Article

A Stereoscopic Optical System for Objective Quantification of the Change in Cumulative Acne Scar Depth Following Various Treatment Interventions

Wiley
Journal of Cosmetic Dermatology
Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Current approaches for assessment of acne scars are subjective. We aimed to evaluate the reliability and feasibility of a new objective stereoscopic optical system for atrophic acne scars cumulative depth and monitoring therapeutic response. This retrospective case study aimed to validate accuracy and present initial data of a new, simple, non-contact, high-resolution 3D stereoscopic optical imaging system (Cherry Imaging, Yokneam, Israel) in the setting of acne scarring. Feasibility of the system was assessed by monitoring the cumulative depth of atrophic acne scars after a single treatment by means of various approaches. investigator’s Qualitative Scarring Grading Score (QSGS) and patient’s Self-Assessment of Clinical Acne-Related Scars (SCARS) were also calculated before and four weeks after the intervention. Scar depth measured by the imaging system correlated significantly with the actual depth of printed surface depressions. The changes in SCARS and 3D optical imaging assessments correlated significantly (R=0.68, P = 0.012), but there were no correlations between changes in QSGS and 3D optical assessment measures, or between the QSGS and SCARS results. The new stereoscopic optical system is a reliable and practical objective method for assessing the cumulative depth of atrophic acne scars and monitoring treatment response. It is more sensitive, accurate, and informative than subjective scales.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... To address exploratory objectives, wounds of the MAD part were scanned using a 3D spectroscopic scanner to evaluate scar area, scar volume and scar redness (Cherry Imaging, Yokneam, Israel, Supplementary methods) and blood perfusion of the wound bed and adjacent skin was measured (Laser Speckle Contract Analysis, LASCA; Perimed AB, Järfälla, Sweden, Supplementary Fig. S2 and Supplementary methods). 15,16 Wound biopsies were taken 48 h post-dosing in the SAD part for assessment of local mechanisms of action (Supplementary methods). ...
... Tolerability, clinical and biologic effects were assessed at each visit (SAD: Day 1, 2, 3, 7, 14, and at 6 weeks, 3 months and 12 months from start of treatment at Day 1; MAD: Day 1,2,3,5,8,10,12,15,17,19,21,32, and at 6 weeks, 3 months and 12 months after last dose at Day 19). All assessments were blinded and occurred by on-site visual inspections of the wounds by the Principal Investigator (or co-investigator), as well as off-site by traceable evaluation and detailed wound area measurements from 2D photographs of all wounds by 3 Independent Evaluators (IEs) with expertise in wound healing. ...
Book
In recent years, probiotics have expanded from their traditional classification as “health promoting food” to the development of live biotherapeutic products (LBP). Traditional probiotics are marketed as food/dietary supplements while LBPs are drug products intended for treatment or prevention of diseases. This type of products offers several advantages over traditional drugs, but also entail potential challenges with development, manufacturing, and demonstration of clinical safety. To obtain a sufficient quality, LBPs are typically produced by cultivation in a bioreactor, followed by formulation and lyophilization. In the first part of the project, the impact of lyophilization parameters on physicochemical and biological properties of Limosilactobacillus reuteri R2LC was evaluated. Using sucrose as a lyoprotectant gave a better freeze-drying survival, vitality and storage stability than using trehalose. A high concentration (20%) of sucrose sometimes resulted in a collapsed structure and 15% gave the overall best properties of the lyophilized bacteria. Interestingly, vitality was positively affected by using a higher concentration (1010 cfu/ml) of bacteria. Another observation was that introducing an annealing step in the process was positive when using sucrose as lyoprotectant, but no effect was seen when using trehalose. The second part of the project describes evaluation of the genetically modified L. reuteri R2LC expressing the human chemokine CXCL12 (ILP100-Topical) in a phase 1 trial on wound healing. The product was safe and well-tolerated. In addition, it gave a larger proportion of healed wounds (76 %) on Day 32 when compared to saline/placebo (59 %) (p=0.020) and the time of wound healing was reduced by 6 days on average and by 10 days at highest dose. Also, ILP100-Topical increased the density of CXCL12+ cells in the wounds and local wound blood perfusion.
