CICATRICES D`ACNE

POSTACNE SCARRING
PHYSIOPATHOLOGY
CLASSIFICATION
LASER MANAGEMENT
Dr LE PILLOUER-PROST A., Marseille, France
[email protected]
Dr BONAN P., Florence, Italy
[email protected]
Thanks to the support of the laser italian company DEKA
Physiopathology
• Adult prevalence (USA 1999)
women 14%, men 11%
• Efficient prevention/grading /rapid cares
risk evaluation
– Family cases : premature and prolonged acne
– Perifollicular elastolysis (Staph.) : bacteria
– Gravity of dermis lesions : intensity and duration
of the inflammation
– Complex personal abnormalities of tissue repair
(cell to cell or cell to cytokine)
MMPs hyperactivity (atrophy)
TIMPs hyperactivity ou MMPs failure (hypertrophy)
TGFβ subunits or IL -notably IL-6- abnormalities
Keratinocytes abnormalities or K/FB regulation failures
MMPs
IL-1α
TGFβ
TGFα
PDGF
bFGF
ET-1
TIMPs
TGFβ
GM-CSF
KGF
HGF
IL-8
Classification – French group « expert
acné »
– Atrophic scars
– Hypertrophic scars
– Red or pigmented mackles (transient)
Atrophic scars
• « Ice pick » or « V-shaped » scars
Epithelialized, vertical, deep and thin
holes
< 2 mm
cheeks
• « boxcar » or « U-shaped » scars
Clear and steep edges and regular and
flat bottom
2-4 mm
• « rolling » or « M-shaped » scars
Soft edges depressions, irregular surface
> 4 mm
Tissue : Soft and pilable
Scars : easily stretched, not fibrotic
Atrophic scars
• Perifollicular elastolysis
Small rounded white spots
Soft consistency
Epidermidis staphylococci (elastase
secreting)
Hypertrophic scars
• Simple
Not exceeding margins / initial lesions
Regressive between 12-18 months
• Keloids
Exceeding margins
Prethoracical region, nucha or mandible
Dystrophic scars
• Complex
with cords, bridges, intradermal
epithelialized tunnels,
multipore comedones, large
plaques of fibrosis with
achromia
and often a persistent
inflammatory disease
French grading scale
Pr Dreno B., Dermatology 2007, 214:46-51
ECCA grading scale
Type
Balance factir (a)
Semi quantitative score (b)
Atrophyic scars
« Ice pick » or « V-shaped » < 2 mm
or punctiform
15
0
1
2
3
=
=
=
=
no scar
a few scars
limited number of scars
many scars
Atrophic scars
« Boxcar » or « U-shaped » : 2 to 4 mm
sheer edges
20
0
1
2
3
=
=
=
=
no scar
a few scars
limited number of scars
many scars
Atrophic scars
« Rolling » or « M-shaped » > 4 mm
Superficial, irregular surface
25
0
1
2
3
=
=
=
=
no scar
a few scars
limited number of scars
many scars
Perifollicular elastolysis
30
0
1
2
3
=
=
=
=
absent
mild
moderate
intense
Hypertrophic anf inflammatory scars < 2 ans
40
0
1
2
3
=
=
=
=
no scar
a few scars
limited number of scars
many scars
Keloids / Hypertrophic scars > 2 ans
50
0
1
2
3
=
=
=
=
no scar
a few scars
limited number of scars
many scars
subgrading 1
Subgrading 2
Global score (1 + 2)
Grade (axb)
English grading scale
Goodman GJ, Dermatol Surg 2007 Oct, 33(10):1175-88
Grade
1- Macular acne
scarring
macular acne scarring and markles visible to patient or observer at any distance,
erythematous or hyper-or hypopigmented and perifollicular
2- Mild acne
scarring
Few
Numerous
mild atrophy or hypertrophy that may not be obvious at social distances of 50cm
or greater and may be covered adequately by makeup or the normal shadow of
shaved beard hair in men or normal body hair if extra facial
Superficial atrophic scars
Superficial « rolling scars »
Papular lesions
3- Moderate acne
scarring
Few
Numerous
moderate atrophic or hypertrophic scarring that is obvious at social distances of
