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Focal Acne Scar Treatment (F.A.S.T.), a New Approach to Atrophic Acne Scars

A Case Series Schweiger ES, Sundick L Abstract Background: Acne scars are a common concern in dermatology.  Fractional CO2 laser resurfacing is a recent addition in our armamentarium of treatment options for acne scars and has been shown to be an excellent option for patients with atrophic acne scars.  Patients with acne scars receiving fractional CO2 resurfacing usually have both the acne scars and surrounding unscarred areas treated in common practice. There has yet to be a study that looked at the implications of only focally treating the acne scars while leaving surrounding normal skin untreated. Objective: To evaluate the safety and efficacy of a focal approach to fractional CO2 laser treatment for acne scars, coined “Focal Acne Scar Treatment” or “F.A.S.T.” Patients and Methods: This retrospective case series was conducted at Schweiger Dermatology, in New York, NY, with patients treated from November 2011 through May 2012.  Overall, six patients (ages 18 to 48) were treated with the fractional CO2 laser resurfacing, using a so called “F.A.S.T.” technique treating only the acne scars and leaving normal skin untreated.  Evaluation was based on physician and patient assessment of improvement at one week and four weeks post-treatment. Results: All six patients treated with the Focal Acne Scar Treatment technique of fractional CO2 laser resurfacing had significant improvement post treatment ranging from 40% to 70% as estimated by the treating dermatologist and patient at four weeks post treatment.  Patient satisfaction was high following F.A.S.T. method. Temporary post-inflammatory hyperpigmentation was seen in 2 patients but resolved after a single 1550 nm Erbium Glass fractional laser treatment. Conclusion: The Focal Acne Scar Treatment technique is an effective method of improving the appearance of atrophic acne scars.  Higher energy and density levels can be used when utilizing this technique, resulting in improved outcomes when compared with whole face fractional CO2 laser resurfacing. Healing is improved and faster with this technique and no increased incidence of permanent adverse events were found. More studies are needed to further evaluate this new technique. Keywords: Acne Scars, Laser Resurfacing, Fractional CO2 Laser, CROSS Introduction Acne is a very common condition affecting 80% of adolescents and young adults.  Approximately 95% of patients with acne eventually develop some type of scarring1, making the treatment of acne scarring a very relevant topic in dermatology today. While there are many options available for the treatment of acne scars, therapies have evolved over time.  Acne scar treatments have transitioned from chemical peels to dermabrasion to traditional laser resurfacing with fully ablative lasers to non-ablative fractional lasers and recently to fractionally ablative lasers.2  Fractional ablative carbon dioxide (CO2) lasers have emerged as the “gold standard” treatment for acne scarring in recent years due to their efficacy, safety and relatively limited downtime3,4.  Fractional CO2 laser resurfacing causes local damage to the skin, ablating the epidermis and portions of the dermis, as well as sending heat down into the dermis to stimulate the formation of new collagen.  The non-ablated areas of a fractional CO2 laser treatment allow for faster tissue healing and minimal postoperative healing time. Currently, when treating facial acne scars with a fractional CO2 laser, resurfacing is usually performed by treating the entire face, including the scarred and surrounding non-scarred skin. The rationale for treating the entire face and not only the scars is to give an “even” appearance to the treated skin and to avoid concerns of irregular appearing hyper- or hypopigmentation. There has yet to be a study that looked at only focally treating the acne scars and leaving the normal surrounding skin untreated. It is logical to think that if only scarred area was treated and non-scarred skin was left untreated then wound healing speed post-procedure would be increased, as there is less tissue needed to heal. It is also logical to think that if you are treating a smaller portion of the skin surface area, a better result may be achieved when using higher treatment settings (increased Watts, density). In addition, it is also logical to think that this technique should be safe and effective based on previous studies documenting the CROSS technique. 5 In this paper, we evaluate a new method of fractional CO2 laser resurfacing in patients who have only focal acne scarring.  We have coined the term ‘Focal Acne Scar Treatment’ (F.A.S.T.) to describe this “double fractionated” approach to the treatment of acne scars in this select patient population.  The reason that F.A.S.T. technique is a “double fractionated” approach is because (1) we use a fractionated CO2 laser (density settings of 15%-40%) to resurface the affected scarred area and (2) we only treat the focal areas of acne scarring (often only 10-20% surface area of the face) and leave surrounding skin completely intact to increase healing time. We suggest that when using the F.A.S.T. technique, increased energy levels and higher density can be used without increased adverse events.  We have found that this technique produces better efficacy, faster healing time, and increased patient satisfaction. Methods Three days prior to fractional CO2 laser treatment, all patients began viral prophylaxis with Acyclovir 400 mg twice daily, which was continued until 5 days post-treatment.  During their treatment appointment, patients were anesthetized with topical benzocaine-tetracaine-lidocaine under occlusion for one hour prior to treatment.  