... To address exploratory objectives, wounds of the MAD part were scanned using a 3D spectroscopic scanner to evaluate scar area, scar volume and scar redness (Cherry Imaging, Yokneam, Israel, Supplementary methods) and blood perfusion of the wound bed and adjacent skin was measured (Laser Speckle Contract Analysis, LASCA; Perimed AB, Järfälla, Sweden, Supplementary Fig. S2 and Supplementary methods). 15,16 Wound biopsies were taken 48 h post-dosing in the SAD part for assessment of local mechanisms of action (Supplementary methods). ...
... Tolerability, clinical and biologic effects were assessed at each visit (SAD: Day 1, 2, 3, 7, 14, and at 6 weeks, 3 months and 12 months from start of treatment at Day 1; MAD: Day 1, 2, 3,5,8,10,12,15,17,19,21,32, and at 6 weeks, 3 months and 12 months after last dose at Day 19). All assessments were blinded and occurred by on-site visual inspections of the wounds by the Principal Investigator (or co-investigator), as well as off-site by traceable evaluation and detailed wound area measurements from 2D photographs of all wounds by 3 Independent Evaluators (IEs) with expertise in wound healing. ...
Article
Full-text available
Background: Impaired wound healing is a growing medical problem and very few approved drugs with documented clinical efficacy are available. CXCL12-expressing lactic acid bacteria, Limosilactobacillus reuteri (ILP100-Topical), has been demonstrated to accelerate wound healing in controlled preclinical models. In this first-in-human study, the primary objective was to determine safety and tolerability of the drug candidate ILP100-Topical, while secondary objectives included assessments of clinical and biologic effects on wound healing by traditionally accepted methods and explorative and traceable assessments. Methods: SITU-SAFE is an adaptive, randomised, double-blind, placebo-controlled, first-in-human phase 1 trial (EudraCT 2019-000680-24) consisting of a single (SAD) and a multiple ascending dose (MAD) part of three dose cohorts each. The study was performed at the Phase 1 Unit, Uppsala University Hospital, Uppsala, Sweden. Data in this article were collected between Sep 20th, 2019 and Oct 20th 2021. In total 240 wounds were induced on the upper arms in 36 healthy volunteers. SAD: 12 participants, 4 wounds (2/arm), MAD: 24 participants, 8 wounds (4/arm). Wounds in each participant were randomised to treatment with placebo/saline or ILP100-Topical. Findings: In all individuals and doses, ILP100-Topical was safe and well-tolerated with no systemic exposure. A combined cohort analysis showed a significantly larger proportion of healed wounds (p = 0.020) on Day 32 by multi-dosing of ILP100-Topical when compared to saline/placebo (76% (73/96) and 59% (57/96) healed wounds, respectively). In addition, time to first registered healing was shortened by 6 days on average, and by 10 days at highest dose. ILP100-Topical increased the density of CXCL12+ cells in the wounds and local wound blood perfusion. Interpretation: The favourable safety profile and observed effects on wound healing support continued clinical development of ILP100-Topical for the treatment of complicated wounds in patients. Funding: Ilya Pharma AB (Sponsor), H2020 SME Instrument Phase II (#804438), Knut and Alice Wallenberg foundation.
Article
Acne scarring is a common sequela of acne vulgaris, which seriously affects facial esthetics. The treatment options for acne scars vary depending on the development stage, color, type, and location of scarring. The objective and precise assessment of acne scars is a prerequisite for treatment, and it is also an important means of monitoring the treatment effect. The traditional methods to evaluate the types and severity grade of acne scars are primarily based on subjective assessment by physicians, which lacks objectivity and accuracy. Novel noninvasive skin imaging techniques, such as skin surface imaging analysis systems, dermoscopy, reflectance confocal microscopy (RCM), high-frequency ultrasound (HFUS), optical coherence tomography (OCT), and multiphoton tomography (MPT), provide new tools for the rapid and objective assessment of acne scars. This article reviews the progress of skin imaging techniques in the diagnosis, classification, and efficacy evaluation of acne scars.
