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Evaluation Of Treatment of Acne Scars with 25% Trichloroacetic Acid Chemical Peel Followed By Manual Dermasanding Hayder R Al-Hamamy, (MBChB, DDV, CABD, PhD) 1, Muhsin A ALDhalimi (MBChB, DDV, CABD, FICMS) 2 and Azhar F Abtan (MBChB, FICMS)3 1. Iraqi Board for Medical Specializations 2. Department of Dermatology, College of Medicine, University of Kufa 3. Department of Dermatology, Al-Kerama Teaching Hospital, Baghdad, Iraq - Conflicts of Interest: The authors have carried out and the ICMJE Form for Disclosure of Potential Conflicts of Interest have been submitted and none were declared. - The study was ethically approved by the ethical committee of the Iraqi medical specialization council. - No funding source for this study. - The data that support the findings of this study are available from AlSder teaching hospital – Najaf- Iraq. Restrictions apply to the availability of these data, which were used under license for this study. Data are available on direct contact with the corresponding author upon reasonable request and after get the acceptance of the hospital.

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/JOCD.13754 This article is protected by copyright. All rights reserved

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*Address for Correspondence: Prof. Muhsin A. Al-Dhalimi, MD University of Kufa, Faculty of Medicine Department of Dermatology P.O. Box 18, Kufa Post Office, Najaf, Iraq E-mail: [email protected]

Evaluation Of Treatment of Acne Scars with 25% Trichloroacetic Acid Chemical Peel Followed By Manual Dermasanding

Conflicts of Interest: The authors have carried out and the ICMJE Form for Disclosure of Potential Conflicts of Interest have been submitted and none were declared. Key words: acne scars, treatment, 25%TCA, chemical peel, dermasanding Running title: Acne scars treatment by 25%TCAand dermasanding

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ABSTRACT BACKGROUND: Acne scars are common problems encountered in daily dermatologic practice. OBJECTIVE: To evaluate the effectiveness and safety of 25% trichloroacetic acid (TCA) alone or followed by manual dermasanding in repeated sessions for the treatment of mild and moderate acne scars. METHODS: Thirteen patients (9 females and 4 males) were enrolled. Twenty-five percent TCA superficial peel was performed in all patients, followed in 11 of them by manual dermasanding. Thirteen sessions of TCA peeling, one session for each patient, were done, and twenty-four sessions of dermasanding with different numbers for each patient. Acne scars were graded into a score ranging from 0-20, the score was recorded at each visit, and the results were compared. RESULTS: The score of scarring acne decreased after TCA peeling and each dermasanding session. The improvement was statistically significant. The improvement continued after the last dermasanding session. After both procedures, no significant complications were recorded except persistent erythema and post-inflammatory hyperpigmentation, which disappeared in all patients at three months follow up visit. CONCLUSION: TCA superficial peel followed by manual dermasanding in separate sessions was effective and the improvement became more This article is protected by copyright. All rights reserved

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significant after repeated dermasanding sessions for the treatment of mild and moderate acne scars.

INTRODUCTION The combined treatment of chemical peeling and dermabrasion of the face been widely accepted since its introduction in 1972 by Dupont and Horton [1]. Trichloroacetic acid (TCA) has been used extensively by dermatologists and plastic surgeons for many years. A 10 to 25 percent solution is used for light peeling; it is safe as its systemic toxicity is less than that of phenol. This peeling is equivalent to a mild sun burn with mild skin erythema for two to three days and light exfoliation at three to five days and can be repeated one week later but it barely penetrates beyond the epidermis. For this reason, a combination of TCA with other treatments such as dermabrasion has been proposed as an effective treatment for acne scars and as a way to potentiate the effect of TCA to achieve a deeper peel [2]. Manual dermasanding is a procedure of skin abrasion using sterile sand paper [3,4]. This article is protected by copyright. All rights reserved

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It removes the epidermis to the mid reticular dermis along with the outer portion of the skin adnexia. Re-epithelialization takes place from the residual portion of the adnexia [5]. It has several advantages over classical dermabrasion as it is simpler and less costly, more readily accessible, and safer with no blood splatter or aerolized particles that can infect the staff [6].

