percutaneous collagen induction using dermaroller versus ... · web viewskin needling is also known...

Assiut Med. J. Vol. (39), No. (3), September, 2015

PERCUTANEOUS COLLAGEN INDUCTION USING DERMAROLLER VERSUS 80% TRICHLOROACETIC ACID IN THE TREATMENT OF

ATROPHIC POST ACNE SCARS: A COMPARATIVE STUDY

Ensaf M. Abdel-Magiud, Emad A Taha, Sohair k. Sayed, Mohamed Makboul and Radwa Bakr

Department of

ABSTRACT

Background: Percutaneous collagen induction (PCI) promotes removal of damaged collagen and induces more collagen immediately under the epidermis. The chemical reconstruction of skin scars (CROSS) method is a focal application of full-concentration trichloroacetic acid (TCA) to atrophic acne scars. The CROSS method has the advantage of reconstructing acne scars by increasing dermal thickening and collagen production. Objective: To compare the safety and efficacy of PCI and the 80% TCA CROSS method for the treatment of atrophic post acne scars. Patients And Methods: Thirty four participants were randomly divided into two groups; group 1(19 patients) underwent four sessions (4 weeks apart) of PCI, and group 2 (15 patients) underwent five sessions (2weeks apart) of 80% TCA CROSS. The two groups were compared regarding photo evaluation, patient satisfaction and adverse effects. Results: All patients improved in both groups. However, the mean percentage of improvement was statistically significantly higher in the first group treated by the dermaroller (59.89%) than in the second group treated by TCA CROSS 80% (42.73%) (p = 0.025) but there was no statistical significant difference regarding the patient satisfaction. Conclusions: PCI and 80% TCA CROSS were effective in the treatment of atrophic acne scars with superior results were in favor of dermaroller.

INTRODUCTION

Acne vulgaris is a common dermatological condition. Although all age groups may be affected by its variants, yet it is primarily a disorder of adolescence experienced by up to 80% of people between 11 and 30 years of age and by up to 5% of older adults (Goulden et al., 1999).

Permanent scarring is an unfortunate complication of acne vulgaris where it is difficult to treat (Nofal et al., 2014). It is usually associated with substantial physical and psychological distress (Leheta et al., 2011).

Treatment of atrophic post acne scars is challenging and there is lack of consensus about which treatment modality gives the best results and the lowest complication rate (Goodman, 2003).

Despite treatment may fail to gain total cure in acne scars, the ultimate goal of any intervention is for improvement (Goodman, 2003).

Skin Needling is also known as percutaneous collagen induction (PCI), with Dermaroller (a needling tool) is an addition for managing atrophic post acne scars (Aust et al., 2008). The treatment is an office procedure that creates thousands of microclefts through the epidermis into the papillary dermis upon rolling of the needling tool over the skin with stimulation of new collagen formation, scar remodeling and also breakdown of old hardened collagen strands that tether the scar (Leheta et al., 2011)

Tissue remodeling continues for months after injury generally starts to be seen after about 6 weeks but the full effects can take at least three months to occur and, as the deposition of new collagen takes place slowly, the skin texture will continue to improve over a 12 months period.

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Abdel-Magiud et al.,

Clinical results vary between patients, but all patients achieve some improvements (Dogra et al., 2014).

TCA CROSS technique (Chemical Reconstruction of Skin Scars); is a technique of focal application of high concentration TCA (60%-100%) to the bottom of the atrophic scar with a wooden toothpick, leading to destruction of the epithelial tract. This is followed by collagen synthesis in the healing phase and filling up of the depressed scar (Lee et al., 2002). It has been found to be useful, as a simple office procedure. Since Ice pick acne scars are deep and difficult to eradicate, this technique is very suitable for them as it uses high strength of TCA (Agarwal et al., 2015).

Our aim was to compare the efficacy of PCI (using Dermaroller) versus high concentrated TCA CROSS (80%) as different therapeutic modalities for the treatment of atrophic post acne scars.