Article
Full-text available
Introduction Scarring on visible areas such as the face is associated with negative psychological impact. Many patients with acne have clinically relevant scarring for which they seek treatment, implying that there is an impact on their lives. Currently there are no validated tools to assess the burden of atrophic acne scarring from the patient’s perspective or to assess treatment benefit. Methods Two patient-reported outcome measures, the self-assessment of clinical acne-related scars (SCARS) and the facial acne scar quality of life (FASQoL) tools, both specific to facial atrophic acne scarring, were developed according to Food and Drug Administration guidance methodology. Patient interviews were conducted first to elicit patient-important concepts about scarring, then to validate patients’ understanding of wording in the tools. These tools focus on symptoms (SCARS) and psychological and social well-being (FASQoL) and were designed to be suitable for self-completion and to be rapidly completed (2–5 min) within a clinical research setting. Results Concept elicitation interviews were conducted with 30 subjects and cognitive interviews with 20 subjects. With acne scarring, important concepts for patients included size, surface area affected, counts, and depth. The SCARS and FASQoL tools were shown to address relevant concepts that were easily understood by patients. Conclusion Two patient-reported measures, SCARS and FASQoL, have been developed to help clinicians assess the severity and impact of acne scars. Responsivity of these instruments to treatment will require further evaluation. Funding Galderma R&D, Sophia Antipolis, France.
Article
Full-text available
Acne scarring remains a stubborn clinical problem. Few treatments have been shown to be definitely effective for this problem. Polymethylmethacrylate (PMMA) microspheres in collagen (ArteFill, Suneva Medical Inc, Santa Barbara, CA) have shown long-term benefit for nasolabial fold treatment. A pilot study has shown benefit for PMMA-collagen in atrophic acne scarring. We sought to demonstrate the safety and effectiveness of PMMA-collagen for acne scarring in a controlled, blinded trial. Subjects with at least 4 moderate to severe rolling, atrophic scars randomly received PMMA-collagen or saline injections. Subjects underwent up to 2 injection sessions and were followed up for 6 months. Efficacy was assessed using a validated rating scale for each scar. In all, 147 subjects underwent injections. Success was achieved by 64% of those treated with PMMA-collagen compared with 33% of control subjects (P = .0005). The treatment showed excellent safety with generally mild, reversible adverse events. No significant differences in efficacy or safety were noted between genders, for darker skin types, or in older age groups. Subjects were followed up for only 6 months. PMMA-collagen demonstrates substantial effectiveness in the treatment of atrophic acne scars of the face while maintaining an excellent safety profile. Further follow-up should be undertaken to demonstrate longer-term benefit and safety.
Article
Full-text available
Acne vulgaris can severely affect social and psychological functioning. The aim of this study was to investigate the impact of acne vulgaris and its severity on Quality of Life of young adolescents in Greece. We conducted a questionnaire based survey among 1560 adolescent between the ages of 11 and 19 years old and 1531 of these were completed. Adolescents with acne filled all the questions including the Children Dermatology Life Quality Index. Adolescents without acne filled the questions about age, family history of acne, stress and smoking. Data were analyzed with Pearson Chi Square test. Acne prevalence was 51.2% affecting both sexes equally. Self reported mild acne was present in 71.2% and moderate-severe acne in 28.8% of the study population. The mean age of the study population was 15.77y. The median score of Children Dermatology Life Quality Index was 4.02. The impact of acne on quality of life is associated with the severity of the acne (p<0.0001). Patients with moderate/severe acne experience greater psychosocial and emotional impairment (p<0.0001). Body image is modified proportionally to the severity of acne (p<0.0001). Symptoms and treatment of acne are factors that also influence their quality of life. Girls and boys are equally affected. Stress and heredity are correlated with acne and its severity (p<0.0001). We didn't find any correlation between smoking and acne. Acne affects Quality of Life of young adolescents in Greece. The impact is proportional to the severity of acne. More severe acne is associated with greater effect on quality of life with implications for self esteem, body image and relationships with others.
Article
Full-text available
Acne has a prevalence of over 90% among adolescents and persists into adulthood in approximately 12%-14% of cases with psychological and social implications. Possible outcomes of the inflammatory acne lesions are acne scars which, although they can be treated in a number of ways, may have a negative psychological impact on social life and relationships. The main types of acne scars are atrophic and hypertrophic scars. The pathogenesis of acne scarring is still not fully understood, but several hypotheses have been proposed. There are numerous treatments: chemical peels, dermabrasion/microdermabrasion, laser treatment, punch techniques, dermal grafting, needling and combined therapies for atrophic scars: silicone gels, intralesional steroid therapy, cryotherapy, and surgery for hypertrophic and keloidal lesions. This paper summarizes acne scar pathogenesis, classification and treatment options.