PATIENTS AND METHODS: This was an interventional, prospective study of an outpatient ambulatory surgical procedure. Thirteen patients (9 females and 4 males), with skin types III and IV, participated in this open- label therapeutic trial at the outpatient department of Dermatology and Venereology, during the period between February 2006 and December 2007. The ages of the patients ranged from 16 to 27 years. The inclusion criteria were patients with facial acne scars of atrophic variety of more than one year duration, whether superficial or deep. Patients who had mild grade inflammatory acne lesions, with few scattered papules or comedones, were also included. The exclusion criteria were included patients with a history of oral isotretinoin treatment during the last 6 months; other medications that could exaggerate the inflammatory reaction of the disease (corticosteroid,

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anabolic steroid, and contraceptive pills); severe grade scars and those with hypertrophic scars, and keloids anywhere on the body, dark brown skin typing and outdoor workers, pregnancy, bleeding tendency, active viral infection (hepatitis, herpes simplex, wart or molloscum), photosensitivity, immunosuppression, melasma, and patients unable to care for their wound and unavailable for follow up. A detailed history was obtained from all patients with an emphasis on disease activity and used treatments. A physical examination was done particularly for acne scar type and grade, activity of inflammatory acne and any sign of skin infection. Special instructions were given to the patients, including avoiding dugs that interfere with blood coagulation like aspirin. Smoking should be avoided for at least one week. After excluding the contraindications, the procedure was fully described for all patients and consent was taken to perform the procedures as well as photos before each session, two weeks after TCA peeling, one month after each dermasanding session, and at three months follow up from the last dermasanding session. All patients were treated with a single session of 25% TCA peel, while 11 of them were also treated after two weeks by dermasanding with different numbers of sessions, 5 patients were treated with 3 sessions, 3 patients were treated with two sessions, and the other 3 patients with one session (Figure 1). The remaining two patients refuse to do dermasanding. TCA Peeling technique: A careful cleansing with 70% alcohol-soaked gauze was done on This article is protected by copyright. All rights reserved

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and around the treated site with vigorous rubbing until it losses the greasy texture, and a faint erythema was seen. An even layer of 25% TCA was applied using a cotton-tipped applicator. The solution layers were applied consecutively at three minutes interval without any force. A white frost started to arise and increased in depth after each application and the procedure continued until an even white frosting was seen. The skin of the treated area was washed with water immediately after the procedure. Each patient was advised to do facial washing three to four times on the first day using an acetic acid solution. The patients were allowed to return to facial and scalp washing with non-irritant soap and water from the second day onward. The patients were instructed to use a steroid ointment of low potency (hydrocortisone 1% ointment) twice daily for the entire first week. Bleaching agent (Hydroquinone 4%cream) was used at night from the beginning of the second week and continued until the following session of dermasanding two weeks later, and to avoid sun exposure and using sunscreen which containing titanium dioxide for at least 10-14 days. The assessment was done before TCA peeling treatment (Pre TCA) and two weeks after the procedure (Post TCA). Only one session of TCA peel was done for each of the 13 patients who participated in this study. Dermasanding technique: The area to be sanded was prepared with povidone iodine 2% and anesthetized by local infiltration anesthesia using This article is protected by copyright. All rights reserved

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2% lidocaine. Sandpaper was used as a tool (Germany sandpaper of aluminium oxide crystals size 80). It was cut into small pieces according to the size of the scar. The area to be abraded was outlined using gentian violet. The bases and edges of the marked scars were smoothened by their abrasion separately. Gentle abrasion was done in a back and forth movement until pinpoint bleeding was observed which indicating that the superficial papillary dermis was reached. The area was then smoothed with the surrounding skin by more gentle abrasion. Hemostasis was achieved by pressure. The wound area was covered with tetracycline and betamethasone ointment topically twice daily for 5-7 days, and oral diclofenac tablet 25mg was prescribed to be taken on need. Oral acyclovir tablet, (400 mg), three times daily was given to all patients with a positive history of infection with viral herpes simplex. After about 5-7 days, the patients were encouraged to use steroid ointment of mild potency (hydrocortisone 1% ointment) twice daily for the entire second week. From the second week onward, the patients were instructed to apply hydroquinone 4% cream at night and to use sun screens with strict sun avoidance for one month. Follow up was performed after one week, one month after each dermasanding session, and three months after the last session with serial photographs. The patient would undergo the procedure again for up to three dermasanding sessions, one month apart. The number

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of sessions given for each patient depended on the degree of improvement, which was decided by the treating physician and patient's satisfaction.

