Revolutionizing Acne Scar Treatment in Indian Skin with Fractional Picosecond Laser

Abstract

Background:

Patients of Asian descent with Fitzpatrick skin types III–V who experience facial acne scars are a relatively under-researched demographic in medical literature, with limited studies specifically addressing their unique skin characteristics and treatment responses. Traditional treatments have variable efficacy and risk of complications. A novel technique that has shown potential in managing scars is the Q-Switched, 1064 nm neodymium-doped yttrium aluminum garnet laser with a fractional beam profile. Picosecond lasers, with extremely short pulse durations, minimize thermal damage and induce tissue remodeling, reducing post-inflammatory hyperpigmentation risk.

Aim:

This prospective study was proposed to judge the efficacy of 1064 nm fractional picosecond laser for treating atrophic acne scars in the Indian skin type.

Methods:

Twenty-two patients completed the study; all were treated at monthly intervals for three sessions. Evaluation based on Investigator’s Global assessment along with patient satisfaction scores was carried out for all patients. The safety of the laser was evaluated by noting down adverse effects.

Results:

Fourteen patients showed improvement of 26–50% by Investigator’s Global Assessment, which was similar to the patient satisfaction scores. Post-treatment edema, pinpoint bleeding, and mild erythema were the only side effects noted. Postinflammatory hyperpigmentation was not noted in any of the patients.

Conclusions:

Fractional picosecond laser can be considered a viable and safe option to treat acne scars in patients with dark skin type.

Keywords

acne scars pico second laser fractional laser Nd-YAG laser

Introduction

Facial atrophic acne scars are a frequent and distressing sequela of acne vulgaris, which affects up to 80% of adolescents and persists into adulthood in many cases. The psychological impact of atrophic acne scars is profound, often leading to decreased self-esteem, social anxiety, and even depression due to their visibility.¹ Effective treatment is crucial for individuals suffering from these scars to improve their quality of life.

In the course of time, a variety of treatment modalities have emerged to address atrophic scars, each with its own mechanism and set of benefits and risks. Traditional methods include chemical peeling, dermabrasion, microneedling, and punch elevation.^2,3 Despite their effectiveness, these traditional methods often come with drawbacks such as variable efficacy, risk of complications like infection and pigmentation changes, and the necessity for multiple treatment sessions. Consequently, the development of laser-based therapies marks a pivotal advancement in the management of atrophic acne scars.

Fractional picosecond lasers (FPLs), with their ultrashort pulse durations, rely on photomechanical effects and feature a diffractive optical element, that creates focused microinjury zones through laser-induced optical breakdown (LIOB). This promotes collagen synthesis and dermal remodeling,⁴ potentially curtailing the risk of postinflammatory hyperpigmentation (PIH), and other pigmentary complications, which are particularly relevant for individuals with darker skin types, including Indian skin.⁴

Despite these advantages, clinical data on the effectiveness and safety of picosecond-based LIOB lasers for treating acne scars in darker skin types are lacking. To fill this gap, a prospective, randomized, controlled trial was proposed to evaluate the 1064-nm Nd FPL for treating atrophic acne scars in Indian skin types, aiming at providing data on its effectiveness and safety while minimizing postprocedural complications.

Materials and Methods

A prospective study was conducted between November 2023 to May 2024 at CUTIS Academy of Cutaneous Sciences (CACS), Bangalore.

Patients, both males and females, more than 18 years of age who had atrophic acne scars participated in the study. Patients with active acne under treatment were excluded. Additionally, patients who had been treated with other lasers, such as CO₂ laser for acne scarring, within 3 months prior to the first treatment were also excluded from the study.

Laser device and laser session protocol

The laser device used for all treatments was the Smart PICO® neodymium-doped yttrium aluminum garnet (Nd: YAG) laser (Medical Electronics Laser Associated (DEKA) M.E.L.A. S.r.l., Calenzano, Italy), which operates at 1064 nm. A fractional handpiece bearing a spot size of 8 mm was chosen with 0.6–0.8 J/cm2 of fluence; pulse duration 450 picoseconds; repetition rate, 5 Hz. Each patient had 3 treatment sessions, spaced 4 weeks apart, during which they underwent one pass of the laser with less than 10% overlap. To aid patient comfort, topical anesthesia was applied. The appropriate endpoints were mild pinpoint bleeding and immediate moderate erythema indicating epidermal ablation. Post-laser, patients were informed to apply an antibiotic cream and moisturizer twice daily for 5 days, avoid sun exposure and utilize sunscreen having an SPF50 for 30 days. The appearance of side effects was monitored.

Clinical outcome assessment

Efficacy assessment

The scar improvement was judged by reduction in acne scars and was represented in terms of percentage of improvement using Investigator’s Global Assessment (IGA), which used a 5-point scale to evaluate the degree of improvement (grade 0 = no improvement; 1 = 1–25% improvement; 2 = 26–50% improvement; 3 = 51–75% improvement; 4 = 76–100% improvement). IGA scoring was done by one blinded dermatologist. Evaluation of all subjects was done 1 month after last treatment.

