-Can Laser skin resurfacing effectively treat facial atrophic acne scars? -Review treatment of acne scar in resurfacing laser -รักษาหลุมสิวด้วยเลเชอร์

1. Can Laser skin resurfacing
effectively treat facial atrophic
acne scars?
Wutinan Sithipolvanichgul, Thailand, MD
University of Hertfordshire, United Kingdom

2. Patient history
•
Female 25 years old suffered from
acne for 1 year +
•
Few comedones on cheeks
•
A mixture of acne scars, including ice
pick scars, boxcar scarring and rolling
scars on both cheeks .
•
Skin type IV
•
No past illness and no keloid lesions
•
Lack of self-confidence

3. Can laser skin resurfacing effectively treat facial
atrophic acne scars?
1. Magnani LR &
Schweiger ES,2013
2. M.W.S. Ong & S.J. Bashir,
2012
Fractional
Co2 laser
Ablative
Resurfacing Laser
2. M.W.S. Ong & S.J. Bashir,
Non2012
Ablative
non
Fractional
Fractional
non
Fractional
FP = Fractional photothermolysis
FPS= Non-ablative 1550-nm erbium-doped fractional photothermolysis systems
CO2 FS = 10 600-nm carbon dioxide fractional laser systems
Er:YAG
Co2 laser
3. Manuskiatti W et al, 2013
Er:glass 1550
or 1540
4. Lene Hedelund et al,2013
5. M.W.S. Ong et al, 2010

4. Evidence for use of selected treatment
Author(s)
Type of evidence e.g.
RCT, guidelines
Details of study or
publication
Key findings & conclusions
Magnani LR,
Schweiger ES.
Systematic Review
Fractional CO2 Lasers
for Atrophic Acne
Scars,
Journal of Cosmetic
Laser Therapy (2013)
2008-2013
20 studies:
18 Prospective,
2 Retrospective
Fractional CO2 laser resurfacing is a safe and
effective treatment for atrophic acne scar.
M.W.S. Ong , S.J.
Bashir
Systematic Review,
Fractional laser
resurfacing for acne
scars: a review, British
Journal of
Dermatology (2012 )
2003-2011
26 studies: 4 RCT
13 ablative FP,
13 nonablative FP
Ablative FP had an improvement range of 26–
83% in acne scar. Non ablative FP had an
improvement range of 26–50%.
“There are limitations for comparing results of
treatments between ablative and nonablative
FP lasers”.
Manuskiatti W,
Iamphonrat T,
Wanitphakdeede
cha R, Eimpunth S
RCT,
Comparison(Er:YAG)
vs (fractional CO2) in
Resurfacing of
Atrophic Acne Scars ,
Dermatologic Surgery
(2013)
N = 24 , randomly
allocated.
No significant differences in scar volume at
baseline between the Er:YAG and fractional
CO2 laser.
One side of face - 24
(Er:YAG) vs 24
(CO2).
Fractional CO2 laser treatment approaches
need more studies to be done using uniform
treatment parameters and reporting in order
2nd treatment showed statistically significant
improvements in scar volume over baseline at
the Er:YAG (p < .01) and CO2 laser (p < .01)
sites

5. Author(s)
Type of evidence e.g.
RCT, guidelines
Details of study or
publication
Lene Hedelund,
Karen Estell R.
Moreau , Ditte M.
Beye
RCT, Fractional non
ablative 1,540-nm
laser resurfacing
of atrophic acne scars,
Lasers Medical
Science (2010)
N = 10. Tx group 10 vs
Control group 10
Author(s)
Key findings & conclusions
Laser-treated scars appeared more
even smooth than untreated control
sites
1 of 2 areas of acne scars
Significantly lower scar texture scores
similar size and appearance
were obtained at
treated with the 1540 laser
4 weeks (4.5, IQR2.0–6.5; P=0.0156)
Areas randomized to
and 12 weeks (4.5,IQR 2.5–6.5;
treatment
Type of evidence or no treatment. study or after treatment &
Details of P=0.0313) Key findings
SB Cho, SJ Lee, S
Cho, SH Oh, WS
Chung, JM Kang,
YK Kim, DH Kim
RCT, Comparison
N = 8: . Tx
e.g. RCT, guidelinesby FPS 8 vs Tx by
publication
Er:glass FPS vs CO2 FS CO2 FS 8 Half of each
for acne scars, Journal subject’s face treated with
of the European
FPS vs other half was
Academy of
treated with CO2 FS
Dermatology and
Venereology (2010)
Clinical improvements observed in
conclusions
acne scars in FPS and CO2 FS groups Clinical improvement scores in acne
scars between FPS-treated sites and
CO2 FS-treated sites were not
significantly different depending on
the scar types (rolling,
P = 0.346; icepick, P = 0.317; and
boxcar, P = 0.15).
Sherling M,
Friedman PM,
Adrian R, Burns
AJ, Conn H,
Fitzpatrick R,
Gregory R, Kilmer
S, Lask G,
Narurkar V, Katz
TM, Avram M et
al.
Consensus
recommendations on
use of an erbiumdoped 1,550-nm
fractionated laser and
applications in
dermatologic laser
surgery. Dermatologic
surgery (2010).
Concluded after reviewing 2 trails and
using own clinical experience that FP
improved acne scars by as much as
50%
2 clinical trials of acne scar
included in recommendation
Conclusions is largely based
on the personal experiences
of the aforementioned laser
experts.