Article
Full-text available
Keloid scars often fail to respond to treatment, so research into new therapeutic regimes is important. However, research is limited by a scarcity of reliable, objective scar assessment tools. The volume of a keloid scar should decrease with successful treatment. This study demonstrates the use of a non-contact 3D digitiser to measure digitally the volume of a keloid scar. The scanner was used to scan 62 keloid scars and one fine-line normal scar. The scan took approximately 9s to complete. The volume was measured using 3D reverse modelling software. A previously validated scar assessment scale was used to score the scars according to their physical parameters. A significant correlation was found between volume and the scar score (Pearson's r=0.627, p<0.001). Linear regression was also statistically significant (p<0.001, R(2)=0.44). Therefore it was possible to predict the scar score from the measured volume. This technique could allow monitoring of a patient on treatment, or comparison of treatments in a research setting. It overcomes previous problems with the measurement of scar volume as it is quantitatively objective and well-tolerated.
Article
Background: One major sequelae of acne is atrophic scarring, yet objective tools to assess scars are lacking. Neither depth nor volume of atrophic scars is readily evaluable clinically and standard 2D photography is significantly affected by lighting and shadows. The aim of our study was to define and evaluate parameters of 3D imaging that can be used to assess severity of atrophic acne scarring. Methods: Single center study of 31 patients with acne scarring. A target area of 3 × 3 cm was defined on the face. The global severity of atrophic acne scarring in the target area was evaluated by 5 dermatologists and scars were counted and categorized by size (scars < 2 mm, 2-4 mm, and > 4 mm in diameter). Three dimensional images of the target area were acquired with the LifeViz Micro®system and analysis was performed using MountainsMaps®software. An algorithm was developed to quantify the scar volume loss: shape removal step, with an order 5 polynomial, and to calculate the Valley void volume 80% (Vvv 80%) defined in the ISO-25178 standard for 3D surface texture. Results: Correlation coefficient of the Vvv parameter to mean global severity at the target area rating was 0.77. The volume of scars evaluated with the Vvv parameter was mainly impacted by scars > 2 mm. The evaluations demonstrated good repeatability (with an intra-class correlation coefficient ICC = 0.98). Conclusions: We demonstrate convergent validation to clinical assessment and repeatability of 3D skin imaging in atrophic acne scarring. Image analysis is straightforward and can be integrated into an automated workflow.
Article
Acne vulgaris is a ubiquitous problem affecting 80 percent of people ages 11 to 30 years, with many patients experiencing some degree of scarring. This review focuses on atrophic scars, the most common type of acne scar. We briefly address the cellular sequelae that lead to scar formation and the initial evaluation of patients with acne scars. We then discuss an algorithmic approach to the treatment of acne scarring based on the classification of scars into erythematous and atrophic types. Lastly, we discuss the future treatment of acne scars and ongoing clinical trials.
Article
Background: Current approaches use subjective semiquantitative or cumbersome objective methodologies to assess physical characteristics of hypertrophic and keloid scars. Objective: This pilot study aimed to evaluate the accuracy and feasibility of a new stereoscopic optical and high-resolution 3-dimensional imaging system, for objectively measuring changes in above-surface scar volume after various interventions. Methods: Feasibility and accuracy were assessed by monitoring the above-surface scar volume of 5 scars in 2 patients for 5 successive months. Above-surface scar volume and Vancouver Scar Scale scores and the investigator and patient volume improvement assessment scores were assessed before and 12 weeks after last intervention. Results: Scar volume measured by the imaging system correlated significantly with the gold standard (actual weight). The greatest volume reduction followed a combination of cryotherapy and intralesional triamcinolone acetonide and 5-fluorouracil injections in Patient 1 and a combination of pulse dye laser and intralesional triamcinolone acetonide injections in Patient 2. Conclusion: The new stereoscopic optical system is a valid, accurate, and practical objective method for assessing scar volume and for monitoring treatment response. It is more sensitive and accurate than semiquantitative objective scales. Further studies with a higher number of patients and scars are required to increase the measurement validity of the system.