PATIENTS AND METHODS

A prospective randomized clinical trial was carried out on 34 clinically diagnosed atrophic post acne scar patients selected from the outpatient clinic of dermatology department, Assuit Universty hospital during the period from April 2013 till April 2015.

Patients:The study included 34 patients (12 male

22 female) with different types of atrophic post acne scars. The mean duration of acne scars was 3.8 years (range 1-6 years). Patients were subjected to full history taking, including onset, course, and duration of scars, previous acne and acne scar treatments, and post-treatment complications such as hyperpigmentation or keloid formation. Dermatologic examination to assess the skin type, the scar type (ice pick, boxcar, and rolling type), the scar severity (Grade 2, 3, or 4) according to the qualitative global acne scarring grading system (Goodman and Baron, 2006) Exclusion criteria were systemic retinoids or immunosuppressive drug intake during the

previous 6 months, coagulation defects or blood diseases, evidence or history of keloid scars, pregnancy or lactation, and unrealistic expectations. Before treatment, the advantages, expectations, and possible complications were explained to the patients.

MethodsParticipants were randomly divided into

two groups; group 1(G1) (19 patients) underwent PCI treatment, and group 2 (G2) (15 patients) underwent TCA 80% CROSS. Each patient in G1 received four sessions of PCI one month apart and in G2 five sessions were done 2 weeks apart.

Group 1 (PCI with Dermaroller)During the procedure , the patients had

sitting or semi-sitting position then at first, facial skin was disinfected and sterilized with povidone-iodine and alcohol. (Proper wiping of povidone-iodine is necessary to prevent foreign body granuloma formation), then a topical anesthetic cream (ezanal cream a mixture of prilocaine 2.5% and lidocaine 2.5%) was applied to the face for approximately 45 to 60 minutes before the procedure. Patients were treated using the needling tool (Dermal Roller SR TM, manufactured by phiderma, Ontario, Canada), which is a sterile plastic cylinder with stainless steel needles protruding from the surface that rolls vigorously over the skin. The tool consists of 24 circular arrays of eight needles (1.5 mm long) each (total 192 needles) in a cylindrical assembly. The treatment was then performed by rolling the needling tool over the areas affected by acne scars four times in the four directions (vertical horizontal, and diagonal) without pressing too hard (lips and eyelids were avoided). In patients with deep scars, an assistant stretched the skin perpendicular to the Dermaroller movement to reach the base of the scar. The skin bled for 30 seconds to 2 minutes, which was less than normal clotting time, and wet gauze swabs were used to soak up any fluid or bloood ooze. Each patient had 4 sessions, with 4 weeks interval in between (Leheta et al., 2011).

Group 2 (CROSS technique with 80% TCA)

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The patients had sitting or semi-sitting position then the skin was cleaned well and disinfected with alchol. Wooden applicators tips were sized to a dull point approximately the size of the scars and used to apply 80% TCA. Focal pressing by the applicator was maintained until an even white frosting formed in each scar then it was washed. Topical antibiotic cream and sunscreen were applied immediately after the procedure. Each patient had 5 sessions, with 2 weeks interval (Fabbrocini et al., 2008).

Clinical Assessment All patients were evaluated by

photographic documentation using identical camera settings and lightning and the same positioning with the same camera at each visit and 4 months after the last session by two non-treating blinded dermatologists in a randomized fashion to determine whether noticeable clinical improvement has occurred. The results were assessed using:

Quartile grading scale (by photos) where the therapeutic response for each patient was classified according to the degree of improvement of acne scars into (poor improvement, 0–25%), (good improvement, >25–50%), (very good improvement, >50–75%) and (excellent improvement, >75–100%).

Patient satisfaction: In addition, each patient was asked to

rate his/her overall satisfaction with the treatment by using a quartile grading system (0 unsatisfied, 1 slightly satisfied, 2 satisfied or 3 very satisfied) (Agarwal et al., 2015).

