Dermabrasion, Chemical Peels, and Acne Surgery

Number: 0251

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

---

Policy

Scope of Policy

This Clinical Policy Bulletin addresses dermabrasion, chemical peels, and acne surgery.

1. Medical Necessity

   Aetna considers the following procedures medically necessary (unless otherwise specified) when criteria are met:

   1. Dermabrasion

      Using the conventional method of controlled surgical scraping (dermaplaning) or carbon dioxide (CO₂) laser for removal of superficial basal cell carcinomas and pre-cancerous actinic keratoses when both of the following criteria are met:
      
      
      1. Conventional methods of removal such as cryotherapy, curettage, and excision, are impractical due to the number and distribution of the lesions; and
      2. The member has failed a trial of 5-fluorouracil (5-FU) (Efudex) or imiquimod (Aldara), unless contraindicated;
         

   2. Chemical peel

      1. medium and deep chemical peels for actinic keratoses and other pre-malignant skin lesions when members have 15 or more lesions, such that it becomes impractical to treat each lesion individually, and they have failed to adequately respond to treatment with topical 5-FU or imiquimod, unless contraindicated;
      2. chemical peels are considered not medically necessary for the treatment of non-malignant (simple) lesions;
         

   3. Acne surgery

      1. acne surgery such as marsupialization, opening or removal of multiple milia, comedones, cysts, pustules for the treatment of acne vulgaris;
      2. intralesional injection of steroid for the treatment of inflammatory nodulo-cystic acne;
      3. surgical treatment, including incision and/or drainage, (Stage I and Stage II), punch debridement, unroofing and/or excision (Stage II and Stage III) for acne inversa (hydradenitis suppurativa);
      4. intralesional injection of steroid for the treatment of acne inversa (hidradenitis suppurativa).

2. Experimental and Investigational

   The following procedures are considered experimental and investigational because the effectiveness of these approaches has not been established:

   1. Dermabrasion and microdermabrasion for treatment of the following:
      
      
      1. active acne because dermabrasion has been shown to increase inflammation associated with active acne;
      2. diffuse silicone granuloma;
      3. dyschromias;
      4. keloids;
      5. melasma;
      6. vitiligo; and
      7. all other indications not listed as medically necessary in Section I or as cosmetic in Section III;
   2. Chemical peels for active acne and for all other indications not listed in Sections I or III;
   3. Cryoslush therapy (solid CO2 mixed with acetone) and liquid nitrogen therapy for acne;
   4. Fractional radiofrequency (including fractional micro-plasma radiofrequency) for the treatment of acne scars;
   5. Intralesional steroid injection for other types of acne not listed in Sections I or III (e.g., acne conglobate, acne fulminans, and pyoderma faciale; not an all-inclusive list);
   6. Micro-needling for acne scars and other dermatological indications (e.g., actinic keratosis, eccrine hidrocystomas, striae distensae, and vitiligo).

3. Cosmetic

   Aetna considers the following as cosmetic:

   1. Dermabrasion for:
      
      
      1. Scar revision
      2. Removal of acne scars;
   2. Chemical peels for:
      
      
      1. Acne scarring
      2. Melasma
      3. Skin wrinkling or lentigines;
   3. Scar injection or any other treatment to smooth or reduce visible acne scarring.

4. Policy Limitations and Exclusions 

   Note: Exceptions to the cosmetic surgery exclusion may apply to revision of scars. Please check benefit plan descriptions.

5. Related Policies

   • CPB 0031 - Cosmetic Surgery

---

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Dermabrasion:
CPT codes covered if selection criteria are met:
15780	Dermabrasion; total face
15781	segmental, face
15782	regional, other than face
15783	superficial, any site (e.g., tattoo removal)
ICD-10 codes covered if selection criteria are met:
C44.01, C44.111 - C44.1192 C44.211 - C44.219, C44.310 - C44.319 C44.41, C44.510 - C44.519 C44.611 - C44.619, C44.711 - C44.719 C44.81, C44.91	Basal cell carcinoma
L57.0	Actinic keratosis
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
L70.0 - L70.9	Acne
L80 - L81.9	Vitiligo and other disorders of the skin
L90.5	Scar conditions and fibrosis of skin [includes acne scarring]
L90.8 - L90.9	Other and unspecified atrophic disorders of skin [includes acne scarring]
L91.0	Hypertrophic scar
L92.3	Foreign body granuloma of the skin and subcutaneous tissue [diffuse silicone granuloma]
Chemical peel, dermal and epidermal:
CPT codes covered if selection criteria are met:
15789	Chemical peel, facial; dermal
15793	Chemical peel, nonfacial; dermal
CPT codes not covered for indications listed in the CPB:
15788	Chemical peel, facial; epidermal
15792	Chemical peel, nonfacial; epidermal
17360	Chemical exfoliation for acne
ICD-10 codes covered if selection criteria are met:
L57.0	Actinic keratosis
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
D23.0 - D23.9	Other benign neoplasm of skin
L70.0 - L70.9	Acne
L81.0 - L81.9	Other disorders of pigmentation
L90.5	Scar conditions and fibrosis of skin
L90.8, L90.9, L91.8	Other atrophic and hypertrophic disorders of skin [skin wrinkling] [includes acne scarring]
Acne surgery:
CPT codes covered if selection criteria are met:
Punch debridement, unroofing and/or excision (Stage III or IV) :
No specific code
10040	Acne surgery (e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)
ICD-10 codes covered if selection criteria are met:
L70.0 - L70.1 L70.3 - L70.9	Other acne
L70.2	Acne varioliformis
L71.0 - L71.9	Rosacea [acute]
L72.0, L72.11 - L72.12, L72.2- L72.3, L72.8- L72.9	Cyst [due to acne]
Cryoslush therapy:
CPT codes not covered for indications listed in the CPB:
17340	Cryotherapy (CO2, slush, liquid N2) for acne
Other CPT codes related to the CPB:
17000 - 17250	Destruction, benign or premalignant lesions
17260 - 17286	Destruction, malignant lesions, any method
ICD-10 codes not covered for indications listed in the CPB:
L70.0 - L70.1 L70.3 - L70.9	Other acne
L70.2	Acne varioliformis
L71.0 - L71.9	Rosacea
L72.11 - L72.12	Pilar and trichodermal cyst
Intralesional Injection of Steroid:
CPT codes covered for indications listed in the CPB:
11900	Injection, intralesional; up to and including 7 lesions
11901	Injection, intralesional; more than 7 lesions
HCPCS codes covered if selection criteria are met:
J3301	Injection, triamcinolone acetonide, not otherwise specified, 10 mg
ICD-10 codes covered if selection criteria are met:
L70.8	Other acne
L73.2	Hidradenitis suppurativa (Stage I or II)
Fractional Radiofrequency, Fractional micro-plasma radiofrequency:
CPT codes not covered for indications listed in the CPB:
Fractional radiofrequency - no specific code:
Fractional micro-plasma radiofrequency - no specific code:
ICD-10 codes not covered for indications listed in the CPB:
L90.5	Scar conditions and fibrosis of skin [includes acne scarring]
Micro needling:
CPT codes not covered for indications listed in the CPB:
Micro needling - no specific code:
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
D23.9	Other benign neoplasm of skin, unspecified [eccrine hidrocystomas]
L57.0	Actinic keratosis
L63.0 - L63.9	Alopecia areata
L65.0 - L65.9	Other nonscarring hair loss
L70.0 - L70.9	Acne
L80	Vitiligo
L81.0 - L81.9	Other disorders of pigmentation
L90.5	Scar conditions and fibrosis of skin
L90.6	Striae atrophicae
L90.8 - L90.9	Other and unspecified atrophic disorders of skin
L91.0	Hypertrophic scar

