Dermaroller for management of acne scars

Transcription

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Percutaneous Collagen Induction with Dermaroller TM
for Management of Atrophic Acne Scars in 31 Thai
Patients
Keywords: Percutaneous collagen induction, Skin needling, Acne scar,
Asian patients
Short title: Dermaroller
Abstract:
TM
in treatment of atrophic acne scars
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Percutaneous collagen induction with Dermaroller TM MF 8 (Horst, Liebel Co, Germany,US
FDA registered no.878-4800), 1.5 mm needles was used for treatment of atrophic ace scar
in 31 Thai patients. All patients had moderate to advance atrophic acne scar with Fitzpatrick
skin type III to V. The treatment was performed under local anesthesia with sterile aseptic
technique. The number of treatments ranged from 1 to 4 at monthly interval. Clinical
evaluation was performed by side by side comparison of standard photographies by two
non-medical independent observers. After six months follow up the clinical severity scores
decreased from 4.24 to 2.33. The improvement of more than 50% was observed in 67.74 %
of cases. Complications were rare and transient,6.45% developed post treatmnent folliculitis
which responded to oral antibiotics. Dermaroller TM had been shown to be effective and safe
percutaneous collagen induction for treatment of atrophic acne scar in Fitzpatrick skin type
III to V Thai patients.
Introduction:
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Journal of Cosmetic Dermatology
Acne vulgaris is one of the most common skin disease. After active inflammatory
phase had subsided a large portion of patients have been left with atrophic scar.
Many studies had confirmed the psycho-social significance of atrophic acne scar.
Severe atrophic acne scar which happened at important period of life i.e.
adolescence had important psychologic impact to the patients. Higher incidence of
introvert personality changes and depression were common in severe acne scar
cases. In the past treatments of atrophic acne scar were difficult and complicated.
Chemical peels, dermabrasion ,laser resurfacing and non-ablative laser resurfacing
had produced false hope. These treatments were complicated, expensive ,with high
complications and inconsistent results. Recently percutaneous collagen induction
(PCI) with Dermaroller TM device had been introduced in Europe with impressive
results. Dr.Des Fernandes was the first to call this technique skin needling or
percutaneous collagen induction (PCI) and presented his study at the XIIth Congress
of the International Society of Aesthetic Plastic Surgery in Paris, France in 1993.He
had also published the technique in detail in 2005.1 Together with his collegues he
had published the first article on PCI for treatment of scars, wrinkles and skin laxity
in his large study of 480 patients from South Africa and Germany , he had reported
good result in majority of cases.2 . The author had been performing this treatment
since 2006 . Since there was no data on efficacy and complications of this technique
for management of atrophic scars in Asians’ Fitzpatrick skin type III to V .This article
will describe clinical findings in the first batch of 31 Thai patients.
Study design:
Long-term (6 months) open prospective study with independent observers
evaluation
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Patients and method:
Thirty one patients with moderate to severe atrophic acne scar . Twenty were male
and ten were female with age ranging from 24 to 45 years old . After fully informed
of the procedures all patients agreed to sign the informed consents. After
throughoutly cleansing of the face, five standard ( direct infront, 45o and 90o to left
and right side of face) studio-type photographies with fixed studio lighting and fixed
distance were taken with digital camera ( Olympus C760, Japan).
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Local anesthesia with topical xylocaine and pilocaine mixture (EMLA, Astra , Sweden)
were applied over the whole face and covered with cellophane tape for one hour.
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Figure 1: Skin needling device ( Dermaroller
TM
, MF 8, 1.5 mm needles,
Horst Liebel Co, Germany)
EMLA was then removed with sterile water. The face was then painted with 1%
Betadine solution. Sterile drape was applied to the face and exposed only the
treatment area.
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Additional to EMLA , infraorbital, supraorbital, mental and superficial nasal nerves
blocks were performed with 1% Xylocaine (Astra, Sweden) injection. Field block with
the same anesthetic was performed at lateral mandibular areas.
