Resurfacing of Pitted Facial Acne Scars with a Long

Resurfacing of Pitted Facial Acne Scars with a Long-Pulsed
Er:YAG Laser
Jeung-Tae Jeong, MD and Young-Chul Kye, MD
Department of Dermatology, Korea University Anam Hospital, Seoul, Korea
background. Conventional short-pulsed Er:YAG lasers show
less effective hemostasis and weak photothermal damage on
papillary dermis. Recently, newer long-pulsed Er:YAG laser
systems has been developed.
objective. To evaluate the clinical and histologic effects of
long-pulsed Er:YAG laser resurfacing for pitted facial acne
scars.
methods. Thirty-five patients with pitted facial acne scars
were treated with a long-pulsed Er:YAG laser. All patients had
Fitzpatrick skin phototypes III–V. A pulsed Er:YAG laser with
a 5 mm handpiece at a setting of 7.0–7.5 J/cm2 with a 10-msec
pulse duration was used. The laser was fired at 5 Hz, with four
to five passes. In 28 patients, the results of laser treatment were
evaluated for the degree of clinical improvement, duration of
erythema, pigmentary change, and any adverse events at 2
weeks, 1 month, and 3 months. In seven patients, skin biopsy
specimens were obtained at the following intervals: immedi-
ately, 1 week, 2 weeks, 4 weeks, and 8 weeks postoperatively
for histologic examination.
results. The results of long-pulsed Er:YAG laser resurfacing
for pitted facial acne scars were excellent in 10 patients (36%),
good in 16 patients (57%), and fair in 2 patients (7%). Erythema
occurred in all patients after laser treatment and lasted longer
than 3 months in 15 patients (54%). Postinflammatory hyperpigmentation occurred in 8 patients (29%). But the pigmentation
faded or disappeared within 3 months. One patient (4%) experienced mild hypopigmentation. Pruritic symptoms that required
medical intervention occurred in 16 patients (57%). Mild to
moderate postoperative acne flare-up occurred in 8 patients
(29%). No other adverse effects such as scarring, bacterial infection, or contact dermatitis were observed.
conclusion. In conclusion, resurfacing with a long-pulsed Er:
YAG laser is a safe and very effective treatment modality for
pitted facial acne scars.
LASER SKIN resurfacing has become a popular treatment option for many patients with wrinkles, photoaging, and acne scarring.1 Recently resurfacing with the
new generation of carbon dioxide (CO2) and Er:YAG
lasers has come to be preferred for the treatment of facial acne scars.2–7 The Er:YAG laser, with a 2940 nm
wavelength, has high absorption in water, so it is almost totally absorbed in a very thin, superficial layer
of skin and can be used for precise and superficial tissue ablation.6,8,9 The main advantage of the Er:YAG
laser is the precise depth control due to the lack of
thermal injury.6,10,11 Healing is more rapid compared
with the CO2 laser. There is less postoperative morbidity and fewer complications.6,7 However, because
of limited residual thermal damage, ranging from 20
to 50 ␮m after a typical resurfacing procedure, intraoperative hemostasis is difficult to achieve. Moreover,
because the thermal effects of short-pulsed Er:YAG ir-
radiation are substantially less than those of CO2, the
rates of intraoperative and postoperative collagen contraction are attenuated as well.12–14 In order to address
the shortcomings of conventional Er:YAG laser resurfacing, newer Er:YAG laser systems have recently been
developed with longer pulse durations.12 The purpose
of this study was to evaluate the clinical and histologic
effects of resurfacing of facial acne scars with a longpulsed Er:YAG laser.
J.-T. Jeong, MD and Y.-C. Kye, MD have indicated no significant interest with commercial supporters.
Address correspondence and reprint requests to: Young-Chul Kye, MD,
Department of Dermatology, Korea University Anam Hospital, 126-1,
5-Ka, Anam-dong, Sungbuk-ku, Seoul, 136-705, Korea, or e-mail: jjtderm
@yahoo.co.kr.