Article
Acne vulgaris is a chronic inflammatory skin disease that can lead to permanent scarring. Although grading scales exist for acne scarring, there are many limitations, and there is still a need for a well validated gold standard scale for use in clinical practice or research trials. An objective measure of scar severity should be a component of global acne severity evaluations. This manuscript reviews currently available acne scar grading modalities: lesion counting; subjective self-assessment; Acne Scar Rating Scale (ASRS); evaluator-based qualitative and quantitative scarring grading systems; Echelle d’Evaluation Clinique des Cicatrices d’acne (ECCA); Global Scale for Acne Scar Severity (SCAR-S); and imaging. Despite the varying tools, most of the currently available scales do not account for scar color, depth, or change over time. A new, validated scale is needed that would allow for a more objective and accurate assessment of scar progression over time to assist with effective treatment and research.
Article
Fractional laser technology is routinely used in the treatment of acne scarring, with thermal injury resulting in collagen synthesis and remodeling. Use of a picosecond pulse duration with a diffractive lens array may be a new technologic advancement in the treatment of acne scarring. To investigate the safety and efficacy of a 755-nm alexandrite picosecond pulse duration laser with diffractive lens array for the treatment of facial acne scarring. This single-center, prospective study performed in a private practice with a dedicated research department included patients with clinically diagnosed scarring secondary to inflammatory or cystic acne. Patients received 6 treatments with a 755-nm picosecond laser with a spot size of 6 mm, fluence of 0.71 J/cm2, repetition rate of 5 Hz, and pulse width of 750 picoseconds in combination with a diffractive lens array, allowing for greater surface area and pattern density per pulse. The pain and satisfaction scores for overall appearance and texture were recorded. Masked assessment of clinical photographs and analysis of 3-dimensional volumetric data were performed. Biopsy specimens were obtained for independent histologic evaluation by 2 investigators at baseline and at 3 months after last treatment. Fifteen women and 5 men (mean age, 44 years; age range, 27-61 years) with Fitzpatrick skin types I through V and facial acne scarring were enrolled. The mean pain score was 2.83 of 10. Patients were satisfied to extremely satisfied with improvement in appearance and texture at their final treatment and follow-up visits. The masked assessment scores of 17 patients were 1.5 of 3 and 1.4 of 3 at 1 and 3 months, respectively (a score of 0 indicates 0%-25% improvement and a score of 3 indicates >75% improvement). A 3-dimensional analysis revealed a mean 24.3% improvement in scar volume, maintained at 1 (24.0%) and 3 (27.2%) months after treatment. Histologic analysis revealed elongation and increased density of elastic fibers, with an increase in dermal collagen and mucin. Treatment of facial acne scars with a diffractive lens array and 755-nm picosecond laser produced improvement in appearance and texture at 3 months after the last treatment, with objective findings similar to those published for a series of fractional ablative laser treatments. Histologic findings suggest that improvement in scarring from this treatment goes beyond remodeling of collagen.
Article
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. To illustrate the range of techniques useful in the therapy of postacne scarring, their relative advantages and disadvantages, and their place in treatment. A review of available techniques is used to illustrate the treatment of indented or atrophic acne scars. 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. Atrophic postacne scars may be satisfactorily treated in many patients, but multiple methods are often required to ensure the best results.
Article
Objective This study assessed the role of self-reported facial scar severity as a possible influencing factor on self-esteem and depressive symptoms in patients with facial burns. Method A prospective multicentre cohort study with a six months follow-up was conducted including 132 patients with facial burns. Patients completed the Patient and Observer Scar Assessment Scale, the Rosenberg Self-esteem Scale and the Hospital Anxiety and Depression Scale. Structural Equation Modeling was used to assess the relations between depressive symptoms, self-esteem and scar severity. Results The model showed that patient-rated facial scar severity was not predictive for self-esteem and depressive symptoms six months post-burn. There was, however, a significant relationship between early depressive symptoms and both patient-rated facial scar severity and subsequent self-esteem. The variables in the model accounted for 37% of the variance in depressive symptoms six months post-burn and the model provided a moderately well-fitting representation of the data. Conclusion The study suggests that self-esteem and depressive symptoms were not affected by self-reported facial scar severity but that earlier depressive symptoms were indicative for a more severe self-reported facial scar rating. Therefore, routine psychological screening during hospitalisation is recommended in order to identify patients at risk and to optimise their treatment.
