Atrophic Acne Scarring and Dermal Filling


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Results of a calcium hydroxylapatitie (Radiesse) study performed on 27 patients with moderate to severe atrophic acne scarring for a period of 12 months. The results show a favorable and possible cheap alternative to laser resurfacing. A comparative HA study (hyaluronic acid) with 13 patients showed this product was of little therapeutic benefit.

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Atrophic Acne Scarring and Dermal Filling

  1. 1. peer-review | fxxxxxxxxs | dermal filler treatment For atrophic acne scarring Patrick Treacy presents the results of a study investigating the efficacy of dermal fillers in the treatment of atrophic acne scarring ABSTRACT degrees of atrophic acne scarring were cohort. Eleven hyaluronic acid patients (85% Full title treated with the CaHA filler over a 12‑month of total) showed a 0–25% improvement in Problems encountered using dermal fillers, period. Thirteen patients were treated treated atrophic scars at 12 months. particularly calcium hydroxylapatite, as a with low molecular weight cross-linked treatment in acne scarring . hyaluronic acid in a comparative study. Conclusions Dermal fillers, especially CaHA, can provide Objectives Results a safe and efficacious method of treating This article aims to establish the efficacy Most atrophic acne scars responded well atrophic acne scars. This compound appears and safety profile of dermal fillers, especially to CaHA dermal filler treatment. Ice-pick to provide a longer-lasting effect owing calcium hydroxyapatite (CaHA) in the scars were not treated. At 12-month to volume replenishment and possible treatment of atrophic acne scars. evaluation, 22% of subjects showed a 75% neocollagenesis. The efficacy of hyaluronic improvement, while 48% showed a 50% acid in repairing atrophic acne scars is not Methods improvement. This compared to an average demonstrable. Twenty-seven subjects with differing 0% improvement for the hyaluronic acidDr Patrick Treacy is AMedical Director of AilesburyClinics Ltd and Ailesbury HairClinics Ltd; Chairman of the cne occurs in approximately unhappiness, anxiety, and even suicidal thoughts as aIrish Association of CosmeticDoctors and Irish Regional 95% of 16–17-year-old boys and 84% of result of their facial appearance5.Representative of the British 16–17-year-old girls1. Although theAssociation of CosmeticDoctors; European Medical condition usually resolves by the BackgroundAdvisor to Network Lipolysis mid‑20s, 1% of men and 5% of women For many years different treatment modalities have beenand the UK’s largest cosmetic still bear the signs of moderately severe used for the revision of atrophic acne scarring, withwebsite Consulting Rooms. He acne scarring at 40 years of age2. Some studies show varying degrees of success. Many controlled trials havepractices cosmetic medicinein his clinics in Dublin, Cork, scarring of some degree may affect up to 95% of patients demonstrated that moderate to severe atrophic acneLondon and the Middle East with acne3. The same study found that keloidal or scars can be safely improved through ablative fractional hypertrophic truncal scarring was more common in CO2 laser resurfacing (fractional laser skin resurfacing;email: men. This form of scarring is usually treated by using FLSR)6. Although FLSR is still the most popular such measures as intralesional steroids, silicone therapeutic modality for the correction of acne scars, it is sheeting, or vascular laser treatment. Atrophic scarring not always effective in all types of atrophic lesions7 — theKeywords will often appear many years later, and can cause great more common type of defects encountered aftercalcium hydroxyapatite,hyaluronic acid, acne scars, distress in patients during their courtship years4. inflammatory acne. The use of higher energy levelsdermal fillers Affected patients report more social inhibition, might have improved the results, and also possibly18 March 2013 |