6. Review of evidence: clinical implications
•It is possible that laser resurfacing seem to improve the acne scarring. A summary of the
overall effectiveness of laser resurfacing in acne scar have the improvement over 26%
from baseline.
•However , overall the published evidence to support use of lase resurfacing is limited
–
–
–
–
–
–
The various parameters studied differed in each study,
Most studies did not have a control or comparison group
There were only few split-face RCTs
Few studies and each has a small sample size
Rating scales for quantifying visual improvement are subjective and differed widely across studies
Using difference types of lasers and parameter for treatment of acne scar
•Therefore, the current evidence to support use of lase resurfacing for improving acne
scarring is insufficient . These studies cannot conclude the general efficacy of laser (or any
particular type of laser resurfacing treatment) to improve atrophic acne scarring and
should not be recommended to patients .

7. Recommendations for clinical practice
•
However, if patient insists on treatment, I would recommend non-ablative
fractional laser resurfacing – (M.W.S. Ong & S.J. Bashirl, 2012; SB Cho et
al.,2010) .
•
Fractional laser resurfacing (Fraxel® SR1500™ ) treatment should consist of eight
passes with a pulse energy of 40 mJ/cm2 at level 6 (17% coverage/cm2/pass). A
series of four to five treatments each spaced 1 month apart(SB Cho et al.,2010).
Adverse effects
•
–
–
–
•
nonablative FP laser experienced erythema for between 1 and 3 days and this resolved within a
week
post-therapy hyperpigmentation can occur about 10% of treated patient, which spontaneously
resolved within 2 weeks.
there are a few evidence support.
Ablative FP laser experienced erythema for 3–14 days which resolved by 12
weeks- (M.W.S. Ong & S.J. Bashir,2012).

8. References
A.F. Alexis.(2013). Lasers and light-based therapies in ethnic skin: treatment options and
recommendations for Fitzpatrick skin types V and VI. British Journal of Dermatology.169(3),
91–97
Cho SB, Lee SJ, Cho S, Oh SH, Chung WS, Kang JM, Kim YK, Kim DH. (2010). Non-ablative 1550nm erbium-glass and ablative 10 600-nm carbon dioxide fractional lasers for acne scars: a
randomized split-face study with blinded response evaluation. Journal of the European
Academy of Dermatology and Venereology.24(8),921-5

9. References
Hedelund L, Moreau KE, Beyer DM, Nymann P, Haedersdal M. (2010). Fractional nonablative
1,540-nm laser resurfacing of atrophic acne scars. A randomized controlled trial with
blinded
response evaluation. Lasers Medical Science . 25(5),749-54.
Magnani LR, Schweiger ES. (2013). Fractional CO2 Lasers for the Treatment of Atrophic Acne
Scars: A Review of the Literature. Journal of Cosmetic Laser Therapy. [Digital Editions
version].(doi:10.3109/14764172.2013.854639)

10. References
Manuskiatti W, Iamphonrat T, Wanitphakdeedecha R, Eimpunth S.(2013). Comparison of
fractional erbium-doped yttrium aluminum garnet and carbon dioxide lasers in resurfacing of
atrophic acne scars in Asians. Dermatologic surgery.39(1 Pt 1),111-20.
M.W.S. Ong and S.J. Bashir.(2012). Fractional laser resurfacing for acne scars: a review. British
Journal of Dermatology.166(6),1160–1169

11. References
Sherling M, Friedman PM, Adrian R, Burns AJ, Conn H, Fitzpatrick R, Gregory R, Kilmer S, Lask G,
Narurkar V, Katz TM, Avram M. (2010). Consensus recommendations on the use of an
erbium-doped 1,550-nm fractionated laser and its applications in dermatologic laser
surgery. Dermatologic surgery.36(4),461-9