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Exoderm
Chemoabrasion
Original Method for the Treatment of Facial Acne Scars
by YORAM
FINTSI, MD
INTRODUCTION
Acne is
a combined problem. It affects aesthetic, psychological, and therapeutic
functions. Acne occurs in early adolescence, peaking at 18 years of
age and generally vanishes by age 25 years. Even in cases of successful
therapy, lesions of various depths remain. These acne scars are challenge
to the treating physician because of suboptimal therapeutic result.
Deep acne scars are rarely eliminated completely by any
known treatment modality. Remarkable improvement, however, may be achieved.
Any treating physician needs to avoid allowing the patient to create
unrealistic expectations when approaching the therapy of acne scars.
Therefore accurate information must be conveyed to the patient.
CLASSIFICATION
OF ACNE SCARS
Facial acne scars are the leading cause (90%) of all facial scars. The
remaining 10% are from post-viral infections, traumatic and iatrogenic
events (See Table 1).
Since there is a difference in the appearance of acne scars
as a result of healing processes at various stages of the active phase,
I suggest classifying the acne scars into two main groups. The first group
is based on the severity of the scar appearance such as dilated pores,
pits, and craterlike scars. The second group is based on the associated
features of all the acne such as shape, confluence, and signs of inflammation
and aging (see Table 2).
MATERIALS
AND METHODS
Classification
During 1994-1997 (30 months) 145 patients were treated with exoderm chemoabrasion
(ECA) in my clinic; 132 were females. The patients were divided by the
severity of the facial scars according to the Table 2 classification.
A-47
B-36
C-34
D-16
E-12
About two
thirds of the cases were classified as A and B, having shallow to medium
depth scars that are the most common outcome of acne vulgaris. Ages
of the 145 patients ranged from age 18-50 years with most being under
35 years.
The associated features (as in Table 2) 0f all cases were:
1-60
2-43
3-8
4-45
5-36
Several patients had scars with more than one associated feature. One
third had acute inflammatory activity in forms of papules and pustules.
All the patients tried one or more medical treatments, topical and systemic,
before coming to my clinic. About half of the patients reported aggravation
of formation of new scars following comedone or sebum extraction.
Table
1. Facial Scars Classification
Post
acne scars*
Viral: pox, varicella
Traumatic: lacerations
Surgical lesions and sutures
Hypertrophic scars: post trauma
*Most
common and react better to ECA method.
BACK
TO TEXT REFERENCE
Table
2. Acne Scars Classification
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General
appearance
A.Pit,
dilated pores "peau d'orange
B.Ice picks - burned out nodular acne
C.Atrophic - "depressed valley"
D.Crater-like
E.Hypertrophic/keloids |
Associated
features
1.V-shape
2.Confluent scars
3.Bridge formation
4.Activity - papules, cysts
5.Wrinkles, aging signs |
BACK TO TEXT REFERENCE
The
ECA Method
Patients who were treated in my clinic with the ECA method for aging skin
problems and who also had acne scars had dramatic improvement of their
scars as well as rejuvenation of their aged skin. The ECA method, divided
into 3 phases, involves both chemical peeling (Exoderm solution) and mechanical
skin abrasion. The combination of these 2 procedures results in a contraction
of the depth and the surface of the scars in the papillo-upper reticular
dermis and flattening of the scar margins.
Phase
1 is based on the 12 components of the Exoderm solution, which is applied
all over the facial skin - including the eyelids.
After the frosting effects on the skin, the solution is then applied with
a wooden toothpick inside the pores and pits.
The face is then covered with an impermeable tape mask for 20-24 hours.
This phase is performed under sedation.
It is necessary to treat the entire face in order to have an even and
homogeneous color and texture of the skin, to contract the small pores
that are not clearly visible, and eliminate aging signs(Fig.1A).
Phase
2
After 24 hours, the tape mask is taken off from the face. The excess of
the liquified skin is removed with a dry Q-tip (Fig.
