Acne occurs in about 95% of 16-17 year-old boys and 84% of 16-17 year-old girls. Although the condi-tion usually resolves by the mid twenties; nevertheless, 1% of men

and 5% of women still bear signs of moderately severe acne scarring at 40 years of age. Some studies show scarring of some degree may affect up to 95% of patients with acne.

Atrophic scarring often appears years later and can cause great distress. Affected patients report social inhibition, unhappiness, anxiety, and even suicide because of their facial appear-ance. For many years different treatment mo-dalities have been used for the revision of acne scarring with varying degrees of success.

Differing modalities for hypertrophic scarring have included intralesional steroids, silicone sheeting or vascular laser treatment. Laser skin resurfacing is still the most popular thera-peutic modality for the correction of atrophic acne scars – the more common type of defects encountered after inflammatory acne – but it is not always effective in all types of lesions. Over the past four years, numerous non-ablative laser resurfacing and radiofrequency (RF) methods have come to the forefront of technology and been shown to create some improvement in the appearance of these atrophic scars.

More recently, a number of autologous and non-autologous techniques attempting dermal and subcutaneous augmentation have been tried to improve the facial aesthetic appearance. The autologous methods have included dermal graft-ing, fat transfer and more recently, implantation of autologous fibroblasts, such as Isolagen®. There has also been interest in some forms of non-autologous augmentation by way of injec-tions of hyaluronic acid, polymethylmethacrylate microspheres and calcium hydroxylapatite. This study looked at the use of calcium hydroxylapa-tite in the treatment of atrophic acne scarring.

Background of calcium Hydroxylapatite Calcium hydroxylapatite (CaHA), the main mineral component of Radiesse™. Calcium is a synthetic analogue of the inorganic salt found in the human body as a constituent of bone and

teeth. The CaHA microspheres (25–45mm) are suspended in an aqueous carboxymethylcellu-lose carrier gel, composed of cellulose, glycerin, and sterile water. None of these materials elicit a chronic inflammatory, infectious or immune response. Multiple clinical and histologic studies have tended to document its safety, efficacy, and longevity in tissue. At the present time, the use of (CaHA) is approved by the US Food and Drug Administration (FDA) for craniofacial surgery, HIV related lipoatrophy and, more recently, for soft-tissue augmentation around the nose and mouth. In view of the fact that many studies have established the biocompatibility and safety of CaHA in facial filling techniques, this filler is gaining popularity in the US and Europe. It was for this reason that the author originally considered the compound in the treatment of acne scarring in 2004.

metHodsA series of 42 patients (22 male 20 female) (skin phototypes I-IV) with varying degrees of atrophic acne scarring were treated in a single-centre, prospective, controlled trial over a one year period. Patients were randomly selected on the basis that they did not want to present for la-ser resurfacing as a treatment for their problem. This meant the patients were collected sporadi-

scar issuesdr patrick treacy evaluates Radiesse™ as a tReatment in

atRophic acne scaRRing

21knoWledge case studY

J u l Y / a u g u s t 2 0 0 8 a e s t H e t i c m e d i c i n e www.aestheticmedicinemagazine.co.uk

23-YeaR-old patient duRing Radiesse™ tReatment 23-YeaR-old patient post Radiesse™ tReatment

Formanyyearsdifferenttreatmentmodalitieshavebeenusedfortherevisionofacnescarringwithvaryingdegreesofsuccess

“

cally rather than all entering the trial at the same time. The subjects ranged in age from 16-63 and all acne scarring severity scores fell between four and 30 on the Goodman system. Patients were also evaluated using digital photography and an improvement graduation scale [0= no improve-ment, 1= 0-25% improvement, 2= 25-50% improvement, 3= 50-75% improvement, 4= 75-100% improvement, 5=100% improvement] at each subsequent treatment visit at one, three, six, 12 and 24 months postprocedurally.

Subscision of each atrophic scar was performed one week prior to injection with CaHA to give a more uniform aesthetic effect. Radiesse™ was injected through a 27-gauge needle into the space left after subscision of the acne scar in the region of the mid to deep der-mis, although final placement also depended on the presence of fibrous and cystic tissue in this region of the skin.

The total volume of CaHA used, varied with each patient, with the end point being agreed be-tween subject and proceduralist. It was decided not to record the amount of product used as this

was felt to be not contributory to the final result. Histologic evaluations of cutaneous biopsies were not obtained before or during treatment, although it was offered to at least one of the patients who had a resultant adverse reaction. Surgical procedure with Betadine® cleansing was used in most patients and Doxycycline 100mgs for two days was given as prophylaxis in 11 patients who were felt to be at risk of infection as they still appeared to have active acne. One patient who had a previous photoal-lergic problem with Doxycycline was prescribed Augmentin Duo bd for two days.

