How to remove atrophic scars: complex therapy

Anna Stenko, MD, PhD, Head. Department of Cosmetology, JSC Institute of Plastic Surgery and Cosmetology (Moscow)

Elena Volkova, MD, professor, dermatologist, director of the scientific and educational department of Premierpharm (Moscow)

Atrophic scars most often form after injuries, burns, and can be iatrogenic (a consequence of surgery). Striae, being one of the forms of atrophic scars, occur during the period of rapid growth in puberty, during pregnancy, and with rapid weight gain. Many authors agree on the presence of a hereditary predisposition to pathological scarring and, in particular, to the formation of atrophic scars. Predisposing factors include Ehlers ⎼ Danlos syndrome (hereditary systemic connective tissue dysplasia), as well as anetoderma.

Atrophic scars are located below the level of the surrounding skin (sink). With a small width, they practically do not differ from normotrophic ones.

The pathohistological picture of atrophic scars is associated with a deficiency of fibrous proteins in the scar area - collagen and elastin, with atrophy of the dermis and hypodermis. The worsening of the appearance of such scars with age is associated with further atrophy of the subcutaneous adipose tissue. As a rule, fibroblasts in the area of scar deformation are inactive, their number is generally reduced.

Currently, a number of methods are used to treat atrophic scars:

• ablative and obligatory laser effects;
• radiofrequency therapy, including in fractional mode;
• mechanical skin resurfacing and microdermabrasion;
• cutting the bottom of the scar (subcision);
• microneedling;
• chemical peels (glycolic, TCA and phenol);
• injections of autologous fat, polylactic acid, preparations based on collagen and hyaluronic acid.

Numerous clinical studies show the effectiveness of fractional photothermolysis (FPT) procedures in the treatment of scars. Under the action of a laser, reparative processes in the skin are activated, due to which scar tissue is gradually replaced by elastic connective tissue. Most clinicians agree that the healing process, even after gentle treatment during PFT, requires additional “reinforcement” with a complex of signaling molecules and trophic factors. For this purpose, it is proposed to use platelet-enriched autoplasma or ready-made complex injectable preparations, among which the most studied and tested is Meso-Wharton P199™ (ABG Lab, USA).

In recent years, it has been found that skin regeneration and cellular renewal are carried out due to the constantly occurring processes of proliferation and differentiation of skin stem cells (SCs). From a pharmacological point of view, in the Meso-Wharton P199™ preparation, the main role in stimulating the synthesis of a cascade of signaling molecules necessary for the activation of proliferative processes is given to the regulatory peptide Wharton Jelly Peptide P199™ - a synthetic analogue of the human polypeptide, which acts as a mobilization factor for the skin's own stem cells , activating their proliferation and differentiation into mature functioning cells of the epidermis and dermis (keratinocytes and fibroblasts). The active participation of stem cells ensures complete regeneration of skin previously damaged by laser exposure. As a result of the complex effect, complete connective tissue is formed in the area of the atrophic scar, identical in composition and properties to the surrounding intact skin.

The analysis indicates the feasibility of combining PFT, which involves gentle skin damage, with the method of positive stimulation - Meso-Wharton P199™ injections. This assumption provided the rationale for planning and conducting the clinical trial.

CLINICAL STUDY

The purpose of this study was to examine the clinical efficacy of Meso-Wharton P199™ for the treatment of atrophic scarring skin lesions in combination with PFT.

Materials and methods

68 patients aged 16⎼64 years with cicatricial skin lesions were observed. The duration of existence of atrophic scars is from 3 months to 9 years. Postoperative scars were observed in 35 patients (52%), post-traumatic scars - in 19 people (28%), post-eruptive scars - in 14 patients (20%).

During the course of treatment, patients underwent a single FFT procedure. Laser exposure was carried out on a Fraxel PR apparatus (CO ₂ laser with a wavelength of 10,600 nm, pulse energy - 25⎼70 mJ at the MLZ, coagulation depth ⎼ up to 1.6 mm). With one laser pass, 125⎼250 thermal zones per 1 cm ² were formed.

To increase the comfort of the procedure, before laser exposure, topical anesthesia was performed by applying a thin layer of Emla anesthetic ointment to the scar area and surrounding skin for 35⎼45 minutes. After the procedure, the skin was treated with panthenol spray to reduce erythema and swelling. Panthenol cream was recommended for home skin care over the next few days.

On days 5–7 after the FFT procedure, patients received injections of Meso-Wharton P199™. When performing multiple intradermal microinjections in the facial area, the needle was inserted at an angle of 45° to the skin surface to a depth of 2 mm with an interval between injections of 5⎼10 mm. In areas with thin skin (around the eyes and on the neck), injections were performed using the micropapule technique: the needle was inserted at an angle of 30° to the skin surface to a depth of 1⎼2 mm, directing the needle bevel upward. The diameter of the papule did not exceed 1 mm. The total volume of the drug for injection in the area of scar deformation was no more than 0.3 ml.

Injections were prescribed at intervals of 7 days, the course of treatment included 5⎼8 procedures.

To assess the results of treatment before and after the course of treatment, a clinical examination was performed with an assessment of the dermatological status, and the dermatological quality of life index was calculated.

To objectively assess and record the condition of the skin of the problem area, photography and ultrasound scanning of the skin were used. Ultrasound scanning was performed using a Skinscanner DUB device (Taberna promedicum GmbH, Germany) with a 22 MHz linear probe and a scanning depth of 10 mm. The use of a frequency of 22 MHz made it possible to visualize the epidermis, dermis, subcutaneous fatty tissue, muscle fascia, hair follicles, and the lumen of skin vessels. Measurement of the acoustic density of the dermis was carried out in the area of the scar before and after the course of injections; for comparison, the acoustic density of the dermis was measured on the healthy contralateral area of the skin.

results

Subjective assessment of results by patients was carried out using the universal scale GAIS (Global Aesthetic Improvement Scale). All patients were satisfied with the result: very good and good clinical results were observed in 81% of patients (55 people), satisfactory – in 19% of patients (13 people). In 81% of patients, there was a reduction in rehabilitation time by 1⎼3 days, accelerated epithelization, and a pronounced leveling of the surface relief of the scar lesion

All study participants noted an improvement in the qualitative properties of scar tissue - increased elasticity, turgor, and equalization of color in relation to the surrounding skin.

When conducting ultrasound scans of the skin before and after the course of treatment, the scanograms showed an increase in the average acoustic density and thickness of the dermis (indicators approached those of healthy skin), which is likely due to active remodulation of the dermis, including through the synthesis of fibrous protein components .

CONCLUSIONS

The combined use of PFT and injections of the Meso-Wharton P199™ drug in patients with atrophic scars helps to reduce the recovery time after laser exposure, smooth out the relief of the surface of the scar lesion and improve the quality characteristics of the skin in the area of scar deformation.

As a result of the therapy, an increase in the thickness of the dermis and an increase in the acoustic density of the tissues of the problem area are observed, which may be due to the restructuring of the skin against the background of activation of the proliferation of dermal cells and the active synthesis of extracellular matrix components.

All study participants expressed high satisfaction with the fact that the rehabilitation period after the laser procedure was shortened and with the result of the correction in general.

Thus, an integrated approach to the correction of atrophic scars, based on a combination of PFT and injections of the Meso-Wharton P199™ drug, has shown high clinical effectiveness.

First published in Les Nouvelles Esthetiques 2017/№4