Materials and Methods
Thirty-five patients with pitted facial acne scars were included in this study. The patients’ ages ranged from 19 to 38
years, with an average age of 26.9 years. In 28 patients (17
men, 11 women), clinical improvement and side effects were
evaluated. In seven patients, skin biopsy specimens were
taken immediately and at 1, 2, 4, and 8 weeks postoperatively for histologic examination. All patients had Fitzpatrick skin phototypes III–V and underwent a pretreatment
regimen at least 2 weeks prior to laser therapy. The pretreatment regimen consisted of 0.025% tretinoin cream which
was applied nightly, broad-spectrum sunscreen, and cetaphil
cleanser. For the anesthesia, topical EMLA cream was used
1 hour prior to the procedure. To maximize patient comfort
and compliance during the procedure, intravenous fentanyl
© 2001 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.
ISSN: 1076-0512/01/$15.00/0 • Dermatol Surg 2001;27:107–110
108
jeong et al.: er:yag laser for facial acne scars
Dermatol Surg
27:2:February 2001
Figure 1. (A) Before treatment, and (B) 3
months after laser resurfacing.
100 ␮g was used. All patients were treated with the variable-pulsed Er:YAG laser, a 5 mm handpiece at 7.0–7.5 J/cm2
with a 10-msec pulse duration. The laser was fired at 5 Hz,
with four to five passes. Laser overlapping was less than
10%. Following laser treatment, patients were managed with
the closed technique, using petroleum jelly and gauze. Dressings were changed after 48 hours, and when necessary thereafter. After 7 days the dressings were removed. After laser
treatment, oral prophylaxis consisted of acyclovir 200 mg
five times and tosufloxacin 150 mg three times a day for
5 days. Also, to decrease postoperative edema, oral prednisone 10 mg three times a day for 5 days was prescribed.
After 2 weeks of laser treatment, topical application of
0.025% tretinoin, 4% hydroquinone, and 1% hydrocortisone cream were recommended nightly for 4–6 weeks. Broadspectrum sunscreen and cetaphil cleanser were also recommended. Facial photographs were taken at baseline and at
2-week intervals postoperatively.
For clinical assessment, photographs taken at pretreatment, 2 weeks, 1 month, and 3 months after laser treatment
were evaluated by two independent physicians. Physicians
categorized the improvement as follows: poor, improvement
less than 25%; fair, improvement of 25–50%; good, improvement of 50–75%; excellent, improvement greater than
Table 1. Degree of Clinical Improvement After Laser Resurfacing
Improvement
Excellent (ⱖ75%)
Good (50–75%)
Fair (25–50%)
Poor (ⱕ25%)
Number of patients (%)
10 (36%)
16 (57%)
2 (7%)
0 (0%)
75%. And physicians evaluated the side reactions: duration
of erythema, pigmentary change, and any adverse events.
Results
The results of long-pulsed Er:YAG laser resurfacing
for pitted facial acne scars were excellent in 10 patients (36%), good in 16 patients (57%), and fair in 2
patients (7%), a 71% clinical improvement on average (Table 1, Figure 1).
Thermal damage extended approximately 80–100 ␮m
beneath the vaporized layer and was observed immediately after laser resurfacing (Figure 2). Two weeks
later, complete reepithelialization was observed (Figure 3). A biopsy specimen obtained at 8 weeks showed
thickening of the epidermis, fine new collagen, and
high vascularity on the upper dermis (Figure 4).
Posttreatment erythema was present in all patients.
In 15 patients (54%), erythema lasted longer than 3
months. Postinflammatory hyperpigmentation occurred
in 8 patients (29%), with a mild degree in 6 patients
and moderate degree in 2 patients. Hyperpigmentation occurred at 2–4 weeks after laser treatment and
lasted longer than 3 months in two patients. One patient (4%) experienced mild hypopigmentation, which
began around 3 weeks after treatment and lasted longer
than 3 months after treatment. Mild to moderate postoperative acne flare-up occurred in 8 patients (29%).
Fifteen patients (54%) experienced an itching sensation that required medical intervention. The duration
of itching was 3–21 days (average 8.3 days). No other
adverse effects such as scarring, bacterial infection, or
contact dermatitis were observed (Table 2).
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27:2:February 2001
Figure 2. Immediately after laser resurfacing the epidermis was
completely vaporized. Thermal damage extended approximately
80–100 ␮m beneath the vaporized layer. (Hematoxylin and eosin;
original magnification 100⫻.)
