Possibilities for correcting post-acne scars

Natalya Bondar , chief physician of the Farmosa restorative medicine clinic, dermatocosmetologist, trichologist, member of the All-Ukrainian Association of Trichologists, Association of Preventive and Anti-Aging Medicine, Ukrainian Academy of Dermatovenerology (Ukraine, Vinnitsa)

Marina Erokhina , chief physician of the Omeda Medical Center, dermatologist, trichologist, member of the Ukrainian Academy of Dermatovenereology, Ukrainian Society of Aesthetic Medicine, All-Ukrainian Association of Psoriasis (Ukraine, Vinnitsa)

Such pathological changes in the skin, such as post-acne, are a consequence of the (most often mechanical) impact on acne by both the patient himself and its improper treatment. Most people are familiar with the problem of acne. When the skin is seriously affected by acne , serious professional dermatocosmetological treatment is required. All attempts by patients to remove pustules and comedones on their own, as a rule, end in cosmetic defects that remain for quite a long time, and sometimes forever, if left untreated. On the contrary, timely contact with a specialist will allow you to successfully cope with acne, and will also prevent the occurrence of post-acne.

Types of post-acne and principles of correction

Post-acne is a complex of cosmetic skin defects resulting from seborrhea and acne, as well as unskilled exposure to them during attempts at self-treatment.

Post-acne include:

• dilated mouths of the excretory ducts of the sebaceous glands;
• persistent erythema and telangiectasia;
• scars (atrophic, hypertrophic, keloid);
• spots of congestive hyperemia;
• post-inflammatory hyper- and depigmentation.

Basic postulates:

• the level of severity and depth of post-acne are directly proportional to the severity of acne;
• lack of professional treatment of acne leads to severe pathological changes in the skin;
• the younger the patient, the greater the skin’s ability to regenerate;
• A gradual and complete effect on all structures of the epidermis and dermis leads to maximum treatment results.

The consequences of acne remain after the disease has subsided, and, unfortunately, in the absence of proper treatment, accompany the entire life. The result of inflammation often ends in the formation of a scar - irregularly structured, rough connective tissue. In order to influence scar tissue, not only long and expensive treatment is necessary, but also a clear understanding of the approach to different types of scars. Based on the above postulates, one should take into account the duration, severity of acne and the age of the patient. The most important thing is to create all the conditions for complete regeneration, restoring, if possible, all the functions of the skin. Improving microcirculation, reducing microthrombosis of blood vessels and venous stagnation, increasing the level of hydration in the skin and normalizing keratolytic processes lead to successful treatment of post-acne. Having ensured maximum functioning of the skin, you can begin stimulating methods of regeneration.

In modern cosmetology, the most striking examples of restoring the functioning of the skin are the use of platelet-rich plasma, redermalization and biorevitalization.

The issue of choosing a post-acne correction method is decided individually in each specific case and depends on the duration of the process, the type of post-acne and the stages of their development.

Use of platelet rich plasma

Platelet-rich plasma (PRP) has been used in medicine for about 20 years. This is plasma, the concentration of platelets in which is five times higher than normal, and is equal to 1 million / μl. Autoplasma enriched with platelets can also be used as an independent method of treating pathological changes due to acne. This is explained by the presence of polypeptide-trophic regulatory substances in PRP (platelet-rich plasma). The most important growth factors include platelet-derived growth factor (PDGF-aa, PDGF-bb, PDGF-ab), transforming growth factor (TGF-β1, TGF-β2), vascular endothelial growth factor (VEGF), epithelial growth factor (EGF), fibroblast growth factor (FGF), insulin-like growth factor (IGF). The most well-studied representative of the group of protein growth factors (mitogens and motogens) is platelet-derived growth factor (PDGF). PDGF induces chemotaxis of leukocytes, granulocytes, and macrophages; an external concentration of PDGF of 1–2 ng/ml is sufficient to stimulate their directed movement. Connective tissue cells are involved in the process: the proliferation of fibroblasts and their directed movement, as well as the synthesis and secretion of extracellular matrix proteins are stimulated.

To affect scar tissue, not only long-term treatment is necessary, but also a clear understanding of how to approach different types of scars. The duration, severity of acne and the patient’s age should be taken into account.

