OFFICIAL HIGHLIGHTS

American Diabetes Association

Conference summaries


Scar treatment

Future of medical scar treatment

Presented by: Prof. Gabriella Fabbrocini Department of Dermatology, University of Naples Federico II, Naples, Italy
  • A broad range of techniques are available to treat acne scars, and combining techniques can often be useful in optimising outcomes.
  • The choice of therapy must be individualised according to the type of scarring.

Scarring is a widely prevalent condition that can have a negative impact on a patient's quality of life and is often worsened by aging. A number of treatments are now available to treat scarring.

  • Frequently acne scars result from severe inflammatory nodulo-cystic lesions occurring deep in the dermis.
  • Scarring can arise from more superficial inflamed lesions, and it is likely that some patients may be more prone than others to develop scarring.
  • Scarring that occurs from acne, particularly severe acne, can persist a lifetime and have long-lasting psychosocial effects.
  • Despite the plethora of topical and systemic treatments available for acne, there is a relative lack of quality evidence for their application.
  • When treating acne scars, it is important to keep in mind that the different types of acne scars require different types of treatment, even in the same patient.
  • Most commonly, the treatments used for acne are the same for other atrophic scars: chemical peeling, skin needling and punch techniques.
  • Chemical peeling is becoming increasingly popular for the treatment of skin rejuvenation where it can improve damaged skin and fine wrinkles.
  • The basic procedure aims at obtaining a controlled chemical burn of the epidermis and/or dermis.
  • This results in epidermal regeneration and post-inflammatory collagen neoformation with remodelling of collagen and elastic fibres and deposition of glycosaminoglycans in the dermis.
  • Various chemicals have been used as peeling agents, of which the most widely used are the alpha-hydroxy acids, such as glycolic acid, beta-hydroxy acids, or salicylic acid.
  • The choice of the compound is linked to the different indications and to the depth of the desired peeling.
  • In general, the safety and efficacy of chemical peels for acne and acne scars, including those of darker skin types, is well established. [1]
  • Existing studies also support the use of chemical peels in the treatment of acne and acne scars in Asians.
  • For ice pick and boxcar scars, peeling with 50% TCA may work best, while for rolling scars a combination of salicylic acid topical retinoids may be preferred.
  • The CROSS technique, or local application of 50% TCA, is a safe, minimally invasive, efficacious and cost-effective technique even in darker skin. [2]
  • Skin needling stimulates the production of collagen to promote skin rejuvenation, and can be performed with either a manual or automatic device.
  • One of the limitations of a manual device is that the entire skin surface is not treated or with the same pressure, and the technique can be very painful for the patient.
  • Automatic needling devices are now available that attempt to overcome these limitations, and active ingredients can be directly supplied to the deeper layers of the skin.
  • Hyaluronic acid-based products may also be beneficial to apply in the post-needling phase.
  • Percutaneous collagen induction (PCI) via skin needling has also been used for treatment of acne scarring.
  • This novel technique may offer a simple and safe modality to improve the appearance of acne scars without the risk of dyspigmentation in patients with all skin types. [3]
  • Another novel technique that can be associated with needling is the use of platelet-rich plasma (PRP) as it contains autologous growth factors, which could act synergistically with growth factors induced by skin needling to enhance the wound-healing response. [4]
  • The combination of treatments, carried out by using skin needling and PRP application, have the potential to enhance the efficacy of both treatments.
  • Studies have indeed shown that both skin needling and PRP is more effective than skin needling alone in improving acne scars.
  • The application of topical retinoids is of interest as histochemical and ultrastructural studies have demonstrated that topical all-trans retinoic acid (RA) stimulates the deposition of a subepidermal band of collagen.
  • Early studies demonstrated that RA-iontophoresis is an effective, non-invasive treatment for atrophic acne scars without undesirable side effects. [5]
  • Overall, topical RA therapy appears to be well tolerated.
  • Four variables appear to be associated with RA tolerability: retinoid concentration, formulation vehicle, skin sensitivity and individual retinoid. [6]
  • Lower retinoid concentrations are associated with less irritation.
  • Vehicle influence tolerability, but whether a gel or cream is better tolerated varies from retinoid to retinoid.
  • Tolerability is better on normal skin vs sensitive skin.
  • Topical RA can be used throughout the year and on all types of skin colours.
  • The application of dermal threads is based on support and stimulation of loose tissues to provide a filling effect.
  • The positioning of suture threads in subcutaneous causes an immediate lifting effect, favouring the natural production of type III collagen.
  • The production of collagen stimulates cellular metabolism and increases microcirculation and therefore blood flow in treated areas.
  • Moreover, dermal and connective mesenchymal stem cells are stimulated to differentiate and contribute to the support structure.
  • Various types of absorbable threads have been used: polylactic acid, PDO (polydioxanone), glycolic acid and caprolactone associated with polylactic acid.
  • This type of treatment for atrophic acne scars may be useful for scars that affect less than 30% of the facial surface and are of the single and box scar type.
  • Results are visible immediately after treatment, with more marked improvement after 6-8 months.
  • A wide range of techniques are now available to treat acne scars
  • Combining techniques can be performed safely and synergistically with optimal patient outcomes

Key messages/Clinical perspectives

  • Chemical peels, needling and application of topical retinoids and absorbable dermal sutures have all been used to treat acne scars.
  • The choice of therapy for acne scarring must be individualised to the patient.


