STUDY Treatment of Atrophic Facial Acne Scars With the 1064-nm Q-Switched Nd:YAG Laser Six-Month Follow-up Study Paul M. Friedman, MD; Ming H.Jik, MD, PhD; Greg R. Skover, PhD; Greg 8. Payonk, PhD, ‘Arash Kimyai-Asadi, MD; Roy G. Geronemus, MD Objectives: To quantitatively assess improvement in acne scarring aller aseries of nonablative laser treatments and to determine efficacy at 1-, 3-, and 6-month follow-up alter treatment Design: Before-after trial of consecutively selected pa- Setting: Private practice at the Laser and Skin Surgery Center of New York, New York. Patients: Eleven patients with mild to moderate atro- phic acne scarring were treated, Interventions: A 3-dimensional optical profiling im- aging system was used to assess skin topography before, during, and after treatment. Patients were treated with a 1064-nm Q-switched Nd:YAG laser and reassessed after 3 treatment sessions and at 1, 3, and 6 months after the nth u Main Outcome Measures: The skin roughness analy sis was quantified at baseline and at each follow-up in- terval. Pain, erythema, and petechiae formation were as- sessed on 3-point scales, Results: At midireatment (1 month after the third reat- ‘ment session), an 8.0% improvement in roughness analy sis was een. This improvement increased to 23.3%, 31.6%, and 39.2%6 at 1, 3, and © months after the fifth teat- iment, respectively. Patients reported mild to moderate pain with treatment. The only adverse effects noted were transient erythema and mild pinpoint petechiae Conelusions: Treatment with the nonablative Lo64-nim Q-switched Nd:VAG laser results in significant quanti tative improvements in skin topography in patients with rild to moderate atrophic acne sears. Continued incre- ‘mental improvements were noted at I-,3-,and 6-month, follow-up, indicating ongoing dermal collagen remod- cling alter the treatment. Arch Dermatol, 2004;140:1337-1341 ‘TROPHIC ACNE often permanent sequelae y acne. Be- cause of the significant cosmetic burden of these of inflamma SCARS ARE — Re tly, nonablative lasers, light sources, and radiofrequency devices have been used to selectively deliver thermal en- ergy to the upper dermis, inducing a con- tolled wound healing response in the Author Affiliations: Dermsurgery Associates (Drs Friedman, jh and Kimyai-Asad), and Department of Dermatology University of “Texas Medical School (br Friedman), Houston; Innovation Incubator, Johnson, { Johnson Consumer Companies, Ine, Skillman, NJ (Drs Skover and Payonk): and Laser and skin Surgery Center of New York, New York (Dr Geronesus). Financial Disclosure: None. (aepRuyeD) ARGH DERNATOUVOL TO, NOV sears, patients frequently seck medical treatment, Acne sears can be revised through a variety of techniques, inelud- ing dermabrasion, punch-excision tech- ‘niques, deep chemical peels, and ablative laser resurfacing." Ablative resurfacing with the carbon dioxide or erbium laser results in de- struction of the epidermis followed by reepithelialization with collagen remod- ling. This method is typically associ- ated with significant recovery time and can be accompanied by prolonged post- ‘operative erythema, which can persist for months." Inaddition, ablative laser re- surfacing can result in significant and of {en permanent pigmentary alterations,"> papillary and upper reticular dermis ‘without epidermal damage." Histologic studies have confirmed production and deposition of new collagen after thermal damage induced by nonablative laser Although pr that nonablative laser treatments result in qualitative improvements in facial thytids and scars, there has been an in- herent difficulty in quantifying the {ects of nonablative resurfacing," Clinical and photographic assessments are subjective and often operator dependent. Thus, a new method was developed us- ing a white-light, noncontacting optical profiler (Phaseshift Rapid In Vivo Mea- fous studies have shown (©2004 American Medical Association. A rights reserved, jamanetwrork.com by a Mexico | Access Provided by JAMA. User on 04/30/2019swan mead "it ge zou Figure, Schonatic agra of the Phasehit Rapid In Vivo Measurement 1 Sun (PIMOS) syste (GF Mestechni, Teton, Germany) A