No oral medications were used.  All patients received and signed informed consent forms, documenting risks, benefits and alternatives to treatment. Patients in this series were treated with a fractional CO2 laser (Mixto, Lasering, Inc, Italy). Aquaphor ointment was applied immediately post-treatment and for 2 days following laser resurfacing.  On Day 3, patients stopped using Aquaphor and began using Biafine topical emulsion twice daily until their one week follow up appointment. Case Series Case 1 FAST NYCC.Z., a 19 year old white male who presented to our dermatology clinic with atrophic acne scarring localized to only his cheeks. After a discussion of treatment options, fractional CO2 laser was decided upon. The patient then received treatment to focal acne scars only with the following settings:  180 microns, 14 Watts, Index of 4, density 20%; 1 pass to scars only. Healthy skin surrounding the scars was left untreated. C.Z. was seen for follow up one week following the procedure.  At that visit, patient was noted to have post-treatment erythema in the areas that were treated, which were not concerning to patient. At 4 week visit, patient had slight post-inflammatory hyperpigmentation that was deemed to be almost resolved.  Approximately 60% improvement in acne scars was agreed upon by patient and physician. Figure 1 demonstrates the patient before treatment, 1 week post-treatment and at his 4 week follow-up appointment. Case 2 B.P., a 26 year old Asian female presented to our office with pitted acne scarring on her cheeks and temples.  She had minimal atrophic scarring over the rest of her face.  Fractional CO2 laser resurfacing was performed on the individual acne scars on her cheeks (180 microns, 13 Watts, Index of 4, density 15%, 1 pass to acne scars) and unaffected skin was left untreated. B.P. was seen for follow up one week following the procedure.  During this visit, approximately 40% improvement in skin texture was noted by both the patient and the physician. Post-procedural erythema was noted on clinical exam, but no other adverse events were noted.  She was next seen in the office 3 weeks after her treatment.  At this time, 60% improvement was seen clinically and the patient was pleased with the improvement but still had residual post-treatment erythema.  A 1550 nm Erbium Glass treatment was performed four weeks after the fractional CO2 laser treatment; the goal of this treatment was to reduce the post-procedural erythema.  The patient and treating dermatologist were satisfied one month post-treatment with degree of acne scar improvement and resolution of erythema. Case 3 Acne Scars NYCC.C., an 18 year old Hispanic male, presented with pitted scarring localized to only his cheeks.  Fractional CO2 laser resurfacing was performed (180 microns, 13 Watts, index of 4, density of 15%, 1 pass to scars only) focally, leaving surrounding skin intact. C.C. was seen for follow up one week following the procedure.  He reported very little “downtime” and was able to return to school after only two days.  At his one month follow-up visit, the clinical improvement of the depth of acne scarring was estimated to be over 70% by both patient and physician. The patient did experience mild post-treatment erythema that was addressed with a single 1550 nm Erbium Glass fractional laser treatment four weeks after his F.A.S.T. treatment. This treatment provided complete resolution of erythema. Figure 2 shows patient before F.A.S.T. and 4 months post-treatment. Case 4 Fractional CO2 Laser NYCK.F., a 48 year old Caucasian male, presented with deep, pitted acne 0scars on his cheeks and forehead. The patient had previously had a 100% TCA peel using the C.R.O.S.S. technique 14 months earlier with only mild improvement. K.F. underwent treatment with the fractional CO2 laser focally, leaving surrounding skin untreated.  The settings used in the treatment were spot size 180 microns, 13 Watts, Index of 4, density 15%, 2 passes to scars. K.F. was seen for follow up one week after the F.A.S.T. treatment.  Approximately 50% improvement in skin texture was noted by both the patient and physician during this visit, (Figure 3).  Mild post-treatment erythema was noted, but patient did not feel that he had excessive downtime.  K.F. was next evaluated one month after the F.A.S.T treatment.  Both the patient and physician estimated 75% improvement of skin texture during this visit.  Mild post-inflammatory hyperpigmentation was noted on treated areas of the skin; the patient was given 5% hydroquinone to begin using nightly.  Two months later, during his three month F.A.S.T. treatment follow up visit, no residual hyperpigmentation or erythema was noted. Case 5 R.R., a 27 year old Indian male, presented with pitted scars on his cheeks.  Six months prior to his initial consultation, R.R. had hyaluronic acid filler injected into the atrophic scars on his cheeks.  He noted some improvement after HA injections, but desired a more permanent solution.  R.R. was pretreated with 5% hydroquinone for two weeks prior to his fractional CO2 laser resurfacing treatment.  During his treatment, the fractional CO2 laser was used at the following settings: 180 microns, 14 Watts, Index 7, density 15%.  Two passes were completed over each pitted scar, surrounding skin was left untreated. R.R. was evaluated one week after the F.A.S.T. treatment.  He noted very minimal downtime after the treatment. Approximately 40% improvement of acne scar depth was noted by both the patient and physician during this appointment.  One month after his F.A.S.T. treatment, both the patient and physician estimated 60% improvement.  