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  3. 3. | xxxxxxxxxxxxxx | peer-reviewinduced significant adverse effects7. Over the pastdecade, non-ablative laser resurfacing8–10, radiofrequency(RF)11, and microneedling12 have been shown to createsome improvement in the appearance of these atrophicscars. A number of autologous and non-autologoustechniques attempting dermal and subcutaneousaugmentation have been tried to improve the facialaesthetic appearance. The autologous methods haveincluded dermal grafting, fat transfer13, 14, and implantationof autologous fibroblasts, such as Isolagen®15. There has been interest in non-autologousaugmentation by way of injections of hyaluronic acid(HA), polymethylmethacrylate microspheres (PMMA),and calcium hydroxylapatite (CaHA)16, 17. CaHA, the mainmineral component of Radiesse® (Merz Aesthetics, SanMateo, CA) is a synthetic analogue of the inorganic saltfound in the human body as a constituent of bone andteeth. The CaHA microspheres (25–45 µ) are suspendedin an aqueous carboxymethylcellulose carrier gel,composed of cellulose, glycerin, and sterile water. Noneof these materials should elicit a chronic inflammatory,infectious or immune response. Multiple clinical andhistologic studies have tended to document its safety, migrate, and does not obscure diagnostic x-rays.efficacy, and longevity in tissue17, 18. At the present time, the use of CaHA is approved by the By its very composition, CaHA is designed to provide Food and Drug Administration (FDA) for the correction ofimmediate correction and long-term biostimulatory moderate to severe facial wrinkles and folds19, 20. CaHAneocollagenesis. Over time, the gel is absorbed, and also gained prominence during the period in whichfibroblasts appear and the process of neocollagenesis dermal fillers were being used for antiretroviral-inducedbegins, stimulating the gradual growth of the patient’s facial lipoatrophy21, 22. It is known to cause persistentown collagen. The nodules in a small percentage of people,carboxymethylcellulose gel carrier especially if it is injected into the vermillionvolumises the ‘lost’ space and acts as a Soft tissue filler use for acne border of the lips23. As many studies havereplacement filler; the microspheres scarring would be an attractive option established the biocompatibility and safetystimulate neocollagenesis so that, as the to most practitioners as they require of CaHA in facial filling techniques21, thegel dissipates, the spheres anchor into little invasive technique and could be product has gained popularity in the USthe soft tissue. There, they serve as a and Europe for this indication, and morescaffold for new collagen growth as early used in combination with other recently in the treatment of acne 4 weeks post-injection, and then treatment modalities. HA has been used in aesthetic medicinecontinue for up to at least 12 months17, 18. CaHA is not for a long time, and has an extended safety profile. In itspermanent, however. The CaHA microspheres are natural form HA has a short duration time in the tissue,metabolised into calcium and phosphate ions through owing to enzymatic degradation and free radicalnormal metabolic processes over 24 months. CaHA will metabolisation. To avoid these effects, HA gel is modifiednot promote osteogenesis in soft tissues, does not through cross‑linking to form a water-insoluble polymer hydrogel, more resistant to degradation, but with a similar Table 1 Four-point grading scale biocompatibility as non-modified HA. Based on the for acne scars experience of other authors, many of the available HA preparations are too short-lived (approximately Grade 1: Macular 3–6 months24, 25 to appropriately treat moderate to severe Erythematous, hyper-, or hypopigmented marks acne scars) and use of such products for this purpose would require a significant total injection volume over Grade 2: Mild disease time, with frequent re-treatments, contributing to a Mild atrophy, can be covered with make-up of facial hair greater total cost and time commitment for the patient. More viscous forms of HA, such as Perlane® (Medicis Grade 3: Moderate disease Aesthetics, Inc., Scottsdale, AZ) or Juvederm® Voluma Moderate scarring, not covered by make-up, but can be (Allergan, Inc., Santa Barbara, CA), may be appropriate for flattened by manual stretching of the skin patients with atrophic scars. The ideal filler for this purpose would be long-lasting, biocompatible, and would Grade 4: Severe disease not elicit further inflammation or granuloma formation Scarring not flattened with manual stretching of the skin in skin already damaged by acne26. Soft tissue filler use for acne scarring would be an | March 2013 20
