Comparison of Treatments for Atrophic Acne Scars
Comparison of Treatments for Atrophic Acne Scars
Acne scars have high prevalence, significant impact on quality of life and are a therapeutic
 challenge for dermatologists. Previous studies have shown promising results for the treatment
 of acne scars with non-ablative fractional laser and microneedling, however there are no
 studies comparing the these techniques. Therefore, the objective of this study is to compare
 the effectiveness of treatment of atrophic acne scars on the face with non-ablative
 fractional erbium laser and microneedling.
Acne is a multifactorial inflammatory dermatosis of the pilosebaceous unit, affecting up to
 80 percent of teenagers and approximately 20 percent of adults. Scaring can occur early in
 acne development and may affect up to 95% of patients with this disease. However, the
 prevalence of acne scarring varies depending on the study.

 Acne scars causes impairment of quality of life and has been described as a risk factor for
 suicide. Furthermore, it has also been linked to poor self esteem, depression, anxiety and
 lowered academic performance.

 The most common type of acne scarring is atrophic, which includes: ice pick, rolling scars
 and boxcar scars.

 Many treatments have been used for atrophic scars, including resurfacing procedures (chemical
 peels, dermabrasion and laser treatments), excisional procedures (punch excision, elevation
 by punch and elliptical excision of scars), application of fillers and microneedling, the
 latter since 2005, with satisfactory results and minimum time recovery.

 Previous studies have shown promising results for the treatment of acne scars with
 non-ablative fractional laser and microneedling. Previous reports have also shown that the
 latter is associated with rapid healing period, a low complication rate and a low risk of
 post inflammatory hyperpigmentation.

 However, there are no studies comparing the efficacy of microneedling with other techniques
 of resurfacing.

 This study will be a single-blinded randomized clinical trial, comparing the application of
 non-ablative fractional erbium laser ProDeep 1340 nm and the technique of induction of
 neocollagenesis by microneedling. The primary objective of this study is to compare the
 effectiveness of treatment of atrophic acne scars on the face with non-ablative fractional
 erbium laser and microneedling. The secondary objectives are: assess the degree of
 satisfaction of participants with both techniques; check tolerability and incidence of
 adverse effects with both techniques; assess time needed for recovery and number of days
 absent from work or social activities after the procedures and evaluate the opinion and
 physical discomfort of each technique.

 For each participant, a questionnaire will be filled out with the following information:
 gender, age, skin type, profession, current or previous history of smoking, use of
 medications, and presence of active acne. To assess the degree of scarring of the
 participants, the scale "Quantitative Global Scarring Grading System for Postacne Scarring"
 will be applied. After this evaluation, patients will be randomly allocated in each study
 groups (simple randomization). The randomization system was performed with the Microsoft
 Excel randomization program. Patients in both groups will undergo three sessions of laser
 treatment or three treatment sessions with microneedling, with an interval of six weeks
 between them.

 Two independent dermatologists, blinded to the group of treatment which each patient belongs
 to, will apply the Quantitative Global Grading System for Postacne Scarring before treatment,
 two months and six months after treatment. There are no clinical signs or characteristics
 that enable the evaluators to identify which group each patient is allocated and patients
 will be instructed to not provide this information. Six months after completion of treatment,
 patients will answer a questionnaire to assess their perceptions of the degree of improvement
 of their scars, pain during treatment and recovery time, assigning values from 0 to 10, where
 0 means maximum dissatisfaction and 10, maximum satisfaction.

 To detect a difference of one standard deviation in the range between the groups (laser and
 microneedling), with a power of 90% and an α error ≤ 0.05, 23 patients are required for each
 group. Data will be inserted in Excel and then exported to SPSS v18.0 for statistical
 analysis. Quantitative variables will be analyzed by mean and standard deviation and the
 groups will be compared by Student's t test for independent samples. To compare the variation
 of the measurements between the groups throughout the sessions the analysis of variance for
 repeated measures will be used. For the analysis of interobserver agreement the intraclass
 correlation coefficient and the Bland - Altman method will be used.

 This project was approved by the Committee of Research Ethics of our Hospital and all
 participants will sign an informed consent.
Inclusion Criteria:

 -  Clinical diagnosis of moderate or severe atrophic acne scars on the face

 Exclusion Criteria:

 -  Previous history of photosensitivity or photosensitive diseases such as systemic lupus
 erythematosus or xeroderma pigmentosum

 -  Previous history or presence of post inflammatory hyperpigmentation

 -  Use of drugs that may induce hyperpigmentation, such as: amiodarone, clofazimine,
 minocycline or chloroquine

 -  Presence of only "ice pick" scars

 -  Pregnancy or lactation

 -  Use of oral isotretinoin in the last six months

 -  History of facial treatments with laser or surgery in the last three months

 -  Herpetic infection, warts or any other active infection of the adjacent skin

 -  Presence of skin cancer or actinic keratoses

 -  Coagulopathies or anticoagulating therapy

 -  Previous history or presence of hypertrophic scars or keloids

 -  Patients being treated with chemotherapy, radiotherapy or corticosteroids at high
 doses

 -  Diabetes mellitus

 -  Inability to understand the goals and risks of treatment