Patient assessment

We used a 5-point satisfaction/improvement scale to quantify the patient’s assessment (0 = 0% no improvement or very dissatisfied; 1 = 1–25% mild improvement or dissatisfied; 2 = 26–50% moderate improvement or slight satisfied; 3 = 51–75% good improvement or satisfied; 4 = 76–100% excellent improvement or very satisfied). Evaluation of all subjects was done 1 month after last treatment.

Results

All 22 patients (17 females and 5 males) completed the study, with a mean age of 27.18 ± 3.44 years. The subjects’ skin color, classified using the Fitzpatrick scale, ranged from type III to type V: 6 patients (27.2%) had type III, 13 patients (59.1%) had type IV, and 3 patients (13.6%) had type V.

According to the IGA, 14 patients showed a 26–50% improvement (grade 2), 6 patients exhibited 51–75% improvement (grade 3), and 2 patients achieved 76–100% (grade 4) improvement (Fig. 1). The total mean value of IGA score was 2.4 (±0.7).

FIG. 1.

Investigator’s Global Assessment (Grade 0 = no improvement; 1 = 1–25% improvement; 2 = 26–50% improvement; 3 = 51–75% improvement; 4 = 76–100% improvement).

In terms of patient self-assessment, 4 patients (18.18%) reported mild improvement (grade 1), 12 patients (54.5%) mentioned moderate improvement (grade 2), 5 patients (22.7%) reported good improvement (grade 3), and 1 patient (4.5%) experienced excellent improvement (grade 4) (Fig. 2).

FIG. 2.

Patient assessment (Grade 0 = 0% no improvement or very dissatisfied; 1 = 1–25% mild improvement or dissatisfied; 2 = 26–50% moderate improvement or slightly satisfied; 3 = 51–75% good improvement or satisfied; 4 = 76–100% excellent improvement or very satisfied).

Some clinical cases are shown in Figures 3,4,5.

FIG. 3.

Photo showing improvement of acne scars after 3 sessions of fractional picosecond laser in a 26-year-old male, skin type 4. Right lateral view prior to treatment (A) and post 3 sessions (B). Left lateral view prior to treatment (C) and post 3 sessions (D).

FIG. 4.

Photo showing improvement of acne scars after 3 sessions of fractional picosecond laser in a 32-year-old female, skin type 4. Right lateral view prior to treatment (A) and post 3 sessions (B). Left lateral view prior to treatment (C) and post 3 sessions (D).

FIG. 5.

Photo showing improvement of acne scars after 3 sessions of fractional picosecond laser in a 28-year-old female, skin type 3. Right lateral view prior to treatment (A) and post 3 sessions (B). Left lateral view prior to treatment (C) and post 3 sessions (D).

Immediate side effects such as edema, erythema, pinpoint bleeding and burning sensation were observed in all patients but resolved within 2–3 days after therapy. No significant side effects such as blistering, scarring, burns, hypopigmentation, or hyperpigmentation were noted in any of the patients (Table 1).

Table 1.

Patient’s Side Effects

Sr no	Age	Sex	Skin type	Immediate adverse effects	Postinflammatory hyperpigmentation/scarring
1	25	F	3	erythema, edema, burning sensation, and pinpoint bleeding	NO
2	25	F	3	erythema, edema, burning sensation, and pinpoint bleeding	NO
3	28	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
4	30	F	5	erythema, edema, burning sensation, and pinpoint bleeding	NO
5	33	M	5	erythema, edema, burning sensation, and pinpoint bleeding	NO
6	26	F	5	erythema, edema, burning sensation, and pinpoint bleeding	NO
7	28	M	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
8	32	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
9	30	M	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
10	32	F	3	erythema, edema, burning sensation, and pinpoint bleeding	NO
11	27	F	3	erythema, edema, burning sensation, and pinpoint bleeding	NO
12	23	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
13	23	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
14	28	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
15	23	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
16	26	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
17	29	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
18	23	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
19	22	F	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
20	28	F	3	erythema, edema, burning sensation, and pinpoint bleeding	NO
21	27	M	4	erythema, edema, burning sensation, and pinpoint bleeding	NO
22	23	M	4	erythema, edema, burning sensation, and pinpoint bleeding	NO

Discussion

Acne scarring is a consequence of moderate and severe acne in patients.⁵ Traditional Fractional lasers (FLs), founded on the theory of fractional photothermolysis, have shown efficacy beyond doubt in treatments for acne scars. FLs create microscopic treatment zones that induce controlled thermal injury, promote collagen remodeling and skin resurfacing.⁶ Among these, ablative FLs such as CO₂ and Er:YAG, physically ablate tissue, leading to significant improvement, but entail longer downtime and a higher risk of side effects. Nonablative fractional lasers (NAFLs) are preferred for their effective improvement with low complication rates, shorter downtime, and re-epithelialization, which is typically completed within 1 day.⁷ However, even these can pose risks, especially in darker skin types, which are prone to PIH. Despite the effectiveness of these lasers, patients often experience some undesirable effects.⁸