50 cm or greater and is not covered easily by makeup or the normal shadow of
shaved beard hair in men or body hair if extra facial, but is still able to be
flattened by manual stretching of the skin (if atrophic)
« rolling scars »
Shallow « boxcar or U » scars
Moderate hypertrophic and keloidal scars
4- Severe
scarring
severe atrophic or hypertrophic scarring that is obvious at social distance greater
than 50 cm and is not covered easily by makeup or the normal shadow of
shaved beard hair in men or body hair if extra facial and is not able to be
flattened by manual stretching of the skin
deep « boxcar or U » scars
« Ice-pick » scars
Dystrophic scars : bridges and tunnels
Significant hypertrophic or keloidal scars
MAIN Interest
• Algorythm of treatment
Grade disease
Likely treatment options
1- Macular
lesions
Time, optimized home skin cares, light strength peels, microdermabrasion,
vascular or pigmented lasers or IPLs
Needling, tattoing, Recell® , excimer laser or lamp for achromic lesions
2- Mild lesions
Few :
Dermal fillers, blood transfer (Regen® ?)
Numerous :
Non ablative lasers, fractional lasers, blood transfer, skin needling or rolling,
microdermabrasion, dermal fillers
+/- subcision
3- Moderate
lesions
Few :
Combined techniques, subcision, blood transfer, non ablative lasers, fractional
lasers, skin needling
Numerous :
Ablatifs lasers, dermabrasion, fractional lasers, radiofrequency devices +/dermal fillers, subcision, blood transfer
For hypertrophic scars : IL corticotherapy or 5FU or vascular lasers/lamps
4- Severe lesions
Punch techniques (float, excision grafting), focal TCA (CROSS technique)
+/- Resurfacing : traditional or fractional ablative lasers
+/- Fat transfer, rhytidectomie
For hypertrophic scars : IL corticotherapy or 5FU or vascular lasers/lamps
Light
Amplification by
Stimulated
Emission of
Radiation
• Vascular lasers
– 595 nm, 532 nm, Multiplex 595/1064 nm
lasers
– Red mackles
postresurfacing erythema
vascular, telangiectatic hypertrophic scars
+/- remodeling
• Pigmentary lasers
– Q-switched lasers (1064 nm, 755 nm)
– Pigmented mackles or scars (theory/time)
Superficial full face or localized abrasion
• IPLs – Flash Lamps
– Lot of devices : 475/650 – 950/1250 nm
– Vascular and pigmented indications
+/- remodeling
PDL and scars
Hypertrophic scars
before /after 2 sessions of low fluence PDL (1.5 ms, 5J/cm²)
Q-switched YAG and scars
IPL sources and scars
Hypertrophic post-surgical scars (18 months) : IPL 5 sessions
Courtesy of Dr Cartier H, dermatologist, Arras
• Infra red, « non ablative » lasers
Used for 10 years, their principles are
– Deep penetration
sufficient dermis thermal alteration / sparing the epidermis
to launch all the dermis cascades of wound healing
processes and…to have remodeling effects
– 1320, 1450, 1540 …nm lasers at first marketed only for NA
dermal remodeling
too modest and slow results
non visible on photos…
« not reproducible »
now used for retentional acne
– LP HP 1064 nm Nd-YAG lasers (new generation of Nd-YAG
lasers/dermatologist offices)
hair removal and leg telangiectasia, vascular…
for a few months : discovered them again with efficiency /
dermal remodeling
LP HP Nd-YAG lasers
Parameters for PAS : ?
- Fast scanning : 0.3 ms, 7 Hz, 2000 spots/hemiface
Lipper GM, Perez M.
Nonablative acne scar reduction after a series of treatments with a short pulsed 1,064-nm
neodymium:YAG laser.