Adverse events: During treatment sessions, patients were

evaluated for adverse events; in the form of erythema, edema and hypo/hyper-pigmentation, brusis, pain and bleeding. The duration of each was recorded for each patient.

Statistical analysisData were analyzed and expressed in

tables as mean values ± standard deviations (SD) using SPSS version 19 program. Wilcoxon Signed Ranks Test was used in comparison of numerical non parametric data within the same group before and after treatment. Mann-Whitney test was used in comparison of numerical non parametric data between different treatment groups. Chi-Square test was used to compare number and percentages between different treatment groups. Values were considered significant when P values were equal to or less than 0.05.

RESULTS

The demographic and clinical data of the studied patients are illustrated in Table (1).

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Table 1: The demographic and clinical data of the atrophic post acne scar patients in the two studied groups.

Derma-roller(n= 19)

TCA cross 80%(n= 15)

No. % No. %Sex:Male 5 26.3 7 46.7Female 14 73.7 8 53.3Age:Mean ± SD 22.21 ± 2.53 24.73 ± 6.18Range 17.0 – 26.0 17.0 – 36.0Skin type:Type III 6 31.6 3 20.0Type IV 12 63.2 10 66.7Type V 1 5.3 2 13.3Scar type:Ice pick 1 5.3 1 6.7Box 1 5.3 0 0.0Mixed (ice pick & box) 14 73.7 13 86.7Mixed (ice pick & box & rolling) 3 15.8 1 6.7Scar duration: (years)Mean ± SD 3.08 ± 1.62 5.00 ± 3.17Range 1.0 – 6.0 1.0 – 10.0

Regarding the photo evaluation using the quartile scale, in group 1, among the 19 patients treated by dermaroller: 8 patients (42.1%) showed excellent improvement, 6 patients (31.6%) showed very good improvement, 3 patients (15.8%) showed good improvement and only 2 patients (10.5%) showed poor response with mean percentage of improvement of 59.89±22.92. Better response was noticed for rolling and boxcar scars over icepick scars.

In group 2, among the 15 patients treated by TCA CROSS 80%: one patient (6.7%) showed excellent improvement, 5 patients (33.3%)

showed very good improvement, 6 patients (40%) showed good improvement and 3 patients (20%) showed poor response with mean percentage of improvement of 42.73±20.02. We concluded that CROSS method was more effective on ice-pick scars, while box and rolling scars showed lower response. Thus, the mean percentage of improvement reached by the dermaroller was significantly higher compared with the TCA 80% CROSS (p-value= 0.025) as shown in table (2) also, the dermaroller recorded higher percentage of excellent improvement than TCA CROSS

Table 2: Mean percentages of improvement by photos evaluation in our studied groups

Photos evaluation Derma-roller (n= 19)

TCA cross 80%(n= 15)

Mean ± SD 59.89 ± 22.92 42.73 ± 20.02Range 15.0 - 90.0 10.0 - 76.0P-value 0.025*

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Table (3) shows the patient satisfaction for our studied atrophic post acne scars patients, high degree of patient satisfaction was noticed in both

groups, group 1 with (94.7%) and group 2 (86.7%) with no significant statistical difference between them.

Table 3: Patient satisfaction in the studied groups

Patient satisfactionDerma-roller

(n= 19)TCA cross 80%

(n= 15)No. % No. %

Unsatisfied 1 5.3 2 13.3Satisfied 18 94.7 13 86.7P-value 0.830

Side effects detected by the roller in group 1 were mild where 100% of the patients suffered from temporary erythema lasting for maximum 2 days and transient pin point bleeding, 73.7% of the patients suffered from pain during the procedure in spite of the application of topical anesthetic cream before the procedure and 57.9% of the patients suffered from transient edema that

usually disappears the same day of the procedure. In group 2, the main complication detected was the hyperpigmentation detected in 11 (73.3%) of the patients which was persistent in 2 of them otherwise, there was no obvious complications from this technique other than erythema detected by 9 patients (60%) which was mild relieved the same day of the procedure .