To obtain platelet-rich plasma, use an EBA 20 centrifuge manufactured by Andreas Hettich GmbH & Co (Germany) or its equivalent. After collection, the blood is placed in a special sterile 9 ml tube for plasma lifting (a tube containing a special quality and a special method of introducing heparin sodium salt) and centrifuged for 10–15 minutes. Next, the patient is injected with ready-made autoplasma rich in platelets. The injection zones are determined by a dermatocosmetologist. As a rule, these are not only post-acne areas, but also healthy adjacent areas of the skin. Injections of platelet-rich plasma are carried out according to the principles of mesotherapy. The effect becomes noticeable soon after the first injection of autoplasma enriched with platelets, if, of course, the procedure is carried out correctly. Naturally, the manipulations take place in a procedural room and with a medical license.

Contraindications to the procedure are:

• severe diseases of the thyroid, pancreas (diabetes mellitus), heart, lungs, kidneys - stimulation can cause unexpected reactions;
• chronic infectious diseases: hepatitis B and C, syphilis, AIDS;
• bleeding disorders;
• autoimmune diseases.

The procedure is not performed in the presence of severely inflamed pustular formations on the skin, during pregnancy, lactation, neuroses, depressive states, and mental disorders.

Redermalization and biorevitalization

Redermalization is the restoration of the dermis at the morphological, biological and functional levels, which occurs through intradermal injections containing succinate and hyaluronic acid. Redermalization has powerful restorative and antioxidant properties, eliminates skin dehydration, actively blocks free radicals, moisturizes by replenishing HA deficiency in tissues, and also improves metabolic processes in the skin, participates in the formation of the intercellular matrix, enhances cellular and tissue respiration, stimulates the production of ATP, maintains intercellular and cellular homeostasis.

Injections enhance microcirculation and the synthesis of structural proteins of the skin (collagen, elastin), activate the endogenous synthesis of HA due to a pronounced effect on fibroblast mitochondria. All of the above processes lead to a complete restoration of the functioning of the dermis: the relief and color of the skin are evened out, the mouths of the excretory ducts of the sebaceous glands are narrowed.

To correct post-acne conditions, redermalization preparations are used at a concentration of 1.1 or 1.8%, depending on the skin type and post-acne condition. The drug is administered intradermally, papularly along massage lines. In case of atrophic scars, the bottom of the scar is first separated by pendulum-like movements of the needle tip, where the redermalizant drug is injected. The first session is best done with the drug at a concentration of 1.1%; the papules last for 1–2 days. When the drug is administered, 1.8% papules can last up to 3 days. Sessions are performed once every 2 weeks. Number of sessions – from 4 to 6.

Contraindications are:

• connective tissue diseases;
• feverish conditions;
• malignant neoplasms;
• pustular diseases;
• active herpes;
• bronchial asthma;
• pregnancy and breastfeeding.

Relative contraindications: menstruation, deep depression, tendency to atopy.
After skin regeneration procedures, as well as maximum hydration, it is possible to use microdamaging stimulating methods. The most popular are Fraxel laser resurfacing, radio wave therapy, and intradermal collagen induction with a dermaroller.

Fractional photothermolysis

Fraxel lasers work using so-called fractional principles: the principle of fractional photothermolysis (Fraxel re:store and Fraxel re:fine) and the principle of fractional ablation (Fraxel re:pair). The advantage of the fractional laser resurfacing procedure is that areas of the skin that have not been subjected to laser damage are included in the regeneration process much faster than the damaged ones. During the procedure, microchannels are created in the skin, which activate fibroblasts and promote the renewal of the collagen matrix. As a result, new collagen and elastin are produced, which increase skin firmness and elasticity. Intact (undamaged) adjacent areas during fractional laser exposure promote rapid healing, which significantly reduces the recovery time after the Fraxel procedure and the risk of developing side effects, as with other skin resurfacing techniques (CO2 laser or dermabrasion). Fractional laser resurfacing of the skin of the face and body forms zones of fractional thermolysis with a predetermined distribution density. The procedure has the ability to select the depth of coagulation, which allows dosed stimulation of collagen remodeling.