Assessment: The severity of acne scars was assessed using a grading system for scarring acne Table 1 [8], in which we graded scarring acne depending on five different parameters (each scores 1, 2, 3 or 4 points). Patient satisfaction was recorded by using ten grades visual analogue scale and side effects including erythema and pigmentary changes were noted. Grading of acne was done according to the calculated score as follows: 1. Mild (5-9), 2. Moderate (10-14) 3. Severe (15- 20). Statistical analysis: The collected Data was analysed statistically using IBM SPSS V.20 (IBM, Chicago, IL, USA). Continuous metric variables were expressed by the mean and SD, while Categorical variables were summarized by counts (frequencies). Paired sample and independent sample T-test were used to compute P value; P-value < 0.05 was considered significant for all statistical tests.

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RESULTS: TCA peeling evaluation by clinical assessment showed that the average score of acne scar grading before TCA peeling was 11.15±1.06, while after TCA peeling changed to 9.61 ±1.8. This represented a (13.8%) reduction and was statistically significant (P=0.013). (Figure2). For the three patients who did one session of dermasanding, before the dermasanding acne score was 9.66±0.57, after the session it changed to 8.66±0.57, and after three months, the score was 6.66±0.57. This reduction in the score was statistically significant (P=0.0002). For the three patients who did two sessions, before dermasanding, the score was 11.00 ±1.00, after the first session it changed to 10.00±1.00, after the second session it became 8.66±0.57, and after three months follow up it decreased to 8.00±0.00. This was statistically significant (P=0.000001). (Figure 3). For the five patients who completed three sessions, before dermasanding, the score was 10.00 ±1.58, after the first session it changed to 9.00±1.22, after the second session it became 8.00±0.7, after the third session, it was 6.8±0.44 and after three months follow up it was 6.00±0.7. This reduction in the score was statistically significant (P=0.000012). Patients’ satisfaction: After TCA peeling, 10 patients out of 13 patients (77%) were satisfied with the peel. While after the first, second and third This article is protected by copyright. All rights reserved

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dermasanding sessions, satisfaction with the session was recorded in 9 patients (82%), 6 patients (75%), and 4 patients (80%), respectively, out of 11 patients who underwent the sessions. Ten patients (91%) were satisfied with the results three months after the last dermasanding session. Regarding the side effects, after TCA peeling erythema was observed in 4 patients (31%). In one patient, the erythema was followed 2 weeks later with post-inflammatory hyperpigmentation, which resolved after one month treatment with hydroquinone cream 4% at night. After the first, second, and third dermasanding sessions, persistent erythema was observed in 8 patients (73%), 5 patients (63%), and 3 patients (60%), respectively. In all patients, erythema disappeared completely within 2-4 weeks without treatment. At three months follow up, no patient had erythema. Post-inflammatory hyperpigmentation was observed after the first dermasanding session in only 3 patients (27%), which resolved within 2 months by using the same bleaching formula that was used previously. Improvement of chronic inflammatory acne lesions was observed in 5 out of 7 patients with mild acne activity.

DISCUSSION: Acne scars are the most unpleasant consequence of acne lesions. They may complicate any form of acne and have serious implications on the psychology of the affected individual that may bear for the rest of his life

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[9]. Every effort should be done to prevent scarring in acne through proper treatment of active lesions. Many patients who develop scarring acne consult for the treatment of these scars. Various treatment procedures have been used to improve the appearance of scars. Smoothening of the scars was tried using surgical scar revision, electrosurgical planning, chemical peeling, dermabrasion, and laser abrasion [10]. Cryoslush with carbon dioxide snow, liquid nitrogen cryopeel, filler substance implantation, and iontophoresis have also been used. However, none of these is suitable for all patients. Many patients benefited from one modality while others needed a combination of treatment modalities, according to the type of skin, and type of scars the patient had [11]. In the present study, TCA superficial peel followed by manual dermasanding was associated with clinical reduction in the scar score and this reduction increased as more sessions of dermasanding were performed. At three months follow up the significance of improvement increased and this may be due to collagen remodelling induced by dermasanding, which takes months to be clinically apparent [12]. This stresses the importance of informing the patient that improvement is expected to continue after the last session, this also indicates the necessity of allowing enough time before judging the improvement and the need for another session. This used protocol is still used in our department with good results.