Discussion
The newer variable-pulse Er:YAG lasers have CO2 laser-like effects, while maintaining the advantages of
Er:YAG lasers,15 therefore variable-pulse Er:YAG lasers are thought to be effective on pitted acne scars as
well as rhytides. Also, long-pulsed Er:YAG lasers show
effective hemostasis and some degree of collagen contraction intraoperatively.12 Thus long-pulsed Er:YAG
laser resurfacing can offer the surgeon an effective
compromise between CO2 and short-pulsed Er:YAG
laser resurfacing systems.12,16 Compared with shortpulsed Er:YAG lasers, more severe thermal necrosis
on papillary dermis was observed on histologic findings.2,10 Complete reepithelialization occurred within
2 weeks, as with short-pulsed Er:YAG laser resurfacing. Although our study was not a side-by-side comparison, improvement of acne scars after long-pulsed
jeong et al.: er:yag laser for facial acne scars
109
Figure 4. Eight weeks after laser resurfacing, fine new collagen
formations and increased vascularity on the upper dermis are observed. (Hematoxylin and eosin; original magnification 100⫻.)
Er:YAG laser resurfacing was better than the results
from conventional short-pulsed Er:YAG laser resurfacing reported previously.2,17 The long-pulsed Er:YAG
laser’s ability to abrade and its deep photothermal effects might have contributed to this favorable result.
Complications such as postinflammatory hyperpigmentation, prolonged erythema, itching, and acne
flare-up were observed after long-pulsed Er:YAG laser
treatment. Postinflammatory hyperpigmentation faded
or disappeared within 3 months after laser treatment.
To prevent or reduce the postinflammatory hyperpigmentation, proper postlaser treatments such as topical
tretinoin, hydroquinone, and mild topical steroids in
selected patients are thought to be important, especially in darker skinned patients. Though erythema
appeared in all patients after laser treatment, the severity of erythema decreased gradually. Prolonged erythema may be due to deep thermal laser effects and
postoperative use of topical tretinoin. In cases of mild
hypopigmentation, long-term follow-up of at least 12–
24 months is needed for the evaluation of late hypopigmentation. Itching was one of the major problems.
More than half of the patients experienced an itching
sensation that required medical intervention. Fortunately these symptoms were treated easily with oral
antihistamines. Acne flare-up was also controlled easily by medical intervention. In conclusion, resurfacing
Table 2. Side Effects Following Laser Resurfacing
Side effects
Figure 3. Two weeks after laser resurfacing the epidermis is completely regenerated and mild inflammatory infiltration and dermal edema were observed. (Hematoxylin and eosin; original magnification 100⫻.)
Erythema
Hyperpigmentation
Hypopigmentation
Pruritus
Acne flare-up
Number of patients (%)
28 (100%)
8 (29%)
1 (4%)
16 (57%)
8 (29%)
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with a long-pulsed Er:YAG laser is a safe and very effective treatment modality for pitted facial acne scars.
Dermatol Surg
8.
9.
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Commentary
This study by our colleagues in Korea provides very useful information about laser skin resurfacing in Asian skin. The new
so-called variable Er:YAG lasers have gained increasing popularity, especially for treating darker Fitzpatrick skin types. In
this study one such Er:YAG laser was used in a “thermal”
mode (10-msec pulse duration). While not as great as that of
the pulsed CO2 laser, this variable-pulse Er:YAG laser produces
a distinct thermal effect that is significantly different from the
shorter pulsed “ablative” mode associated with the “traditional” use of the erbium resurfacing laser.
About half of the patients in this study experienced 3
months or more of posttreatment erythema and nearly a third
experienced transient postinflammatory hyperpigmentation. These
clinical findings are consistent with the thermal effects produced by this mode of the variable Er:YAG laser. However,
there were no significant permanent complications and the
overall improvement was good. The results in this report of 35
patients should encourage clinicians that, with proper and
skilled use, the new generation of variable-pulse Er:YAG lasers
may help us to provide patients with darker ethnic skin new
therapeutic options for treating pitted acne scars.
David H. McDaniel, MD
Virginia Beach, Virginia