Dermatol Surg. 2006 Aug;32(8):998-1006.
- Thermal elevation: HP LP parameters to warm the dermis about 60°C deep
Keller R, Belda Júnior W, Valente NY, Rodrigues CJ.
Nonablative 1,064-nm Nd:YAG laser for treating atrophic facial acne scars: histologic and
clinical analysis.
Dermatol Surg. 2007 Dec;33(12):1470-6.
15 mm
30-40 ms
25-30 J/cm²
Platform « SYNCHRO HP » - DEKA
1 or 2 pulses
Clinical cases
Nd-YAG High Peak Power remodeling alone
CHA Ab, 32 years old: atrophic acne scars (severe, numerous)
Surgery and traditional resurfacing indication (cost, PIHP)
Collection Dr LE PILLOUER-PROST
1 month after 2 sessions
Nd-YAG: 30-40 ms, 15-25J/cm², 2 passes,
cooling device Zimmer about 2
/No anesthesia, pain 7-8/10 ( 60°C dermis)
Traditional resurfacing
• 10 600 nm CO2 lasers and 2940 nm Erbium (+ new Er_YAG
2790 nm )
• Principles, pre-per-post-operative cares: www.scar-club.com
Gold standard for many years for DB with up-to-date scanners
Results : very good or excellent
Infrequent / frightening side effects
Greatest fear : definitive hypopigmentation or scars
• For PAS :
CO2 lasers : first system used / mechanical DB or chemical
peeling
Gold standard / moderate to severe atrophic AS (+/-preliminary
surgery)
Latest high energy generation CO2: about 70-75% improvement
often max at month 18th
Moderate rolling scars, negative stretching test, great alteration of QOL
CO2 laser alone 1 session under general anaesthesia - 6 months postop results (weight loss : 10 kg)
Surgery / Erbium
•
Firstly : Pure ablative effect is expected :
– young people
– mild to moderate PAS
Long pulse Erbiulm with underlying thermal effect…
•
Example :
Few «V» and numerous «U» scars
Scores : 75 (ECCA) : (15 x 1 ) + (20 x 3); 9 (Goodman); Grade 4
Punch technique
Excision and sutures
One month before
Conventional resurfacing
CO2 laser under GA
Erbium under NB and TA
(LP : CO3, from Cynosure)
Treatment and results
Grade 4: severe atrophy ( «V» and «U» scars)
15 days after
3 days after conventional ERBIUM resurfacing
•
Limited number « M-shaped » or « rolling » scars
Scores : 50 (ECCA), 6 (Goodman)
Grade 2 : mild, > 20
-Resurfacing +/- subcision
- Dermal fillers
•
Numerous « M » or rolling scars
Scores : 75 (ECCA), 6 (Goodman)
Grade 2
- conventional
CO2 resurfacing
+/- subcision
- fractional
resurfacing or
radiofrequency
device
- dermal fillers or
fat transfer
…
« FRACTIONAL » lasers
Latest breakthrough
Micro Thermal Zones (MTZs)
Principle:
Not to ablate
Not to only warm with sparing ep.
