Treatment of scars - Lasers and Energy Devices for the Skin - page 205

Adverse events were transient pain, erythema, and edema with
no incidence of PIH or scarring.
Chrastil and colleagues used the second-generation Fraxel
SR1500 that allowed higher fl uence to achieve deeper penetra-
tion into the dermis to treat 29 patients with Fitzpatrick skin
types I-V and facial and back acne scarring of all types (ice-pick,
boxcar, and rolling) (141). Two to six treatments at 1-month
intervals were performed with pulse energies from 35 to 40 mJ
and densities from 20% to 35%. At 1 month after last treatment,
at least 50-75% improvement was seen in 23 of 29 patients.
Five patients had greater than 75% improvement, fi ve patients
had 25-50% improvement, and one patient had less than a 25%
response to treatment.
Cho and colleagues used the Mosaic 1550-

appearance ( p <0.001), there was no statistically signifi cant
difference between results of 10 and 40 mJ regarding acne
scarring or overall appearance. Six patients developed moder-
ate PIH even though patients had received the triple combina-
tion cream (fl uocinolone 0.01%, hydroquinone 4%, and
tretinoin 0.05%) before and after laser treatment. No signifi -
cant difference was found in PIH induced by 10 mJ from that
induced by 40 mJ, although the authors highlighted that the
small number of subjects in the study may not have had
enough power to conclude that the results from the two groups
were the same. Overall patients were satisfi ed with the results,
with 11 of 13 subjects rating 50% or greater improvement in
their acne scars.
Glaich and colleagues reported marked improvement in
postinfl ammatory erythema resulting from acne vulgaris in two
patients who received a single treatment session with Fraxel laser
(136). Pulse energies of 18 or 6 mJ with 125 (7-14% densities) or
250 MTZ/cm 2 and fi nal densities of 1250 or 2000 MTZ/cm 2 were
used for each of the patients, respectively. Moderate to marked
clinical improvement in atrophic and ice-pick acne scars was
noted 3 months after a series of fi ve to six Fraxel treatments. The
authors speculated that by targeting water, a major element of
blood vessels, the 1550-nm wavelength may lead to photother-
mal destruction of dermal blood vessels, resulting in the
improvement of erythema. Previous reports have shown histo-
logical evidence of damage to dermal vasculature in patients
undergoing FP; therefore, blood vessels located at various skin
depths could be targeted for treatment by adjusting the pulse
energy (146,147).
The use of the Affi rm Laser (Cynosure) has shown to be
effective for acne scars according to Kim and Lloyd (137,138).
Kim and colleagues used the Affi rm laser, which emits 1320-
and 1440-nm wavelengths, for treatment of acne scars in
37 Korean patients (137). Three or four treatments were per-
formed at monthly intervals with fl uences of 3-4 J/cm 2 and
2 passes per treatment. Six of 18 patients and 13 of 19 patients
had 51-75% improvement after three and four treatments,
respectively (Fig. 9.12).
Lloyd and Tanghetti compared two treatment modalities
with the Affi rm laser for treatment of acne scars in 21 patients
(138). The 1320-nm wavelength at 10 J/cm 2 was compared with
the combination 1320 nm at 10 J/cm 2 plus 1440 nm at 2 J/cm 2
(Multiplex) after fi ve treatments at 3-week intervals. All patients
showed improvement in their scars, but both physicians and
patients considered the Multiplex modality superior.
Skin tightening in 12 Asian patients with acne scarring after
treatment with NAFR was reported by Dainichi and colleagues
(148). A random half of the face was irradiated twice at 4-week
intervals using a fractional 1540-nm Er:Glass (Lux 1540),
45 mJ/mb, and 3 passes. Statistical analysis of the facial images
showed signifi cant skin tightening effect 4 weeks after the fi rst
and second irradiation ( p <0.001 after both treatments).
In 2010, consensus recommendations from experienced
physicians on the use of Fraxel Re:Store were reported by
Sherling and colleagues (149). The panel contended that NAFR
improved the appearance of acne scars by as much as 50% after
a series of four to fi ve treatments, each spaced 1 month apart.
Acne scarring associated with PIH also showed signifi cant
improvement with FP. The recommended treatments settings
for acne scars depend on the skin type. For skin types I-III,

m Er:Glass laser
(Lutronic Corporation, Gyeonggi, Korea) to treat 12 patients with
mild-to-moderate acne scars and enlarged facial pores (142).
Three sessions were performed at monthly intervals using pulse
energies of 20-28 mJ and 400-900 spots/cm 2 in dynamic mode
with a 10-mm handpiece. Results at 4 months after last treatment
revealed that for acne scars, 5 of the 12 patients demonstrated
clinical improvements of 51-75% and 3 had 76-100% improve-
ment. Two patients had moderate improvements of 26-50%
and two showed minimal to no improvements (<25%). As for
enlarged facial pores, 5 of the 12 patients demonstrated 26-50%
improvement, 3 had 76-100% improvement, 3 showed 51-75%
improvement, and 1 showed minimal to no improvement
(<25%).
Kim and colleagues compared the Mosaic laser to chemical
reconstruction of skin scars (CROSS) using 100% trichloroacetic
acid to ice-pick and rolling hills scars in a split-face study involv-
ing 20 patients (143). One side was treated with the 1550-nm
Er:Glass fractional laser three times with a 6-week interval using
a pulse energy of 30-32 mJ and density of 300-350 spots/cm 2
with a 6 mm × 6 mm handpiece. The other side was treated with
CROSS method two times every 12 weeks. The fractional laser
was found to be superior for treatment of rolling scars and equal
to CROSS method for ice-pick scars. Although pain scores
were signifi cantly higher in the laser sides (4.49 vs. 3.33 on a
10-point scale), downtime (3.17 vs. 9.72 days), and lasting days
of erythema (3.30 vs. 12.13 days) were signifi cantly longer in the
sides treated with the CROSS method.
Hu and colleagues reported similar improvement in 45 patients
treated with a single treatment of Fraxel SR750 (fi rst genera-
tion) or Fraxel SR1500 (second generation) for moderate-to-
severe atrophic acne scars (144). Thirty-two patients received
15-20 mJ and densities of 1000-2000 MTZ/cm 2 with the fi rst-
generation laser and 13 received 30-40 mJ and densities of
392-520 MTZ/cm 2 with the second generation. There was no
signifi cant difference between the two groups. Physician eval-
uations revealed excellent results in 18%, good results in 31%,
and fair results in 51%. Six patients (13%) developed PIH that
lasted about 1 week.
Mahmoud and colleagues were the fi rst to report the use of
nonablative erbium 1550-nm fractional laser in the treatment
of facial acne scars in patients with Fitzpatrick skin types IV-VI
(145). Fifteen patients were randomized for treatment in
two groups: one was treated with 10 mJ and the other with
40 mJ. Treatment level 6 (17% density) was used for both
groups. Five monthly treatments were completed. Although
there was signifi cant improvement in acne scarring and overall

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