Article
Consensus concerning nomenclature and classification of acne scars is lacking. Classification based solely on clinical examination represents an unmet need that could be improved with the use of objective, reproducible assessments. To assess clinical and ultrasound morphologic features in 41 patients with scars resulting from moderate to severe acne and to determine whether correlation exists. Eighty-one lesions clinically identified as boxcar, ice pick, rolling, hypertrophic, or keloidal were evaluated using high-frequency ultrasound (22 MHz). Ultrasound results generally correlated with clinical appearance. Eight scars clinically classified as ice pick showed a typical boxcar morphology upon ultrasound examination. Ultrasound showed that ice pick and boxcar scars were the deepest, with 95.8% between 0.2 and 0.5 mm. High-frequency ultrasound is a noninvasive technique that is useful in the evaluation and correct classification of acne scars. It represents an important adjunct to clinical examination, because it provides reliable objective and reproducible information useful to the selection of the best treatment option specifically customized to each individual patient's needs.
Article
Atrophic acne scarring is an unfortunate, permanent complication of acne vulgaris, which may be associated with significant psychological distress. General dermatologists are frequently presented with the challenge of evaluating and providing treatment recommendations to patients with acne scars. This article reviews a practical, step-by-step approach to evaluating the patient with atrophic acne scars. An algorithm for providing treatment options is presented, along with pitfalls to avoid. A few select procedures that may be incorporated into a general dermatology practice are reviewed in greater detail, including filler injections, skin needling, and the punch excision.
Article
Scars can be devastating and disfiguring, because they are clearly visible, stigmatizing, and permanent reminders of the initial accident or surgical event. Yet, there is still no consensus about the optimal scale or tool to assess the characteristics and evolution. Our aim was to evaluate the clinical importance of scar scales specifically developed for burn scars. The systematic literature search involved PubMed and the Web of Science (including Science Citation Index). The search resulted in 29 articles (including seven reviews) dealing with a new, modified, or validated scale. Scar scales assess several characteristics, of which color, pliability, and thickness were considered the most important. Physical limitation, pain, and pruritus are often more disturbing than the appearance of the scar, and are therefore also introduced in scar evaluation, as well as the interference with daily life activities (e.g., psychologic impact). In contrast to the more objective scar assessment tools, scar scales usually cover more aspects of the scars and are less time-consuming in clinical practice. However, no strong conclusions can be made about their efficacy and validity. In addition to digital photography, scar scales are a valuable instrument in the clinical evaluation and follow-up of scars.
Article
Cutaneous scarring is affected by genetic, physiologic, and biochemical factors. These produce a continuum of scar types (i.e., keloid, hypertrophic, atrophic, contracted, and fine line) that can be symptomatic, aesthetically unsatisfactory, psychologically distressing, and functionally restrictive to the affected individual. Accurate scar assessment allows for quantification of scar evolution and management, and is key to evaluating the effectiveness of applied modulating therapies and treatments. Numerous objective instruments exist for the evaluation of different scar characteristics, but no consensus has been reached as to the most appropriate device. This review aims to explore the current range of noninvasive objective assessment tools available for cutaneous skin scarring, with specific emphasis on their application to research trials and clinical practice. An extensive search of the literature was completed to assemble comprehensive data surrounding the objective assessment of skin scars by both validation studies and clinical trials. A wide range of tools exist to monitor cutaneous scar physical characteristics. Primarily, there are four parameters explored by these instruments: (1) color, including pigmentation and vascularity (e.g., laser Doppler); (2) surface area (e.g., three-dimensional scanning); (3) height/depth (e.g., ultrasonography); and (4) pliability (e.g., tonometry). Many studies appraise single instruments in specific scar patient groups with subjective comparator tools. There is no overall valid and reliable noninvasive objective assessment tool for measurement of cutaneous skin scar characteristics. Further studies are warranted that compare multiple, parameter-specific instruments in a single-sample group and across a range of scar types.