Table. Fraxel procedure. Effectiveness of scar treatment and number of procedures required

The fractional laser resurfacing procedure is only the optimal way to change the scar, making it similar to the surrounding skin: in shape (change the profile of the scar), in color (remove the vascular component and add/remove pigmentation), in texture (make the transition from scar to healthy skin invisible) fabrics). The procedure cannot affect the scar deep in the skin (2–3 mm or deeper), and the scar will be palpable after treatment, although it will become much softer.

Side effects:

• after treatment, swelling may appear, but it goes away quickly;
• slight erythema (redness) that goes away within 2–3 weeks;
• itching and dryness of the treated area is common as the skin heals, peeling and dryness gradually disappear; Using light moisturizers and/or moisturizing sunscreens that are recommended and do not cause irritation should alleviate this condition;
• If pain or discomfort occurs, ice packs may be applied, and sedatives may be used to relieve pain and itching.

Currently, Fraxel is one of the most popular hardware procedures for post-acne treatment in Europe and the USA.

Previously, radio wave lifting was used only as anti-age therapy, but recently experience has accumulated in its use for the treatment of stagnant spots and atrophic scars.

Radio wave therapy

The basis of this method is electromagnetic radiation in the radio frequency range, which helps to change the functional activity of cells. These processes are accompanied by heat transfer, as a result of which the irradiated tissues become very hot. In aesthetic medicine, devices with heat control are used. Previously, radio wave lifting was used only as anti-age therapy, but recently experience has accumulated in its use for the treatment of stagnant spots and atrophic scars. Increasing the temperature in the deep layers of the skin using radiofrequency energy provides compaction of collagen-containing tissues, as the fibrils located inside the collagen fibers are compressed and thickened. Due to the high conductivity of connective tissue fibers (fibrous septae) of subcutaneous fat, radiofrequency energy penetrates to the level of the hypodermis, providing tissue strengthening from the inside. Within six months after the procedure, increased formation of new collagen and further strengthening of the dermis occurs, which leads to a long-term aesthetic result, especially with atrophic scars. After 6–8 sessions, it is possible to obtain a pronounced effect of increasing skin tone, as a result of which its structure changes: pores narrow, atrophy decreases. For this method, special electrodes-manipules are used, coated with a semiconductor that limits the penetration of radio frequency waves.

The main contraindications are:

• pacemaker;
• metals in the affected area;
• diabetes;
• pustular skin diseases;
• active herpes;
• pregnancy and breastfeeding;
• connective tissue diseases;
• blood clotting disorder.

Radio wave exposure is successfully combined with PRP and redermalization, mesotherapy 2 weeks after radiotherapy.

Intradermal collagen induction with dermaroller

Using a dermaroller, many perforations with a diameter of 0.08 to 0.22 mm are made in the skin. The penetration depth of microneedles is from 0.2 to 2.5 mm, depending on the severity of the problem and its location. Up to 150 perforations can be made per 1 cm2. By creating many perforations in the skin, the needles injure both collagen fibers and fibroblasts along the way, stimulating the production of islands of new collagen in the skin. Thus, neocollagenesis is formed in the dermis (in the deep layers of the skin), which is especially important in the treatment of atrophic scars. Patients require several courses of 3–5 procedures, every 6–8 weeks.

The application technique, on the one hand, is not complicated, but on the other, it requires a complete understanding of the process and medical conditions for the procedure.

After cleansing, the skin should be treated with a solution of chlorhexidine bigluconate 0.05% for external and local use. If pain relief is necessary, it is recommended to treat the skin with an anesthetic cream before the procedure (exposure under the film for 30 minutes) or apply 10% lidocaine with adrenaline using a 0.3 mm dermaroller. Next, a multi-injection treatment is carried out using a dermaroller, while the skin is slightly stretched with your fingers. Treatment with a dermaroller is performed for 5-10 minutes in different directions - horizontally, vertically and diagonally. First, the large zones (cheeks), then the smaller ones (T-zone). After treatment, autoplasma enriched with platelets is applied for maximum regeneration in the post-acne area.

Dermaroller (mesoroller) today is a minimally invasive method that can significantly reduce the depth and amount of post-acne, improve skin turgor over large areas without introducing toxic substances. Contraindications are the same as for many of the above methods.

First published in Les Nouvelles Esthetiques