Figure 1. A female patient in group 1 (A) before and (B) 4 months after four sessions of PCI showing excellent improvement.

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Figure 2. A male patient in group 1 (A) before and (B) 4 months after four sessions of PCI showing very good improvement.

Figure 3. A female patient in group 2 (A) before and (B) 4 months after five sessions of 80%TCA CROSS showing very good improvement.

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Figure 4. A male patient in group 2 (A) before and (B) 4 months after five sessions of 80%TCA CROSS showing good improvement.

DISCUSSION

Because of the prevalence of acne scarring and the strong negative emotions it causes in affected patients, dermatologists are frequently presented with the challenge of evaluating and providing treatment recommendations to patients (Nofal et al., 2014).Simple and definitive treatments for acne scarring are few; meanwhile, microneedling therapy using the dermaroller is a recent addition to the treatment options for managing atrophic post-acne scars (Daddaballapur, 2009). Excellent to good results are achieved in treating rolling and box scars using dermaroller (Fernands, 2002). The full result may take 8–12 months to achieve as the deposition of new collagen occurs slowly. Also, there were no significant adverse effects or downtime with the added advantages of being easy to perform with affordable equipment (Lotfi et al., 2013).

Our study revealed that Percutaneous induction (PCI) performed by dermaroller on 19 patients improved atrophic acne scars in 100% of patients with mean percentage of improvement of (59.89±22.92). This was consistent with the study done by Leheta et al., 2011 that showed that dermaroller improved atrophic acne scars in 100% of patients, with overall scar improvement of up to 91.7% (mean 68.37%±19.3).

Variable degrees of improvement (40%-80%) were also reported by (Alam et al., 2014; Dogra et al., 2014;Niwat, 2009 and Aust et al., 2008)

Regarding the photo evaluation according to the quartile scale among the 19 patients treated by dermaroller: 8 patients (42.1%) showed excellent improvement (75%-100%), 6 patients (31.6%) showed very good improvement (50- <75%), 3 patients (15.8%) showed good improvement (25- <50%) and only 2 patients

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(10.5%) showed poor response (0- <25%)). Better response was noticed for rolling and boxcar scars over icepick scars

Our results were consistent with some previous published studies using the dermaroller. In leheta and her colleagues, 2011 seven patients (46.7%) showed significant improvement, five (33.3%) showed moderate improvement, two (13.3%) showed mild improvement and one (6.7%) showed minimal improvement. Fabbrocini and colleagues, 2009 achieved better overall clinical improvement (100%), (without specification of degrees of improvement) that the severity of the acne scars in all patients was greatly reduced. Lotfi et al., 2013 reported a good to excellent response achieved in 27 of 30 patients (90%). A good to excellent response was found in rolling and boxcar scars, whereas ice-pick scars showed poor-to-moderate improvement. Majid 2009 studied the efficacy of PCI through the dermaroller in treatment of atrophic facial scars of varying etiology and reported excellent response in 72.2% of patients.Recently, El-Domyati et al., 2015 reported significant clinical improvement with microneedling therapy for atrophic acne scars, where there was good enhancement of scar appearance (51–60%). Very good response was seen in rolling and boxcar scars, while moderate response was seen in ice pick scars.

High degree of patient satisfaction was noticed in those patients treated by dermaroller where 18 patients (94.7%) were satisfied by the therapy. This is consistent with El-Domyati et al., in 2015 who recorded very good (80–85%) degree of patient satisfaction and Alam et al., 2014 who reported that most participants were very satisfied with their procedure. Lotfi and her colleagues, 2013 recorded at the end of the treatments, 21 patients (70%) rated their response as excellent, six (20%) as good, and three patients (10%) as poor while Leheta and her colleagues, 2011 reported 70% of patients reporting subjective improvement of their acne scars (range 50– 80%).The side effects detected by the roller were mild where 100% of the patients suffered from temporary erythema and transient pin point bleeding, 73.7% of the patients suffered from pain during the procedure in spite of the application of

topical anesthetic before the procedure and 57.9% of the patients suffered from transient edema that usually disappeared the same day of the procedure. These were the same adverse effects observed by Niwat, 2009 for transient pain during the session and mild erythema that was tolerable for all patients. Alam et al., 2014 also declared that no adverse events were reported except for mild transient erythema and edema. Leheta et al., 2011 after PCI, patients experienced transient erythema and edema that lasted for a mean of 3 days which is consistent with other studies