Sterile single use disposable skin needling instrument ( DermarollerTM, MF 8,Horst
Liebel Co, Germany, European FDA approval number CE 0373, US FDA registered
number 878,4800) with 1.5 mm 192 needles was used for the treatment.(Figure 1)
The treatment area was tightened while with firm pressure ,the author hold the
handle of the device and rolled the instrument on a small plot of treatment area.
Each pass of rolling produced 16 micro-punctures/cm2. The instrument was rolled
back and forth with different directions for 10-20 times on the treatment plot. During
treatment few drops of Oxoferin TM solution (,Holopack Verpackungstechnik GmBH,
Germany) were applied to the treatment areas. The purpose of application of this
solution was to enhance wound healing .(Figure 2) The Dermaroller TM device would
produced tangentially needle holes 250 micrometers down into middermis. (Figure
3)
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Minimal bleeding from needle holes were observed while the author varied directions
to avoid repeated puntures on the same needle holes. The treatment was repeated
on adjacent areas to cover the entire faces. After treatments ,the bleeding was
controlled with light pressure with sterile gauze and application of Oxoferin TM.1%
Fucidic acid ointment ( Fucidin TM, Leo, UK ) was then applied to the treatment area.
All the treatments had been performed by the author.
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Figure 2: Treatment of atrophic acne scar with Dermaroller
TM
10-20 passes of firm pressure, multi-dirction rolling of device on each area
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Figure 3: Histologic changes immediately after DermarollerTM
(MF 8, 1.5 mm needles) . There was 1-1.5 mm. deep
needle holes into the dermis.
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Oral antibiotics ( Cloxacillin, Dicloxacillin ,Augmentin or Co-trimoxazole) for seven
days were prescribed in some cases with active acne pustules.
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The patient was advice to clean face with sterile normal saline and applied open
wound care technique with application of FucidinTM ointment twice daily until the
wounds were completely healed ( between 5-7 days). There was mild to moderate
facial edema for few days. Usually the post treatment pain was minimal.
Follow up and retreatments:
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The patient was followed up at seven days. Topical sunscreen and emollients were
then prescribed. Standard studio type photographies similar to pre treatment were
taken. Post treatment facial skin usually was not sensitive to sunlight which was
differed from after laser resurfacing.
The repeated treatments were performed at interval of 1-2 months. The number of
repeated treatments were as followed 7 cases had one treatment,12 cases had two
treatments, 5 cases had three treatments and 7 cases had four treatments. The
duration of follow-up was six months.
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Acessment of results:
Two independence nonmedical observers were requested to evaluate clinical
improvement scores from side by side comparison of recorded standard
photographies. Standard six points improvement scores were used.
5 = severe atrophic scar pre treatment
4 = improvement between 0-25%
3 = improvement between 26-50%
2 = improvement between 51 – 75%
1 = improvement between 76 – 90%
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0 = improvement > 91%
Results:
Figure 4 demonstrated clinical severity scores after 1-4 treatment with Dermaroller
TM
in 31 patients. The number of treatments varied from 1 to 4 . Usually the mild
cases were treated once, while severe cases had 3-4 treatments.
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Clinical Improvement of acne scar after dermaroller in 31 cases
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Acne scar severity scores
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3
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P re Rx
P os t Rx
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Case No.
Figure 4: Clinical improvement as graded by independent observers in 31 cases. All cases
had clinical improvement at six months. The number of treatment ranged from 1 to 4.
The mean clinical scores decreased from 4.24 to 2.33 at six months of follow-up.
(Figure 4).Five case ( 16.13%) had improvement more than 75% while 21 cases
(67.74%) had improvement more than 50%.(Figure 5,6,7,8) Two cases(6.45%)
developed folliculitis within a few days after treatments. This cleared rapidly after
oral antibiotics.
Table 1: Mean acne scar severity scores after 1-4 Skin needling (Dermaroller
TM
)
by two indepencence non-medical observers for side by side standard
photographies comparison in 31 cases.
