defects, or blood diseases; and a history of keloid scars. Patients with more than five active lesions (papules or pustules) on each side of the face were excluded, as were those with nodulocystic acne. A thorough personal and medical history and a general dermatological examination were performed for all recruits. Acne scar severity was graded according to the qualitative global acne scaring grading system (1 = macular: erythematous, hyper- or hypopigmented flat marks, 2 = mild: mild atrophy or hypertrophy that may not be obvious at social distances of 50 cm or greater, 3 = moderate: moderate atrophic or hypertrophic scarring obvious at social distances of 50 cm or greater but still able to be flattened by manual stretching of the skin, and 4 = severe: severe atrophic or hypertrophic scarring obvious at social distances of 50 cm and not able to be flattened by manual stretching of the skin). 6 For each patient, rolling scars on the left side of the face were treated using the TCA 100% CROSS technique, and subcision was performed for the scars on the right side. Methods The skin of both sides was cleaned and degreased with acetone. A nontoxic gentian violet surgical marker was used to outline the scars to be treated with the patient in an upright position. The patient laid down with the head resting at 451, and the size of the scar (length width) was measured using the cm/mm scale on the barrel of the marker from edge to edge at the center widest point for width and from point to point of the tangential arcs for length. The depth was measured using a wooden stick scaled in millimeters and dipped to the center of each scar; the part below the skin surface was calculated and measured to represent the depth. The same instruments were used for all patients. The mean size and depth of all scars that were to be treated per side of face per patient were calculated at baseline, at each visit, and at the end of follow-up. For local anesthesia, Mepecain L (carpule: mepivacaine HCL 2% and levonordefrin 1:20,000) was administered intralesionally on the side of subcision. While waiting for maximal vasoconstriction and anesthesia, TCA CROSS was performed on the opposite side. 100%TCA CROSS: Wooden applicator tips were sized to a dull point to approximate the size of the scars and used to apply the 100% TCA, which a local pharmacy made to order (Figure 1). Subcision: A 1.5-inch NoKor Admix needle (Becton Dickinson and Co, Franklin Lakes, NJ) was capped on an insulin syringe and subcision performed as described in the literature. Topical antibiotic cream and a loose bandage were applied, to be left on for 24 hours. Postoperative Care: After each session, patients were instructed to minimize sun exposure, trauma, and tension to the scar site for as long as possible. Antibiotic cream was applied on both sides until focal crust formation on the TCA CROSS side. Daily sunscreen was prescribed for 1 month after the procedure. Follow-Up: Patients were instructed to come back 1 week after the first session and monthly after that. At each visit, clinical appearance was compared with baseline and reported for up to 10 months. Improvement Criteria 1. Size: any measurable decrease in size was considered to be a sign of improvement. 37:5:MAY

3 TREATMENT OF ROLLING ACNE SCARS version 15 (SPSS, Inc., Chicago, IL) for analysis. Data were summarized using means and standard deviations for quantitative variables and percentages for qualitative variables. The two sides were compared using the McNemar test and marginal homogeneity test for qualitative variables and the NPar Wilcoxon signed rank test and Mann-Whitney test for quantitative variables. Po.05 was considered statistically significant. Results Figure 1. Trichloroacetic acid chemical reconstruction of skin scars technique for rolling acne scars. 2. Depth: any measurable decrease in depth was considered to be a sign of improvement. 3. Color: improvement was defined as no color changes or return of scars to skin color after the procedure. 4. Three blinded dermatologists were asked to record percentage of improvement for each patient by comparing side-by-side before-and-after digital photographs of both sides of the face. At the final visit, patients were asked to assess the overall response and their satisfaction with each side as a percentage and which technique they recommended. Data Management and Statistical Analysis An Excel spread sheet (Microsoft, Redmond, WA) was developed for data entry after the data were coded. All data obtained were transferred to SPSS The study included 20 patients (14 (70%) female, 6 (30%) male) with bilateral rolling facial acne scars. Fifteen patients were of skin type III, and five were skin type IV. Ages ranged from 20 to 52 (mean ). The duration of scars ranged from 2 to 38 years (mean years). Patients had different grades of acne scars; four (20%) had mild, 14 (70%) had moderate, and two (10%) had severe scars, according to the qualitative global acne scaring grading system. All patients underwent from one to three sessions at intervals ranging from 1 to 4 months. Scar parameters before treatment are given in Table 1. There was a statistically significant difference in size (p =.001) and depth (p =.01) between the sides before treatment. The baseline mean size of all scars treated using subcision was cm 2 ; at the end of follow-up, this had decreased to cm 2 (po.001) (Figure 2). Depths of all scars decreased after subcision (po.001). Two patients had statistically insignificant residual erythema at the end of follow-up. The baseline mean size of all scars treated using 100% TCA CROSS was cm 2,it decreased to cm 2 by the end of follow-up (p =.001) (Figure 2). Depths of all scars decreased after 100% TCA CROSS (po.001) (Figures 3 and 4). Five patients had residual erythema, three developed hyperpigmentation, and two showed mild 628 DERMATOLOGIC SURGERY