References

References


  1. Handog EB, Datuin MS, Singzon IA. Chemical peels for acne and acne scars in asians: evidence based review. J Cutan Aesthet Surg. 2012 Oct;5(4):239-46.
  2. Fabbrocini G1, Cacciapuoti S, Fardella N, et al. CROSS technique: chemical reconstruction of skin scars method. Dermatol Ther. 2008 Nov-Dec;21 Suppl 3:S29-32.
  3. Fabbrocini G, De Vita V, Monfrecola A, et al. Percutaneous collagen induction: an effective and safe treatment for post-acne scarring in different skin phototypes. J Dermatolog Treat. 2014 Apr;25(2):147-52.
  4. Cosderm.com. Available at: https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/024040177.pdf.
  5. Schmidt JB, Donath P, Hannes J. Tretinoin-iontophoresis in atrophic acne scars. Int J Dermatol. 1999 Feb;38(2):149-53.
  6. Leyden J, Grove G, Zerweck C. Facial tolerability of topical retinoid therapy. J Drugs Dermatol. 2004 Nov-Dec;3(6):641-51.

Presenter disclosure information: G Fabbrocini: None disclosed.

Medical writer: Patrick Moore, PhD

Reviewer: Martina Lambertini, MD

Local reviewers: Martina Lambertini, MD (Italian); Alain Brassard, MD (French); Jorge Moreno González, MD (Spanish); Swen Malte John, MD, PhD (German); Marcelo Arnone, MD (Portuguese)

Scientific Editor: Prof. Brigitte Dréno, MD


CLINICAL TRIALS

PSORIASIS

Efficacy and safety of ixekizumab in a phase 3, randomized, double-blind, placebo-controlled study in paediatric patients with moderate-to-severe plaque psoriasis

Presented by: Prof. Kim A. Papp, Department of Medicine, Division of Dermatology, University of Toronto, Toronto, Canada

ATOPIC DERMATITIS

Efficacy and safety of baricitinib in combination with topical corticosteroids in moderate to severe atopic dermatitis: results of a phase 3 randomized, double-blind, placebo-controlled 16-week trial (BREEZE-AD7)

Presented by: Prof. Kristian Reich, Translational Research in Inflammatory Skin Diseases, Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, and Skinflammation® Center, Hamburg, Germany

PRURIGO NODULARIS

Phase 2b study of nemolizumab in patients with moderate to severe prurigo nodularis and associated severe pruritus

Presented by: Prof. Sonja Ständer, Department of Dermatology and Center for Chronic Pruritus (KCP), University Hospital Münster, Germany

VITILIGO

Efficacy and safety of a 52-week, randomized, double-blind trial of ruxolitinib cream for the treatment of vitiligo

Presented by: Dr. Amit G. Pandya, University of Texas Southwestern Medical Center, Dallas, TX, USA
 

EMERGING TERAPIES

PSORIASIS

Emerging therapies for psoriasis

Presented by: Prof. Michel Gilliet, Department of Dermatology, Lausanne CHUV, Switzerland

ATOPIC DERMATITIS

New and emerging therapies in atopic dermatitis

Presented by: Prof. Dagmar Simon, Department of Dermatology, Inselspital, Bern University Hospital, Bern, Switzerland

ONYCHOMYCOSIS

Emerging treatments for onychomycosis

Presented by: Dr. Ditte Marie L. Saunte, Department of Dermatology, Institute for Clinical Medicine, Zealand University Hospital, Roskilde, Denmark
 

REVIEW & UPDATES

ACNE & ROSACEA

Isotretinoin for acne and rosacea

Presented by: Dr. Pedro Mendes-Bastos, Dermatology Centre, Hospital CUF Descobertas, Lisbon, Portugal

ALOPECIA AREATA

New drugs for alopecia areata

Presented by: Prof. Spyridon Gkalpakiotis, Department of Dermatovenereology, Third Faculty of Medicine and University Hospital of Kralovske Vinohrady, Prague, Czech Republic.

DERMATOSURGERY

Update in dermatosurgery

Presented by: Prof. Eduardo Nagore, Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain

EPIDERMOLYSIS BULLOSA

New start of gene therapy in epidermolysis bullosa

Presented by: Prof. Leena K. Bruckner-Tuderman, University Medical Center, Albert-Ludwigs-University of Freiburg, Germany

MELANOMA

Treatment resistance in metastatic melanoma

Presented by: Prof. Martin Röcken, Department of Dermatology, Eberhard-Karls-University Tübingen, Germany

SCAR TREATMENT

Future of medical scar treatment

Presented by: Prof. Gabriella Fabbrocini, Department of Dermatology, University of Naples Federico II, Naples, Italy
 

EDUCATION FORUM

NON-MELANOMA SKIN CANCER

Systemic treatments of non-melanoma skin cancer

Presented by: Prof. Henrik F. Lorentzen, Department of Dermatology, Aarhus University Hospital, Denmark
 

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