Greg J. Goodman

postacne Scarring: A Review of its Pathophysiology and Treatment

Background. There has been a largely unheralded revolution in the number of techniques that can now be used in the treatment of atrophic postacne scarring. Atrophic scarring is the more common type of scarring encountered after acne. Objective. To illustrate the range of techniques useful in the therapy of postacne scarring, their relative advantages and disadvantages, and their place in treatment. Method. A review of available techniques is used to illustrate the treatment of indented or atrophic acne scars. Results. The individual architecture of the indented scar must be assessed so that treatment may be designed to maximize its improvement. A variety of new methods now exist, including newer resurfacing tools such as infrared lasers, dermasanding, and others in their infancy such as nonablative resurfacing and radiofrequency methods. A true explosion in autologous and nonautologous tissue augmentation and the advent of tissue undermining and the use of punch replacement techniques has added more precision and efficacy to the treatment of these scars. Conclusion. Atrophic postacne scars may be satisfactorily treated in many patients, but multiple methods are often required to ensure the best results.

Postacne scarring – a quantitative global scarring grading system

Background  There is no global quantitative grading system for assessing the disease load and global severity of disease in a patient with postacne scarring.

Management of Post-Acne Scarring

Post-acne scarring is a very distressing and difficult problem for physician and patient alike. Recently, newer techniques and modifications to older ones may make this hitherto refractory problem more manageable. Options for dealing with post-acne scarring are explored. The patient, his or her overall appearance and the morphology of each scar must be assessed and treatment designed accordingly. To adequately address the patient with scarring, a thorough knowledge of the pathophysiology and anatomy of the different types of scars should be sought. Once an understanding of what the pathology is and where it is occurring is attained, the most pertinent treatment for that scar may be devised. A variety of post-acne scars is produced including superficial macules, dermal troughs, ice picks, multi-channelled fistulous tracts and subcutaneous atrophy.The wide variety of new treatment methods for post-acne scarring includes newer resurfacing tools such as CO2 and erbium infrared lasers, dermasanding and possibly some future techniques such as non-ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous and nonautologous tissue augmentation and the advent of tissue undermining have greatly improved treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary.The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser, and intralesional cytotoxics are interesting developments. Most often occurring extra-facially and in males these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.

Efficacy and safety of a hyaluronic acid filler in subjects treated for correction of midface volume deficiency: a 24 month study

Background Hyaluronic acid (HA) fillers are an established intervention for correcting facial volume deficiency. Few studies have evaluated treatment outcomes for longer than 6 months. The purpose of this study was to determine the durability of an HA filler in the correction of midface volume deficiency over 24 months, as independently evaluated by physician investigators and subjects. Methods Subjects received treatment with Juvéderm™ Voluma™ to the malar area, based on the investigators’ determination of baseline severity and aesthetic goals. The treatment was administered in one or two sessions over an initial 4-week period. Supplementary treatment was permissible at week 78, based on protocol-defined criteria. A clinically meaningful response was predefined as at least a one-point improvement on the MidFace Volume Deficit Scale (MFVDS) and on the Global Aesthetic Improvement Scale (GAIS). Results Of the 103 subjects enrolled, 84% had moderate or significant volume deficiency at baseline. At the first post-treatment evaluation (week 8), 96% were documented to be MFVDS responders, with 98% and 100% graded as GAIS responders when assessed by the subjects and investigators, respectively. At week 78, 81.7% of subjects were still MFVDS responders, with 73.2% and 78.1% being GAIS responders, respectively. Seventy-two subjects completed the 24-month study, of whom 45 did not receive supplementary Voluma™ at week 78. Forty-three of the 45 (95.6%) subjects were MFVDS responders, with 82.2% and 91.1% being GAIS responders, respectively. At end of the study, 66/72 subjects were either satisfied or very satisfied with Voluma™, with 70/72 indicating that they would recommend the product to others. Adverse events were transient and infrequent, with injection site bruising and swelling being the most commonly reported. Conclusion Voluma™ is safe and effective in the correction of mild to severe facial volume deficiency, achieving long-term clinically meaningful results. There was a high degree of satisfaction with the treatment outcome over the 24 months of the study.

