postinfl-180902074904

1. POST INFLAMMATORY SCARRING

2. POST INFLAMMATORY SCARRING
 The term scarring refer to a fibrous process in which
new collagen is laid down to heal a full thickness injury.
 It affects 30% of those with moderate or severe acne
vulagaris.
 It is particulary common in nudolocystic acne, acne
conglobata or acne vulgaris.
 It may also be a long term consequence of infantile
acne.
 Acne has a prevelance of over 90% among adolescents
and persists into adulthood in approximatel 12-14% of
cases with psychological and social implication.

3. ACNE SCAR
 Acne scars are permanent textural changes and indentations that
occur on the skin as a result of severe acne. The term scarring is not
used for the temoparary red and brown marks left early after acne
has occurred as these marks will almost improve without treatment.
 Two main cause of acne scar formation:
Increase tisssue formation
• Eg. Hypertropic scars, keloids
Loss or damage of tissue
• 3 primary acne scar-icepick, rolling, boxcar

4. HYPERTROPHIC SCARS
 Hypertrophic and keloidal scars are associated with excess collagen
deposition and decreased collagenase activity
 Hypertrophic scars are typically pink, raised and firm, with thick
hyalinized collagen bundles that remain within borders of the original site
of injury
 Keloids form a reddish-purple papules and nodules that proliferate
beyond the borders of the original wound. Histologically, they are
characterized by thick bundles of hyalinized acellular collagen arranged
in whorls.
 Hypertrophic scars and keloids appear predominantly on the back,
shoulders, sternal region and over the jaw angles

6. ATROPHIC SCARS
 Atrophic scars occur predominantly on the face. Atrophic acne
scars are more common than keloids and hypertrophic scars with
a ratio 3 : 1. They have been subclassified into ice pick, boxcar,
and rolling scars . With atrophic scars, the ice pick type represents
60%–70% of total scars, the boxcar 20%–30%, and rolling scars
15%–25% .

8. ACNE SCAR MORPHOLOGICAL CLASSIFICATION
Acne Scars Subtype Clinical Features
Icepick Icepick scars are narrow (<2mm), deep, sharply marginated
epithelial tracts that extend vertically to the deep dermis or
subcutaneous tissue.
Rolling Rolling scars occur from dermal tethering of otherwise
relatively normal-appearing skin and are usually wider than 4
to 5mm. Abnormal fibrous anchoring of the dermis to the
subcutis leads to superficial shadowing and a rolling or
undulating appearance to the overlying skin.
Boxcar
Shallow <3mm diameter
>3mm diameter
Boxcar scars are round to oval depressions with sharply
demarcated vertical edges, similar to varicella scars. They
are clinically wider at the surface than icepick scars and do
not taper to a point at the base.
Deep
<3mm diameter
>3mm diameter
They may be shallow (0.1–0.5mm) or deep (≥0.5mm) and
are most often 1.5 to 4.0mm in diameter.

9. QUALITATIVE SCARRING GRADING SYSTEM
Grades of
Post Acne
Scarring
Level of
disease
Clinical features
1 macualr These scars can be erythematous, hyper- or hypopigmented flat marks.
They do not represent a problem of contour like other scar grades but of
color.
2 mild
3 moderate Moderate atrophic or hypertrophic scarring that is obvious at
social distances of 50cm or greater and is not covered easily by
makeup or the normal shadow of shaved beard hair in men or
body hair if extrafacial, but is still able to be flattened by manual
stretching of the skin (if atrophic).
4 severe Severe atrophic or hypertrophic scarring that is evident at social
distances greater than 50cm and is not covered easily by makeup
or the normal shadow of shaved beard hair in men or body hair if
extrafacial and is not able to be flattened by manual stretching of
the skin.
Mild atrophy or hypertrophy scars 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
extrafacial.

10. ACNE SCAR MANAGMENT
• Retinoids
• Topical/Injectable
steroids
• Silicone dressing
• Other substances
Medical
managment
• Punch exsicion
• Eliptical exsicion
• Skin grafting
• subcision
• debulking
Surgical
managment • Cryosurgery
• Electrodessication
• Radiation treatment
• Chemical peel
• Microdermabrasion
• dermabrasion
Procedural
managment

11. SCARS TREATMENT
Chemical peeling
Microdermabrasion
Skin Needling
Subcision
Punch Excision Techniques
Laser treatment

12. CHEMICAL PEELING
 Effective therapeutic for scars treatment.
 Chemical peeling is recommended to treat skin aging, dyschromias,
wrinkles, and acne scars are the major clinical indications for facial
chemical peeling . (Ghersertieh et al, 2003).
 Salicylic acid, glycolic acid, pyruvic acid, trichloroacetic acid are all
hydroxy acid used as peeling agents.
 The choice of concentration depends on :
 peeling agent used
 On the skin areas treated
 Severity of the acne scaring