asta Iicroirr creates pall spe pate imaging projected ont the skin Dgtzsd images te obtained van camara ranted it a comer ‘aaa procs -monsonal rte of he sn sare rconstucted (cb indestos charge-coupled deve ee Taeanet — ne ral inst va cn Eee ‘aap i gure 2. Changes in shin oughnas nasi betean baseline and ‘Eton at etmentSgneant provements re sana el “month te theft eaten wih the 164-pm Ose YA sat (00) Further igneant improvements acared at 3-mnth (P= 3) and moat fellow-ips (P= O01). Bars neato rea value, at ines, tad deviation surement of Skin [PRIMOSI; GF Messtechnil, Tetlow Germany) that projeets a stiped pattern onto the skin surlace Minute dflerences in surface clevaion result in deflection ofthe parallel stripes rom ther reference po- sion, which is recorded by a high-resolution digital earn cra (Figure 1) and isised to caculatea point loud based on x,y, and z coordinates. The image is acquired in less than 100 milliseconds, minimizing noise disturbance caused by normal skin movement. Usinga triangulation technique combined with an interferometric technique, the optical profiling imaging system can capture more than | million data points in less than 100 milliseconds, delivering height resolution of approximately 2 ym, The point cloud ts visualized with specially written sofware ODL: Research Systems Ine, Boulder, Colo) that gener- sles an accurate 3-dimensional model ofthe skin sur- face. These surfaces are suitable for quantitating topo graphic changes such as in the extent of acne searing or thytids. Inthis study, we used multiple treatment sessions with the 1064-nm Q-switched Ne-YAG las forthe treatment (aepRuyeD) ARGH DERNATOUVOL TO, NOV of atrophic acne scars and quantified the effect by using the optical profiling imaging system and data analysis. —_ 2s} leven patients (6 women, 3 men; ages, 28-50 year: skinpho- ) with mild o moderateatophic ache scarring were study after tnformed consent was obained. A {ota of 13 ates were tested. Patients with histor of sotei- hoin us, filler substance Infction,or dermabrasion within the Previous year were excluded from the study, s were pallens {th facial tatoos or permanent makeup Each patient recived lace treatment ofthe ene face by a single operator (PLE), A 10e%-nim Q-svitched NEAG lo- ser (Medlte1V; Continuum, Santa lara, ali was used with amaveragefiuence of34 en @mmspotsize, 24 too-nano- second pulse duration, and a repetition rate of 10 Hz, Ove lapping pulses were delivered nl the immediate treatment end pont of mild to moderate erythema was achieved. A total of teatments at 3-week intervals were administered Objective evaluation ofthe severly of acne scaring was performed in vive with the opical profiling imaging system a Erclin, afer 3 reatmentsexsions and at, 3, and 6 months ser the ith restment session, Subjects were positioned in iad restraint forthe baeline image To ensure repreductoi- ity between the images, the baseline image was recalled a fuleinensty. The subjects head position war adjusted unt itwas diecly aligned with the bacline image before image Capture. Point cloud daia were uploaded into the software (RAPIDFORM; INUS Technology Ine, Seoul, Kore), perm ting follow-up images tobe acuately aligned with the bace- Tine images, The images were registered and witnmed andthe difference from arlerence plane was calculated asthe sith tmelic average ofthe absolute values ofall points in the profil (Goughnes says (Ra). skin Ra was quanted by means of andard International Organization of Standardization algo- Tims embedded in the optical profiling analysis software “The investigators evaluation of erythema and pinpoint pe- techiae andthe patent subjective evaluation pain Were graded onan ablirary point sale: mld, 2, moderate and SToevere,Ifnecesary,avopeal anesthetic (EMLA cream Ar- {ra USA, Westborough, Mats) was applied 1 hour befor laser treatment. Saistcl analysis was performed with the pated, Salle test ass Results were obtained from total of 13 treatment sites in 11 patients at baseline. Follow-up data were completed for 12 sites after 3 treatment sessions, and for Ll sites at 1, 3 and 6 monthsafter the fifth treatment session. A