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Mean, Pre treatment
Mean, Post treatment
( 6 months)
4.24
Discussions:
2.33
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Management of atrophic acne scar in dark skin types were difficult. The standard
treatments in white skin (Fitzpatrick skin type I,II) included dermabrasion, chemical
peels, carbondioxide or erbium laser resurfacing. 3,4,5,6 Even in white skin patients
results from these treatments were far from satisfactory. 4 The treatments were
complicated to perform with prolong healings and long term dyschromias. Post
treatments erythema was found in all cases, lasting average 4.5 weeks after CO2
laser and 3.6 weeks after long-pulsed Er:YAG laser. Hyperpigmentation was seen in
46% after CO2 laser and 42% after Er:YAG laser .This hyperpigmentation lasted 12.7
and 11.4 weeks respectively 7 .In dark skin types ( Fitzpatrick skin type III –VI)
these laser treatments were abandoned because of serious post treatment
complications especially post inflammatory hyperpigmentation and late onset
permanent hypopigmentation . Alster TS and West TB had reported 81.4%
improvement after pulsed CO2 laser in Fitzpatrick skin type I-IV but also observed
prolong erythema in all cases with 36% post treatment hyperpigmentation.3
Nonablative laser resurfacing with absence of downtime often resulted in minimal
improvement. Most of the study had shown that after repeated treatment the
degree of improvement were less than 30%.8,9.Chan et al had found that after 1,320
nm Nd:YAG laser treatment monthly for six months, patients’ satisfaction score was
4 from scale 0-10. From an independent observer the improvement was considered
to be mild or no changes in majority of cases .8 Only recently with introduction of
fractional laser resurfacing with Erbium-doped or laser which produced array of
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minutes thermal necrotic holes deep into the dermis that there were fair to good
clinical improvement after multiple treatments (30-50%). Lee et al had reported
marked improvement in the appearance of acne scars at 3 months post-treatment in
27 Korean patients. Patients' self-assessed degrees of improvement were as follows:
excellent improvement in eight patients (30%), significant improvement in 16
patients (59%), and moderate improvement in three patients (11%). Adverse events
were limited to transient pain, erythema and edema. 9 The complications after
fractional laser resurfacing was related to thermal injuries. Too high density of laser
spots often resulted in post treatment erythema and post inflammatory
hyperpigmentation especially in dark skin type. PIH after fractional laser resurfacing
in Asians had been reported in 15% of cases. The cost of fractional laser equipment
and high consumable cost had discouraged wide acceptance of this laser in most of
developing countries.
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Skin needling with special roller instrument with 298 tiny sharp stainless steel
needles (250 Km, diameter) and length between 0.5 to 2 mm. had been introduced
in Europe and South Africa by Des Fernandes since 1993.1He named this technique
minimally invasive percutaneous collagen induction and had the first publication in
2005.1 The result after treatment of atrophic acne scar had been found to be
satisfactory with minimum downtimes. 2 The mechanism behind clinical improvement
was purposed to be results of tangentially cutting of fibrotic scars by pressure rolling
and induction of blood clot, platelets activation, released of cytokines especially
platelet-derived growth factor , fibrous growth factor, transforming growth factor
etc. These resulted in induction of new collagen formation together with scar
remodeling. This results in elevation of atrophic scar and reduction of fibrotic
scarborders.1 Due to small size of needle holes healing was rapid. Usually the tiny
needle wounds healed in three days. The degree of scar improvement from wound
remodeling went on for many months after even single treatments.1,2
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Since this PCI technique had gained acceptance in Europe and South Africa1,2 but
the clinical study in Asians’ skin was lacking. This study had shown that with good
patients selection, sterile method and good technique the degree of clinical
improvement for treatment of atrophic acne scar in Fitzpatrick skin type III to V
,Asian patients was moderate to good result, with 67.74% had more than 50%
clinical improvement. This result was almost equal to those after CO2 laser
resurfacing3 but with better healing and much lower post treatment complications. It
also is about the same efficacy with fractional laser resurfacing.10 Post inflammatory
hyperpigmentation which was directly related to thermal injury was more common
after fractional laser resurfacing 11 was absent after skin needling. The overall cost
after multiple treatments with skin needling was much lower than fractional laser
resurfacing.