---

Background

Dermabrasion

Dermabrasion is a dermatologic procedure that exerts its therapeutic effect by removing the epidermis and superficial dermis, allowing re-epithelialization from the underlying skin to occur. With dermabrasion, a specialized hand held instrument is used to "sand" the skin, removing the epidermal surface in order to improve contour. Therefore, the technique is best used for superficial lesions of the face (Fitzpatrick et al, 1993). 

Standard dermabrasion uses a wire brush or diamond fraise (a stainless steel wheel on which diamond chips have been bonded) abraders to plane the skin whereas laser dermabrasion involves use of the argon laser, ultrapulse carbon dioxide (CO₂) laser, or flashlamp-pumped pulsed dye laser to resurface the entire face, and has been used as an alternative to standard dermabrasion in treating patients with inactive acne with disfiguring scarring (Wheeland, 1995; Alster and McMeckin, 1996; Alster and West, 1996; Ruback and Schoenrock, 1997; Aronsson et al, 1997; Fulton, 1996).  Manufacturers of lasers cleared by the Food and Drug Administration for general skin resurfacing include Laser Industries, Coherent, Tissue Technologies, and Heraeus Surgical.

Dermabrasion is contraindicated in patients with active acne, as it may exacerbate skin inflammation (AAD, 1994; Arnold et al, 1990).  Acne is active when inflammation is present, and is treated with oral and topical antibiotics and retinoids (e.g., isotrentinoin (Accutane) or retinoic acid (Retin-A).  Dermabrasion conducted within 6 months of isotrentoin treatment has been associated with increased scarring (Fitzpatrick et al, 1993; AAD, 1994).  Coverage is not provided for dermabrasion for inactive acne (such as in removal of scars from chronic cystic acne) as dermabrasion is considered a cosmetic procedure for this indication.

Because of a lack of evidence of safety and effectiveness, dermabrasion of active acne is considered investigational.  Dermabrasion for post-acne scarring is considered a cosmetic procedure.

With microdermabrasion, abrasive crystals are used to remove the dead epidermal cells from the face.

In an evidence-based review on microdermabrasion, Karimipour and colleagues (2009) stated that the role of microdermabrasion in the treatment of dyschromias and acne vulgaris is limited.

In an observational study, Garg and colleagues (2011) evaluated the usefulness of a less-painful method of repigmentation of vitiligo patches.  A total of 40 vitiligo patches in 22 consecutive patients with resistant vitiligo were treated with microdermabrasion followed by topical 5 % 5-FU.  One-third of the patches showed more than 50 % re-pigmentation, and 1/4 showed more than 75 % re-pigmentation.  Gratifying results were obtained in 7 patches after 1 session.  The authors concluded that microdermabrasion is adjunctive with topical 5 % 5-FU in the treatment of resistant vitiligo patches.  They stated that further well-controlled randomized trials are needed to validate the observations of the study.

Patel et al (2014) stated that atrophic scars cause significant patient morbidity.  While there is evidence to guide treatment, there does not appear to be a systematic review to analyze the effectiveness of treatment options.  These researchers retrieved all evidence relating to atrophic scar treatment and evaluated using the Clinical Evidence GRADE score in order to allow clinicians to make evidence-based treatment choices.  Searches were performed in Medline, EMBASE, CINHL and Cochrane to identify all English studies published evaluating treatment of atrophic scars on adults excluding journal letters.  Each study was allocated a GRADE score based on type of study, quality, dose-response, consistency of results and significance of results.  The end score allowed categorization of evidence into high, moderate, low or very low quality.  A total of 41 studies were retrieved from searches including randomized controlled trials (RCTs), observational studies, retrospective analyses and case reports of which 7 % were allocated a high-quality score, 10 % a moderate score, 7 % a low score and 75 % a very low score.  Treatment modalities included ablative laser therapy, non-ablative laser therapy, autologous fat transfer, dermabrasion, chemical peels, injectables, subcision, tretinoin iontophoresis and combination therapy.  The authors concluded that there is a paucity of good-quality clinical evidence evaluating treatment modalities for atrophic scarring.  Evidence supports efficacy of laser, surgery and peel therapy.  Moreover, they stated that further biomolecular research is needed to identify targeted treatment options and more RCTs would make the evidence base for atrophic scar treatment more robust.

