Fractional carbon dioxide laser monotherapy improves acne scars

Fractional carbon dioxide laser solely improves acne scars- IDOJ study

Acne is a chronic inflammatory disease of pilosebaceous unit with nearly 1/5th of patients suffering from its sequelae of scars. The different types of acne scars are atrophic, hypertrophic, and keloidal. Atrophic acne scars are divided into three types: icepick, rolling, and boxcar scars (further divided into shallow (0.1–0.5 mm) and deep (≥0.5 mm). Various treatment methods of atrophic acne scars include subcision, needling, dermabrasion, chemical peels, punch techniques, non ablative lasers, fillers, and autologous fat transfer.

Fractional carbon dioxide laser (FCL) re surfacing technique results in thermal ablation of microscopic epidermal columns and dermal tissue in a regularly spaced manner. Re epithelialization is stimulated, which is mediated by adjacent normal tissue, and collagen fiber production is initiated leading to scar remodelling. It has shown a good clinical outcome in case of acne scars. Platelet rich plasma (PRP) contains a platelet concentration about 4 to 7 times the baseline concentration of human platelets, and contains alpha and dense granules. Activation of platelets cause degranulation leading to release of growth factors within 10 minutes of activation

Recently a split face study, comparing the efficacy and safety of FCL alone against the combined use of FCL and PRP was published in the Indian Dermatology Online Journal.

Materials and Methods

This was a prospective, comparative split face study conducted over a period of 1 year. Thirty two patients out of 40 completed the study. All adult males and females in the age group of 18–40 years with moderate to severe atrophic scars according to Goodman and Baron qualitative scoring were included. Those patients with active acne, herpes infection, bleeding disorders, keloidal tendencies, and connective tissue disorders; pregnant and lactating mothers; and patients with unrealistic expectations were excluded from the study. High resolution photographs were taken with the help of a digital camera and with constant camera settings at baseline and 6 weeks after each session. A written informed consent was taken prior to the start of treatment.

In the study, the right side of the face was treated with FCL and PRP and the left side was treated with FCL alone. A total of 3 sessions were performed with an interval of 6 weeks between every session. FCL was set at a power of 15 W, with a distance and duration of 0.5 mm and 0.5 ms, respectively. One to two passes were delivered.

PRP was centrifuged with a first spin of 1000 rpm for 10 min and a second spin of 2000 rpm for 5 min. The anti coagulant used was citrate phosphate dextrose. Patients were advised topical antibiotics, emollients, and sunscreens post procedure and were asked to follow up on the third day for the assessment and documentation of side effects.

Assessment of scar improvement was analyzed with the help of

1. Goodman and Baron’s qualitative and quantitative score

2. Visual Analog Scale (VAS)

3. Physician assessment.

Data were statistically analyzed using software R Version 4.0.2.

Results

Of the 32 patients who completed the study, there were 18 females and 14 males. On assessing Goodman and Baron qualitative scores, 68.75% patients had moderate scars, and 31.25% had severe scars at baseline over both sides of the face. At the end of the study, on the right side, there were 68.75% with mild scars, 25% had moderate scars, and 6.25% had severe scars. Over the left side of the face, 62.5% had mild scars, 31.25% had moderate scars, and 6.15% had severe scars. However, two patients (6.15%) remained to be severe over both the sides.

The mean of quantitative score was calculated at baseline and at the end of the study. There was a statistically significant improvement in scars, but the results were comparable over both sides. On analyzing VAS score for patient satisfaction, the majority of patients were very satisfied over both sides. Even though patients were more satisfied over the right side of the face, the values were not statistically significant. In physician assessment grading, the majority of the patients had 26–50% (Grade 2) improvement. However, there was no statistically significant improvement over the PRP treated side (right) as compared to the left side of the face.

Erythema, burning sensation, edema, scabbing, and post inflammatory pigmentation were the side effects observed. Immediate side effects such as erythema, burning sensation, and scabbing were seen in almost all patients. Side effects resolved with a downtime of 4–5 days except post inflammatory pigmentation, which took 4–6 weeks to subside. There was no difference in adverse effects between both sides of the face.

Discussion

The majority of patients in present study (72%) had mixed type of scars which included rolling, boxcar, and icepick scars. Assessment of the type of scars is relevant as FCL laser and PRP treatment modalities have shown to be more efficacious for rolling and superficial boxcar scars. On the basis of subjective analysis, the rolling type of scars found better improvement. On comparison of Goodman and Baron quantitative scores and VAS score there was no statistically significant improvement over the right side of the face as compared to the left side (P value 0.82 and 0.86 respectively).

To conclude addition of PRP did not provide any synergistic effects in the treatment outcome neither improved the side effect profile in patients of acne scars. Therefore, by avoiding PRP, an extra interventional therapy can be omitted thereby reducing the cost and increasing patient compliance.

Source- Priya, Devi; Patil, Shivakumar. A Split Face Comparative Interventional Study to Evaluate the Efficacy of Fractional Carbon Dioxide Laser against Combined use of Fractional Carbon Dioxide Laser and Platelet-Rich Plasma in the Treatment of Acne Scars. Indian Dermatology Online Journal 14(3):p 371-374, May–Jun 2023. | DOI: 10.4103/idoj.idoj_462_22