Create dense network
of microscopic thermal wounds
in tiny wells in the dermis
Dermoscopy day 3
Non ablativedevice
(Affirm, Cynosure)
Immediate prints
Ablative CO2 device
Smartxide-dot, Deka
« FRACTIONAL » lasers
Micro Thermal Zones (MTZ)
Fibroplasia column responses
Non ablative,
Affirm,
Cynosure
3 month histology
250 µ fibroplasia
columns
Ablative CO2,
AFR Reliant
3 month histology
Hantasch and coll
« Fractional » devices…
•
NON ABLATIVE fractional photothermolysis
– 1500 nm 750/1500 Re:store FraxelTM (Reliant)
– 1440 nm AffirmTM (Cynosure) / 1320-1440 nm AffirmTM
(Cynosure)
– 850-1350 nm: Lux DeepIR FractionalTM (Palomar)
– 1540 nm: Lux 1540 Fractional (Palomar)
– 1500 nm Mosaïc
– Plateform DOT 1540 nm (DEKA)
•
ABLATIVE fractional photothermolysis
– CO2 10600 nm
• Deep Fx/Active FxTM (Lumenis)
• Exelo (Quantel)
• SmartXide-dot (Deka)
•
•
•
•
…
Fraxel re:pair (Reliant)
Mixto
Juvia Fractiona
10 600nm Pixel CO2 (Alma laser/Mediforml
– Erbium 2940 nm
• 2940 nm PixelTM (Alma laser/Mediform))
• ProFractional (Sciton)
Literature : Fraxel 750/1500
First report : Manstein D. Las Surg Med 2004 : + 18% /
wrinkle clinical score
Clinical cases/ new device Fraxel re:store 1500
Hasegawa T, 2006: 10 patients acne scars, successfully treated (all)
minimal adverse effects
Behroozan DS, 2006: surgical scars, one case
Chan HH, 2007: postinflammatory hyperpigmentation after FT in
Asians (Fraxel): 7-12% Density > energy / cooling
Alster T and coll, 2007 : 50 patients, 50-75% improvement for
90% acne scars and for 73% facial UV-damage and 55% extrafacial UVdamage
Jih MH, 2007 : hands rejuvenation
Acne scars : very good
results
90% patients: 50-75% impr.
UV-damage : good or
mild results
facial areas >
extrafacial areas
Naito SK, 2007 : resistant melasma chinese women, 3/6
improvement > 50%
Kim BJ, 2007 : stretch marks, clinical and histological improvement
Glaïch, 2007 : hypochromic scars, 6/7 50-75% pigmentation and
textural improvement
Chrastil, 2007 : actinic porokeratosis, one case
Lee HS, 2008 : 27 korean patients PAS
Melasma : mixed
results
FRAXEL 750 : French experience
Group of 9 dermatologists « LASER 84 » in the south of France
357 patients, 266 evaluable (2006-02 to 2007-04)
Doctors evaluation
Wrinkles
182
Acne scars
44
Pigmentations
24
Good
results
41 %
(75)
55 %
(24)
50 %
(12)
Mild
results
41 %
(75)
38 %
(17)
46 %
(11)
Bad
results
18 %
(32)
7%
(3)
4%
(1)
Docteur Christine Noé
Cavaillon
Laser 84
Good results after 2
sessions
Docteur Christine Noé
Cavaillon
Laser 84
Very good results after 2
sessions
Docteur Christine Noé
Cavaillon
Physiology : Fraxel 750/1500
Laubach HJ, Las Surg Med 2006
Hantash BM, J Biomed Opt 2006
Hantash BM, Dermatol Surg 2007
Chronology of wound healing after FP
1h : MTZs and dermal collagen denaturation, HSP 70 expression
1 day : Formation of MEND, basal epidermal stem cells (reepithelialization)
3-5 days : MEND elimination, TGF béta pu-regulation
1 week : MEND exfoliation, collagen type III synthesis
1 month : collagen type III replaced by collagen type I
3 months : Complete replacement of MTZs by neocollagenesis
Sufficient biological accounts / efficient « visible » clinical results ???
Does penetration depth matter for better results? (ongoing study)
Main problem : COSTS (purchase and consumables)
ABLATIVE FRACTIONAL LASER CO2
Smartxide-dots (DEKA)
30 Watts
350µ microspots
New generation scanning systems
(April 2008)
3 DOT modes
- Normal
sequential
- Interlaced
odd lines before even
lines
- Smart-track
algorithm
Parameters
- Watts: 15-20-30 W
- dot dwell time: 200-2000 µs
- dot distance: 200-2000 µ
500 µs
Pulse duration
70 µm
700 µm
Precise depth control / parameters
Fluence : ablation depth
Pulse duration : thermal damage depth
Skin
200
J/cm²
Fluence
Fluenza
Ablation (vaporization)
700 µm
Thermal damage
Courtesy of Dr Paolo Bonan
Fibroblast stimulation
• How it works with fractional CO2?