Diffuse Silicone Granuloma

Zarei et al (2015) noted that formation of a foreign body granuloma is one of the serious complications of silicone injection, which can be difficult to treat.  These investigators reported their successful experience with dermabrasion as an innovative treatment in a patient who presented with diffuse silicone granuloma.  The patient was a 51-year old woman, with areas of induration and hyper-pigmentation on both her legs with intermittent fevers and generalized malaise.  The patient had a history of numerous bilateral hip injections of liquid silicone 5 years ago for cosmetic purposes.  A skin biopsy showed a foreign-body granuloma consistent with a paraffinoma with "Swiss cheese" appearance.  After unsuccessful medical therapy and liposuction, an extensive bilateral dermabrasion was performed on both legs.  Post-operatively, her wounds exuded a collection of thick, yellow viscous fluid under the transparent semi-occlusive dressings, which showed a markedly elevated level of silicone after analysis.  She experienced no complication related to dermabrasion.  The authors concluded that the findings of this case demonstrated that dermabrasion may be an effective treatment option for diffuse silicone granuloma, particularly when the material resides superficially in the dermis.  These preliminary findings need to be validated by well-designed studies.

Chemical Peels

With chemical peels/chemical exfoliation, a chemical solution is applied to the skin, resulting in destruction of the superficial layer, allowing a new layer of skin regeneration.

Chemical peels can be classified according to the type of "wounding" agent used and targeted depth of exfoliation (i.e., superficial, medium, deep).  Chemicals most often used in superficial peels are: 10 to 35 % trichloroacetic acid (TCA), resorcin, Jessner's solution, Retin-A, 5-FU, azelaic acid and alpha hydroxy acids (glycolic and lactic acid).  For medium peels 50 % TCA is used or lower concentrations of TCA in combination with Jessner's solution, 5-FU or carbon dioxide cryotherapy.  Baker's phenol or a 50 to 70 % solution of TCA are used for deep peels.  There is a paucity of data in the literature which compares the effectiveness of the various chemicals used in chemical peels.

Chemical peeling is a long-standing and accepted dermatologic technique.  However, clinical studies comparing the various types of chemical peels, and comparing chemical peels to other forms of therapy are unavailable.  The main coverage issue regarding the technique is the determination of whether the chemical peel is primarily cosmetic in nature.  Actinic keratoses are pre-malignant lesions and the medical necessity for their destruction/removal is not questioned.  However, a chemical peel for the treatment of actinic keratoses would only be appropriate when there are numerous lesions, making treatment of the individual lesions impractical.  For example, Morganroth and Leffell (1993) suggested that patients with less than 10 actinic keratoses should be treated with cryotherapy.

Additionally, curative treatment of actinic keratoses requires a full thickness necrosis of the epidermis.  Brodland (1988) estimated that this depth of necrosis would be unlikely with concentrations of TCA less than 35 %.  Therefore, coverage requests for superficial chemical peels as a treatment of actinic keratoses may actually represent primarily cosmetic procedures and should be carefully evaluated. 

Superficial chemical peels with alpha-hydroxy acids, so called fruit acids which include glycolic acid and lactic acid, have been used for the treatment of acne.  While low concentrations of glycolic acid can be administered by the patient at home, higher concentrations (50 to 70 %) are administered in the office. 

Guidelines from the American Academy of Dermatology (AAD) observe that both glycolic acid-based and salicylic acid-based peeling preparations have been used in the treatment of acne (Strauss et al, 2007).  The guidelines state: "There is very little evidence from clinical trials published in the peer-reviewed literature supporting the efficacy of peeling regimens. Further research on the use of peeling in the treatment of acne needs to be conducted in order to establish best practices for this modality."

Dreno and associates (2011) examined the evidence that supports the widespread use of superficial peels in the treatment of acne and acne-prone oily skin.  A search of the English language medical literature was performed to identify clinical trials that formally evaluated the use of chemical peeling in active acne.  Search of the literature revealed very few clinical trials of peels in acne (n = 13); a majority of these trials included small numbers of patients, were not controlled and were open label.  The evidence that is available does support the use of chemical peels in acne as all trials had generally favorable results despite differences in assessments, treatment regimens and patient populations.  Notably, no studies of chemical peels have used an acne medication as a comparator.  As not every publication specified whether or not concomitant acne medications were allowed, it is hard to evaluate clearly how many of the studies evaluated the effect of peeling alone.  This may be appropriate, however, given that few clinicians would use superficial chemical peels as the sole treatment for acne except in rare instances where a patient could not tolerate other treatment modalities.  The authors concluded that in the future, further study is needed to determine the best use of chemical peels in this indication.

Cryotherapy utilizes liquids such as liquid nitrogen to reduce the skin temperature to very low levels causing the skin to peel, thereby removing whiteheads and/or blackheads.

Soleymani and associates (2018) noted that chemo-exfoliation, also known as chemical peeling, is a method of targeted cutaneous ablation using specific caustic agents that allow for rapid, predictable, and uniform thickness of chemo-ablation to a desired cutaneous depth, ultimately resulting in an improved appearance of skin.  These investigators provided an up-to-date analysis of all currently available chemical peels for dermatologic use, as well as a step-by-step instructional protocol for an algorithmic approach to treatment.  They carried out a comprehensive search of the Cochrane Library, MedlineE, and PubMed databases to identify relevant literature investigating chemical peeling agents.  In addition, a search of all commercially available, prescription-based peeling agents was performed to identify all products currently available in the United States market.  The authors concluded that chemical peels are the 3rd most commonly performed non-invasive cosmetic procedure in the U.S., with over 1,300,000 procedures performed in 2016 alone.  There has been a paradigm shift in recent years, with lasers largely supplanting deep peels.

