|
Whether
to Peel or Laser
for Acne Scarring and Hyperpigmentation
by Yoram
Fintzi, M.D., Haim Kaplan, M.D., and Marina Landau, M.D.
Abstract
Introduction:
The correction of acne scarring continues to be a challenge for physicians
despite the variety of peeling methods. A comparison of the efficacy and
side effects of different techniques in the same patient is not usually
feasible. The authors have used two different techniques for acne scarring
and hyperpigmentation in the same patient to compare the two methods.
Materials and Methods: Simultaneous treatment by two different methods
was used in the same patient who had acne scars and hyperpigmentation. Each
half of the face was treated simultaneously by laser on one side and phenol-based
(Exoderm) peel on the other side. Pretreatment and posttreatment biopsy
samples were obtained.
Results: More profound effects on acne scarring were shown on the
Exoderm-treated side. There were more abundant collagen and elastic fibers
shown on histological examination on the Exoderm-treated side. There was
no difference noted between the modalities in the effect on pigmentation.
Conclusions: Exoderm peel was shown to be superior for the treatment
of acne scarring, in some aspects, as compared with laser peeling after
using simultaneous treatment with both modalities in the same patient. There
was no difference between the modalities in the treatment of hyperpigmentation.
Techniques
for the treatment of acne scarring and hyper-pigmentation have improved
over the past few years because of the introduction of new technologies
and modification of the classic peeling agents. An objective comparison
among the various methods is usually impossible because patients respond
differently to the same method. The authors compared laser with phenol-based
(Exoderm) peel in one patient with acne scars and hyperpigmentation by
treating one half of the face with a laser, and the other half with Exoderm
peel -- simultaneously. Biopsy samples were taken before and after treatment.
Materials
and Methods
A 41-year-old
female patient with Fitzpatrick skin type IV-V was treated for extensive
acne scarnng, dilated pores, and uneven hyperpigmentation of the forehead
and cheeks (Figure 1). After providing a full explanation regarding the
potential effects and risks of both the modified phenol-based (Exoderm)
peel and CO2 laser resurfacing, the patient was offered the opportunity
of undergoing simultaneous half-face treatment with Exoderm and half-face
treatment with CO2 resurfacing.
A pretreatment
biopsy sample taken from the left preauricular area showed moderately
sun-damaged skin with postinflammatory hyperpigmentation, atrophic epidermis,
uneven distribution of melanin in the epidermis, abundant melanophages,
disrupted collagen and elastic bundles, and an increased amount of glycosaminoglycans
in the upper dermis.
Laser Resurfacing
Before the procedure,
the patient received intravenous morphine (5 mg) and prothiazine (15 mg).
Infraorbital and mental nerve blocks as well as local infiltration anesthesia
were performed using 2% lidocaine with 1:200,000 epinephrine on the right
side of the face. The patient's face was degreased with ether. The procedure
was performed with a CO2 Silktouch laser (Sharplan) using two passes at
16 to 18 J/cm2 fluence per pass with minimal overlap of the spots. A thick
layer of Vaseline gauze was applied after the procedure (Figure 2).
Exoderm Treatment
At the same
session, the left side of the face was scrubbed with acetone and the Exoderm
solution was applied with a cotton applicator and rubbed onto the skin.
The skin was then taped with impermeable, hypoallergic, zinc-oxidebased
plastic tape, which was applied in strips of 3 to 4 cm in length in an overlapping
fashion. After 24 hours, the tape mask was removed and the liquified epidermis
was dislodged by a dry cotton applicator. The face was covered immediately
with bismuth subgallate powder, which was kept on for 7 days (Figure 2).
On the seventh day, the powder mask was dissolved with Vaseline.
Results
After the
procedure, the patient reported more burning discomfort on the side of
laser resurfacing than on the side of Exoderm peeling. Five weeks after
the procedure, an even erythema was seen on both sides of the face with
no signs of hyperpigmentation. The improvement of the acne scars was more
prominent on the Exoderm-treated side (Figure 3). Seven weeks after treatment,
bilateral preauricular biopsy samples were obtained. Both sides showed
even distribution of melanin in the epidermis and larger amounts of collagen
in the form of compact parallel bundles oriented horizontally to the surface.
Fine elastic fibers were more prominent on the Exoderm treated side. The
Exoderm side showed a thinner epidermis, fewer rete pegs, less elastosis,
and decrease in the number of sebaceous glands (Figure 4).
Colloid iron
stain showed a decreased amount of intracellular glycosaminoglycans. Two
months after treatment, the laser-treated side began to show slight postinflammatory
hyperpigmentation. At the ninth week, at the patient request, Exoderm
peeling was performed on the previously treated laser side. Complete blending
of the demarcation line between the two sides of the face was seen within
5 weeks (Figure 5).
Discussion
The correction
of acne scarring and hyperpigmentation continues to be a challenge for the
practicing clinician. A variety of techniques have been developed, including
traditional chemical peels, dermabrasion, and recently, laser assisted skin
resurfacing. Nevertheless, in severe cases with deep tissue defects, none
of these methods shows satisfactory results and meets the patient's expectations.
