Lasers Med Sci
DOI 10.1007/s10103-015-1850-2
ORIGINAL ARTICLE
High versus moderate energy use of bipolar fractional
radiofrequency in the treatment of acne scars: a split-face
double-blinded randomized control trial pilot study
Weeranut Phothong 1 & Rungsima Wanitphakdeedecha 1 & Angkana Sathaworawong 1 &
Woraphong Manuskiatti 1
Received: 6 July 2015 / Accepted: 8 December 2015
# Springer-Verlag London 2015
Abstract Bipolar fractional radiofrequency (FRF) device
was firstly FDA-approved for treating atrophic acne scar in
2008 through the process of dermal coagulation and minimal
epidermal ablation. The average energy at 60 mJ/pin was
widely used to treat atrophic acne scars. However, the higher
energy was delivered, the deeper ablation and coagulation
were found. At present, the new generation of a device with
bipolar FRF technology with electrode-pin tip was developed
to maximize ability to deliver energy up to 100 mJ/pin. The
objective of the study was to explore and compare the efficacy
of utilizing high energy (100 mJ/pin) and moderate energy
(60 mJ/pin) of bipolar fractional radiofrequency in treatment
of atrophic acne scar in Asians. This is a split-face, double-
blinded, randomized control trial, pilot study by using parallel
group design technique. Thirty healthy subjects with
Fitzpatrick skin phototype III-IV diagnosed as atrophic acne
scares were enrolled. All subjects received four monthly ses-
sions of bipolar FRF treatment. Left and right facial sides of
individual patients were randomly assigned for different ener-
gy (high energy at 100 mJ/pin versus moderate energy at
60 mJ/pin). Acne scars improvement was blinded graded by
dermatologist using global acne scarring score (GASS) which
was subjectively evaluated at baseline, 1-, 3-, and 6-month
follow-up. Objective scar analysis was also done using
UVA-light video camera to measure scar volume, skin
smoothness, and wrinkle at baseline, 3-, and 6-month fol-
low-up after the last treatment. Side effects including pain,
* Rungsima Wanitphakdeedecha
rungsima.wan@mahidol.ac.th
1
Department of Dermatology, Faculty of Medicine Siriraj Hospital,
Mahidol University, 2 Pran-nok Road, Bangkoknoi, Bangkok 10700,
Thailand
erythema, swelling, and crusting were also recorded. Thirty
subjects completed the study with full 4-treatment course. The
mean GASS of high energy side and moderate energy side
was significantly reduced at 1-, 3-, and 6-month follow-up
visits. At 1 month follow-visit, high energy side demonstrated
significant improvement compared with moderate energy side
(p = 0.03). Postinflammatory hyperpigmentation (PIH) devel-
oped in 21/120 sessions in high energy side (17.5 %) and 16/
120 sessions in moderate energy side (13.3 %). Pain score and
the duration of erythema after treatments were significant
higher on the side that was treated with high energy. Bipolar
FRF device was safe and effective in the treatment of atrophic
acne scars in Asians. High energy setting demonstrated sig-
nificant higher efficacy at 1 month follow-visit. However, the
efficacy of both energy settings was comparable at 3- and 6-
month follow-up. In addition, side effects were significantly
more intense on the side treated with high energy.
Keywords Acne scars . Bipolar fractional radiofrequency .
Energy
Introduction
Acne scar is a burden of disfigurement following a common
dermatologic condition. Based on histopathology and patho-
physiology of acne scars, collagen fibers and elastin were
found to be diminished and deposited irregularly either in
whole dermis or middle to deep dermis in 74 % of scars [1,
2]. As a result, many dermatologic modalities have been de-
veloped toward the goal of re-collagenosis and re-elastosis.