  4. 4. peer-review | fxxxxxxxxs | study over a 1-year period. Patients were randomly selected on the basis that they did not want to present for laser resurfacing as a treatment for their problem. This meant the patients were enrolled sporadically, rather than entering the study at the same time. The subjects ranged in age from 16–63  years, and all acne scarring severity scores fell between 4 and 30 on the Goodman system (Table  1). Patients were also evaluated using digital photography and an improvement graduation scale at each subsequent treatment visit, at 1, 3, 6, 12 and 24 months post-procedurally: ■■ 0 = no improvement ■■ 1 = 0–25% improvement ■■ 2 = 25–50% improvement ■■ 3 = 50–75% improvement ■■ 4 = 75–100% improvementFigure 2 17-year-old male patient (A, B, C) before treatment with Radiesse, and (D, E) immediately after ■■ 5 = 100% improvement.treatment. 1.3 ml CaHA was used Multiple acne scar grading classification systems of varying complexities have been introduced. The mostattractive option to most practitioners as they require basic, practical system divides atrophic acne scars intolittle invasive technique and could be used in three main types: icepick, rolling, and boxcar scars29combination with other treatment modalities, such as (Figure 1). It is common for patients to have more than onemicroneedling or laser resurfacing. Although studies type of scar.have shown that HA injections do stimulate collagen Subscision of each atrophic scar was performed 1 weekformation in the short term, this effect is probably morerelated to the physical act of injection, rather than to theHA itself. Subcision is a term introduced by Orentreich andOrentreich27 to describe the minor surgical procedure fortreating depressed acne scars and wrinkles, using ahypodermic needle inserted through a puncture in theskin surface and its sharp edges manoeuvred under thedefect to make subcuticular cuts or ‘cisions’. The principleof this procedure is to break the fibrotic strands, whichtether the scar to the underlying subcutaneous tissue.The depression is lifted by the releasing action of theprocedure, as well as from connective tissue that formsduring the course of normal wound healing28.MethodsA series of 27 patients (17 male, 10 female; skin phototypesI–IV), with varying degrees of atrophic acne scarring, Figure 3 23-year-old female patient (A) during treatment with Radiesse, and (B) 2 weeks afterwere treated in a single-centre, prospective, controlled treatment21 March 2013 |
  5. 5. peer-review | fxxxxxxxxs | A series of 13 patients (7 male, 6 female; skin phototypes I–IV) with varying degrees of atrophic acne scarring were treated in a similar manner with low molecular weight cross-linked HA, and monitored over a 12‑month period. Patients were randomly selected on the basis that they did not want to present for laser resurfacing as a treatment for their problem. Results Twenty-seven patients entered this 12-month study. Moderate to excellent clinical improvement was observed after 4 weeks in almost all of the patients studied (20 patients with score 4, 75–100%; siz patients with score 3, 50–75%). One patient had score 1, 0–25% improvement, while no subjects scored either 0 or 5. At the 6-month assessment 12 patients (44% of total) had score 4 (75–100% improvement) and 11 patients (40%) hadFigure 4 23-year-old male patient (A) before treatment with Radiesse, and (B) 2 weeks after treatment score 3 (50–75% ). At 12-month evaluation, six patients (22%) showed 75% improvement; 14 patients (48%)prior to injection with CaHA to give a more uniform showed between 50% improvement, and five patientsaesthetic effect. Radiesse was injected using a 27  gauge (18%) showed a 25% improvement in treated atrophicneedle into the space left after subscision of the acne scars.scar in the region of the mid- to deep dermis, although Thirteen patients entered the 12-month HA study. Atfinal placement also depended on the presence of 3‑month assessment, zero patients had score 4 (75–100%fibrous and cystic tissue in this region of the skin. The improvement) and four patients (23%) had score 3 (50–total volume of CaHA used varied with each patient, withan end-point being agreed between patient andphysician. It was decided not to record the amount ofproduct used as this was not felt to be contributory to thefinal result. Histologic evaluation of cutaneous biopsieswere not obtained before or during treatment, although itwas offered to at least one of the patients who had aresultant adverse reaction. Betadine® cleansing was usedin most patients and doxycycline 100 mg for 2 days wasgiven as prophylaxis in 11 patients, who were felt to be atrisk of infection as they still appeared to have active acne.One patient, who had a previous photoallergic reactionto doxycycline, was prescribed Augmentin-Duo twicedaily for 2 days. Subjects were not excluded from the study on thebasis of bleeding disorders or whether they were takinganticoagulants/anti-inflammatory agents, as it was feltthat while the bruising may be unsightly, it would likelyimprove overall healing. Patients who had receivedsynthetic collagen, HA, PMMA, CaHA, or autologousfibroblast injections to treated areas within the previous6 months were excluded from the study. Clinicalassessment