In a systematic review of RCTs, Chen and colleagues (2018) evaluated current evidence regarding the effectiveness of chemical peeling for treating acne vulgaris.  Standard Cochrane methodological procedures were used.  These investigators searched Medline, Cochrane Central Register of Controlled Trials and Embase via OvidSP through April 2017.  Reviewers independently assessed eligibility, risk of bias and extracted data.  A total of 12 RCTs (387 participants) were included.  Effectiveness was not significantly different: TCA versus salicylic acid (SA) (percentage of total improvement: risk ratio (RR) 0.89; 95 % confidence interval (CI): 0.73 to 1.10), glycolic acid (GA) versus amino fruit acid (the reduction of inflammatory lesions: mean difference (MD), 0.20; 95 % CI: -3.03 to 3.43), SA versus pyruvic acid (excellent or good improvement: RR 1.11; 95 % CI: 0.73 to 1.69), GA versus SA (good or fair improvement: RR 1.00; 95 % CI: 0.85 to 1.18), GA versus Jessner's solution (JS) (self-reported improvements: RR 1.00; 95 % CI: 0.44 to 2.26), and lipohydroxy acid versus SA (reduction of non-inflammatory lesions: 55.6 % versus 48.5 %, p = 0.878).  Combined SA and mandelic acid peeling was superior to GA peeling (percentage of improvement in total acne score: 85.3 % versus 68.5 %, p < 0.001).  GA peeling was superior to placebo (excellent or good improvement: RR 2.30; 95 % CI: 1.40 to 3.77).  SA peeling may be superior to JS peeling for comedones (reduction of comedones: 53.4 % versus 26.3 %, p = 0.001); but less effective than phototherapy for pustules (number of pustules: MD -7.00; 95 % CI: -10.84 to -3.16).  The authors concluded that commonly used chemical peels appeared to be similarly effective for mild-to-moderate acne vulgaris and well-tolerated.  However, based on current limited evidence, a robust conclusion could not be drawn regarding any definitive superiority or equality among the currently used chemical peels.  These researchers stated that well-designed RCTs are needed to identify optimal regimens.  The main drawback of this study was that the methodological quality of the included RCTs was very low to moderate; meta-analysis was not possible due to the significant clinical heterogeneity across studies.

Acne Surgery

Surgical treatment of acne involves physical removal of the material forming the blockages and causing the lesions by various methods such as excision of cysts or pustules, incision and drainage, punch debridement or unroofing of nodules or sinuses.

The AAD found limited evidence published in peer-reviewed medical literature that addresses the efficacy of comedo removal for the treatment of acne, despite its long-standing clinical use (Strauss et al, 2007).  The guidelines concluded, however, that "[i]t is ... the opinion of the work group that comedo removal may be helpful in the management of comedones resistant to other therapies.  Also, while it cannot affect the clinical course of the disease, it can improve the patient’s appearance, which may positively impact compliance with the treatment program."

The guidelines make no mention of the use of liquid nitrogen or cryoslush in the treatment of acne (Strauss et al, 2007).

Levine and Rasmussen (1983) evaluated the effectiveness of intralesional injections of corticosteroids in the therapy for nodulo-cystic acne.  Triamcinolone acetonide at a concentration of 0.63 mg/ml was as effective as a higher concentration of 2.5 mg/ml.  Betamethasone phosphate had little, if any, effect on nodulo-cystic acne lesions at concentrations of 3.0, 1.5, and 0.75 mg/ml, when compared with saline controls.  Mahajan and colleagues (2003) compared the effectiveness of intralesional triamcinolone with that of a combination of intralesional lincomycin and intralesional triamcinolone in nodulo-cystic acne.  A total of 10 patients of nodulo-cystic were injected with intralesional triamcinolone acetonide (2.5 mg/ml), while 9 patients were given lincomycin hydrochloride (75 mg/ml) in addition to the intralesional triamcinolone.  They were followed-up 48 hours, 1 week and 1 month later.  At 1 week, 7 patients (70 %) treated with injection triamcinolone showed 66 % improvement, whereas all 9 (100 %) patients treated with lincomycin and triamcinolone showed 100 % improvement that was stable at 1 month.  The authors concluded that c combination of intralesional triamcinolone and lincomycin is superior to intralesional triamcinolone alone in the treatment of nodulo-cystic lesions of acne.

The AAD’s "Guidelines of care for acne vulgaris management" (Strauss et al, 2007) noted that intralesional corticosteroid injections are effective in the treatment of individual acne nodules; there is limited evidence regarding the benefit of physical modalities including glycolic acid peels and salicylic acid peels.  The guideline stated that "In the opinion of experts, the effect of intralesional injection with corticosteroids is a well- established and recognized treatment for large inflammatory lesions.  It has been found that patients receiving intralesional steroids for the treatment of cystic acne improved.  Systemic absorption of steroids may occur.  Adrenal suppression was observed in one study.  The injection of intralesional steroids may be associated with local atrophy.  Lowering the concentration and/or volume of steroid utilized may minimize these complications".

An UpToDate review on "Light-based, adjunctive, and other therapies for acne vulgaris" (Dover and Batra, 2013) states that "Intralesional glucocorticoids are a treatment option for nodular acne lesions that might otherwise take weeks to resolve.  Treated lesions typically flatten in 48 to 72 hours, improving appearance and discomfort.  Triamcinolone acetonide, in concentrations of 1.25 to 2.5 mg/ml, is typically injected using a 30 gauge needle.  There is no high quality evidence demonstrating the efficacy of such injections, but extensive clinical experience supports their use.  Lower concentrations of triamcinolone may be as effective as higher concentrations and may reduce the risk of adverse effects; in one small randomized trial, lesions treated with 0.63, 1.25, or 2.5 mg/ml of triamcinolone acetonide exhibited similar improvement scores.  Patients should be cautioned regarding potential side effects including cutaneous atrophy, hypopigmentation, and telangiectasias".

Scar injection involves the use of synthetic material or autologous fat injected under the skin to fill a scar or improve its appearance.

Acne Inversa (Hydradenitis Suppurativa)

Acne inversa (hidradenitis suppurativa) is a chronic follicular occlusive disease primarily affecting the axilla, waist, groin, perianal, perineal and inframammary areas.

Manifestations vary and may include recurrent inflamed nodules, abscesses, draining sinus tracts and bands of scar formation. Severity of the condition may be classified according to the following stages:

Stage I:

Abscess formation (single or multiple) without sinus tracts and scarring.

Stage II:

Recurrent abscesses with sinus tracts and scarring, single or multiple widely separated lesions.

Stage III:

Diffuse or almost diffuse involvement or multiple interconnected sinus tracts and abscesses across the entire area.

The goals of acne inversa (hidradenitis suppurativa) treatment are to heal existing lesions, reduce the extent and progression of the disease and bring the disease activity to the mildest stage possible. 