Laser, both ablative and non-ablative, was used with either
water or hemoglobin/melanin as a chromophore targeting
ground substance, blood vessels, and adnexal structures,
resulting in collagen stimulation [3]. Ablative lasers were

Table 1 Technical parameters of
high versus moderate energy Technical parameters
settings
Energy (mJ/pin)
Power (watts) for 200 ohms skin resistance
RF frequency (hertz)
RF pulse duration (seconds)
preferred to non-ablative ones due to their superior efficacies.
However, the high incidence of postinflammatory hyperpig-
mentation (PIH) followed by ablative technology were found
several studies, especially in Asian population ranging from
45.5 to 90 % [4–7].
Radiofrequency (RF), a non-laser source of energy, was
then developed to treat atrophic acne scars. Instead of
chromophore-dependent mechanism of action, radiofrequen-
cy exerts in impedance-specific fashion (the inherit resistance
property of each tissue) [8]. In bipolar fractional radiofrequen-
cy device (FRF), arrays of negative and positive electrodes are
orderly placed on the contact tip in order to generate multiple
waves at radiofrequency [9]. When meeting the high imped-
ance tissue, this electromagnetic energy creates a bulk of heat
through either microneedles or multi-electrode pins resulting
in coagulation of the dermis with minor epidermal ablation
[10]. The higher energy of FRF is related to both deeper ab-
lation and deeper dermal depth of coagulation [11]. The stan-
dard energy for bipolar FRF has been 60 mJ/pin for the treat-
ment of acne scars. At present, the new generation MatrixTM
RF (Syneron Medical Ltd., Yokneam Illit Israel), a device
with bipolar FRF technology with electrode-pin tip, was de-
veloped to maximize ability to deliver energy up to 100 mJ/
pin. On the theory that more energy means deeper ablation
Fig. 1 The study flow diagram
Lasers Med Sci
High energy Moderate energy
100 mJ/pin 60 mJ/pin
200 W 200 W
1 MHz 1 MHz
20 ms for 200 ohms 32 ms for 200 ohms
and coagulation and greater mitigation of the atrophic scar-
ring. However, this hypothesis remained to be tested and
therefore we undertook this study.
The primary objective of this study was to compare the
efficacy of utilizing high energy (100 mJ/pin) and moderate
energy (60 mJ/pin) of bipolar FRF in treatment of atrophic
acne scar in Asians. In addition, adverse reactions such as pain
and PIH were also studied as secondary objective.
Methods
This is a split-face double-blinded randomized control trial
pilot study. Based on statistical calculation with 80 % power,
30 healthy subjects enrolled at Siriraj Skin Laser Center,
Siriraj Hospital. Patients were eligible for entry the study if
they were 18–60 years old, Fitzpatrick skin type III-IV, and
had mild to moderate atrophic acne scars without concurrent
hypertrophic scar. We excluded patients with specific facial
conditions; active acne, current infection, and photosensitive
dermatoses. Patients must have neither laser/radiofrequency
treatment within 3 months nor history of alpha hydroxyl
acid/topical retinoid use within 6 months. Other exclusion
criteria were current smoking, pregnancy, and lactation.
Lasers Med Sci
Table 2 Subjective evaluation of
acne scar improvement between Global Acne Scarring
high energy and moderate energy Scale (GASS)
sides
Baseline
1-month follow-up
3-month follow-up
6-month follow-up
p value
All subjects received four monthly sessions of bipolar
FRF for the treatment of atrophic acne scars (eMatrixTM;
Syneron Medical Ltd., Yokneam Illit, Israel). Before each
session, topical 2.5 % lidocaine and 2.5 % prilocaine
(RACSER cream; Zenta Healthcare, India) were applied
1 h prior to treatment. Left and right facial sides of indi-
vidual patients were randomly assigned for different ener-
gy (moderate energy of 60 mJ/pin or high energy of
100 mJ/pin) using block randomization. The technical pa-
rameters of these two energy settings were described in
Table 1. At each treatment session, two passes were per-
formed with assigned energy for each facial side in non-
overlap fashion all over the face. Then, additional up to
three passes were done on the area with deep acne scars,
depending on severity of scars and response from patients.