In addition, the skin type limits the number of patients who can be treated
with these techniques; associated hyperpigmentation is a frequent complication
in dark-skinned patients.
CO2 laser resurfacing has been introduced as a high-technology method of
treatment for skin aging and defects. The procedure is now well established
and includes pretreatment preparation of the skin by the Kligman formulation,
systemic antiherpetic preventive treatment, deep sedation combined with
local blocks, and tissue evaporation to remove skin irregularities.
Exoderm is a modified phenol-based peel composed of three groups of agents:
(1) chemical agents such as crystallized and liquid phenol, resorcin, and
citric acid; (2) a mixture of oils such as sesame, olive, glycerin, and
croton; and (3) adjuvant components such as alcohol, septisol, distilled
water, and mainly buffered tris. Because of the constant pH of the solution,
controlled by the tris buffer, this formula blocks its own penetration at
the upper reticular dermis. The phenomenon ensures that no scarring will
occur. In contrast to laser resurfacing, in which the depth of penetration
is surgeon-dependent (surgeon's own training and experience), the Exoderm
solution "recognizes" the histological layer and even repeated applications
do not augment the depth of penetration. This allows an effective and homogeneous
correction of skin irregularities without the risk of posttreatment scarring.
In contrast, the traditional Baker-Gordon method has delayed re-epithelialization,
whereas Exoderm peeling is similar to other deep resurfacing techniques,
with re-epithelialization in 7 days. No significant hypopigmentation or
hyperpigmentation was encountered with the use of Exoderm.
Histological sections before and after treatment provide insight into the
repair mechanisms. With both methods, histological changes of the treated
skin are seen in the epidermal and dermal levels, with decreased and more
evenly distributed melanin in the basal layer, increased amount of collagen
and elastic fibers, and decreased amounts of intercellular glycosaminoglycans.
All of these changes were more prominent on the Exoderm-treated side presumably
because of the direct effect of the solution on collagen, elastic fiber
synthesis, and the sebaceous glands. A decrease in the number of sebaceous
glands was observed exclusively on the Exoderm-treated side (Figure 4).
As opposed to the classical phenol peel, in which there is no difference
in tissue reaction in comparison to laser resurfacing, Exoderm was shown
to have more beneficial effects regarding the dermal reaction and pigmentary
disturbances. The classic phenol peel causes arrest of melanin synthesis,
thus inducing permanent hypopigmentation. This side effect does not occur
with the Exoderm peel. The Exoderm formulation may impair the penetration
of phenol into the melanocytes, which decreases the toxic effect on melanogenesis.
Slight hypopigmentation rarely occurs, and this is appreciated by the dark-
and olive-skinned patients.
Conclusions
Exoderm peel
is a novel method for skin rejuvenation and acne scar repair. It is superior
in some respects to laser resurfacing, and is devoid of the classic phenol
peel side effects.
References
1.
Ho C, Nguyen Q, Lowe NJ, et al. Laser resurfacing in pigmented skin.
Dermatol Surg 1995;21:1035-1037.
2. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed carbon dioxide
laser resurfacing of photodamaged skin. Arch Dermatol 1996;132:395-402.
3. Fintzi Y Exoderm-a novel, phenol-based peeling method resulting
in improved safety. Am J Cosm Surg 1997;14:49-54.
4. Fitzpatrick RE, Tope WD, Goldman MP Satur NM. Pulsed carbon
dioxide laser, trichloracetic acid, BakerGordon phenol, and dermabrasion:
a comparative clinical and histologic study of cutaneous resurfacing
in a porcine model. Arch Dermatol 1996;132:469-471.
5. Kligman AM, Baker TJ, Gordon HL. Long-term histologic follow-up
of phenol face peels. Plast Reconstr Surg 1985;75:652.
6. Stuzin JM, Baker TM, Kligman AM. Histologic effect of the high-energy
pulsed COZ laser on photodamaged facial skin. Plast Reconstr Surg
1997;99:2036-2050.
Figure 1. Uneven pigmentation and postacne scarring before
treatment.
|
Figure 2. Fourth day after treatment with Exoderm on the left
side of the face, covered with bismuth subgallate mask, and laser
resurfacing on the right side, covered with Vaseline.
|
Figure
3. Five weeks after treatment there is slight erythema on
both sides of the face. On the laser side (right), shallow scars
are still seen.
|
Figure 4. Skin biopsies 7 weeks after treatment.
(A)Hematoxylin and eosin stain, x200. The Exoderm-treated side
shows thinner epidermis, fewer rete pegs, less elastosis, and
decrease in the number of sebaceous glands. (B)Hematoxylin and
eosin stain, x200. The laser-treated side.
|
Figure 5. Eight weeks after Exoderm treatment of the laser-treated
side (right). The scars are almost invisible on both sides of
the face, and complete blending of the demarcation line can be
noted.
|
|
Download Videos