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• Best peeling agent.
• It is β-hydroxy acid agent has a lipophilicity.
• Combination of salicylic acid with resorcinol and lactic acid in 95% ethanol is
known as Jessner’s peels.
• The most efficacious concentration for acne scars is 30% in multiple
sessions, 3–5 times, every 3-4 weeks
Salicylic acid
• Glycolic acid is an alpha-hydroxy acid,
• It increases dermal hyaluronic acid and collagen gene expression by
increasing secretion of IL-6.
Glycolic acid
• Pyruvic acid is an alpha-ketoacid
• Strong antimicrobial effect.
• 40-70% pyruvic acid used to treat moderate acne scar.
• promote collagen synthesis and formation of elastic fibers.
Pyruvic acid
• it causes protein denaturation, well-known as keratocoagulation
• It is mixed with 100 mL of distilled water to create the desired concentration.
• TCA in a percentage of 10%–20% results in a very light superficial peel with
no penetration below the stratumgranulosum
• use of highconcentration (65% and 100%) trichloroacetic acid (TCA) applied
locally in the atrophic acne scars, known as Chemical Reconstruction Of
Skin Scars (CROSS)
Trichloroacetic
acid
• Iontophoresis is a non invasive method able to enhance transdermal drug
delivery using a small electrical current applied by a iontophoretic chamber
containing a similarly charged active agent and its vehicle
• iontophoresis with 0.025% tretinoin gel in atrophic acne scars
Tretinoin-
iontophoresis
CHEMICAL PEELING AGENTS

14. RESULT
• Philip et al., found that high concentration
trichloroacetic acid (TCA), icepack scar may respond
well.
• 53 adult patients with atrophic acne scars, 70% TCA
applied locally every two weeks using a chemical
reconstruction of skin scars therapy (CROSSS therapy)
resulted in good or excellent.
• 16 patients treated with 100% TCA, showed excellent
result.
• So high-strength TCA is thought to cause remodeling of
the dermal collagen.

15. TCA Cross: patient before
the treatment
TCA Cross: patient after
the treatment

16. MICRODERMABRASION/DERMABRASION
 Microdermabrasion and dermabrasion are facial resurfacing
techniques that mechanically ablate damaged skin in order to promote
reepithelialisation
 Microdermabrasion removes the outer layer of the epidermis,
accelerating the natural process of exfoliation .
 Dermabrasion, with respect to microdermabrasion, completely
removes the epidermis and exposes the papillary or reticular dermis,
inducing remodeling of the skin’s structural proteins
 Microdermabrasion is usually painless, it does not require anesthesia
 All microdermabraders include a pump that generates a stream of
aluminum oxide crystals with a hand piece and vacuum .
 sodium chloride, sodium bicarbonate, or magnesium oxide crystals are
used.
 It shouldn’t be used to treat deep scars
 Dermabrasion is performed under local or general anaesthesia. It
usually uses highspeed brush, diamond cylinder, fraise, or manual

18. SUBCISION
 Subcision is a nonoperative technique to manage depressed scars
by percutaneously releasing scar bands within the dermis and
subcutaneous tissue.
 The entire area to be subcised is marked and local anesthetic is
administered.
 a needle is used to release the fibrous septa within the scar,
resulting in the formation of new connective tissue underneath the
scar.
 Then sharp hypodermic needles, usually 19 to 21-G, were used.
Bleeding and nodule formation are the main side effects.
Schematic demonstrating subcision. A
hypodermic, tribevelled, or filter needle is
inserted into the subdermal plane and
rotated in a fanning motion to undermine
the scar, disrupting fibrous attachments

19. RESULT
 Cunliffe et al., showed that in a study of 40 patients
undergoing subcision for rolling scars, the overall degree of
improvement was rated 51%.
 Subcision is adequate stand-alone treatment, improved
result was achived when it is combined with other
modalities. In a split-face, single-patient trial of subcision
alone versus subcision and the nonablative 1320nm
neodymium-doped:yttrium aluminum garnet (Nd:YAG) laser
at two week intervals, the combination treatment was
superior.

20. Effect of subcision on acne scars. Before (A) and after (B) two
treatments.

21. PERCUTANEOUS COLLAGEN
INDUCTION BY SKIN
NEEDLING
 Skin needling is a recently proposed technique that involves using a
sterile roller comprised of a series of fine, sharp needles to puncture
the skin.
 facial skin must be disinfected, and then a topical anaesthetic is
applied. 90 minutes after anaesthetic cream application, patients can
undergo the skin needling session.
 The procedure consists of rolling a performing instrument on the
cutaneous areas affected by acne scars, several times, at least four-six
times, in four directions: horizontally, vertically and diagonally right and
left.
 The needles penetrate about 1.5 to 2mm into the dermis.
 More recently, Fabbrocini et al. have proposed the combined use of
skin needling and PlateletRich Plasma (PRP).
 the combined use of skin needling and PRP is more effec tive in
improving acne scars than skin needling alone .