1B). The Exodern solution is topically reapplied to the scar areas,
until the frosting effect or bleeding is seen. The scar areas are than
abraded with a mechanical rotor or sterile sand-paper. The dermabrasion
causes desired bleeding to indicate that the abrasion has reached the
dermo epidermal vascular bed. Immediately afterwards an antiseptic bismuth
subgalate power is applied on the face to form a mask(Fig.
1C). During the following week a crust forms. The crust should be
removed after seven days by applying vaseline gel. A new reddish skin
appears.
Figure 1.A. Phase 1 of treatment: The face is covered by tape
mask after application of solution. B. Phase 2: The skin
is completely liquified. C. The face is covered by powder
mask of bismuth subgalate for the next 7 days. BACK
TO TEXT REFERENCE
Phase 3 (optional)
Local treatment on residual scar areas is performed 6 to
8 weeks after the removal of the face mask. The Exoderm solution is applied
to the scarred areas 3 to 5 times in 5-minute intervals. The treated area
is abraded 5 to 7 minutes later with either sand-paper 3-0 or with the
electric instrument. When bleeding of the treated area occurs, it should
be covered with bismuth subgalate powder. Then follow up as in phase 2
(Fig.2).
Figure 2. The patient in the treatment in figure 1, before and
after. Improvement of the crater-like scars.
RESULTS
The
145 patients have undergone this procedure uneventfully. Only 28 patients
required a third-phase reapplication. Of the other 117 patients, 95 were
satisfied with the results after the first treatment (phase 2).There were
22 patients who considered having phase 3 performed in the near future.
All patients showed remarkable improvement of the skin with regard to
the quantity and the depths of the scars.
Pits and shallow scars disappeared completely, and patients who were classified
A, B, and C (Table 2) said that they were completely satisfied with the results
(Fig.3-5).
Associated aging signs of the skin such as wrinkles, solar spots, and
senile spots disappeared as well, with a significant lifting effect.
Figure 3. 48-year-old woman with improvement of scars as well
as the lifting effect of the wrinkles.
Figure 4. 22-year-old female with dramatic improvement of scars
during the active phase of scars.
Figure 5. 55-year-old patient after disappearance of scars and
pits.
BACK
TO TEXT REFERENCE
DISCUSSION
Acne
scars are a challenge for the treating physician, as the remedies for
this disease are still suboptimal. Furthermore, it is difficult to meet
the patients' expectations. The first attempt with ECA had been very encouraging
and, with further refinement, the results became very satisfactorty. ECA
developed from our extensive experience with Exoderm for skin rejuvenation
over the 12 years and was modified for treatment of acne scars by adding
abrasion to the chemical peel.
The abrasion is performed after the skin liquefaction and a second application
of the liquid solution. This guarantees the optimal penetration of the
solution and leveling of the scars. Initially, a high-powered rotor was
used to abrade and smooth the scar margins. Subsequently, we discovered
that equal results could be obtained by using sandpaper. Regardless of
the technique, the aim is to reach the epidermal-dermal junction. Bleeding
is a sign that the adequate anatomical region was reached. As the Exoderm
lift solution causes autoblockage at the upper reticular dermis, there
is no concern that the solution will penetrate deeper. The use of bismuth
subgalate is crucial because of its antibacterial and regenerating capacities.
The post-op period lasts 8 days and is not associated with any discomfort.
Since most acne-scar patients have dark complexion
(Fig.6 and 7) (skin type 4/5) the prophylactic treatment
with creams based on retin A, hydroquino, and dexamethasone require a
6- to 8-week period. This is the reason that hyperpigmentation is negligible.
Phase 3 is not necessary trophic scars that were only little affected,
whereas the regular scars around them improved dramatically.
All associated lesions resolved, and the lifted appearance of the facial
skin improved the general appearance, including that of the scars. This
is why the basic treatment is performed all over the facial skin. In conclusion,
ECA is a method based on a combined chemical and physical approach that
is devoid of side effects and results in the improvement of scars in the
majority of patients.
 Figure
6. Skin type 5, with improvement of scars and aging signs.
Figure
7. Skin type 4, with dramatic improvement of deep scars and pits.
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