After the treatment, patients were instructed to use petro-
latum ointment to apply on the treatment area four times a
day for 7 days. Sun avoidance and protection were also
emphasized.
All subjects and evaluators were blinded for energy level
used. Global acne scarring score (GASS) [12] which assessed
both morphological and quantity aspects of scarring was sub-
jectively graded by a dermatologist as a primary outcome at
baseline, 1-week, 1-, 3-, and 6-month follow-up visit. All dig-
ital photographs used for evaluation were performed with a
facial photo fixture using a Canon PowerShot G10 stand-off
camera (OMNIA ImagingSystem, Canfield Scientific, Inc,
Fairfield, NJ).
Fig. 2 Clinical improvement of
acne scars after bipolar FRF
treatments with high and
moderate energy
High energy Moderate energy p value 95 % CI
(100/mJ/pin) (60 mJ/pin)
(Mean ± SD) (Mean ± SD)
4.9 ± 3.0 5.4 ± 2.8 0.11 −1.3 to 0.1
4.0 ± 2.8 4.6 ± 2.7 0.03 −1.1 to −0.1
3.8 ± 2.5 4.1 ± 2.5 0.16 −0.7 to 0.1
3.1 ± 2.5 3.3 ± 2.5 0.34 −0.5 to 0.2
<0.001 <0.001
In addition, acne scars analysis was objectively done by
using UVA-light video camera (VisioScan® 186 VC 98,
Courage-Khazaka, Köln, Germany) with analysis software
(Surface Evaluation of the Living Skin; SELS, Courage-
Khazaka). Concerned parameters included scar volume, skin
smoothness, and wrinkle. The measurement was performed
on the same selected area by the same technician at baseline,
1-, 3-, and 6-month follow-up after the last treatment. PIH was
also graded as the followings; 0 = none, 1 = mild, 2 = normal,
and 3 = severe. The pain score was rated by using visual analog
scale (VAS). Other side effects including erythema, swelling,
and crusting were also recorded.
GASS of two energy levels was compared and analyzed
using paired T test while GASS of each energy level at differ-
ent follow-up period was analyzed by repeated measure
ANOVA. SELS parameters and post-treatment reaction pa-
rameters were compared using paired T test. Cumulative
PIH scale was compared using Wilcoxon signed-rank test.
All statistical analysis was performed with SPSS statistical
analysis software version 18.0 (SPSS Inc., Chicago, IL, USA).
This study was approved by the Siriraj Institutional Review
Board (SIRB), Faculty of Medicine Siriraj Hospital’s human
research review committee, Mahidol University, and
conformed to the guidelines of the 1975 Declaration of
Helsinki. Written informed consent was obtained from all
study subjects. In addition, this study has been registered in
Thai Clinical Trials Registry (TCTR). The TCTR identifica-
tion of this study was TCTR20150629004.

Fig. 3 Clinical improvement was
demonstrated in the photographs
taken with UVA-light video
camera. The improvement could
be seen over time with both high
and moderate energy used
Results
Thirty subjects completed the study with full 4-
treatment course. Two subjects missed the 6-month fol-
low-up visit. Intention to treat analysis with last-
observation-carried-forward method was then applied.
The study flow diagram was shown in Fig. 1. Of all
30 subjects, there were 17 male (56.7 %) and 13 female
(43.3 %) patients with mean age of 31.1 years and
standard deviation of 7.6 years. Most of the subjects
had Fitzpatrick skin type IV (73.3 %), followed by type
V and III which were 23.3 and 3.3 %, respectively.
Median of acne scar duration was 8 years with inter-
quartile range of 3.8–10.5 years.
