pISSN 1013-9087   eISSN 2005-3894
Open Access, Peer-reviewed
    Ann Dermatol. 2023 Dec;35(6):400-407. English.
    Published online Nov 30, 2023.
    https://doi.org/10.5021/ad.22.230
    Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology
    Review

    Dermal Fillers in the Treatment of Acne Scars: A Review

    Eman Almukhadeb, Faisal Binkhonain, Abeer Alkahtani,1 Sarah Alhunaif,2 Feras Altukhaim and Khalid Alekrish
      • Department of Dermatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
      • 1Department of Dermatology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
      • 2Department of Dermatology, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
    • Corresponding Author: Khalid Alekrish. Department of Dermatology, College of Medicine, King Saud University, Riyadh 11564, Saudi Arabia. Tel: +966-592162977, Fax: +011-2033479, Email: khalidalekrish@gmail.com
    Received January 12, 2023; Revised April 08, 2023; Accepted May 18, 2023.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Acne vulgaris (AV) is the eighth most common disease in the world. This condition can impair the affected patients’ social and psychological functioning and lower their quality of life. In general, scar reduction, rather than complete scar removal, is the aim of AV treatment. Dermal abrasion, chemical peeling, laser resurfacing, subcision, punch methods, tissue-improving substances, and dermal fillers are the currently available therapeutic options. In this study, we focused on the rapidly developing field of dermal fillers used alone or in combination with other therapies to reconstruct skin affected by acne scars and to evaluate the improvement of facial appearance after using different types of dermal fillers.

    Keywords
    Acne; Cosmetics; Dermal fillers; Review

    INTRODUCTION

    Acne vulgaris (AV) is the eighth most common disease in the world. Over 10% of the population are affected by AV, with the highest prevalence in adolescents1. Among adolescents, the prevalence is up to 85%2, while up to 12% of adults are affected3, 4. In all ethnic groups, AV affects more than 90% of men and 80% of women5, 6. Despite this, acne is neither physically dangerous nor life-threatening, but it can impair patients’ social and psychological functioning and lower their quality of life (QOL). Moderate to severe acne lesions may leave atrophic scars or post-inflammatory hyperpigmentation that can impair a patient’s QOL, lower self-esteem, and reduce social interactions7. Up to 95% of acne patients experience scarring as a typical long-term side effect, most frequently on the face8. The majority of acne scars are atrophic or marked by tissue loss. Although these lesions are typically divided into icepick, boxcar, rolling, keloidal, and hypertrophic scars, there is no universal agreement on the classification of atrophic scars9. Since there is no established standard of care in clinical practice, the treatment option must be customized for each patient.

    Additionally, a combination of treatment approaches is typically necessary due to the variable nature of scarring among the patients in terms of both the scar types and the severity of the scars (as discussed in Sanchez Viera 2015)10. In general, scar reduction, rather than complete scar removal, is the aim of AV treatment11. Dermal abrasion, chemical peeling, laser resurfacing, subcision, punch methods, tissue-improving substances, and dermal fillers are the currently available therapeutic options9, 10, 11. In this study, we focused on the rapidly developing field of dermal fillers used alone or in combination with other therapies to reconstruct skin affected by acne scars and to evaluate the improvement of facial appearance after using different types of dermal fillers.

    FILLER TYPES

    Fillers can be categorized as either temporary (effects that endure for up to 18 months, with hyaluronic acid [HA] being one example), semi-permanent (results lasting for up to two years, with examples including calcium hydroxyapatite [CH] and poly-L-lactic acid [PLLA]), or long-lasting (effects lasting for more than three years, with examples including silicone, polymethylmethacrylate [PMMA], polyacrylamide, and polyalkylimide). Several techniques are used to inject the fillers, such as droplet injection, linear threading, fanning, or three-dimensional volumization. The augmentation of dermal and subcutaneous tissue scaffolding, as well as the acceleration and enhancement of collagen and tissue synthesis, are the postulated mechanisms of action of these fillers12, 13. Despite their use in the past, human-, bovine-, and porcine-collagen-based fillers have been replaced by longer-lasting alternatives due to their limited duration of action.

    TEMPORARY FILLERS

    Hyaluronic acid

    HA is a temporary filler that was approved by the United States Food and Drug Administration (FDA) in 2003. It is a polysaccharide composed of repeating disaccharide units of N-acetylglucosamine and D-glucuronic acid14. Intradermal injections of HA fillers stimulate collagen synthesis by activating the dermal fibroblasts. They are commonly used to restore skin volume and improve the appearance of wrinkles and nasolabial folds15. There are multiple products containing HA fillers, and each has its own characteristics16. Seven studies have been performed to assess the effectiveness of different products containing HA fillers in the treatment acne scars, and all of them showed improvements in the appearance of acne scars, with no or minimal adverse events (AEs) (Table 1)17, 18, 19, 20, 21, 22, 23. In the most recent publication by Mahamoud et al. (2020)23, the study incorporated a considerably larger patient population in comparison to earlier studies investigating the employment of HA for the treatment of acne scars. This study involved 30 participants who underwent three sessions of full-face fractional CO2 laser, accompanied by intradermal HA injections or platelet-rich plasma injections on each facial side. Subsequently, the patients were monitored for a period of four weeks following each session. A significant reduction in acne scar severity was observed on both sides of the face, utilizing qualitative and quantitative assessment tools. Minimal AEs were reported in a few patients such as postprocedural pain, erythema, and edema.