Chemical reconstruction of skin scars TCA (CROSS) was first described by Lee and his colleagues in 2002 referring to focal application of higher concentration TCA which was beneficial especially in icepick scars due to its depth from the downward pull of fibrous tissue at the base of the scar and the loss of both collagen and elastin

Our study revealed that TCA CROSS performed on 15 patients improved atrophic acne scars in patients with mean percentage of improvement 42.73±20.02. Our results were similar to those detected by Kitano and Uchida in 2006 who reported that 50.5% of patients showed improvement, with better clinical response in deep than shallow boxcar scars. Ramadan and colleagues, 2011 studied the efficacy of 100% TCA on rolling acne scars, there was decrease in the scar depth and size in 100% of scars. On the other hand, better results were reported by Leheta et al., 2011 who showed that improvement of atrophic acne scars in patients receiving CROSS occurred by mean of 75.3±9.4. This may be due to the fact that they used a higher concentration of TCA (100%).

On evaluating the photos using the quartile scale out of these 15 patients: (one patients (6.7%) showed excellent improvement (75%-100%), 5 patients (33.3%) showed very good improvement (50- <75%), 6 patients (40.0%) showed good improvement (25- <50%) and 3 patients (20.0%) showed poor response (0- <25%)). We concluded that CROSS method was more effective on ice-pick scars while box and rolling scars showed lower response.

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Our results are similar to Ahmed et al., 2014, using the CROSS technique, three patients (21.4%) had 51 – 75% improvement, 7 patients (50%) had 30 – 50% improvement and 4 patients (28.6%) had 30% improvement.

Our results are also similar to those of Agarwal et al., 2015, where physician assessment revealed that 35 patients (66%) had >50% clinical improvement. Of these, 12 (22.6%) achieved excellent (>75%) improvement and 23 (43.4%) had good (51%–75%) improvement. Nofal et al., 2014 as it showed that no patients showed excellent improvement, 4 patients (26.7%) very good, 5 patients (33.3%) good and 6 patients (40.0%) with poor response.

Improvement in atrophic post acne scars was even reported by lower concentration of TCA as Fabbrocini and his colleagues, 2008 who used TCA (50%). Kim and his colleagues, 2009 reported that on application of 100% TCA, results were very impressive comparable with those results obtained by using erbium glass laser in ice pick scars they recommended CROSS technique for ice pick scars over fractional Er:Glass laser in spite of short downtime. Bhardwaj and Khunger, 2010 using 100% TCA on ice pick and rolling scars 100% of the patients had good or excellent response. Khunger and his colleagues, 2011 used 100% TCA on ice pick scars 93.3% of patients had good or excellent results. All the previous results were much better than our results which may be due to the fact that most of them were done on only icepick scars with the exclusion of other types of scars while our study included mixed types of atrophic post acne scars.

Better results were also achieved by Leheta and collegues in 2011 where eight patients (66.7%) showed significant improvement, three (25%) showed moderate improvement, one (8.3%) showed mild improvement and this may be due to the use of higher concentration of TCA (100%).Lee and colleagues, 2002 used two different concentrations of TCA (CROSS) 65% and 100% and variable intervals between applications. They noted that higher concentration of TCA at shorter intervals was more effective than lower

concentrations and longer intervals, without causing an increase in complications.Regarding the patient satisfaction 13 patients (86.7%) showed different degrees of satisfaction by the results reached by this technique. This is in accordance with Agarwal et al., 2015 who reported that (81.1%) were either satisfied or very satisfied with the treatment given and dissatisfaction in the remaining 18.9% patients, Nofal et al., 2014 showed satisfaction in all treated patients which may be due to the use of higher concentration (100%), Yug and colleagues, 2006 who reported high patient satisfaction upon using 95% TCA CROSS on patients with ice pick scars and Lee and colleagues, 2002 showed higher patient satisfaction rates with 100% TCA.