Fractional Radiofrequency (Including Fractional Micro-Plasma Radiofrequency) for the Treatment of Acne Scars

Simmons and colleagues (2014) noted that a more recent technique for the treatment of acne scars is non-ablative radiofrequency (RF) that works by passing a current through the dermis at a preset depth to produce small thermal wounds in the dermis which, in turn, stimulates dermal remodeling to produce new collagen and soften scar defects.  This review article demonstrated that out of all RF modalities, micro-needle bipolar RF and fractional bipolar RF treatments offered the best results for acne scarring.  An improvement of 25 % to 75 % can be expected after 3 to 4 therapeutic sessions using 1 to 2 passes per session.  Results were optimal approximately 3 months after final treatment.  Common adverse effects (AEs) can include transient pain, erythema, and scabbing.  The authors concluded that further studies are needed to determine what RF treatment modalities work best for specific scar subtypes, so that further optimization of RF treatments for acne scars can be determined.  They also stated that available studies using RF treatments on acne scarring did not address the long-term sustainability of responses to treatment; although the results of this review were promising, more studies with longer follow-up are needed to determine the place of RF in the treatment of acne scarring.

Forbat and Al-Niaimi (2016) stated that fractional RF (FRF) is renowned for its use in cosmetic dermatology, with regard to the treatment of rhytides, striae, scarring and cellulite.  These investigators analyzed evidence for the use of FRF in acne scars.  Their search identified 15 articles, 1 single-blinded RCT, 2 split-face trials, and 13 prospective clinical studies, mostly single-centered; case reports were excluded.  A total of 362 patients were treated.  The longest follow-up was for 210 days, and the average follow-up was 3 months (range of 1 to 7).  This review found that there were many small studies showing promising results for the use of FRF in acne scars, either as an adjunct or more importantly as the sole treatment.  However, the authors concluded that there is a need for larger trials against ablative and non-ablative lasers, in order to affirm the evidence present already.

In a Cochrane review, Abdel Hay (2016) evaluated the effects of interventions for treating acne scars.  These investigators searched the following databases up to November 2015: the Cochrane Skin Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 10), Medline (from 1946), Embase (from 1974), and LILACS (from 1982).  They also searched 5 trials registers, and checked the reference lists of included studies and relevant reviews for further references to RCTs.  These researchers included RCTs, which allocated participants (whether split-face or parallel arms) to any active intervention (or a combination) for treating acne scars.  They excluded studies dealing only or mostly with keloid scars.  Three review authors independently extracted data from each of the studies included in this review and evaluated the risks of bias.  They resolved disagreements by discussion and arbitration supported by a method expert as required.  The primary outcomes were participant-reported scar improvement and any adverse effects (AEs) serious enough to cause participants to withdraw from the study.  These investigators included 24 trials with 789 adult participants aged 18 years or older; 20 trials enrolled men and women, 3 trials enrolled only women and 1 trial enrolled only men.  These researchers  judged 8 studies to be at low risk of bias for both sequence generation and allocation concealment.  With regard to blinding they judged 17 studies to be at high risk of performance bias, because the participants and dermatologists were not blinded to the treatments administered or received; however, they judged all 24 trials to be at a low risk of detection bias for outcome assessment.  They evaluated 14 comparisons of 7 interventions and 4 combinations of interventions; 9 studies provided no usable data on the outcomes and did not contribute further to this review's results.  For this review’s outcome "Participant-reported scar improvement" in 1 study fractional laser was more effective in producing scar improvement than non-fractional non-ablative laser at week 24 (RR 4.00, 95 % CI: 1.25 to 12.84; n = 64; very low-quality evidence); fractional laser showed comparable scar improvement to FRF in 1 study at week 8 (RR 0.78, 95 % CI: 0.36 to 1.68; n = 40; very low-quality evidence) and was comparable to combined chemical peeling with skin needling in a different study at week 48 (RR 1.00, 95 % CI: 0.60 to 1.67; n = 26; very low-quality evidence).  In a further study chemical peeling showed comparable scar improvement to combined chemical peeling with skin needling at week 32 (RR 1.24, 95 % CI: 0.87 to 1.75; n = 20; very low-quality evidence).  Chemical peeling in 1 study showed comparable scar improvement to skin needling at week 4 (RR 1.13, 95 % CI: 0.69 to 1.83; n = 27; very low-quality evidence).  In another study, injectable fillers provided better scar improvement compared to placebo at week 24 (RR 1.84, 95 % CI: 1.31 to 2.59; n = 147 moderate-quality evidence).  For this review’s outcome "Serious AEs" in 1 study chemical peeling was not tolerable in 7/43 (16 %) participants (RR 5.45, 95 % CI: 0.33 to 90.14; n = 58; very low-quality evidence).  For the secondary outcome "Participant-reported short-term adverse events", all participants reported pain in the following studies: in 1 study comparing fractional laser to non-fractional non-ablative laser (RR 1.00, 95 % CI: 0.94 to 1.06; n = 64; very low-quality evidence); in another study comparing fractional laser to combined peeling plus needling (RR 1.00, 95 % CI: 0.86 to 1.16; n = 25; very low-quality evidence); in a study comparing chemical peeling plus needling to chemical peeling (RR 1.00, 95 % CI: 0.83 to 1.20; n = 20; very low-quality evidence); in a study comparing chemical peeling to skin needling (RR 1.00, 95 % CI: 0.87 to 1.15; n = 27; very low-quality evidence); and also in a study comparing injectable filler and placebo (RR 1.03, 95 % CI: 0.10 to 11.10; n = 147; low-quality evidence).  For the outcome "Investigator-assessed short-term AEs", fractional laser (6/32) was associated with a reduced risk of hyperpigmentation than non-fractional non-ablative laser (10/32) in 1 study (RR 0.60, 95 % CI: 0.25 to 1.45; n = 64; very low-quality evidence); chemical peeling was associated with increased risk of hyperpigmentation (6/12) compared to skin needling (0/15) in 1 study (RR 16.00, 95 % CI: 0.99 to 258.36; n = 27; low-quality evidence).  There was no difference in the reported AEs with injectable filler (17/97) compared to placebo (13/50) (RR 0.67, 95 % CI: 0.36 to 1.27; n = 147; low-quality evidence).  The authors concluded that there is a lack of high-quality evidence about the effects of different interventions for treating acne scars because of poor methodology, under-powered studies, lack of standardized improvement assessments, and different baseline variables.  There is moderate-quality evidence that injectable filler might be effective for treating atrophic acne scars; however, no studies have assessed long-term effects; the longest follow-up being 48 weeks in 1 study only.  Other studies included active comparators, but in the absence of studies that establish effectiveness compared to placebo or sham interventions, it is possible that finding no evidence of difference between 2 active treatments could mean that neither approach works.  They stated that the results of this review did not provide support for the 1st-line use of any intervention in the treatment of acne scars.  Although the aim was to identify important gaps for further primary research, it might be that placebo and or sham trials are needed to establish whether any of the active treatments produce meaningful patient benefits over the long-term.