    Table 1
    Summary of studies conducted on the use of dermal fillers in the treatment of atrophic acne scars

    SEMI-PERMANENT FILLERS (BIO-STIMULANTS)

    Poly-L-lactic acid

    PLLA is a semi-permanent filler that was approved for soft tissue augmentation in 1999. Currently, PLLA dermal filler is marketed under the brand name Sculptra. It is a synthetic biodegradable polymer that corrects volume loss by stimulating the fibroblasts and, therefore, collagen synthesis. The gradual effect of PLLA on dermal volume can last for up to 2~3 years from the time of treatment24. Five studies have been conducted from 2007 to 2015 to assess the efficacy and safety of PLLA for acne scars, with sample sizes varying from 1 to 80 patient. All studies demonstrated positive outcomes in enhancing the appearance of atrophic acne scars, despite the considerable variability in the number of sessions each patient received, which ranged from one to seven sessions. Additionally, the follow-up intervals in these investigations varied, extending from three months to four years after the final treatment sessions. With regard to AEs, the majority of patients in these studies exhibited minimal or no AEs. Examples of the AEs reported in these articles include mild pain, erythema, edema, swelling, and bruising. In one case, a non-visible palpable nodule and an epidermal inclusion cyst were observed (Table 1)12, 25, 26, 27, 28.

    Calcium hydroxylapatite

    CH is a naturally occurring substance in the human body, especially in human bones and teeth. The injectable form is developed using uniform CH microspheres dissolved in an aqueous carboxymethylcellulose gel carrier. Since 2006, Radiesse has been the only FDA-approved CH filler29. It provides long-lasting deep dermal and subdermal soft tissue augmentation, as it can instantly create significant changes in volume and replenish lost volume30. In addition to their volumizing effects, CH fillers tend to stimulate neocollagenesis and, subsequently, tissue formation, and their effects can last for up to 18 months29.

    Although CH fillers are commonly used, only two studies have investigated their role in the treatment of atrophic acne scars, one of which was a clinical trial that showed a beneficial effect and improvement in all treated individuals after 12 months, with the exception of deep icepick scars31. A recent study was conducted in 2019 by Koren et al.32 supported the use of CH fillers followed by fractional ablative CO2 laser treatment in separate treatment sessions, as these products yielded better cosmetic outcomes compared with the other evaluated modalities (Table 1).

    PERMANENT FILLERS

    Polymethylmethacrylate

    PMMA is a synthetic, permanent filler that was approved for soft tissue augmentation in 200633. In December 2014, the FDA also approved its use for moderate to severe atrophic acne scars34. Currently, collagen-PMMA dermal filler is marketed under the brand name Bellafil (Suneva Medical). This is the most recent formulation of collagen-PMMA, with its particles modified to obtain a diameter of 30 to 50 µm35, 36. This diameter was shown to have a better tolerability and resulted in fewer cases of foreign body reactions37. In contrast to other biological filler materials, PMMA contains a bovine collagen carrier as well as microsphere particles that cannot be metabolized. These residual particles stimulate the replacement of the bovine collagen carrier by autologous collagen, and the induction of autologous collagen production is a unique advantage of PMMA fillers38.

    Four studies have been conducted to determine the efficacy of PMMA dermal filler in the treatment of atrophic acne scars, and all showed positive outcomes (Table 1)13, 34, 39, 40. The most recent study was conducted in 2019 by Joseph et al.34 where they used Bellafil® for full-face acne scar treatment. Participants underwent two treatment sessions with a one-month interval, followed by a seven-month follow-up period. The researchers employed the Acne Scar Assessment Scale to objectively evaluate the treatment outcomes. Scars on the lower face demonstrated a more substantial improvement compared to those on the upper face. The authors reported no filler-related AEs in their study.

    Silicone

    In 1983, the use of liquid silicone injection as a treatment for atrophic acne scars was first attempted41, and since then, it has been used as an off-label filler substance42. Given its permanent nature, side effect profile, and the scarcity of data proving its safety, the FDA has not approved liquid silicone injections for tissue augmentation, regardless of the body site43. To date, a single study has been conducted to assess the efficacy and safety of liquid silicone injections in the treatment of atrophic acne scars, studied over 30 years. The investigators concluded that the treatment was effective and safe. However, only five patients were included, and the improvement was based solely on a photographic evaluation, with no objective scale employed to quantify the improvement (Table 1)42.

    Polyacrylamide and polyalkylimide

    To this day, no research has substantiated the use of polyacrylamide and polyalkylimide in the treatment of atrophic acne scars (Table 1).

    CONCLUSION

    Today, an increasing number of patients are seeking medical solutions for their acne scars. Acne scarring is a prevalent and challenging pathology that leads to stress and anxiety. Dermatologists have used abrasion, chemical peeling, laser resurfacing, and subcision as therapeutic options, with varying degrees of efficacy. Although the use of fillers for facial tissue augmentation is widespread, their role in the management of acne scars is yet to be capitalized. Multiple studies have been conducted to assess the efficacy and safety of dermal fillers in the treatment of acne scars. While most of them were limited by a low number of participants, they all showed promising results, with no or minimal AEs. The continuation of such studies is critical in order to further ensure the efficacy and safety of dermal fillers in the management of acne scars and the development of appropriate therapeutic protocols.

    Notes

    CONFLICTS OF INTEREST:The authors have nothing to disclose.

    FUNDING SOURCE:None.

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    MeSH Terms
    Acne Vulgaris*
    Cicatrix*
    Dermal Fillers*
    Quality of Life
    Skin
    Metrics
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