The main side effects detected by the TCA 80% CROSS technique in our study was the hyperpigmentation which was detected in 11 (73.3%) of the patients which was persistent in 2 of our patients where they failed to respond to any of the treatment modalities used for treatment of hyperpigmentation. Those patients were with dark skin colour (type V) with continuous sun exposure. Otherwise there was no obvious complications from this technique other than erythema detected by 9 patients (60%) which was mild relieved the same day of the procedure. These were the same as detected by Nofal et al., 2014 as cosmetic discomfort was noticed because of the presence of brownish crusts that appeared within 2 days and lasted for 2 to 7 days. As previously reported by Lee et al., 2004 and Kim et al. ,2009 transient postinflammatory hyperpigmentation occurred in 4 patients who were treated with CROSS, all of them were skin type V. Fabbrocini et al., 2008 also reported the same side effect.

Leheta et al., 2011 reported the same side effects as patients experienced cosmetic discomfort due to the presence of brownish crusts within 2 days that lasted for 7 to 10 days and post-crust erythema that lasted for a mean of 15.9±4.3 days.

Leheta and colleagues, 2011 compared the PCI versus 100% TCA cross and their results disagreed with ours as there was statistically significant improvement in degree of overall scar

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severity before and after treatment for both groups (p0.001 for both) but there was no statistically significant difference between the groups, Rolling scars showed better results with the dermaroller (PCI) (a statistically significantly greater percentage improvement in group 1 (87.8%) than in group 2 (66.5%) (P=0.001). While ice pick scars showed a statistically significantly greater percentage of improvement in group 2 (86.2%) than in group 1 (52.5%) (P =0.001). These better results may be due to the fact that they used higher concentration of TCA (100%) than ours.

In conclusion, the current study showed that the dermaroller was superior to the TCA CROSS (80%) in term of improvement of atrophic post acne scars as detected by photo evaluation (higher percentage of excellent improvement and percentage of improvement) and Goodman and Baron scale (higher percentage of patients having macular scars after treatment) however, no significant difference was detected as regard the patient satisfaction.

We would recommend PCI over 80% TCA CROSS for treatment of rolling acne scars, PCI maybe more suitable for patients with a history of skin dyschromia because of a higher incidence of consequent postinflammatory hyperpigmentation with 80% TCA CROSS. TCA CROSS is better to be used in the treatment of ice pick acne scars where it is more suitable for patients who cannot tolerate pain, patients with fair skin, and patients with deep scars that cannot be fully reached with a dermaroller. In addition, it is less invasive and more economic modality especially in developing countries. More than one session is also recommended because greater improvement is achieved after multiple sessions with both techniques, especially PCI. Combining both procedures may have an even better response.

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جانبية أثار اى وحدوث المرضى رضي ومدى الجلسات وبعد قبل الصور استخدام طريق عن .المرضى

يلى : فيما النتائج وتلخصتالندبات فى التحسن درجة ولكن المجموعتين فى الدراسة في المشمولين المرضى جميع تحسن) بنسبة الديرمارولر باستخدام عالجها تم والتي األولى المجموعة فى إحصائية وبدالله اعلي %)59.8كانت

الترايكلورواسيتيك حمض باستخدام عالجها تم والتى الثانية بالمجموعة 0.025( %) 42.7بنسبة% (80مقارنة =p _value ( وكانت المجموعتين بين المرضى رضى درجة فى إحصائية داللة ذات فروق هناك يكن لم ولكن

الجلسات بعد الجلدى التصبغ يخص فيما وبالذات الثانية المجموعة فى أكثر .المضاعفات

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percutaneous collagen induction using dermaroller versus ... · web viewskin needling is also known...

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