slight but not significant reduction in Ra was noted at midtreal- ‘ment, which corresponded to 1 month after the third treat- ‘ment (rom baseline of 60 to 54 yim). Significant redue- ‘don in Ra from baseline was seen as early as 1 month alter the ith laser treatment session (from 60 to 46 pm; P‘<.001) (Figure 2). Further significant reductions in Ra oc- curred between the I-month and 3-month follow-up (P=.003), and the 1-month and 6-month evaluations af- ter the fifth treatment session (P<.001) (Figure 2). Al- ‘though additional reductions in Ra occurred between the 3- and 6-month follow-up, this difference was not statis tically different. Overall, there were significant improve- ‘ments in Ra score both from baseline and from the I-month (©2004 American Medical Association. A rights reserved, jamanetwrork.com by a Mexico | Access Provided by JAMA. User on 04/30/2019follow-up to the final 6-month follow-up evaluation after the fifth treatment session (igure 2). The 8.9% improvement in Ra was not significant at midtreatment. However, significant improvements of 23.3% in skin roughness were observed 1 month alter the fifth treatment (P=.01), which increased to 31.6% jonths (P=.01) and to 39.2% at 6 months (P=.01) (igure 3). Figure 4 demonstrates a clear improve- ‘ment in the surface topography seen at baseline com- pared with that seen at 6 months alter the last treatment Visit. Figure 8 shows the corresponding clinical image at baseline and 6 months after the last treatment visit. Images were from the left cheek of a male patient, adja- cent to the nasolabial fold, Pretreatment and posttreat- ‘ment images were registered before deviation analysts therefore, measurements accurately assess changes in the anatomic field. The total change measured in this pa- Lent was an improvement of 26%. (Overall, patients had only mild to moderate pain, with aan average rating of 1.5 on a 3-point scale, Only 2 pa- Udents required topical anesthesia before treatment. The only adverse elfects noted were transient, mild to mod- erate erythema (average, 1.9 on a3-point scale) and mild pinpoint petechiae (average, 1.1 on a 3-point scale). No dyspigmentation or scarring was seen in any patient. Eee} Nonablative lasers such asthe 585-nm pulsed dye, 1064-nm Q-switched Nd:YAG, 1520-nm Nd:YAG, 1450-nm diode, and 1540-nm erbium: glass lasers, as well as intense pulsed light sources and radiofrequency devices, have been shown to provide qualitative improvements in facial rhytids and scars." Most of these systems combine epidermal sur- face cooling with long wavelengths that allow for penctrs- tion into the dermis, resulting in selective dermal thermal injury with preservation of the overlying epidermis. Al- though all of these systems provide qualitative improve- ments in rhytids or acne searring, quantitative improve- ments have been difficult to demonstrate. In this study, after 5 treatments with the 1064-nm, Q- switched Nd:YAG laser, significant qualitative and quan- Uitative improvements in facial acne scars were demon- strated. Althouigh a trend toward improvements in aene scarring was noted at midireatment, these changes were not statistically significant. Significant improvement was seen as early as | month after the fifth treatment ses- sion, with the greatest percentage of improvements noted a3 months after the last treatment. Thereafter, improve- ‘ments were noted to plateau by the 6-month evaluation. The continued improvements we and others have ob- served several months alter the last nonablative laser treat- ment session suggest that continued long-term dermal remodeling occurs even alter cessation of actual laser teeal- ment." Histologically, mild dermal fibrosis and de- crease in solar elastosis with thickening ofthe papillary dermal collagen have been noted after treatment with the 1064-nm Q-switched Nd:YAG laser.!