THE PREVALENCE AND ACCURACY OF DIAGNOSIS OF NON‐MELANOTIC SKIN CANCER IN VICTORIA*

Surveys of Victorian dermatologists and pathologists were undertaken to determine the number of patients attending medical practitioners with non‐melanotic skin cancers and solar keratoses. Results suggest that at least 1,000 patients per week are attending for diagnosis and treatment.

Adverse reactions to polylactic acid injections in the periorbital area.

Background  Correction of aging changes and contour deformities has been addressed largely by tissue augmentation agents whose volume is injected into tissues to achieve the required result. Polylactic acid (PLA) is an agent that is injected with the aim of enhancing the hosts own collagen deposition.

Post-acne scarring: a short review of its pathophysiology.

The onset of acne is an expected phenomenon in adolescence. However, its arrival produces long‐term psychological and physical sequelae for the individual. A review of available data illustrates the pathophysiological sequence of the advent of post‐acne scarring from its humble beginnings as a microscopic comedone to its eventual devastating end point of indented or exophytic scars. Acne scarring shows many different forms and is explainable by the depth and severity of the antecedent inflammation and the ability of the individual to heal these lesions. Post‐acne scarring is debilitating and socially disabling for many and is the avoidable outcome of untreated or inadequately treated acne. Treatment will depend on the resultant scar topography.

Treatment of Acne Scarring

Background  Post-acne scarring remains a common entity despite advances in the treatment of acne. This represents limitations in our quality of therapy and a failure of public education. The level of severe scarring remains as much an ongoing challenge to prevent as well as manage. Methods  This review will concentrate on the methods by which acne scarring may be improved and the available evidence for their utility. It will also rely on a grading scale of disease burden to classify patients and their ideal therapy. New therapies allowing treatment of scarring in areas other than the face will also be highlighted. Results  Tabulated treatment planning will present algorithms summarizing best practice in the treatment of post-acne scarring. Conclusion  Post-acne scarring is being better managed. Grade 1 scars with flat red, white, or brown marks are best treated with topical therapies, fractionated and pigment or vascular-specific lasers and, occasionally, pigment transfer techniques. Grade 2 mild scarring as seen primarily in the mirror is now the territory of non-ablative fractionated and non-fractionated lasers as well as skin rolling techniques. Grade 3 scarring, visible at conversational distance but distensible, is best managed by traditional resurfacing techniques or with fractional non-ablative or ablative devices, sometimes including preparatory surgical procedures. Grade 4 scarring, where the scarring is at its most severe and non-distensible, is most in need of a combined approach.Background  Post‐acne scarring remains a common entity despite advances in the treatment of acne. This represents limitations in our quality of therapy and a failure of public education. The level of severe scarring remains as much an ongoing challenge to prevent as well as manage.

Cleansing and Moisturizing in Acne Patients

Affecting over 80% of adolescents, acne is a widespread condition with substantial negative physical and emotional effects, and significant societal cost. Cleansing the acne patient involves several considerations, including matching skin type to the right type of cleanser, optimal times and methods of cleansing, treating parts of the body other than the face, and patient perceptions of the cause and treatment of acne. Moisturizing prevents and alleviates skin irritation, soothing the skin by slowing the evaporation of water. Many liquid face cleansers also moisturize, which may be all that is needed for a patient with oily skin. Protection from sun and environmental damage is important for all patients. While sunscreens are often irritants, the best options for young, oily, acne-prone skin tend to have a water or light liquid base. Moisturizing sunscreens are appropriate for patients with dry, sun-damaged skin, as well as those who wear makeup, have other skin diseases, or are easily irritated by products. Overall, treating acne patients should include education in patient-friendly terms and promoting healthy daily skin care practices, including cleansing and protection against environmental damage.

NON-MELANOTIC SKIN CANCER AND SOLAR KERATOSES IN VICTORIA—CLINICAL STUDIES II

The light exposed areas of the head and neck, forearms and dorsa of hands of two thousand adults aged forty years and older were at the Alfred Hospital between 1982 and 1983. There were 1,029 males and 971 females. Fifty‐nine people (3%) had at least one non‐melanotic skin cancer and 754 (37.7%) had at least one solar keratosis. The results of this study confirm the impression that sunlight exposure is a major determining factor in development of these tumours.