Acne is a common disorder of adolescence and acne scarring is seen in around 43% of acne sufferers presenting to dermatology clinics.1,2 Whilst there is a broad range of treatment options available for acne scarring including chemical peels, microneedling, ablative laser treatments and dermabrasion, these options have varying degrees of effectiveness and risks.
Furthermore, the tolerability of treatments to patients is an important factor for clinicians to consider when prescribing a treatment plan. For example, whilst microneedling tends to be moderately uncomfortable and have little downtime, patients may find it hard to commit to the large number of treatment sessions required to achieve an improvement; and whilst fully-ablative CO2 laser tends to yield excellent improvements in scarring, the pain, risks of hyperpigmentation and downtime mean that not all patients would tolerate or be suitable for the treatment.
A novel approach combining radiofrequency (RF) microneedling with fractional ablative CO2 laser attempts to bridge the gap between effectiveness and risk, whilst also improving tolerability to patients. Both RF microneedling and fractional ablative CO2 laser treatments have been found to be effective in the treatment of acne scarring.3-6 Combination therapy using both treatment modalities in the same session has also seen some success in recent years.4,7,8 In our experience, combination therapy appears to achieve a significant improvement in scarring, whilst minimising downtime and the risk of complications such as hyperpigmentation in darker skin types.
A 33-year-old patient with skin type V presented to our clinic with acne scarring predominantly affecting her cheeks. She had no medical problems, medication or allergies. She is a non-smoker and had no previous aesthetic or skin treatments to address the scarring. Her acne vulgaris was considered to have ceased at least five years prior. She did have a history of cold sores.
During her initial appointment she was seen by Dr Lapa and then had an OBSERV skin scan with the therapist to look at inflammation, pigmentation, oiliness and texture. She was started on a topical skincare regime consisting of:
AM: gentle cleanser (patient’s own), OBAGI Clear Skin Brightening Cream, OBAGI Exfoderm Forte Exfoliator, vitamin C (patient’s own), sunscreen (patient’s own)
PM: gentle cleanser, OBAGI Pore Therapy Salicylic Acid, OBAGI Tretinoin 0.025% with OBAGI Blender
The patient was booked for three sessions of RF microneedling to address deeper scars, followed by one session of combined RF microneedling with fractional CO2 laser to address superficial scars, pores and pigmentation. All treatments were performed at intervals of around one month. The patient had a CO2 laser patch test one month prior to the combination session to ensure she would have no adverse reactions, and started Aciclovir prophylaxis tablets two days prior to treatment to reduce the risk of a herpes simplex outbreak. The patient was advised to pause all active skincare except the use of a cleanser, vitamin C and sunscreen for seven days prior to treatment and to restart seven days post-treatment. This was to ensure the skin was calm, not actively peeling and optimally protected from the sun and oxidative damage.
On the day of the combination treatment (the patient’s fourth session of treatment at our clinic), her skin was reviewed for progress, the patch test was reviewed for any complications, pictures were taken, and she was asked to read and complete the consent form. A 4% lidocaine cream was applied and cling film placed over the cream to prevent it from drying out. This was then removed in sections using a non-alcohol based antiseptic solution. Each section was first treated with RF microneedling, and the anaesthetic cream was reapplied before moving on to the next section of treatment.
The Cutera Secret PRO device using a 24-pin semi-insulated cartridge was used for the treatment. This cartridge delivers a pulse of RF energy exclusively at the pin-tip with the remaining length of the needle insulated and not thermally active. The temples and mid and lower face were treated at 2mm depth, 50% intensity, 200ms energy and 50% overlap and followed with a second pass at 1mm depth, 50% intensity, 100ms energy and 50% overlap. The forehead was treated at 1.2mm depth, 30% intensity, 120ms energy and 50% overlap. The periorbital region and nose were treated at 1.5mm depth, 50% intensity, 150ms energy and 50% overlap. A total of 220 pulses were administered for the full face. This protocol is similar to what the patient had in her first three sessions of RF microneedling, alone.
Once the full face was treated with RF microneedling, the fractional CO2 laser treatment was performed. The patient underwent fractional CO2 laser treatment using the Cutera Secret PRO platform with the following settings: 51mj, 1.5mm distance between thermal zones, no stacking and only one pass was performed. The skin was cooled throughout the laser treatment using the Zimmer cryocooler device and smoke was extracted using a surgical smoke evacuator.
The post-procedure regime given to the patient included a mineral sunscreen (ZO Broad Spectrum SPF 50) and a paraffin-based ointment (50 liquid paraffin: 50 white soft paraffin). The patient was sent home with the topical products, topical hydroquinone 4% (OBAGI Clear for four to six weeks), an antiviral (Aciclovir 200mg QDS for one week) to reduce the risk of a herpes outbreak, and antibiotics (Flucloxacillin 500mg QDS for one week) to reduce the risk of infection. She was also given strict instructions on skin hygiene and sun avoidance, which she needed to maintain for six weeks.
The patient was reviewed at two weeks and again at four months after her combination treatment and she was delighted with her results. The ‘after’ picture was taken at the four-month review. You can observe an improvement in the patient’s pigmentation, scarring and general skin vitality. In our experience, the improvement in skin texture is likely to be long-term. Some of the deeper scars remain and this patient is planned to have a second session of combination treatment at her six-month review to further optimise her results.
Based on our experience using the technology, the expected side effects of this particular combination therapy can include redness, pain, crusting, blistering, weeping, swelling and bruising. Although rare, it is important that the patient is also aware of potential complications such as post-inflammatory hyperpigmentation (PIH), nodule formation, worsening of scarring, allergy, skin infection and potentially triggering acne-flare or milia formation. Some of these complications can be minimalised through proper pre-care and aftercare. For example, the topical application of clobetasol ointment immediately post-procedure has been found to significantly reduce the risk of PIH in darker skin types.10
Consider the combination approach
We have been performing combination microneedling RF with fractional ablative CO2 laser therapy for skin types I-V for more than four years. We have observed excellent improvements in acne scarring and often in a single treatment session. We have, thus far, not experienced any serious or long-lasting complications.