Journal of Dermatological Treatment.

2008; 19: 45–49

ORIGINAL ARTICLE

Fractional photothermolysis for the treatment of acne scars: A report of

27 Korean patients

HYOUN SEUNG LEE1, JONG HEE LEE2, GUN YOUNG AHN1, DONG HUN LEE2,
JUNG WON SHIN2, DONG HYUN KIM2 & JIN HO CHUNG2
1
Gowoonsesang Dermatology Clinic, and 2Department of Dermatology, Seoul National University College of Medicine,
Laboratory of Cutaneous Aging Research, Clinical Research Institute, Seoul National University Hospital, and Institute of
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Dermatological Science, Seoul National University, Seoul, Korea

Abstract
Objectives: Atrophic post-acne scarring remains a therapeutically challenging condition despite various currently available
technologies. Fractional photothermolysis (FP) is a novel concept of cutaneous resurfacing which induces non-contiguous
microscopic thermal injury. The aim of this study is to evaluate the safety and efficacy of FP in the treatment of acne scars in
Asian patients. Methods: A total of 27 Korean patients (Fitzpatrick skin types IV or V) with moderate to severe facial acne
scars received three to five sessions of FP treatment (Fraxel2 Laser; Reliant Technologies, CA, USA), each spaced 3–4
weeks apart. Standardized digital photographs were obtained before each treatment and 3 months after the final treatment.
For personal use only.

In addition, the patients’ perceived degrees of improvement were assessed 3 months after the final treatment using a five-
point grading scale. Results: FP led to marked improvement in the appearance of acne scars at 3 months post-treatment.
Patients’ self-assessed degrees of improvement were as follows: excellent improvement in eight patients (30%), significant
improvement in 16 patients (59%), and moderate improvement in three patients (11%). Adverse events were limited to
transient pain, erythema and edema. Conclusions: The 1550-nm erbium-doped FP is associated with significant patient-
reported improvement in the appearance of acne scars, with minimal downtime.

Key words: Acne scar, fractional photothermolysis, laser resurfacing

Introduction considered as the gold standard in laser skin

Atrophic acne scarring, a well-known and often
disfiguring sequel of acne vulgaris, is a common
dermatologic condition that can be devastating to
sufferers (1). Post-acne scarring may affect approxi-
mately 95% of patients with acne and was related to
both its severity and delay before adequate treatment
(2). There have been great achievements in treating
acne over the past few decades, but post-acne
scarring still presents a therapeutic challenge. The
wide variety of therapeutic modalities that have been
employed to improve the appearance of acne scars
include punch excision, punch elevation, dermabra-
sion, subcutaneous incision (subcision), chemical
peeling, ablative or non-ablative laser skin resurfa-
cing, and subcutaneous or dermal fillers such as
hyaluronic acid derivatives (3). While ablative lasers
such as carbon dioxide (CO2) or erbium:yttrium-
aluminum-garnet (Er:YAG) lasers have been
resurfacing, patients can undergo post-laser
erythema, swelling and even dyspigmentation for a
significant period of time. In contrast, non-ablative
remodeling lasers such as Nd:YAG (1320 nm or
1064 nm) and diode (1450 nm) lasers, along with
radiofrequency devices, can also ameliorate the
appearance of acne scars without significant down-
time, but with less efficacy.
In order to address these shortcomings of previous
resurfacing modalities, fractional photothermolysis
(FP) has been recently developed. FP deploys
multiple non-contiguous arrays of thermal injury to
create unique damage patterns called microthermal
treatment zones (MTZ), and characteristically
spares the tissue surrounding each MTZ (4).
Although there have been some reports of the
successful treatment of scars using fractional photo-
thermolysis (FP) technology (5–8), a prospective
study on Asian patients has not yet been performed.