Subjective evaluation of acne scars improvement
using mean GASS was shown in Table 2. Baseline
GASS of high energy and moderate energy sides was
not statistically significant difference (4.9 vs. 5.4,
p = 0.11, mean difference = −0.6). The mean GASS of
high energy side and moderate energy side was signifi-
cantly reduced at 1-, 3-, and 6-month follow-up visits
(p < 0.001 and p < 0.001, respectively). Significant differ-
ence of GASS between two energy levels was found at
1-month follow-up visit (p = 0.03, 95 % CI −1.1 to
−0.06). We follow up subjects at 3 and 6 months after
the last treatment and found no significant difference in
GASS (p = 0.16 and 0.34, respectively). The clinical im-
provement of acne scars was shown in Fig. 2.
Table 3 Side effects of bipolar
FRF treatments Side effects High energy (100/mJ/pin)
(Mean ± SD)
Pain (VAS) 5.0 ± 1.6
Erythema (days) 3.6 ± 1.9
Swelling (days) 1.9 ± 1.2
Crusting (days) 6.0 ± 2.4
* p < 0.05
Lasers Med Sci
Objective evaluation with various parameters (scali-
ness, smoothness, roughness, wrinkles, surface, and vol-
ume) by using UVA-light video camera was analyzed by
SLES software. Only Wrinkles parameter demonstrated
statistically improvement over time in both high energy
and moderate energy sides (p = 0.001 and p = 0.039, re-
spectively). However, there was no statistically signifi-
cant difference found between two groups of different
energy (p = 0.590) (Fig. 3).
PIH developed in 21/120 sessions in high energy side
(17.5 %) and 16/120 sessions in moderate energy side
(13.3 %). Cumulative PIH scales of both high and mod-
erate energy side were not statistically significant differ-
ent (p = 0.142). Most of PIH were mild to moderate in
intensity and spontaneous resolved within 4 weeks. The
mean pain score on the side that was treated with high
energy was significantly higher than the side that was
treated with moderate energy (5.0 vs. 4.5, p = 0.001). In
addition, erythema after bipolar FRF with high energy
was lasted longer when comparing to moderate energy
(3.6 vs. 3.4, p = 0.04, respectively). Other side effects
found in this study were also demonstrated in Table 3.
Discussion
Radiofrequency (RF) technology is classified as unipo-
lar, bipolar, or multipolar depending on the number of
Moderate energy (60 mJ/pin) p value
(Mean ± SD)
4.5 ± 1.7 0.001*
3.4 ± 2.0 0.040*
1.8 ± 1.3 0.230
6.1 ± 2.6 0.630
Lasers Med Sci
electrodes used with additional modalities including
FRF, sublative RF, phase-controlled RF, and combina-
tion RF with light, massage, or pulsed electromagnetic
fields (PEMFs) [13]. The clinical efficacy of using FRF
in the treatment of acne scars in Asians has been shown
in several studies [14, 15].
Many studies were conducted to evaluate efficacy of RF in
the treatment of acne scar. Most of them reported 25–75 %
clinical improvement. Total number of sessions ranged from 2
to 4. Gold and colleagues [16] good to excellent cosmetic
result in 73 % of subjects after four bipolar FRF treatments
at 32–56 mJ/pin at monthly interval.
Since bipolar FRF at higher energy causes more of
epidermal ablation and deeper coagulation, most studies
conducted in darker Fitzpatrick skin type participants
were limited the energy used to lower or moderate level
in order to avoid PIH. To the best of our knowledge,
this study was the first to explore the use of bipolar
FRF at high energy up to 100 mJ/pin in Asians.
However, there was no statistically significant difference
in cumulative PIH scale found between high and mod-
erate energy side (p = 0.142). But, PIH incidence in this
study of high and moderate energy (17.5 and 13.3 %,
respectively) was higher than other study in patients
with Fitzpatrick skin type III-IV [17]. This might result
from our exclusion criteria of history and current uses
of retinoid and/or bleaching agents while previous study
included them.
Apart from the improvement of acne scar, objective
evaluation by using UVA-light video camera and SLES
software demonstrated the improvement of wrinkles.