– Ablative events : wound healing cascades and apoptosis, settlement
new FB
– Heat mediated events : collagen denaturation, dehydration, loss of
glycosaminoglycans between fibers…(immediate transient shrinkage) and
delayed myofibroblast response (second persistent contraction)
•
•
Enhanced fibroplasia thickness per μ depth of injury versus other modalities with less or no
RTD (mechnical, chemical or « cold » lasers DB…)
Better benefit-risk ratio / scarring
• Role of energy (right parameters?) CO2 laser / to enhance
wound healing, to modulate KF phenotype
– Ablation depth?
– Thermal damage depth?
Literature
Rare reports…
2 recent studies: ex vivo and in vivo / CO2 Reliant (Hantash
BM and coll., 2007)
– Histology : ablation columns (900-1000µm)
– Histology and immunohistocal studies at 3 month : HSP 47,
72, myofibroblastes…: persistent collagen remodelling
response
20 mJ
J7
M1
M3
HSP 72 M3
CO2
Dot-mode
25 W
400 µs
700 µ
CO² resurfacing
Courtesy Dr Bonan P.
Literature
13 patients : moderate to severe atrophic PAS
AFR CO2 Re:pair
2 to 3 sessions, spaced out from 1 to 2 months
25 to 50 % clinical improvement for all the subjects and
43 to 80 % of improvement (average:67 %) with objective
depth measures of scars (PRIMOS technique)
Clinical cases :
20 patients
Photo-aging, acne scars, scars, stretch marks
20/30 Watt
D.O.T
500-1000 µm
Session
interval
Downtime
Phototype I
0.5-1-2 ms
3
2-4 weeks
3-8 days
Phototype IIIII
0.5-1-2 ms
3
2-4 weeks
3-8 days
Phototype IVV
0,3 ms
0.5 ms
4/5
3-5 days
2-4 weeks
Preoperative cares
Antiseptic face washing and shampoo
herpes prevention (Zelitrex), +/- nasal Mupirocine)
Postoperative cares (3 to 5 days)
Office cares: Ice pack, thermal water, neutral ointment (petrolatum,
« tolérance extrême » – avène…)
Home cares: Thermal water and neutral cream 3 to 5 times per day
After effects
•
•
•
Immediatly
– VAS : 2-4 (stinging or burning sensations / parameters)
– Erythema, oedema 24 h
¼ to ½ h
– VAS : 3-6 (burning)
3 to 5 days of superficial crusting and desquamation
GRO Jea, 52 years old
3 month after 3 sessions (Full face 500µ- s1:300- s2:500 and s3:1000 µs)
No anaesthesia (EVA 2-6)
Downtime 3 to 6 days (6 days for last session:1000 µs)
Day 2
41
Results M3/ last session
ORL Chr, acne scars / skin tone
1 session of Active Fx
+ 2 sessions Smartxide dots (500µ-500 µs)
MAR , 30 years old
4 sessions : 30 W, 500µ, 1000 µs
EVA : 3/5
Downtime 3/4 days
Before
3 months after 4 sessions
MAR , 30 years old
4 sessions : 30 W, 500µ, 1000-2000 µs)
EVA : 3/6
Desquamation 3/6 days
Before
M3S4
Better results : dwell time of 2000
ms/last session
DROU Val, 40 years old
3 sessions (30 Watts, 500-1000 µs, 350-500 µ)
EVA : 2/5
Before
M3S3
Test areas
Nd-YAG + CO2 fractional remodeling
CHA Ab, 32 years old
Atrophic acne scars : severe, numerous
1 month after 2 sessions
6 month after 2 sessions
• Favourable long term biological
processes
• Easyness
• Reduced down-time
• Lack of side effects
• Cheeper costs (no consumable)
• Our impressive short term clinical
results
Open multicenter study