Commentary on: "Combination Therapy in the Management of Atrophic Acne Scars".

The article titled “Combination therapy in the management of atrophic acne scars”[1] describes an important principle of combining procedures to maximise results in the complex world of treating post-acne scarring. We have seen papers documenting that combining procedures is a preferred approach with addressing volume, surface and movement being synergistic treatments in the management of photoaging.[23]

With post-acne scarring this approach has also gained favour[4567] and a combination of treatments is often suggested as being superior to single treatments.

With regards to cutaneous wounding, conventional wisdom has suggested that the degree of improvement reflected the degree of cutaneous wounding, yet here we see that persistent low-grade wounding may achieve substantive results.

Quite extraordinary results are seen here with minimally invasive techniques. One wonders why this particular combination of peels, subcision and needling was proven to be so effective, but the method of attacking the scars from a multitude of vantage points is probably the reason.

First the epidermis is prepared the with retinoic acid so the skin barrier will not be an impediment to the light 15% TCA peel.

Next the authors have approached the dermis with the needling performed by a dermaroller set at 1.5 mm and use these holes to introduce retinoic acid 0.05% into the dermis to induce deeper modulating effects of this agent in the deep dermis.

Subcision was performed with a fine 24# needle and probably it acted in the deep dermis or superficial subcutaneous level.

Hence the authors have formulated treatment acting at many levels of the skin inducing many different wounds. Added to this they have kept this barrage of insults going for many weeks inducing much scar remodeling. I really think this is breakthrough thinking and they should be congratulated.

The other aspect I wish to discuss in this paper is the use of a global severity scale combined with attention to individual scar morphology.

Methods of examining patient outcomes require a method of analysis that is simple and meaningful. This was the thinking behind the scale that was developed some years ago to allow easy global analysis of a patient's overall appearance with respect to their scarring[8] and has been utilised in this study.

People are variably conscious of their scarring and some will lament even very mild scarring, others seemingly oblivious to the most severe. Yet most people will show a fairly linear response between the global severity of their scarring and their concern about them. A meaningful social outcome, such as, scarring being obvious to others (Grades 3, 4) reverting to scarring only being visible to oneself (Grades 1, 2) should be a useful change to the patient. This is both an objective and a subjective scale of severity. The patient is just as able to assess their overall scar severity with this scale, and improvement with treatment as is the practitioner.

However, objective observations of how individual scars such as ice pick scars.[9] respond to treatment are valid and the authors have used this objective scale of scar types as well to assess progress.

I think we might see combination therapy for the treatment of post-acne scarring with low morbidity procedures becoming very popular in the treatment of post-acne scarring.