Both high and moderate energy side demonstrated the
significant improvement on wrinkle at 6-month follow-
up visit (p = 0.001 and p = 0.039, respectively) without
any significant difference of improvement between these
two groups. This finding supported the benefit of reju-
venation by FRF in previous studies [18].
In addition, this present study demonstrated the con-
tinued clinical improvement of acne scars over time af-
ter bipolar FRF treatment when using either 100 or
60 mJ/pin (Table 2, Fig. 3). This finding was consistent
with the previous studies using ablative fractional
carbon-dioxide laser, ablative fractional erbium:YAG la-
ser, and fractional RF microneedle system [19, 20]. The
authors also reported the improvement of acne scars up
until 6 months after the last treatment as the replace-
ment of dermal tissue with newly formed collagen per-
sistently progressed [21].
At 1 month after the last treatment, high energy
treated side demonstrated significant higher GASS
while this difference was not found at 3 and 6 months
after the last treatment. The initial effect of wound
healing process was more obvious in high energy
setting which might be a result of bigger ablative col-
umn. However, the collagen formation occurred gradu-
ally and later so the longer period of follow-up, the
lesser difference of scar appearance was found.
Higher energy level employed in FRF treatment was
significantly related to the increased pain and accumulative
heating sensation. In our study, subjects rated higher pain
on the high energy side and this was statistically signifi-
cant (p ≤ 0.05). This uncomfortable experience might pre-
vent patients from participation in the following sessions.
In the study of Yeung et al., 12.5 % of participants with-
drawn from the study due to significant pain during the
procedure [22]. Higher energy setting was related to lon-
ger erythematous appearance (p = 0.04). However, when
95 % CI (0.1–0.3) was taken into account, the difference
could be estimated as 2–7 h which might not significantly
affect subject’s daily activities.
Our limitation included different number of passes in
each patient which depended on the performer’s opin-
ion. However, every patient received treatments from
the same dermatologist; this result should be reproduc-
ible. In our study, subjects rated higher pain on the high
energy side and this was statistically significant (p = 0.001).
This uncomfortable experience might prevent patients from
participation in the following sessions.
In summary, this study demonstrated that bipolar FRF
device was safe and effective in the treatment of atro-
phic acne scars in Asians. High energy setting demon-
strated significant higher efficacy at 1 month after treat-
ment when compared with moderate energy setting.
However, pain was significantly more intense on the
side treated with high energy. Therefore, risks and ben-
efits must be taken into account prior to changing any
treatment parameters.
Acknowledgment This research project is supported by Faculty of
Medicine Siriraj Hospital, Mahidol University. The authors wish to thank
Ms. Phassara Klamsawat and Ms. Phonsuk Yamlexnoi for their assis-
tances in recruiting subjects and managing the database.
Author contributions Dr. Manuskiatti had full access to all of the data
in the study and takes responsibility for the integrity of data and the
accuracy of the data analysis.
Study concept and design: Dr. Manuskiatti
Acquistition of data: Drs. Phothong and Sathaworawong
Analysis and interpretation of data: Drs. Phothong, Sathaworawong,
and Wanitphakdeedecha
Drafting of the manuscript: Dr. Phothong
Critical revision of the manuscript for important intellectual content:
Drs. Wanitphakdeedecha and Manuskiatti
Statistical analysis: Drs. Phothong and Sathaworawong
Obtained funding: none
Administrative, technical, or material support: Drs.
Wanitphakdeedecha and Manuskiatti
Study supervision: Dr. Manuskiatti

Compliance with ethical standards This study was approved by the
Siriraj Institutional Review Board (SIRB), Faculty of Medicine Siriraj
Hospital’s human research review committee, Mahidol University, and
conformed to the guidelines of the 1975 Declaration of Helsinki. Written
informed consent was obtained from all study subjects. In addition, this
study has been registered in Thai Clinical Trials Registry (TCTR). The
TCTR identification of this study was TCTR20150629004.
Conflict of interest The authors declare that they have no competing
interests.
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