The quality ,hardness and sharpness of needles are important property of good skin
needling device. Basically ice-hardening steel with tensile strength more than 2,200
Newtons will ensure better chance of good result and also without complications.
High ratio of tip length VS diameter of 13:1 is another important property of good
needles .The depth of neocollagenesis was found to be average 5-600 micrometers
even after 1.5 mm length needle. So the needle length longer than 1.50 mm was
unnecessary. 1The Dermaroller TM had obtained CE approval and US FDA approval as
medical device from Germany and USA since January 2006. Poor quality needles of
the roller device often resulted in bending at needle tips after repeated treatments
.Thes resulted in in more tissue damages and hemorrhage with linear hypertrophic
scars or post inflammatory hyperpigmentation.1This reason together with problems
of cross contamination is the reason why single-use device is recommended. To
avoid any possible complications doctors who are interested in performing this
technique should attend a hand-on training course from experience dermatologic
surgeons.
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In conclusion, percutaneous collagen induction by skin needling with high quality
single-use device (Dermaroller TM, Horst Liebel Co, Germany) had been shown to be
highly effective and safe method for treatment of atrophic scar in Fitzpatrick skin
type III to V Thai patients.
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References:
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1.Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofacial
Surg Clin N Am. 2005;17: 51-63
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2.Aust MC, Fernandes D, Kolokvthas P, Kaplan HM, Vogt PM. Percutaneous collagen
induction therapy: an alternative treatment of scars, wrinkles, and skin laxity. Plast
Reconstr Surg. 2008; 121(4):1421-9
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3.Alster T, West TB. Resurfacing of atrophic facial acne scars with a high-energy
pulsed carbondioxide laser. Dermatol Surg. 1996:22(2),154-155
4.Goldman MP, Manuskiatti W. Combined laser resurfacing with the 950 microsecond
pulsed CO2 + Er:YAG lasers. Dermatol Surg . 1999: 25(3): 160-3
5.Woo SH, Park JH, KveYC. Resurfacing of different types of facial acne scar with
short-pulsed, variable-pulsed , and dual-mode Er:YAG laser. Dermatol Surg .
2004;30:488-93
6.Jeong JT, Kve YC. Resurfacing of pitted facial acne scars with a long-pulsed
Er:YAG laser. Dermatol Surg. 2001;276:107-10
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7.Tanzi EL, Alster T. Single-pass carbon dioxide versus multiple-pass Er:YAG laser
skin resurfacing:a comparison of post operative wound healing and side effect rates.
Dermatol Surg .2003:29;80-4
8.Chan Hm ,Lam LKm Wong DS, KonoT, Trendekk-Smith N. Use of 1320 nm NdYAG
laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians.
Lasers Surg Med .2004;34:98-103
9.Chua SH, Ang P, Khoo LS, Goh CL. Nonablative 1450 nm diode laser in the
treatment of facial atrophic acne scars in type IV to V Asian skin: a prospective
clinical study. Dermatol Surg. 2004:30;1287-91
10.Lee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, Chung JH. Fractional
photothermolysis for the treatment of acne scars: A report of 27 Korean patients. : J
Dermatolog Treat. 2008;19(1):45-9.
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11. Kono T, Chan HH, Groff WF, Manstein D, Sakurai H, Takeuchi M, Yamaki T,
Soejima K, Nozaki M. Prospective direct comparison study of fractional resurfacing
using different fluences and densities for skin rejuvenation in Asians. Lasers Surg
Med. 2007 Apr;39(4):311-4.
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Figure 5 : Good clinical improvement (>75%) after two monthly
Dermaroller
TM
treatment of moderate atrophic acne scars
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Figure 6. Good clinical improvement (>75% ) in severe atrophic acne scar after
fourth monthly treatments
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Figure 7. Good clinical improvement after fourth Dermaroller
TM
treatments
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Figure 8: Good clinical improvement (>75%) after fourth monthly Dermaroller
treatments of moderate atrophic acne scar
TM

Dermaroller for management of acne scars

Transcription

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