°" These changes are similar to but ofa lesser degree than the dermal wound healing response that occurs after ablative laser treat- ment with the carbon dioxide laser”? Since new colla- (aepRuyeD) ARGH DERNATOUVOL TO, NOV Taser nid folonp me ae ele Figur 3. Mean parentage improvement in sin roughness analysis in acne fearing afer onsite fast rmaceling. gen synthesis occurs, the results are expected to be long- lasting, compared with short-term improvements that are seen with filler substances. This study is also the first, to our knowledge, to quan- titatively measure changes in acne scars after nonablative laser treatment with the 1064-nm Q-switched Nd:YAG la- ser. Previously, quantifying acne scarring and changes in acne sears alter laser treatment had been particularly dif ficult Initial methods fordetermining improvement in acne scarring used optical profilometry with the use of si cone rubber replicas to capture skin topography.» The mea- surements oblained by this technique were highly vari able and operator dependent. However, inthis study, we used the 3-dimensional optical profiling skin measure- ‘ment device to obtain rapid and in vivo quantitative as- sessment of improvements in aene scarring. This method provides real-time, objective analysts of the skin surface ‘with minimal noise interference. Nevertheless, minimal positional changes ean influence the angle of the light pro- jected onto the surface, potentially leading to variability {in baseline and follow-up images. The system enables the user to call up the original image at half intensity and fit the present surface to the original image, ensuring accu- rate alignment. Furthermore, the ability to digitally reg- {ster the baseline and follow-up images enables accurate quantification of the change occurring in a precise ana- tomic location, providing reproducible measurements of changes in surface topography that correlate with clinical changes." Because of the length of the tral, other fac- tors may have contributed to the changes observed, such ‘as weight gain or changes in issue perfusion, These con- ditionsare frequently overlooked in tral design but should be considered in the future because of the improvement {in the method to quantify structural surface changes, In conclusion, this study demonstrated that the 1004-nm Nd:YAG laser provides a safe and effective non- invasive treatment for mild o moderate facial acne sear- ring. The results are long lasting and continue well be- yond the last treatment, indicating ongoing collagen remodeling alter completion of the laser treatment ses- sions. Nonablative treatment with the 1064-nm Q- switched Nd:YAG laser offers significant advantages to patients in terms ofits minimal recovery period and mini- (©2004 American Medical Association. A rights reserved, jamanetwrork.com by a Mexico | Access Provided by JAMA. User on 04/30/2019igh-aslution dimensional images obtained vith he pti profing imaging system lusting improvement in stn surface oprah pag io provement sin roughtess rom basen lo the 6monh falaw-ip Colr-suace lopograpic mages corespnd to varaansia Hight in the zplne. The gay oor ste za vle hl colars going totus and ed apace negative a posite devon, rerpatvay. The lal ehange ot Improvement measured in thi gatiet rm seen to th mont low-up vas 26% ase 5 Fatt Figure 3. Cia irage ra mal pant showing th ot check facnt the nasolabial ol at aselne and 6 mors arto ith watment session, The teal eninge meseve in th allen as 25%, mal risk of infectious and pigmentary complications. In have developed a method that will enable future studies addition to documenting the therapeutic effectiveness of to accurately measure subile changes occurring in pre nonablalive laser treatment in this patient population, we cise 3-dimensional, anatomic locations. Downloaded From: https:/fjamanetwork.com/ by a Mexico | Access Provided by JAMA. User on 04/30/2019Accepted for Publication: June 25, 2004 cual requny: nl istic evn of al esutclng ing Correspondence: Paul M. Friedman, MD, DermSurgery ier wang, Doma Sur 108 2434530, pondenee: (aul M. Ertedinany MD_DermsurRe"Y 1, GaldergD, tut. sth NeAS syed provement rom Associates, 7515 Main, Suite 240, Houston, TX Date ermal remodeling J Catan Laser Te 2002157160, (pmfriedman@dermsurgery.org). 