22. RESULT
 Fabbrocini et al.,2009 found that eight week after the first session of skin
needling, all patients had smoother facial skin and slight reduction in
lesion severity. Eight week after the second session of skin needing, the
improvement in the acne rolling scar was evident. In total patients (20
female, 12 male) patient with acne rolling scars were enrolled.
Conclusion
 Study confirms that skin needling has an immediate effect in improving
acne rolling scars and have advantage over other procedures.

23. Needling: the procedure
Needling: patient before the treatment
Needling: patient after the treatment

24. Application of PRP on the skin immediately
before the treatment with the microneedles.

25. PUNCH EXCISION TECHNIQUES
 Punch excision is mainly indicating for ice-pick or
boxcar scars.
 According to diameter, depth and shape of scar, a
biopsy punch of appropriate size is used to excise
the scar and, then, closure or elevation or grafting
is possible options to perform.

26. RESULT
 Grevelink et al demonstrated that excellent result may be
achived when punch excision is combined with concurrent
co2 laser resurfacing.
 21 patients with skin type i-iii with mild to severe facial acne
scarring were treated with a combination off laser skin
resurfacing and punch excision of acne scars.
 There was a range of clinical improvement by the
independent assessor of 25-50% in skin type I, 50-70% in
skin type II, and 50-75% in skin type III. There was a patient
subjective improvement of 25-50% for skin type I, 50-75%
for skin type II and75-100% for skin type III.

27. TISSUE AUGMENTING AGENTS
Augmentation is a further alternative for management of acne
scarring.
 Several filler materials used.
 An ideal filler material has to be hypoallergenic and safe, painless
and easy to inject, inexpensive and long lasting.
 Hyaluronic acid is the recommended one.
Dermal filler classification
Filler class Average clinical
efficacy
Examples
Temporary 3–18 months Hyaluronic acid and
collagen
Semipermanent Up to 24 months Poly-L-lactic acid and
calcium hydroxylapatite
Permanent Many years if not
lifelong
Silicon, polyacrylamide,
polymethacrylate, and
hydroxyethylmethacrylat
e

28. RESULT
 Richard et al., Used the HA-based filler Matridex, CaHA
and the polyalkylimide Bioalcamid. In total 27 patient were
enroolled in 12 month study. At 12 month evaluation 6
patients (22%) showed 75% improvement, 14 patient (48%)
showed between 50% improvement and 5 patients (18%)
showed a 25% improvement in treated atropic scars.

29. LASER TREATMENT
 There are two main types of laser treatments – ablative and
non-ablative. Ablative (or wounding) lasers remove thin
layers of skin. Non-ablative (non-wounding) lasers stimulate
collagen growth and tighten underlying skin. Although non-
ablative laser resurfacing is less invasive and requires less
recovery time, it is less effective than ablative laser
resurfacing for deeper scars.

30. ABLATIVE (WOUNDING) LASERS
 Ablative lasers are the “gold standard” for the treatment of box car
scars.
 There are two types of ablative lasers, fractional ablative and fully
resurfacing.
 If fully ablative, CO2 lasers are best employed on lighter skin types,
whilst erbium lasers have a wider safety threshold for darker skin
types. Fractional CO2/Erbium lasers have a higher safety profile
than fully ablative lasers and can be used in all skin types.
Fully ablative lasers such as CO2 or
Erbium can effectively reduce acne scars.

31. FRACTIONAL NON-ABLATIVE (NON-WOUNDING)
LASERS
 Variable wavelengths of fractional laser devices have been shown to improve acne
scarring. They are best used for atrophic and rolling scars.
 These lasers can cause some temporary redness but do not actually break the skin
surface.
 The advantages of non-ablative fractional lasers are rapid recovery times, the ability
to treat darker skin types and higher safety profile.
 Recovery time following fractional laser treatment ranges between 3 to 8 days.
 Most people will benefit from a series of fractional laser treatments (2 to 5). Darker
skin types will usually require more treatments compared with lighter skin types.
Fractional laser resurfacing can reduce scars

32. TREATMENT OPTIONS FOR ACNE SCARS

33. RESULT
 Alster et al., showed a mean improvement of 81.4% in 50 patients
with moderate-to-severe acne scars, used ablative co2 and
Er:YAG lasers.
 Weiss et al., 500 acne scar patints were treated with the 1540nm
fractionated laser, with a median improvement of 50-75% after
three treatments.
 Mahmoud et al., used second-generation erbium doped 1550nm
laser in study of 29 pateint. 18 patients achived 50-75%
improvement in acne scarring.
 Chapas et al., showed that 13 patients with acne scarring
received 2 0r 3 monthly treatments with fractional co2, resulting in
a mean scar depth improvement by topographic analysis of
66.8%.

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