Subjects were not excluded from the study on the basis of bleeding disorders or whether they were taking anticoagulants/anti-inflam-matory agents as it was felt the bruising may be unsightly but would probably improve overall healing. Patients were excluded from the study if they had received synthetic collagen, hyaluronic acid, polymethylmethacrylate microspheres, calcium hydroxylapatite or autologous fibroblast injections to treated areas within six months of the study.

Clinical assessment scores were determined at each treatment session and follow-up visit. Patient satisfaction surveys and digital photog-raphy were used where they were appropriate to both parties, although both were considered subjective with patients tending to focus on the smallest detail and physicians photographi-cally favoring the better results. All patients were reviewed at two or four weeks post initial treatment for a top up of Radiesse™ if required. It was noted that 17 patients required a top up of at least 0.15ml CaHA at one of the first two visits. Smaller amounts (<0.1ml) were not recorded as it was felt that the patient may have seen some defects under deeper scrutiny that were initially missed during the procedure.

resultsA total of 42 patients entered the one-year trial. From the 42 patients who completed 12 months assessment, 30 patients (72% of total) initially scored 4 (75-100% improvement) and 11 patients (27% of total) scored 3 (50-75% improvement). One patient had score of 0-25% improvement while no subjects scored either maximum or no improvement. At the three-month review the number showing score 4 (75-100% improvement) reduced to 24 patients (58% of total), at six months to 20 patients (40% of total) and to six patients (22% of total) by completion of the year. At the 12-month evaluation, nine patients (22% of total) showed 75% improvement, 20 patients (48% of total) showed 50% improvement, and 14 patients (30% of total) showed 25% improvement in treated atrophic scars. Thirteen patients followed over a 72-week period, showed some residual benefit in 23% patient related to the compound or neocollagenesis related to subscision. The au-thor felt that monitoring the reduction of score 4 over the 12-month period largely related to the efficacy of the compound in treating acne scars. Side effects of treatment were mostly limited in the group to mild transient erythema, bruising or localised edema. Some patients required top up or remodeling on initial review.

conclusionMost atrophic acne scars responded to treat-ment. At 12-month evaluation, 22% of subjects showed 75% improvement; while 48% showed 50% improvement. One patient had a score of 0-25% improvement while no subjects scored either maximum or no improvement. The author concludes that dermal fillers may provide a new means of therapy in some patients being treated for acne scarring. Newer injectable fillers are becoming more biocompatible and safer and are becoming a popular means of treating acne scarring as an alternative in patients not opt-ing for laser resurfacing. Despite the obvious reservations in using long-term fillers in this type

knoWledge case studY22

www.aestheticmedicinemagazine.co.uk a e s t H e t i c m e d i c i n e J u l Y / a u g u s t 2 0 0 8

0

5

10

15

20

25

3030

25

20

15

10

5

0

4 Weeks

12 Weeks

24 Weeks

36 Weeks

patient satisfaction with Radiesse™ in tReatment of athRophic acne scaRRing oveR 12 month peRiod

n 25-50%n 50-75%n 75-100%

1

11

30

2

16

24

13

20

9

13

0 0

of procedure, CaHA may be considered a safe method of treatment.

The author is aware of some recent reports that CaHA is not without adverse events, as described by Jansen et al 2006. The adverse events reported, however, consisted of the normal adverse events associated with all dermal fillers. The exception herein may be the reported occurrence of nodules, which typically formed after injections of the lip mucosa. The author found no side effects associated with CaHA, in keeping with the fact it is the only filler for which no confirmed granulomas have been reported to date. In conclusion, the author considers CaHA (Radiesse™) is a cost effective, safe, and longer-lasting dermal filler, which can be used for treat-ment of facial atrophic acne scarring.

[references](1) Cotterill JA, Cunliffe WJ. Suicide in

dermatological patients. Br J Dermatol 1997; 137: 246-250

(2) Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol 1994; 19: 303-308

(3) Seaton ED, Mouser PE, Charakida A, Alam S, Seldon PE and Chu AC. (2006) Investiga-tion of the mechanism of action of non-ab-lative pulsed-dye laser therapy in photo-re-juvenation and inflammatory acne vulgaris. British Journal of Dermatology 155:4, 748-755

(4) Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse™) for facial soft tissue aug-mentation. Plast Reconstr Surg 2006;118 (Suppl):22S-30S

(5) Treacy P, Goldberg D. Use of a BioPolymer Filler for Facial Lipodystrophy in HIV-posi-tive patients undergoing treatment with Anti Retro Viral Drugs. Journal of Dermatologi-cal Surgery Volume 32, Number 6, June 2006, pp. 804-808(5)

23knoWledge case studY

J u l Y / a u g u s t 2 0 0 8 a e s t H e t i c m e d i c i n e www.aestheticmedicinemagazine.co.uk

TheauthorconsidersCaHA(Radiesse™)isacosteffective,safe,andlonger-lastingdermalfiller,whichcanbeusedfortreatmentoffacialatrophicacnescarring

“27-YeaR-old patient pRioR to Radiesse™ tReatment

27-YeaR-old patient afteR Radiesse™ tReatment