Lan and colleagues (2018) noted that acne scarring is a common disfiguring sequela of acne vulgaris that can lead to serious psychosocial problems and have a negative effect on patients' quality of life (QOL).  Although a variety of approaches can be used to treat atrophic acne scars, disadvantages such as long-healing time, dyspigmentation, infections, and prolonged erythema make these treatments unsatisfactory especially for Asians.  Fractional micro-plasma RF is a novel technology that produces minor ablation to the epidermis to promote rapid re-epithelialization, while the RF-evoked thermal effect can stimulate regeneration and re-modeling of dermal fibroblasts.  These researchers evaluated the safety and effectiveness of micro-plasma RF for the treatment of facial acne scars in Chinese patients.  A total of 95 patients with facial atrophic acne scars were treated by micro-plasma radio-frequency using 3 sessions at 2-month intervals.  Patients were examined 1 week after each treatment and 1, 3, 6 months after the final treatment.  Improvement was evaluated by 3 independent dermatologists who compared photographs taken before the 1st treatment and 6 months after the last treatment; AEs were assessed by a dermatologist who did not participate in the study.  Patients also provided self-evaluation of satisfaction levels at the last follow-up visit.  A total of 86 patients with atrophic acne scars completed the entire study.  There was a significant improvement in acne scars after 3 treatments.  The mean score of ECCA grading scale (Echelle d'Evaluation Clinique des Cicatrices d'Acné) was reduced from 107.21 to 42.27 (p < 0.05); 15 of 86 patients showed more than 75 % improvement, 57 patients showed 50 to 75 % improvement, and 14 patients showed 25 to 50 %.  After 3 treatments, all subjects showed improvements in spots, large pores, texture,  ultra-violet (UV) damage, red areas, and porphyrin fluorescence.  Pain, erythema, edema, effusion, and scab formation were observed in all patients.  The average pain score on a visual analog scale (VAS) was 6.14 ± 1.12, and all patients tolerated the treatments.  The average duration of erythema was 6.26 ± 0.92 days.  Hyper-pigmentation, hypo-pigmentation, infections, and worsening of scarring were not observed.  All patients were either "very satisfied" or "satisfied" with the treatment outcomes.  The authors concluded that fractional micro-plasma RF is a safe and effective treatment for acne scars, and might be a good choice for patients with darker skin.  This was a relatively small study (n = 86 who completed the study) with only 6 months of follow-up.  These preliminary findings need to be validated by well-designed studies.

Eubanks and Solomon (2022) stated that the effectiveness of FRF specifically for acne scarring has not been widely established.  In a prospective study, these researchers examined the safety and effectiveness of FRF for moderate-to-severe acne scarring in a wide range of Fitzpatrick skin types using 2 different applicator tips to deliver energy to the skin (80-pin of up to 124 mJ/pin and 160-pin of up to 62 mJ/pin).  Enrolled subjects received a series of 3 FRF treatments to the full face, each 4 weeks apart.  A VAS was used to evaluate pain of the treatment.  Subject satisfaction questionnaires were completed at follow-up visits at 6 and 12 weeks after the final treatment.  Photographs were graded for change by 3 blinded evaluators using the Global Aesthetic Improvement Scale (GAIS).  Image sets of 23 enrolled subjects were evaluated by blinded evaluation, showing a statistically significant improvement (p = 0.009) from the baseline visit to the 12-week follow-up on the GAIS for acne scarring.  Subject satisfaction was high with subjects giving an average satisfaction score of 3.27 ("satisfied") out of 4.  Pain was "mild" as treatments were rated an average of 2.15 on a 10-point VAS.  The GAIS score of the 80-pin tip improved patients' acne scars treated with that applicator by 1.06 points and 0.85 for the 160-pin tip; 95.5 % of subjects reported either a mild, moderate, or significant improvement to their treatment area; 91 % of subjects reported that they would recommend the treatment to a friend.  The authors concluded that the findings of this study suggested that FRF was effective in the treatment of acne scars in subjects of all skin types, without significant AEs.  Furthermore, FRF treatments were safe with no AEs and subjects had limited downtime as the treatments allowed for quick recovery times.  These researchers stated that the FRF device may be a viable alternative for fractional laser devices for the treatment of acne scars for subjects looking for shorter recovery times and looking to avoid the drawbacks of fractional laser treatments.

The authors stated that drawbacks of the study included the relatively small sample size (n = 23) that limited the power of the study and the ability to show a significant difference in effectiveness between the 80- and 160-pin tips.  Furthermore, a shorter follow-up period of GAIS could have shown results much faster than at 12 weeks, and a longer follow-up period to examine the longevity of all the outcomes (e.g., 6 or 12 months after treatment) would be interesting.