Correspondence: Jin Ho Chung, Department of Dermatology, Seoul National University Hospital, 28, Yongon-Dong Chongno-gu, Seoul, 110-744, Korea.
Fax: +82 2 742 7344. E-mail: jhchung@snu.ac.kr

(Received 31 August 2007; accepted 16 September 2007)

ISSN 0954-6634 print/ISSN 1471-1753 online # 2008 Informa UK Ltd.
DOI: 10.1080/09546630701691244
 46 H. S. Lee et al.

The objective of this study was to investigate the 1500 MTZ/cm2. Treatment parameters were
safety and efficacy of FP in the treatment of adjusted based on the scar severity and each
moderate to severe acne scars in Asian patients. patient’s tolerability. Forced air-cooling was used
throughout the treatment to improve patients’
comfort and compliance. Three to five successive
Patients and methods treatment sessions were performed at intervals of 3–
4 weeks.
Twenty-seven patients (seven men and 20 women)
Therapeutic outcomes were assessed by standar-
with moderate to severe atrophic acne scars were
dized digital photography and patients’ self-assess-
enrolled in this study. Their ages ranged from 20 to
ment of treatment outcome at 3 months after the
43 years (mean age: 28.5 years old) and their
final treatment. Digital photographs of the face were
Fitzpatrick skin types were IV–V. The severity of
obtained using identical camera settings (Epson
acne scars was determined based on the qualitative
Photo PC 3000Z; Epson America, Inc., Long
grading system proposed recently (9). Briefly, we
Beach, CA, USA) and lighting conditions at each
included patients with significant rolling, shallow
follow-up session. The self-assessed level of
boxcar, deep boxcar, and icepick scars. Written
improvement from the patients was evaluated using
informed consent was obtained from each patient.
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the following five-point scale: 05no change;

Exclusion criteria included known photosensitivity,
15slight improvement (0–25%); 25moderate
pregnancy or lactation, history of hypertrophic or
improvement (26–50%); 35significant improve-
keloidal scarring, and the use of isotretinoin or other
ment (51–75%); 45excellent improvement
physical acne treatments over the past 6 months.
(w75%). In addition, the participants were asked
Patients who had any medical illness that could
to report any cutaneous or systemic side effects
influence the wound healing process were also
associated with FP treatment. In particular, a pain
excluded. Patients were allowed to continue pre-
scale of 0–10 was used to determine the level of
vious acne medications during the study except
discomfort during the procedures.
isotretinoin.
Prior to each treatment, the face was cleansed with
For personal use only.

a mild non-abrasive detergent and gauzes soaked in

70% isopropyl alcohol. A topical anesthetic cream
(EMLA; AstraZeneca, Wilmington, DE, USA) was
applied under an occlusive dressing for 1 hour and
subsequently washed off. A water-soluble blue dye
(OptiGuide Blue; Reliant Technologies, CA, USA)
was applied on the face to accentuate scar contours
and to guarantee laser–skin contact. A 1550-nm
erbium-doped FP laser (Fraxel2 Laser; Reliant
Technologies) was delivered to the areas at a fluence
of 12–20 mJ/MTZ, a total density of 750–
Results
All patients completed the study, including the 3-
month follow-ups. Most patients had mixed types of
atrophic acne scars, including icepick, boxcar, and
rolling scars. FP was associated with substantial
improvement in the appearance of all types of acne
scars, which included the softening of scar contours
as well as the reduction of scar depth (Figure 1).
Most patients began to show a visible improvement
following only one session (Figure 2). At 3 months

Figure 1. Acne scars on the face of a representative patient showed substantial improvement at 3 months post-treatment (A: baseline; B: 3
months after three sessions of FP treatment).