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AL-Waiz etal [13] used three sessions of TCA moderate chemical peel to induce improvement in their patients with acne scars and their results were comparable to our results. AL-Aadamy [9] used two to six dermasanding sessions to treat acne scars and to achieve clinical improvement, however; the number of patients in his study was small and the duration of follow up was short. Chemical peeling using glycolic acid and Jessner's solution has been tried alone or in combination with microneedling, using dermapen, in two previous studied [14,15]. The results showed that three a significantly higher rate of improvement in acne scars in combination group than in groups using either technique alone. Microneedling also showed improvement of pigmentation as well as acne scar appearance when used in pigmented patients [16].

Good results were obtained in the treatment of acne scars using non ablative lasers (Nd:YAG) by Yaghmai [17], and CO2 laser resurfacing by Maluki [18]. Although laser achieves precise depth when operated by experienced people, it is expensive. The improvement in acne scars observed in the present study could be attributed to the fact that acne scars are caused by loss of tissue as a result of inadequate wound healing with too few connective tissue formation [19],

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and as superficial dermabrasion correlates strongly with increased collagen of both types (I and III), which leads to a new regenerated dermal layer in addition to the inter-island contraction phenomenon, this contraction is responsible for a reduction in the surface area of the dermal wound and made deep pits of acne scars constricted and collapsed after dermabrasion [9]. The most common side effect seen in the present study was erythema which is a possible complication of all peels, and the percentage of persistent erythema decreased after each dermasanding session. The resultant erythema was transient and mild form that requiring no treatment in most of the patients. It represents a normal stage of wound healing associated with increased angiogenesis in all patients [20]. Hyperpigmentation was observed after TCA peeling, and the percentage increased after the first dermasanding session. Hyperpigmentation was reverted completely to normal within 1-3 months by using hydroquinone 4% cream at night and sunscreen in the morning with strict sun avoidance. People with Fitzpatrick skin types IV, V, and VI are known to develop post-inflammatory hyperpigmentation as a response to trauma or inflammation; hence, resurfacing is advised to be done with caution and need strict sun avoidance in this group [12,20,21]. Hypopigmentation, milia, infection and formation of new scars were not observed in this study. This may be due to the use of superficial peel followed by repeated sessions of superficial abrasion, rather than a single aggressive session, which may damage the skin and lead to This article is protected by copyright. All rights reserved

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more complications [22]. In this study, it was also observed that TCA and dermasanding were effective in the improvement of chronic inflammatory acne lesions of mild activity. The precise mechanism of this therapeutic advantage is not known, but it may be attributed to drainage and de-roofing of comedones or due to their direct effect on pilosebaceous apparatus [10]. In conclusion, Combination of dermasanding and TCA 25% peeling was showed acceptable results. It is a good and cheap method that can be used when the more expensive laser technologies can’t be used due to clinic or patient factors.

References [1] Emsen IM. Effect of dermasanding (manual dermabrasion) with sandpaper on the appearance of both postsurgical and burn scars. Aesth Plast Surg 2007;31:608–11. [2]

Ayhan S, Baran CN, Baran NK, Latifoglu O, et al. Combined chemical peeling and dermabrasion for deep acne and posttraumatic scars as well as aging face. Plast Reconstr Surg 1998;102:1238–46.

[3] Poulos E, Taylor Ch, and Solish N. Effectiveness of dermasanding (manual dermabrasion) on the appearance of surgical scars: A

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prospective, randomized, blinded study. J Am Acad Dermatol 2003; 48: 897-900. [4] El-Domyati M, Attia S, Saleh F, Ahmed H and Uitto J. Trichloroacetic Acid

Peeling

versus

Dermabrasion:

A

Histometric,

Immunohistochemical, and Ultrastructural Comparison. Dermatol Surg 2004;30:179-188. [5] Gillard M, Wang TS, Boyd CM, Dunn RL, Fader DJ, Johnson TM. Conventional Diamond Fraise vs Manual Spot Dermabrasion With Drywall Sanding Screen for Scars From Skin Cancer Surgery. Arch Dermatol. 2002;138(8):1035–1039. [6]

Picosse

FR,

Yarak

S,

Cabral

NC,

Bagatin

E.

Early chemabrasion for acne scars after treatment with oral isotreti noin.

Dermatol Surg. 2012;38(9):1521-6.