scores were determined at each treatmentsession and follow-up visit. Patient satisfaction surveysand digital photography were used where they wereappropriate to both parties, although both wereconsidered subjective, with patients tending to focus onthe smallest detail and physicians photographicallyfavouring the better results. All patients were reviewed at2 or 4 weeks post-treatment for a top-up of Radiesse, ifrequired. It was noted that 17 patients required a top-up ofat least 0.15 ml CaHA at one of the first two visits. Smalleramounts (< 0.1 ml) were not recorded, as it was felt that thepatient may have seen some defects under deeperscrutiny that were initially missed during the procedure. Figure 5 26-year-old old male patient (A) before treatment with CaHA and (B) 4 weeks after treatment
  6. 6. | xxxxxxxxxxxxxx | peer-review75% ). At 6-month evaluation, 12 patients (92%) showed a0–25% improvement. The author felt both of the fillers initially provided asimple physical volumising effect. There was a longevityassociated with the therapeutic effect of the calciumhydroxylapatite (CaHA), probably secondary to theduration of the filler and some level of neocollagenesisnoted in other studies. There was little evidence ofdelayed biostimulatory effect of collagen formationowing to HA injections, although the physical act ofinjection and subcision was of some benefit to thepatient. Side-effects of treatment were mostly limited in thegroup to mild transient erythema, bruising or localisedoedema. Some patients required top up or remodellingon initial review. One 23-year-old male patient (skin type4, of Asian origin) with minimally active acne on aprevious trial developed cellulitis and laterdesquamation.Discussion Figure 6 Improvement rates in patient cohort treatment with CaHAThere are many methods that can be used in thetreatment of atrophic acne scarring. Most tend to replacethe volume lost by the atrophic effects of the acne. Newerinjectable fillers are biocompatible and safer, and canprovide an alternative means of treating acne scarring inpatients not opting for laser resurfacing. The author hasused the HA-based filler Matridex® (BioPolymer GmbH &Co., Germany), CaHA, and the polyalkylimide Bio-Alcamid® (Polymekon, Brindisi, Italy) for this purposeover the years. Some of these fillers simply provide aphysical filling effect, while others induce a delayedcollagen stimulatory effect (e.g. CaHA and poly-L-lacticacid). An ideal filling agent should restore atrophicvolume and stimulate the dermis to synthesise newcollagen for a long-lasting effect. Based on the experience of this study, the author feelsCaHA is a suitable product for this purpose, showing aclearly demonstrable benefit still present at 6–12 months.A comparative study performed with HA preparationsshowed the compound was not of medical or commercialbenefit to either the physician or patient, with most of theproduct disappearing at only 6–12  weeks. More viscousforms of HA, such as HyaCorp® (BioScience GmbH,Germany) showed no extra benefit. [AQ9: any limitations to this study?]Conclusions Figure 6 Improvement rates in patient cohort treatment with HACaHA is biosynthetically produced and does not elicit achronic inflammatory or immune response. In vivo andin vitro studies have established the biocompatibility andsafety of CaHA. No evidence of granuloma formation,ossification, or foreign body reactions have been found inlong-term animal studies. CaHA implants have persistedintact at the injection site in areas such as the face at up to12–18 months. No skin testing is required for thecompound as company information states that noanimal or animal products are used in the manufactureof the product, thus there is no risk of transmitting diseaseor causing allergic reactions in patients who are sensitive | March 2013 23
  7. 7. peer-review | fxxxxxxxxs |to common foods. Key points This study documents the efficacy of CaHA in the Referencestreatment of atrophic acne scars. The author is aware that n Acne occurs in 1. Burton JL, Cunliffe WJ, Stafford 17. Marmur ES, Phelps R, Goldberg I, Shuster S. The prevalence of DJ. Clinical, histologic and electronthese benefits may last 18 months or more. approximately 95% of acne vulgaris in adolescence. Br J microscopic findings after 16–17-year-old boys and Dermatol 1971; 85 (2): 119–26 2. Cunliffe WJ. The acnes. London: injection of a calciumDeclaration of interest none 84% of 16–17-year-old Dunitz, 1989 hydroxyapatite filler. J Cosmet girls. Some studies show 3. Layton AM, Henderson CA, Laser Ther 2004; 6(4): 223–6 acne scarring of some Cunliffe WJ. A clinical evaluation of 18. Godin MS, Majmundar MV,Figures 2–7 ©Patrick Treacy acne scarring and its incidence. degree may affect up to Clin Exp Dermatol 1994; 19(4): Chrzanowski DS, Dodson KM. Use 303–8 of radiesse in combination with 95% of patients with 4. Wu SF, Kinder BN, Trunnell TN, restylane for facial augmentation acne Fulton JE. Role of anxiety and Arch Facial Plast Surg 2006; 8(2): anger in acne patients: a n Although fractional relationship with the severity of 92–7 laser skin resurfacing is the disorder. J Am Acad Dermatol 19. Goldberg DJ. Fillers in 1988; 18(2 Pt 1): 325–33 Cosmetic Dermatology. Abingdon, still the most popular 5. Cotterill JA, Cunliffe WJ. Suicide Oxon, UK: Informa, 2006 therapeutic modality for in dermatological patients. Br J Dermatol 1997; 137(2): 246–50 20. Roy D, Sadick N, Mangat D. the correction of acne Clinical trial of a novel filler 6. Omi T, Kawana S, Sato S, Bonan scars, it is not always P, Naito Z. Fractional CO2 laser for material for soft tissue effective in all types of the treatment of acne scars. J augmentation of the face Cosmet Dermatol 2011; 10(4): atrophic lesions 294–300 containing synthetic calcium hydroxylapatite microspheres. n Soft tissue filler use 7. Hedelund L, Haak CS, Dermatol Surg 2006; 32(9): 1134–9 Togsverd-Bo K, Bogh MK, Bjerring for acne scarring would P, Hædersdal M. Fractional CO2 21. Comite SL, Liu JF, be an attractive option laser resurfacing for atrophic acne Balasubramanian S, Christian MA. scars: a randomized controlled to most practitioners, as trial with blinded response Treatment of HIV-associated facial they require little evaluation. Lasers Surg Med 2012; lipoatrophy with Radiance FN 44(6): 447–52 (Radiesse). Dermatol Online J invasive technique and 8. Seaton ED, Mouser PE, 2004; 10(2): 2 could be used in Charakida A, Alam S, Seldon PM, 22. Treacy PJ, Goldberg DJ. Use of a combination with other Chu AC. Investigation of the mechanism of action of biopolymer polyalkylimide filler modalities, such as nonablative pulsed-dye laser for facial lipodystrophy in microneedling or laser therapy in photorejuvenation and HIV-positive patients undergoing inflammatory acne vulgaris. Br J resurfacing Dermatol 2006; 155(4): 748–55 treatment with antiretroviral 9. Nouri K, Rivas MP, Bouzari N, drugs. Dermatol Surg 2006; 32(6): n Many studies have Faghih S. Nonablative lasers. J 804–8 established the Cosmet Dermatol 2006; 5(2): 23. Product used to enlarge lips 107–14 biocompatibility and 10. Bellew SG, Lee C, Weiss MA, can cause bumps. Bioform does safety of CaHA in facial Weiss RA. Improvement of not recommend using this product atrophic acne scars with a 1,320 on the red portion of lips. filling techniques. The nm Nd:YAG laser: retrospective product has gained study. Dermatol Surg 2005; 31(9 Pt 2): 1218–21 24. Goldberg DJ, Snehal A, Hussain popularity in the US and M. Acne scar correction using 11. Prieto VG, Zhang PS, Sadick NS. Europe for this Evaluation of pulsed light and calcium hydroxylapatite in a indication, and more radiofrequency combined for the carrier-based gel. J Cosmet Laser treatment of acne vulgaris with recently in the histologic analysis of facial skin Ther 2006; 8(3): 134–6 treatment of acne biopsies J Cosmet Laser Ther 25. Alam M, Dover JS. Treatment of 2005; 7(2): 63–8 acne scarring. Skin Therapy Lett scarring 12. Majid I. Microneedling therapy 2006; 11(10): 7–9 n This study documents in atrophic facial scars: an objective assessment. J Cutan 26. Buck DW 2nd, Alam M, Kim JY. the efficacy of CaHA in Aesthet Surg 2009; 2(1): 26–30 Injectable fillers for facial the treatment of 13. Coleman WP Lipocytic dermal rejuvenation: a review. J Plast augmentation. In: Klein AW. ed, Reconstr Aesthet Surg 2009; 62(1): atrophic acne scars. The Tissue augmentation in clinical 11–8 author is aware that practice. Procedures and techniques. New York: Marcel 27. Orentreich DS, Orentreich N. these benefits may last Dekker, 1998: 49–62 Subcutaneous incisionless 18 months or more 14. Coleman SR. Long-term (subcision) surgery for the survival of fat transplants: correction of depressed scars and controlled demonstrations. Aesthetic Plast Surg 1995; 19(5): wrinkles. Dermatol Surg 1995; 421–5 21(6): 543–9 15. Chu A, et al. A pilot study to 28. Chandrashekar BS, Nandini A. assess the efficacy of Isolagen Acne scar subcision J Cutan (autologous fibroblasts) treatment in acne scarring. Br J Dermatol Aesthet Surg 2010; 3(2): 125–6 2006 29. Goodman GJ, Baron JA. 16. Tzikas TL. Evaluation of the Postacne scarring – a quantitative Radiance FN soft tissue filler for global scarring grading system. J facial soft tissue augmentation Arch Facial Plast Surg 2004; 6(4): Cosmet Dermatol 2006; 5(1): 234–9 48–5224 March 2013 |