Micro-Needling for Acne Scars and Other Dermatological Indications

Bonati and colleagues (2017) stated that micro-needling procedures are growing in popularity for a wide variety of skin conditions.  These investigators reviewed the literature regarding the safety and efficacy of skin needling in all skin types and in multiple dermatologic conditions.  They carried out a PubMed literature search in all languages without restriction and reviewed bibliographies of relevant articles.  Search terms included: "microneedling","percutaneous collagen induction", "needling", "skin needling" and "dermaroller".  Micro-needling is most commonly used for acne scars and cosmetic rejuvenation, however, treatment benefit has also been seen in varicella scars, burn scars, keloids, acne, alopecia, and periorbital melanosis, and has improved flap and graft survival, and enhanced transdermal delivery of topical products. Side effects were mild and self-limited, with few reports of post-inflammatory hyperpigmentation, and isolated reports of tram tracking, facial allergic granuloma, and systemic hypersensitivity.  The authors concluded that microneedling represents a safe, cost-effective, and efficacious treatment option for a variety of dermatologic conditions in all skin types; they stated that more double-blinded, randomized, controlled trials are required to make more definitive conclusions

Hou and associates (2017) performed a comprehensive review of micro-needling in human subjects and its applications in dermatology.  These investigators performed a search using PubMed/Medline and Science Direct databases.  Search terms included "microneedling", "needling" and "percutaneous collagen induction".  All available studies involving human subjects were included in the discussion, with priority given to prospective, randomized trials.  Studies demonstrated micro-needling’s safety and efficacy for the treatment of scars, acne, melasma, photo-damage, skin rejuvenation, hyperhidrosis and alopecia and for facilitation of transdermal drug delivery.  While permanent AEs are uncommon, transient erythema and post-inflammatory hyper-pigmentation are more commonly reported.  The authors concluded that micro-needling appeared to be a safe and effective therapeutic option for numerous dermatologic conditions.  Moreover, they stated that larger and more RCTs are needed to provide greater data on the use of micro-needling for different dermatologic conditions in different skin types.

Ramaut and co-workers (2018) stated that patients who suffer from scars or wrinkles have several therapeutic options to improve the appearance of their skin.  The available treatment modalities that provide desirable results are often overtly invasive and entail a risk of undesirable AEs.  Micro-needling has recently emerged as a non-ablative alternative for treating patients who are concerned with the aesthetic changes that result from injury, disease or ageing.  These researchers evaluated the current evidence in the literature on micro-needling.  They carried out a systematic literature review by searching the electronic databases PubMed and Google Scholar.  The reviewed articles were analyzed and compared on study design, treatment protocol, outcome parameters, efficacy measurement and results to evaluate the strength of the current evidence.  Micro-needling was examined in experimental settings for its effects on atrophic acne scars, skin rejuvenation, hypertrophic scars, keloids, striae distensae, androgenetic alopecia, melasma and acne vulgaris.  Several clinical trials used randomization and single-blindation to strengthen the validity of the study outcome.  Micro-needling showed noteworthy results when used on its own and when combined with topical products or radiofrequency.  When compared with other treatments, it showed similar results but was preferred due to minimal side effects and shorter downtime.  The authors concluded that this systematic review positioned micro-needling as a safe and effective therapeutic option for the treatment of scars and wrinkles.  These investigators stated that the current literature shows some methodological shortcomings, and further research is needed to truly establish micro-needling as an evidence-based therapeutic option for treating scars, wrinkles and other skin conditions.

Furthermore, an UpToDate review on "Striae distensae (stretch marks)" (MacGregor JL, Wesley) states that "Improvement in striae distensae using microneedling has been documented in small uncontrolled studies.  Larger studies are needed to confirm efficacy and compare the efficacy of microneedling with fractional laser resurfacing".

In a systematic review, Mujahid and associates (2020) analyzed the current literature on micro-needling (MN) techniques used for acne scarring.  These investigators carried out a PubMed search (2009 to current) to identify literature on MN for acne.  All randomized and non-randomized clinical trials, case cohorts, case reports, and case series were included with the exception of 2 studies, which were excluded due to unavailability.  All 33 articles evaluated showed improvement of acne scar appearance after MN.  Evidence was inconsistent when comparing MN monotherapy to dual therapy or to fractional laser treatment.  The authors concluded that MN improved acne scarring, however, further studies are needed to compare MN with other minimally invasive treatments.

In a prospective, observational study, Alster and Li (2020a) reported the results of MN on 20 patients with a variety of scars.  A total of 120 consecutive patients (skin photo-types I through VI) with facial and non-facial scars from a variety of etiologic sources (acne, trauma, surgery) were treated using a mechanical MN device.  No additional treatments (topical or intralesional) were applied.  Two assessors blinded to treatment protocol rated clinical improvement of scars 1, 3, 6, and 12 months after treatment on a 5-point scale.  Side effects were monitored and tabulated.  Patients received 1 to 6 consecutive monthly MN treatments.  All scars improved at least 50 % after an average of 2.5 treatments.  Over 80 % of patients had 50 to 75 % improvement, and 65 % of patients demonstrated over 75 % improvement.  No significant clinical differences were observed in treatment responses of facial scars versus non-facial scars nor between responses of atrophic acne scars and traumatic or surgical scars.  The authors concluded that the findings of this study supported the use of MN for various facial and non-facial scars across a broad range of skin photo-types with minimal risk of adverse effects.  Moreover, these researchers stated that further studies would aid in establishing standardized protocols to optimize treatment outcomes for different scar types.  Level of Evidence = IV.

In a systematic review and meta-analysis, Steeb and colleagues (2020) examined if MN plus photodynamic therapy (PDT) is superior to monotherapy with PDT for the treatment of actinic keratosis (AK).  The systematic search in the databases and trial registers identified 1,482 references, and 11 records underwent full-text review.  Finally, 5 RCTs with a sample size of n = 213 met the eligibility criteria.  The combination of MN and 5-aminolevulinate (ALA)-PDT was more effective in clearing lesions than ALA-PDT monotherapy based on the mean lesion complete clearance per patient (MD 6.01; 95 % CI: 0.84 to 11.17; I2 = 11 %; p = 0.02; GRADE +---).  There was no significant difference between ALA-PDT combined with MN compared with monotherapy (RR 1.19; 95 % CI: 0.90 to 1.67; I2 = 35 %; p = 0.22; GRADE +---).  Participants treated with a combination approach showed partial clearance rates similar to those achieved with ALA-PDT only (RR 1.38; 95 % CI: 0.97 to 1.97; p = 0 .07; GRADE ++--).  PDT monotherapy was perceived as equally painful as the combination of PDT with MN reported on a VAS from 0 (none) to 10 (extreme pain) (MD 0.66; 95 % CI: -0.23 to 1.55; I2 = 86 %; p = 0 .15; GRADE +---).  The authors stated that the treatment protocols of the studies were highly heterogeneous, which resulted in indirectness of the comparisons.  The drawbacks of this work included the high heterogeneity of the included studies and the low quality of the evidence according to the GRADE rating.  Although these researchers included only RCTs in the analysis, the studies were de-valued because of methodologic shortcomings.  The most common reason for this was a small number of patients and a high variability of reported data with wide CIs.  Nevertheless, a combination of MN plus PDT appeared to be slightly more effective than PDT alone.  However, the MN procedure needs to be standardized for use in daily practice.

