الفهرس 
Acne vulgarisOnly 14 pages are availabe for public view
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Abstract
Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles, characterized by comedones, papules, pustules, cysts, nodules, and often scars. Sites of predilection are the face, neck, upper trunk, upper arms and to a lesser degree the back, chest, and shoulders.
Depending on the severity and extent of involvement, treatment varies from application of topical medications to systemic therapy with antibiotics or retinoids. The primary end point of current acne therapy is to decrease sebaceous gland activity, reverse hyperkeratinization, minimize P. acnes overgrowth, and correct hormonal imbalances with the goal of preventing scarring.
Major sequelae of acne includes; dyspigmentation (hyper-or hypopigmentation) and scarring. Scarring can occur despite appropriate or effective treatment of acne in 95% of patients.
Jacob et al. divided acne scars in July (2001), into icepick scars, rolling scars and boxcar scars. While Goodman in (2003), classified the acne scars into: atrophic, hypertrophic and keloidal scars. Another similar classification, was done by Kadunc and Trindale de almeida, (2003), which classified acne scars into: elevated scars, dystrophic scars and depressed scars.
Our interest in treatment of acne scars is growing and many measures for treatment of acne scars became popular. For the atrophic acne scars, there are; Chemical peels and skin fillers, while the hypertrophic scars treatment can be carried out using intalesional injection of steroid.
Surgical measures for atrophic acne scars include; dermabrasion, punch elevation, subcision and finally lasers. In case of hypertrophic or keloidal acne scars, surgical measures include; lasers, cryosurgery and excision.
Chemical peeling is the application of a chemical agent to the skin, which causes controlled destruction of a part of or the entire epidermis, with or without the dermis, leading to exfoliation and removal of superficial lesions, followed by regeneration of new epidermal and dermal tissues.
Concerning focal TCA peeling, the chemical reconstruction of skin scars (CROSS) method was described for the treatment of atrophic scars using a sharpened wooden applicator to deeply deliver trichloroacetic acid (TCA) in higher concentration.
In our study, 20 patients with atrophic acne scarring were included and treated with CROSS method to deeply deliver TCA in 2 concentrations 50% and 95%. Then biopsies were taken to compare the efficacy of both concentrations on collagen deposition.
No sedation or topical anesthesia was done and immediately before peeling, the skin was washed with soap and water followed by adequate rinsing with water to remove any soap residue. Using gloved hand the skin was carefully cleansed with 70% alcohol and acetone soaked gauze to remove the cutaneous oils.
A concentration of 50% TCA on one side of the face and 95% on the other side was DROPped or applied within atrophic scars, and the scar was pricked with a sharpened wooden applicators to facilitate deeper penetration. The emergence of white frosting in the treated sites was monitored closely. The areas showing insignificant frosting were recoated and special attention was drawn to the pain and erythema. Three sessions of TCA peeling were done with 4 weeks interval between each.
Immediate post peel washing to the skin with water was mandatory to minimize pain and erythema. A steroid-antibiotic cream twice daily was applied for the first week. The patients were instructed to avoid irritating soaps and crust picking. The patients were also instructed to avoid sun exposure and to use sunscreens with SPF>30 regularly.
Healing was within 1 week in the cheek side treated with TCA 50% with no prolonged erythema and no post inflammatory hyperpigmentation, compared to the other cheek side treated with TCA 95% in which the healing time was within 10 days with prolonged erythema and post inflammatory hyperpigmentation.
Skin biopsies were performed before treatment and eight weeks after the treatment. The histopathological measurements were carried out on hematoxylin and eosin and Masson’s trichrome stain to assess the collagen formation.
In our study we observed much more prominent perivascular inflammatory infiltrate and collagen remodeling with higher TCA concentration.
Clinical improvement in group 2 was excellent in 2 (10%)of the patients, good in 5 (25%) of the patients, fair in 9 (45%) of the patients and poor in 4 (20%) of the patients, However, in group 1 improvement was good in 6 (30%) of the patients, fair in 10 (50%) of the patients and poor in 4 (20%) of the patients.
Comparing between the effect of different TCA concentrations the number of collagen fibers and collagen remodeling was markedly improved on the side of the cheek treated with TCA 95% (group 2).