Case Study: Treating Acne Scars Nurse prescriber Adrian Baker shares a case study combining microneedling, LED and topicals for treating acne scars Acne vulgaris is a common skin condition affecting 650 million people worldwide with a 95% prevalence of acne in adolescence.1 It is reported that 12-14% of cases will continue into adulthood with psychosocial effects2 and 20-35% will develop moderate to severe acne that has an increased risk to cause textural skin changes to the superficial and deep dermis.1,3 These dermal changes result in permanent scarring of the skin, leading to substantial physical and psychological distress, particularly in adolescents.4 It is crucial that acne treatments are sought early on, and that acne scarring is not overlooked, in order to reduce the incidence of psychological distress. For this reason, treatments should be effective and delivered in a timely manner.
Treatment options There are a variety of treatment options available for acne scarring, which can include topical preparations, dermabrasion, laser resurfacing, non-ablative and fractional laser, punch excision, subcutaneous incision, chemical peels, dermal grafting, and fillers, as well as focal treatment with trichloroacetic acid, and skin microneedling (automated or roller devices).3 With such a variety of treatment modalities available, both evidence of efficacy and safety profile needs to be taken into account when deciding upon which treatment is suitable for the patient. Aust et al. state that the ideal treatment for acne scarring should preserve epidermal integrity whilst also promoting the normal formation of collagen and elastin structures within the dermis.5 Treatments that disrupt the epidermal integrity such as punch excision, ablative laser resurfacing, and deep peeling agents remove the epidermis in its entirety and can give rise to biological adverse skin responses, resulting in post-inflammatory hyperpigmentation (PIH) and further scarring.6 With this in mind, in my opinion, microneedling brings us closer to the ideal scar treatment as epidermal integrity is maintained by needles that penetrate, but do not remove, the epidermis, thus reduce the
risk of adverse outcomes.5 Upon penetration of the stratum corneum, small channels are created, known as micro-conduits, that lead to a natural inflammatory healing cascade; stem cells located within the dermal papilla are activated7 and platelets and neutrophils are recruited to release growth factors TGF-alpha, TGFbeta, and platelet-derived growth factor (PDGF).8 This, in turn, stimulates the fibroblastic action of collagen and elastin production in the papillary dermis.9 The mechanical action of the needles passing through scar tissue is also thought to play a role in the breakdown of existing fibrous collagen type III that forms within scar tissue, replacing over time with the preferred collagen type I.10 Newer treatment modalities, such as fractional lasers and non-ablative lasers, also appear to provide effective results through a similar mechanism of action.11 However, a study in 2016 revealed that microneedling is a more cost-effective approach, with comparably effective results, a better safety profile and less downtime than non-ablative fractional laser treatments.12
Whilst microneedling has been shown to be an effective treatment of acne scarring,13 downtime and discomfort can remain problematic, albeit less so than other forms of treatment in my opinion. Erythema, oedema, and microbruises are the most commonly-reported side effects,3,7,11 however, there are very few studies detailing the average time that this can last. In my experience, post-procedural erythema can last three to four days post acne scar microneedling because an aggressive needle depth of 1.5-2mm is required.14 In a busy world where recovery time is often restricted for patients, one strives to reduce post-procedural side effects as soon as possible without reducing the efficacy of the treatment itself. As erythema and oedema are the result of the natural immune response to heal, it could be hypothesised that any treatment given to address this skin response could in fact reduce the efficacy of the treatment itself. Acute inflammation, which occurs immediately after an injury, is a temporary event to limit further injury as well as to begin the repair and healing process.15 When inflammation persists, however, not only is the patientâ&#x20AC;&#x2122;s downtime prolonged, but excessive healing responses are activated which could increase the risk of adverse events.15 For this reason I chose to include cord-lining stem-cell conditioned media into my microneedling protocol. This fluid contains epithelial and mesenchymal secreted bioactive molecules, including proteins, cytokines, and growth factors, that are able to effectively communicate with the epidermal and dermal cells of the skin via the paracrine effect.16 The paracrine effect is the process in which stem cells can communicate to local cells via bioactive signaling molecules.17,18 This multitude of paracrine factors form part of a complex network that confers stability to the cells as well as amplification of the regenerative response, thus exerting beneficial effects upon injured tissues via biomodulation, promoting angiogenesis and tissue regeneration and inhibiting fibrosis, apoptosis and inflammation.17,18
My protocol I devised my own clinical protocol for the treatment of acne scarring in my clinic, called CellRenew Microneedling. Utilising a combination of gentle enzymatic peeling, automated microneedling with cord-
Reproduced from Aesthetics | Volume 6/Issue 10 - March 2019