Article
Acne is a prevalent condition in society and often results in secondary damage in the form of scarring. Of course, prevention is the optimal method to avoid having to correct the physically or emotionally troublesome scars. However, even with the best efforts, scars will certainly arise. This article attempts to give a broad overview of multiple management options, whether medically, surgically, or procedurally based. The hope is that a general knowledge of the current available alternatives will be of value to the physician when confronted with the difficult task of developing a treatment plan for acne-scarred individuals, even in challenging cases.
Article
Despite scarring being a recognized sequel of acne, the actual extent and incidence of residual scarring remains unknown. One hundred and eighty-five acne patients were included in this study (101 females, 84 males). Patients were selected from acne clinics and their acne scarring was examined. The scarring was quantified according to a lesion count and allocated a score. The type and extent of scarring was correlated to the age and sex of the patient, the site of the acne, the previous acne grade according to the Leeds Technique, acne type (noted in clinic at the original referral time) and duration of acne, before adequate therapeutic measures had been instituted. Results indicate that facial scarring affects both sexes equally and occurs to some degree in 95% of cases. Total scarring on the trunk was significantly greater in males, as was hypertrophic and keloid scarring in these sites (P < 0.05). There were significant correlations between the initial acne grade and the overall severity of scarring in all sites and in both sexes (P < 0.01). Superficial inflamed papular acne lesions as well as nodular lesions were capable of producing scars. A time delay up to 3 years between acne onset and adequate treatment related to the ultimate degree of scarring in both sexes and in all three sites. This emphasizes the need for earlier adequate therapy in an attempt to minimize the subsequent scarring caused by acne.
Article
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.
Article
Acne is a common condition experienced by up to 80% of people between 11 and 30 years of age and by up to 5% of older adults. In some patients, the severe inflammatory response to Propionibacterium acnes results in permanent, disfiguring scars. Over the past several decades, numerous descriptive terms and surgical techniques have been used to diagnose the types, and improve the appearance, of scarring in those persons with acne. We propose a descriptive, simple, universally applicable acne scar classification system that includes 3 scar types: icepick, rolling, and boxcar. We also have developed an effective treatment algorithm for reconstructing and improving the appearance of acne scars including punch excision, punch elevation, subcutaneous incision (Subcision), and laser skin resurfacing. This new classification system for acne scars enables the physician to more precisely identify scar subtypes. Once the scar type has been defined, appropriate and effective treatment protocols can be developed.
Article
Many patients with inflammatory acne suffer from significant scarring, which is disfiguring and difficult to treat. A cell-mediated immune response is considered to be involved in the pathogenesis of acne, although the extent of this response has been found to differ among patients. To assess whether there were differences in the cell-mediated immune responses at different time points in inflamed lesion development and resolution in patients who were prone (S patients) and those with the same degree of inflamed acne who were not prone (NS patients) to develop scarring. Cellular and vascular markers were investigated using standard immunohistochemical techniques on biopsies of inflamed lesions of known duration, i.e. < 6 h (n = 14), 24 h (n = 14), 48 h (n = 10), 72 h (n = 10) and 6-7 days (n = 11) from the backs of acne patients. In early lesions from NS patients there was a large influx of CD4+ T cells, macrophages and Langerhans cells with a high number of cells expressing HLA-DR. Also there was significant angiogenesis and vascular adhesion molecule expression. Cell recruitment peaked in 48 h lesions, after which leucocyte numbers decreased and vascular activity returned to normal. Of the T cells, only 50% were memory/effector (CD45RO+) and naive (CD45RA+) cells, while the remainder were unclassified (CD45RO-, CD45RA-). In early lesions from S patients, CD4+ T cell numbers were smaller, although a high proportion were skin homing memory/effector cells. Langerhans cell numbers and cellular HLA-DR expression were low, while numbers of macrophages, blood vessels and vascular adhesion molecules were high. In resolving lesions angiogenesis remained high, with a further influx of macrophages and skin homing memory/effector cells and increased cellular HLA-DR expression. The cellular infiltrate was large and active with a greater nonspecific response (few memory T cells) in early lesions of NS patients, which subsided in resolution. In contrast, a predominantly specific immune response was present in S patients, which was initially smaller and ineffective, but was increased and activated in resolving lesions. Such excessive inflammation in healing tissue is conducive to scarring and suggests that the use of topical anti-inflammatory treatments would be appropriate for these patients.