Picosecond lasers produce a more noticeable photoacoustic effect rather than photothermal and supply fluence with a smaller pulse width than nanosecond laser therapy.⁹ This approach has scouted a brand new means of wound healing and validated its success in treating acne scars.^4,10

FPL uses a fractional placement of microbeams with minuscule diameters and incredibly high peak fluences to restrict energy to small regions and superficial depths inside the epidermis and dermis.¹¹ FPL has the capability to create vacuoles in the intraepidermal and/or dermal layers via LIOB, with the characteristics such as depth, size, and quantity of these vacuoles being influenced by fluence and the skin melanin index.⁹ After treatment with 1064-nm FPL, the histopathologic assessment demonstrated a proliferation of elastic fibers, mucin, and collagen in dermis.⁴

Consistent with earlier research, our results demonstrated that FPL could alleviate atrophic acne scars in regard to physician evaluation.^11,12 Bernstein et al. reported improvement of 28% in the acne scars as per IGA assessment comparable to our study.¹¹

As a result, FPL and other FLs appear to provide similar therapeutic benefits for atrophic acne scars. Our study also found that the FPL effectively improved atrophic acne scars.

Adverse events have a direct impact on the device preferred by patients. Our results did not show any cases with PIH. Other studies have also shown that the prevalence of PIH in the FPL group is lower than that in the NAFL group. Another investigation on wound recovery after FPL did not note increased melanin or melanophages in the dermis two weeks after treatment.¹⁰ This advantage of FPL stems from the lack of thermal damage to surrounding tissues.⁴ Because melanin is the predominant absorber, patients whose skin has larger melanin content may readily develop LIOBs with a lesser fluence threshold and lesser collateral effects. This shows that FPL may be safer and more effective than other traditional FLs.^4,10 Other trials also did not report any hypopigmentation after treatment.^11–13 A study of CO₂ laser on acne scars found PIH to be the most common adverse effect observed in 92% of the subjects.¹⁴

As a result, FPL is an efficacious and reliable treatment alternative for patients with skin types III–V who are likely to develop pigmentation, as indicated in our study.

Our results demonstrated that even though pinpoint bleeding was more likely after FPL treatment (because hemoglobin is the next in line absorber for FPL), it resolved soon after.⁴ Other studies also reported that erythema and edema resolve within few days after treatment.

Conclusions

FPL can be considered a viable and safe option to treat acne scars in patients with dark skin type. The occurrence of PIH being reduced when compared with CO₂ laser making it an excellent choice in darker skin types. Patients undergoing FPL therapy have shorter recovery time when compared with other fractional ablative lasers as seen in our clinical experience. To further this finding, we would suggest conducting a split-face comparison of both these technologies for better comparison of downtime and side effect profile.

Authors’ Contributions

Conceptualization, B.S.C., C.S., P.V., O.C.L., and M.S.R. Methodology, B.S.C., C.S., P.V., O.C.L., and M.S.R. Software, B.S.C., C.S., P.V., O.C.L., M.S.R., and T.Z. Validation, B.S.C., C.S., P.V., O.C.L., M.S.R., I.F., and T.Z. Formal analysis, B.S.C., C.S., P.V., O.C.L., M.S.R., and T.Z. Investigation, B.S.C., C.S., P.V., O.C.L., and M.S.R. Resources, B.S.C., C.S., P.V., O.C.L., and M.S.R. Data curation, B.S.C., C.S., P.V., O.C.L., M.S.R., and T.Z. Writing—original draft preparation, B.S.C., C.S., P.V., O.C.L., and M.S.R. Writing—review and editing, B.S.C., C.S., P.V., O.C.L., M.S.R., I.F., and T.Z. Visualization, B.S.C., C.S., P.V., O.C.L., M.S.R., I.F., and T.Z. Supervision, B.S.C., C.S., P.V., O.C.L., M.S.R., I.F., and T.Z. Project administration, B.S.C. and T.Z. Funding acquisition, B.S.C. and T.Z. All authors have read and agreed to the published version of the article.

Footnotes

Author Disclosure Statement

I.F. and T.Z. are employed by El.En. Group. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Information

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the principles of Declaration of Helsinki. Ethical approval was not required as the study device is already CE marked since 2021. No activity was carried out outside the scope of the device intended purpose, or that no additional invasive or burdensome procedures were carried out compared with procedure performed under the normal conditions of use of the device.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this article.

Data Availability Statement

The data that supports the findings of this study are available from the corresponding author upon reasonable request.

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