R.R. continued to use 5% hydroquinone nightly for 3 weeks after the treatment and did not experience any post-inflammatory hyperpigmentation. Case 6 B.S., a 21 year old Caucasian male, presented with icepick scarring on his cheeks; the remainder of his face was free of scarring.  B.S. underwent the F.A.S.T. treatment with the fractional CO2 laser (180 microns, 14 Watts, Index 7, density 15%).  Two passes were completed over each individual acne scar only. B.S. was seen for follow up ten days after his F.A.S.T. treatment.  Minimal post-treatment erythema was appreciated.  Both the patient and physician estimated 50% improvement at ten days following the fractional CO2 laser resurfacing treatment using the F.A.S.T. technique. One month following the F.A.S.T. treatment, an estimated 70% improvement of acne scar depth was appreciated by both the patient and physician.  B.S. did not require treatment for post-treatment erythema, which resolved one month after his treatment. Discussion The F.A.S.T. method is an effective technique that can be utilized in the treatment of acne scarring with a fractional CO2 laser.  It is modeled after the C.R.O.S.S. method of high concentration TCA peeling to only the areas of acne scarring.  Traditional fractional CO2 treatments yield improvement of acne scarring, but often not the desired degree of improvement.  The lengthy healing time associated with full face fractional CO2 laser treatments may sometimes deter a patient from pursuing this treatment for their acne scars. Dermatologists have previously been hesitant to fractional laser resurface only partial faces, due to concern over obvious delineation of the treated areas and untreated skin.  Our observation when treating patients with full face fractional CO2 laser resurfacing was that there was no apparent delineation between treated and untreated skin along the jawline; this observation gave us the confidence to test out higher treatment levels in a fractionated pattern over only the acne scarred area.  This lead to the development of the F.A.S.T. technique, and the usage of higher settings with increased efficacy. The basis for the F.A.S.T. technique was conceived with the C.R.O.S.S. (Chemical Reconstruction of Skin Scars) method in mind. C.R.O.S.S. method uses trichloroacetic acid (TCA) to treat focal acne scars, while using a higher percentage of TCA than what is used in traditional peels or had been previously considered safe.  CROSS utilizes the same philosophy of treating only the areas of acne scarring and leaving normal healthy tissue surrounding the treated area. Ice pick acne scars are successfully treated by applying between 50-100% TCA acid directly into the scar5.  The C.R.O.S.S. method had raised concern over the potential for uneven pigmentation secondary to localized treatment.  Peer-reviewed articles based on studies in darker skin types have stated that this phenomenon is not a major concern6,7, though the potential for uneven pigmentation may be even lower when using a fractionated CO2 laser device instead of TCA. Fractional CO2 laser treatments are predictable, replicable and precise treatments. In the F.A.S.T. technique, post-treatment localized erythema is sometimes seen, which is known to be the most common side effect in high-fluence laser resurfacing treatments. 8  The post-treatment localized erythema that is sometimes seen after using the F.A.S.T method can be remedied by incorporating a single 1550 nm Erbium Glass fractional laser treatment  one month post F.A.S.T treatment. This was required in 1/3 of the patients in this series. We found that using shorter dwell times (higher index levels on the Mixto Fractional CO2 laser) resulted in less post-treatment erythema and we now use an Index of 7 routinely with the F.A.S.T. technique. The laser punch-out method for acne scars9 supports the idea that acne scars should be treated differently than the healthy surrounding skin. The F.A.S.T. method reduces healing time by allowing healthy skin to be left intact and therefore allows for higher treatment levels to be used over the treated areas, which leads to better immediate results and higher percentages of long-term improvement of acne scarring.  This “fraction of a fraction” technique mimics the fractionation of the laser itself. In conclusion, patient satisfaction is very high in patients treated with the F.A.S.T. method.  All patients noted improvement of their acne scarring, as well as minimal healing time. Additional studies are needed to verify these results in a larger patient population. We suggest other laser surgeons consider utilizing the F.A.S.T. technique of laser resurfacing with appropriate focal acne scars patients to maximize results and reduce downtime. References
  1. Shamban AT, Narurkar VA. Multimodal Treatment of Acne, Acne Scars and Pigmentation. Dermatologic Clinics. 2009;27:459-471.
  2. Tarijian AI, Goldberg DJ. Fractional ablative laser skin resurfacing: A review. Journal of Cosmetic and Laser Therapy. 2011;13:262-264.
  3. Chapas AM, Brightman L, Sukal S, et al. Successful Treatment of Acneiform Scarring with CO2 Ablative Fractional Resurfacing. Lasers in Surgery and Medicine. 2008;40:381–386.
  4. Omi T, Kawana S, Sato S, et al. Fractional CO2 laser for the treatment of acne scars. Journal of Cosmetic Dermatology. 2011;10:294-300.
  5. Weber MG, Machado RB, Hoefel IR, et al.  Complication of Cross-Technique on Boxcar Acne Scars: Atrophy.  Dermatologic Surgery. 2011;37:93-95.
  6. Khunger N, Bhardwaj D, Khunger M. Evaluation of CROSS technique with 100% TCA in the management of ice-pick acne scars in darker skin types. Journal of Cosmetic Dermatology. 2011;10:51-7.
  7. Lee JB, Chung WG, Kwahck H, Lee KG. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatologic Surgery. 2002;28:1017-21.

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