Kuan and Tey (2021) stated that eccrine hidrocystomas (EH) are benign cystic tumors of the eccrine glands with no established treatment yet.  Eccrine glands are activated by acetylcholine released from innervating sympathetic nerve fibers.  Use of oral anti-cholinergic agents is rare due to the possibility of systemic side effects while topical atropine and scopolamine have been found to be ineffective.  In this study, these investigators tried using topical glycopyrrolate over the entire affected region followed by MN.  The objective was to create micro-channels through the epidermis and dermis, delivering the drug to EH lesions in the deeper dermis.  These researchers only performed MN over the left half of the chest to compare the difference made by MN.  The effective percutaneous delivery of topical glycol was evident by the patient's transient systemic side effects and reduction of the EH lesions.  Specifically, the lesions were reduced more significantly over the left half where micro-needles were applied.  The authors concluded that the treatment was effective for the patient and he was satisfied with the improvement in cosmesis; these researchers stated that the method described may serve as a therapeutic option for patients with EH.  These preliminary findings need to be validated by well-designed studies.

Alster and Li (2020b) noted that striae distensae have notoriously been difficult to treat due to their extensive involvement of non-facial skin.  The lack of thermal injury during MN renders it a viable therapeutic option in darker skin tones and non-facial regions due to the reduced risk of post-inflammatory hyper-pigmentation.  These investigators described the clinical results and side effects of MN in a series of 25 individuals with striae distensae.  Subjects were adults (SPT I-V) with striae distensae involving the trunk and extremities; they were treated using a MN device.  Treatments were delivered by the same operator at monthly intervals using a motorized MN device with 1.5- to 3-mm needle depths.  No additional treatments (topical or intralesional) were applied.  Representative clinical photographs were obtained at baseline, prior to each treatment, and 1, 3, 6, and 12 months after treatment.  Two assessors blinded to treatment protocol rated clinical improvement of striae on a 5-point scale (0 = no change, 1 = 1 % to 25 % improvement, 2 = 26 % to 50 % improvement, 3 = 51 % to 75 % improvement, 4 = 76 % to 100 % improvement). Side effects were monitored and tabulated.  Patients received 1 to 3 consecutive monthly treatments.  All striae improved at least 50 % after an average of 1.8 treatments, and 28 % of patients demonstrated more than 75 % clinical improvement.  No significant differences were observed in clinical responses of striae in patients with different skin photo-types.  Striae in thicker skin regions (e.g., buttocks/thighs) showed comparable clinical improvement than those in thinner skin areas (e.g., breasts) and did not require additional treatment sessions.  Side effects were limited to transient erythema in all skin photo-types.  No infections or dyspigmentation were observed.  The authors concluded that the clinical results obtained in this study supported the safe and effective treatment of striae distensae with MN in light and dark skin tones in various body locations; standardization of treatment protocols are anticipated with further (ongoing) studies.

Furthermore, an UpToDate review on "Striae distensae (stretch marks)" (MacGregor and Wesley, 2020) stated that "Treatment of striae distensae is optional.  A paucity of high-quality trials has led to uncertainty about the best approach to therapy".

Ebrahim and Albalate (2020) noted that combination therapies have reported to augment the re-pigmentation in vitiligo; MN facilitates drug delivery across the skin barrier.  These researchers compared the safety and efficacy MN combined with tacrolimus versus MN alone or tacrolimus 0.1%  ointment for treatment of localized and stable vitiligo.  A total of 90 patients with vitiligo were randomized into 3 groups: group I received MN with tacrolimus, group II MN only both at 2 weeks interval for 12 sessions, and group III applied tacrolimus ointment 0.1 % twice-daily for 6 months.  Skin biopsies were taken at baseline and after treatment.  The overall improvement (76.6 %) was significantly higher in the combined group compared with other groups.  Re-pigmentation was excellent in 66.6 of group I versus 33.3 % in the other 2 groups (p < 0.03).  A highly significant improvement of the extremities was observed in the combined group than in the other groups (p < 0.001).  A fewer number of sessions have reported in the combined group (I) than in the MN group (II; p < 0.001).  Immunohistochemical results showed a significantly higher expression of HMB-45 in group I than in other 2 groups (p < 0.04).  Side effects were mild and tolerable in all groups.  The authors concluded that the combination group has shown promising results over the other 2 groups.  These encouraging findings need to be validated in well-designed studies.

Sitohang and colleagues (2021) noted that to-date, treatment of atrophic acne scars remains a therapeutic challenge for dermatologists, yet there is no standard option on the most effective treatment.  Micro-needling (MN) is a minimally invasive technology that involves repetitive skin puncture using sterile microneedles to disrupt dermal collagen that connects the scar tissue.  Recent studies have shown the potency of MN, such as dermaroller and fractionated micro-needle radiofrequency, in the treatment of atrophic scars.  In a systematic review, these investigators examined the current literature on MN for atrophic acne scars.  They carried out a systematic search of literature from PubMed, Medline, Cochrane Central, and Google Scholar databases for articles published during the last 20 years.  Only RCTs with full-text version of the manuscript available were included in this review; a total of 9 RCTs were included in this review.  All treatment modalities demonstrated consistent results that MN was effective in treating atrophic acne scars as a monotherapy or in combination with other treatments.  Moreover, no serious adverse effects were reported in all studies following MN treatment.  The authors concluded that MN is a well-tolerated and effective therapeutic modality in treating atrophic acne scars.  Moreover, these researchers stated that further research is needed to validate the efficacy of MN with a larger sample size and longer follow-up.

---

References