4 RAMADAN ET AL TABLE 1. Scar Parameters of Both Sides Before Treatment Parameter 100% Trichloroacetic Acid Chemical Reconstruction of Skin Scars Side Subcision Side p-value Size, cm 2, mean 7 SD (range) ( ) ( ).001 Depth, cm, mean 7 SD (range) ( ) ( ).01 Color, n (%) Skin 18 (90%) 20 (100%) F Erythematous 1 (5%) F Hypopigmented 1 (5%) F SD, standard deviation. hypopigmentation after treatment. There was a statistically significant difference (p =.008) in color before and after therapy. Comparison of Subcision Side and 100% TCA CROSS Side at End of Follow-Up Mean decrease in size for subcised scars was cm 2, whereas for scars treated with 100% TCA, it was cm 2 (po.001). A statistically significant difference between subcision and 100% TCA CROSS in terms of decrease in scar depth was also observed, with depth decreasing more on the subcision side (p =.001). Pigmentary alteration from baseline was more on the 100% TCA CROSS side (50%) than on the subcision side (10%). The difference in improvement in facial acne scarring with subcision and 100% TCA CROSS side was statistically significant according to physician evaluation and subjective patient assessment (Figure 5). There was a significant negative correlation between scar depth after 100% TCA CROSS and follow-up duration (r = 0.534). There was also a significant negative correlation between patient age and scar depth (r = 0.635), the older the patient, the greater the scar depth improvement. Discussion The surgical choice for rolling or depressed scars (although not for ice pick or atrophic scars or infected areas) is subcision. 7 The CROSS method has been described for the treatment of atrophic scars, especially of the ice pick type. 4 A study by Hee Jung et al. also showed improvement in rolling acne scars. 8 Results of the current study show that subcision and the 100% TCA CROSS technique are useful in the treatment of rolling acne scars. Rolling acne scars respond better to subcision than TCA 100% CROSS, with a significantly greater decrease in scar depth and size on the subcised side. Figure 2. Mean scar size (cm 2 ) before and after treatment on both sides. Scar depth seemed to decrease with time after 100% TCA CROSS, as indicated by a negative correlation 37:5:MAY

5 TREATMENT OF ROLLING ACNE SCARS Figure 3. Rolling acne scars (A) before subcision, (B) 10 months after subcision, (C) before chemical reconstruction of skin scars (CROSS), and (D) 10 months after CROSS. between scar depth measurement and length of time after procedure (r = 0.534). The fact that the high concentration of TCA stimulates dermal collagen remodeling for several months after the peel explains this. 9 Many investigators have observed that the clinical effects of TCA were due to reorganization in dermal structural elements and an increase in dermal volume as a result of an increase in collagen content, glycosaminoglycan, and elastin Similar to Lee et al., 4 the degree of clinical improvement was proportional to the number of courses of CROSS treatment, although in most cases, two sessions were sufficient for favorable results in our study. Vaishnani 13 stated that results after subcision differ at 2 months and 6 months, with greater improvement observed over time, because scar remodeling is a continuous process, and it cannot be considered to be in a steady state until at least 2 years after wounding. Although, we observed a decrease in the size and depth of subcised scars over time, it was not statistically significant in our cases, although 630 DERMATOLOGIC SURGERY

6 RAMADAN ET AL Figure 4. Rolling acne scars (A) before subcision, (B) 10 months after subcision, (C) before chemical reconstruction of skin scars (CROSS), and (D) 10 months after CROSS. follow-up was 10 months, and further improvement may have occurred after this period. The CROSS method is used to maximize the effects of TCA and to overcome complications such as scarring and postinflammatory hyperpigmentation and hypopigmentation, which are known to develop frequently in dark-skinned patients. 4 None of our patients whose scars were treated using 100% TCA CROSS developed scarring; five patients showed persistent erythema at the end of follow-up that was mild and subsiding, three (15%) developed hyperpigmentation, and two (10%) had mild hypopigmentation. The one patient who presented with an erythematous scar at baseline had normal-looking skin by the end of follow-up, whereas another patient with a hypopigmented scar at baseline remained unchanged. These changes were not seen for subcised scars except for persistent erythema in 2 patients. Two patients developed residual erythema on both sides, which was a personal factor rather than the effect of the modality used. Nonetheless, the 37:5:MAY