12 hati KA, Ros EV, Greve JM, Mago CM, Andersen FR. Comparison of Acknowledgment: We express sincere appreciation to ‘um ¥AG an earn vi ser rcurtacig of cl hye. Ach Marisol Edward, RN, Judy Dulberg, RN, Alexis Moreno, Derma 199135:91-397 and Michelle Turnbull, RN. of the Research Depart, At. inca hs eon of six bamYA es rt rent, Laser and Skin Surgery Center of New York, for 44 faye, Su’ Hstope eaten she MEYASsrin their clinical assistance; and to Dick Jackson, D-Jackson ‘isn teamntoaretn Dua uy tbtan tus Software Consulting, Calgary, Alberts for his invaluable 15. Morar GM Weon O ilams AM Tsao eal yi wih expertise in developing the software for the 3-dimen- aca and lg sty. Dermat Su 19625: Sonal image processing and analysis, 16 Levy Tels M, Lagarde JM, Bol MT, Morn 8. Traben of winks ‘wth henna 1320 nr MA-YAG laser. Pst Su. 2001-47 482 ue EEE tists srt conan a 80am saad 1200 NGVAG sri he teste of ropa scars a rospctclncalané 1. uptick. Goleman M Str Tope. Pld akon sid aes isonet, Cumatl Sur 20042015217 nut hnioueasuh sch ene be aoa ale 18 FouriarW Danan Sra Ge Nona remodeling: nl No 2 Walt, Kar ANB, ernerus RG, Skin surtacig oth fie today loi uasound imaging ad protons rann of 1840 nm Erglss ‘hye singh ebon oie rind tis, emt Sug. 95 laser: Demat Surg 2001:27:790-06. rowoate 19, Golder Suma. nnseplse ight and AAS se non aiane at 4. AlsurTS, Nani Wins CM, Comarisn lout abo ieee et offi ies, Lasers Su ea 20028 19-18 ing sor: a incl an hspataog erauron. Demat Surg 186025: 20, Glider OV, Cuter KB onal atm of yes wth tars puss 18 gases Surg Me, 20 25:18 200. 4 Nelson8 Majucir6, rifts CE, tl Cnialimprovenentaloingéem- 2. Fkdman PM, Shoe GR, Payonk 6, aver AUB, Georemus RS. 30 inivo ‘rast potapd secon with cogen Arch Demat. ‘ope kn iaging for topographica quae assesment of orale font 10136-110. laser tno, Demat Sug 202.28:100-208 5. Caton J Hod AF Gann essn WH, Hanke CW Hslogi eahton ot 22. RulsEspara Barb Gamer Nala radsequne fr ace acne freaiusr ad potauriclr Raman skin argh ney, seule a ute st of op cal eat he une omer to seeractne ton oie Arc smal 0612242528, ene vlgars (therapy aap of 2 pans. Derma Su 203 6 Taal EL. Aor TS Tesnont of rap al ace sas wh a unnode passe0. ECYAG ler Dnt Sur 202.2851 55 28, Roaches AS, ussainM, Golbrg J. Arophicanéa mine pata tae 7 Jong J, Kyr Yo. Resurcing pte al ane sar wih along pulsed sca inproed witha 120-m NOG sar. Dart! rg. 208 20:008- CVA lar Demat Surg 20012710710. ne. 8. Zleaon B, Kamer SL, erst a Ped ye sara sun daaged 24, FndmanP,SkoverGRPayrk, Goonenus RG Ountave evn at Shin Lasers Sue 00.25 700-256 anabbtve ser tectloy- Sm Cutan Med Surg. 200221 266.273. ©. Goldberg 0 ivan Laser tin esuraring th th C-swiched WAVAG 25, Fourier, akan, amen ta Nonlinear 14 month cS laser, ert Sg. 1957; 2800307, cal ulvasoundinaging anaemic ruaonata 1540 nm Ergas set 10. Gln, Ri Pa The C-wihed modi (NYAS ar wth Dermat Sug 20278906 31, Dates of 2005 ABD Examinations: in 2005, the cetyng examination ofthe American Hoard of Derinatology (ABD) willbe held a the Holiday ton © Ware International Rosemont Ion August 14 and 15,2005. The deadline for eceip fap Catone March 12005, The recertification examination ofthe ABD wil be administered onlin rom May’ 2 Jane 16,200. The dealin fo = celpto applications forthe eerlation examination Jnary 12008. The examina for suspect certification in dermatopthlogy wll be administered September 15 and 16, 205, atthe seating center af the mean Bo of Pathology in Tampa, Fs The deadline for ecelp applications i May 1, 2003 Dermtclogits must submit applications tothe American Hau of Dermatology and palologo tote Amica Board of Pathology. ‘The next examination for subspecialty certification in pediatric dermatology will be administered in 2006 (the date will be anounced in 2005) The raining examination for dermatology residents (administered online at dermatology resdency raining centers the Unite Sates and Cada) wil be held on April 212005, The dealin for esi of applications e February 1,200. or arthe information about tec examinations, pcae contact Antoine F Hood, MB. Execulive Director, American Board of Dermatology, Henry Ford Health Sytem, Ford Pac, Detal, Ml 48202-9450 (phone: 3138741088 a 313- 872-3221; coma sbdcrm@hiorg Web ite: wwe aber on) (©2004 American Medical Association. 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