Article
There is no global quantitative grading system for assessing the disease load and global severity of disease in a patient with postacne scarring. The purpose of this article is to provide a quantitative grading system that would allow more objective communication between practitioners of a patient's global disease severity and between investigators, educators, and proceduralists of the efficacy of grade-specific operative interventions or therapies. We describe a global scoring system that we have found clinically useful to assess disease load and severity of acne scarring and illustrate the reproducibility of this system in a small prospective study. Photographs of 21 patients were assessed independently by four observers, two of whom were physicians and the other two nurses. A quantitative global acne scarring grading system is presented. No substantial difference among acne scarring scores was seen between observers, with inter-rater agreement within four score points in 19 of the 21 patient-photos assessed. A global acne scarring grading system is presented that would allow investigators, educators, and proceduralists to compare their cases more accurately and to have a more objective discussion of the efficacy of operative interventions or therapies. This scoring system is shown to be reproducible among observers independent of medical background, suggesting that patients can be assigned scores equally by physicians and nurses.
Article
There is no global qualitative grading system for assessing the disease load and global severity of disease in a patient with postacne scarring. The purpose of this article is to provide a simple qualitative grading system that would allow better communication between practitioners of a patient's global disease severity and the most appropriate corresponding therapy for that degree of acne scarring. Four grades of postacne scarring are described, and appropriate therapeutic interventions are presented for each. Grade assignment is made by lesion morphologies and disease load as indicated by patient perception of severity (i.e., whether or not an individual can easily disguise his or her disease at social distances). A simple qualitative global acne scarring grading system is presented. The determination of disease load in terms of patient perception of severity is intrinsically imperfect due to varying subjectivity among individuals. A global acne scarring grading system is presented that is simple to use and may optimize therapeutic intervention. This system would also allow investigators, educators, and proceduralists to compare their cases more accurately and to have a more objective discussion of the efficacy of operative interventions or therapies.
Article
Treatment of keloid scars poses a significant challenge. Assessment of treatment response and research in this area depend on the availability of objective, accurate, and reproducible outcome measures. At present, scars are assessed using subjective grading systems, or with cumbersome investigations such as direct casting. The authors assessed the feasibility of objectively monitoring response to intralesional steroid treatment in routine clinical practice with quantitative three-dimensional imaging. Scar volume was quantified using a validated three-dimensional speckle-pattern stereophotogrammetry before and for a minimum of 8 weeks after intralesional steroid therapy in 12 patients with keloid scars. Mean scar volume at the start of treatment was 0.73 +/- 0.701 cc (range, 0.12 to 2.15 cc); this was reduced to 0.14 +/- 0.302 cc (range, 0.007 to 1.08 cc) after monthly intralesional injections of triamcinolone acetate (p < 0.001; analysis of variance). The majority of patients achieved a greater than 50 percent response within 8 weeks of the start of therapy, but poor treatment response was noted and quantified in a minority of patients. Three-dimensional stereophotogrammetry is a rapid and noninvasive method of scar volume assessment that could allow accurate and objective monitoring of treatment response to be incorporated into clinical practice. Therefore, it can be of considerable value in assessing treatment efficacy and evaluating new therapeutic strategies.
Article
Scars evolve through a maturation stage during which it is necessary to adapt different treatments. To adapt treatments, it is necessary to assess various parameters linked to inflammation. To this end, clinical scar assessments are subjective though reliable, and validation is operator dependent. The Vancouver Scar Scale, Visual Analogic Scale, Patient and Observer Scar Assessment Scale, and the Manchester Scale assess different scar characteristics. These scales are interesting, depending on the type of scars, and are easy to use but subject to errors. To use clinical a scale, the raters must be trained. Parameters can also be precisely assessed by technical means, whereby they rate only one parameter, but are more accurate. Some scales are easy to use, have low cost, and can be used for clinical assessment. Others scales are more complex and expensive, and can be used in research or treatment evaluation.