7 TREATMENT OF ROLLING ACNE SCARS degree of improvement of these two methods. Most patients included in this study had no active acne lesions, and in the few patients who had mild inflammatory lesions, subcision, and TCA CROSS did not seem to exacerbate acne vulgaris lesions. In conclusion, for rolling acne scars in patients of Fitzpatrick skin types III and IV, subcision shows better results and fewer side effects than 100% TCA CROSS, although 100% TCA CROSS can be a useful alternative in patients with contraindications to subcision. Figure 5. Mean estimate of physicians and patient of overall improvement on each side. color changes associated with the 100% TCA CROSS method are expected to be less in fairskinned individuals (Fitzpatrick skin types I and II). Subcision severs the tethering fibrous bands that cause rolling scars and formation of connective tissue and focal collagen deposition, resulting in augmentation of depressed sites TCA causes necrosis of collagen in the papillary to upper reticular dermis, 17 followed by reorganization in dermal structural elements and an increase in dermal volume as a result of an increase in collagen content, glycosaminoglycan, and elastin The better response of scar depth in older patients suggests that scar duration may affect the results of CROSS and subcision. Because both procedures were associated with tightening of the skin at the areas treated, this may be the cause of the superior results in our older patients. Even though this study was limited by the greater mean size and depth of scars on the right side of the face (the subcision side) at baseline, subcision resulted in greater improvement at the end of the study than TCA CROSS. It would be interesting to examine whether scar parameters influence the References 1. Choi JM, Rohrer TE, Kaminer MS, Batra RS. Surgical approaches to patients with scaring. In: Arndt KA, Dover JS, Alam M, editors. Scar Revision. 1st ed. Philadelphia: Elsevier; p Alam M, Dover JS. Treatment of acne scaring. Skin Ther Lett 2006;11: Yug A, Lane JE, Howard MS, Kent DE. Histologic study of depressed acne scars treated with serial high-concentration (95%) trichloroacetic acid. Dermatol Surg 2006;32: Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatol Surg 2002;28: Alam M, Omura N, Kaminer MS. Subcision for acne scarring: technique and outcomes in 40 patients. Dermatol Surg 2005;31: Goodman GJ, Baron JA. Postacne scarring: a qualitative global scarring grading system. Dermatol Surg 2006;32: Rivera Albert E. Acne scarring: a review and current treatment modalities. J Am Acad Dermatol 2008;59: Hee Jung K, Tae Gyun K, Yeon Sook K, Park JM, et al. Comparison of a 1,550 nm Erbium:Glass fractional laser and a chemical reconstruction of skin scars (CROSS) method in the treatment of acne scars: a simultaneous split-face trial. Lasers Surg Med 2009;41: Otley CC, Roenigk RK. Medium-depth chemical peeling. Semin Cutan Med Surg 1996;15: Stegman SJ. A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthet Plast Surg 1982;6: Brodland DG, Roenigk RK, Cullimore KC, Gibson LE. Depths of chemexfoliation induced by various concentrations and application techniques of trichloroacetic acid in a porcine model. J Dermatol Surg Oncol 1989;15: Butler PE, Gonzalez S, Randolph MA, Kim J, et al. Quantitative and qualitative effects of chemical peeling on photo-aged skin: an experimental study. Plast Reconstr Surg 2001;107: DERMATOLOGIC SURGERY

8 RAMADAN ET AL 13. Vaishnani JB. Subcision in rolling acne scars with 24G needle. Indian J Dermatol Venereol Leprol 2008;74: Goodman GJ. Postacne scarring: a review of its pathophysiology and treatment. Dermatol Surg 2000;26: Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. In: Harahap M, editor. Surgical Techniques for Cutaneous Scar Revision. New York: Marcel Dekker; p Fulchiero GJ Jr, Parham-Vetter PC, Obagi S. Subcision and 1,320- nm Nd:YAG nonablative laser resurfacing for the treatment of acne scars: a simultaneous split-face single patient trial. Dermatol Surg 2004;30: Brody HJ. Variations and comparisons in medium-depth chemical peeling. J Dermatol Surg Oncol 1989;15: Address correspondence and reprint requests to: Mohamed Hussein Medhat EL-Komy, MD, 5 Falaky Square Bab EL-Louk, Cairo, Egypt, or komy_m@yahoo.com 37:5:MAY