[7] Deprez P. "Anterior" chemabrasion for acne scars treatment. Clin Cosmet Investig Dermatol. 2019;12:141-149 [8] Sharquie KE, Al-Hamdi KI, Noaimi AA, Al-Battat RA. Scarring and non scarring facial acne vulgaris and the frequency of associated skin disease. The Iraqi Postgraduate Medical Journal 2009; 8 (4):332-8. [9] Al-Aadamy AW, Al-Hamamy HR, Salman HA and Al-Waiz MM. Sandpaper dermabrasion for the treatment of acne scars and amateur

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tattoos in dark skinned individuals. Iraqi postgrad Med J 2008; 7: 141-146. [10] Savant SS. Facial Dermabrasion in acne scars and genodermatosis. Indian J Dermatol Venereol 2000; 66: 79-84. [11] Jacob CI, Drover JS, and Kaminer MS. Acne scarring: A classification system and review of treatment options. J Am Acad Dermatol 2001; 45: 109-17. [12] Savant SS. Dermabrasion. In: Savant SS, Shah RA, Gore D eds. Textbook and Atlas of Dermatosurgery and Cosmetology. 1 st ed. Mumbai: ASCAD, 1998; 162-168. [13] Al-Waiz MM, and Al-Sharqi AI. Medium-depth chemical peels in treatment of acne scars in Dark-skinned individuals. Dermatol Surg 2002; 28:1-5. [14] Saadawi AN, Esawy AM, Kandeel AH, El-Sayed W. Microneedling by dermapen and glycolic acid peel for the treatment of acne scars: Comparative study. J Cosmet Dermatol. 2019;18(1):107-114. [15] Ali B, ElMahdy N, Elfar NN. Microneedling (Dermapen) and Jessner's solution peeling in treatment of atrophic acne scars: a comparative randomized clinical study. J Cosmet Laser Ther. 2019;21(6):357363.

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[16] Al Qarqaz F, Al-Yousef A. Skin microneedling for acne scars associated with pigmentation in patients with dark skin. J Cosmet Dermatol. 2018;17(3):390-395. [17] Yaghmai D, Garden JM, Bakus AD, and Massa MC. Comparison of a 1064 nm laser and a 1320nm laser for the non ablative treatment of acne scars. Dermatol Surg 2005; 31(8pt1): 903-9. [18] Maluki AH. Facial resurfacing of atrophic acne scars using highenergy pulsed carbon dioxide laser. J Arab Board Med Specializations 2003; 5, No 2: 8-11. [19] Goodman GJ. Post-acne scarring: A short review of its pathophysiology. Australas J Dermatol 2001;42(2):84-90. [20] Shim EK, Barnette D, Greenway HT. Microdermabrasion: a clinical and histopathological study. Dermatol Surg 2000; 27(6):524-530. [21] Goldman MP, Fitzpatrick RE, and Smith SR. Resurfacing complications and their management. In: Coleman WP, Lawrence N (eds). Skin Resurfacing. 1st edn. Baltimore: Williams and Wilkins Co. 1998; 295-301. [22] Alt TH, Goodman GD, and Coleman WP. Dermabrasion. In: Coleman WP, Hanke CW, Alt TH eds. Cosmetic sugery of the skin. 2 nd ed. St.Louis: Mosby Year book Inc., 1997; 112-151.

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TABLE 1: Scoring system for grading scarring of acne vulgaris [8].

Figure 1: Diagram showed the Plan for the treatment of the included.

FIGURE 2: Patient with acne scars (A) before and (B), Three months after TCA peeling.

FIGURE 3: Patient with acne scars (A) before, (B) after TCA treatment and (c), three months after the third dermasanding session.

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Score

1

2

3

 10

11-20

21-30

4

Param eter

1

No.

of

> 30

scars

2

Area

1

4

of face

>1/4-1/2

>1/2-3/4

>3/4

involved

3

Type of

Flat

Depressed

Hypertrophic

Keloid

Skin colored

Erythematous or

Hyperpigment

Bluish or

hypopigmented

ed

grayish

scars

4

Color of scars

5

Effect on

No effect or

Mild dysmorpho-

Moderate

Severe

psych

mild

phobia

dysmorpho-

dysmorp

phobia

ho-

discomfort

phobia or social with drawal

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Included patients (n=13)

All Get TCA 25% peel

five patients were treated with three sessions of dermasanding

Three patients were treated with two sessions of dermasanding

Three patients treated with one session of dermasanding

Figure 1: Diagram showed the Plan for the treatment of the included

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Accepted Article Evaluation Of Treatment of Acne Scars with 25% Trichloroacetic Acid Chemical Peel Followed By Manual Dermasanding Hayder R Al-Hamamy...
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