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Figure 2. Acne scars, including deep boxcar and icepick scars, showed visible improvement following only one session of FP treatment (A:
baseline; B: 4 weeks after one session of FP treatment).
after the final treatment, eight patients (30%)
reported excellent improvement, 16 patients (59%)
significant improvement, and three patients (11%)
moderate improvement in the appearance of the
For personal use only.
acne scars. The mean score of the overall degree of
improvement as reported by patients was 3.19
(Figure 3).
The laser treatment was generally well tolerated.
All participants underwent treatment-related pain
with a mean pain score of 5.65, but there was no
need for extra anesthesia. All participants reported
mild erythema for approximately 3 days, and 80% of
patients experienced edema for 24–48 hours follow-
ing laser treatment. Social activity could commence
as early as 1 day after the laser treatment. Other
possible adverse events related to laser treatment,
such as pigmentary alterations, vesiculation, crust,
scarring, and infection were not observed.
Discussion
Atrophic acne scars occur as a consequence of
impaired resolution or would healing after the
Figure 3. Patients’ self-assessment of treatment outcome at 3
months after the final treatment using a five-point scale: no
change, slight improvement (0–25% improvement), moderate
improvement (26–50%), significant improvement (51–75%), and
excellent improvement (w75%).
Fractional photothermolysis for acne scars 47
damage of sebaceous follicles during active inflam-
mation (10), and are usually classified into icepick,
rolling, and boxcar scars according to shape and
depth (11). They affect deeper structures, and draw
the tissues on the surface, and thereby cause
indentation or atrophy. There is also loss of tissue
by the inflammatory mediators from disrupted acne
follicles and cysts (12). Although ablative and non-
ablative laser skin resurfacing has greatly improved
the treatment of atrophic acne scars, these scars still
present a therapeutic challenge. Ablative laser
resurfacing has been carried out using CO2 and
Er:YAG lasers with 25–90% efficacy for the treat-
ment of acne scars (13). However, postoperative
erythema can last up to 3 months on average, and
dyspigmentation, infection, and scarring may ensue.
In particular, postoperative hyperpigmentation,
although usually transient, is relatively common in
darker skin types.
On the other hand, non-ablative lasers stimulate
collagen production and remodeling through dermal
heating with concomitant epidermal cooling.
Clinical improvement of scars by 40–50% might be
expected after the series of treatments (14).
Previously, 1320-nm Nd:YAG (15–20), 1064-nm
Nd:YAG (21,22), and 1450-nm diode (16,23) lasers
were reported to be effective for the treatment of
post-acne scarring. The amelioration of acne scars
by non-ablative lasers, however, is usually limited to
rolling or shallow boxcar scars with no epidermal
resurfacing effect. The rate of post-laser hyperpig-
mentation varied, with the range of 3–11% for 1320-
nm Nd:YAG and 7–9% for 1450-nm diode lasers in
studies including darker skin types [24].
In contrast to the aforementioned modalities, FP
generates multiple non-contiguous zones of thermal
damage (MTZ) in the epidermis and dermis, sparing
 48 H. S. Lee et al.
the viable tissue surrounding each MTZ. FP
stimulates epidermal turnover and dermal collagen
remodeling, which leads to significant improvements
in a variety of scars (5–8). In addition, the use of the
1550-nm wavelength, targeting water as its active
chromophore, in a pixilated manner allows rapid re-
epithelization and reduces the risk of pigmentary
sequelae in dark-skinned patients.
Whereas photothermal effects of ablative lasers are
associated with shrinkage of collagen, neocollagen-
esis and collagen remodeling (14), sublethal injury of
vascular endothelial cells and fibroblasts by non-
ablative lasers appears to initiate a cascade of dermal
remodeling through the induction of a various array
of cytokines and enzymes involved in the wound
healing process (21). Skin responses to FP are
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concordant with the induction of the wound healing
response, and the recruitment of myofibroblasts can
provide additional skin tightening effects (25).
More recently, Hasegawa and colleagues reported
case reports of 10 patients with acne scars (without
remarking on the initial severity of acnes scars) who
responded to FP treatment using a fluence of 6 mJ
and a density of 1000–1500 MTZ/cm2 (7). We used a
fluence of 12–20 mJ and a density of 750–1500 MTZ,
based on the depth of scars and each patient’s
For personal use only.
tolerability to laser treatment. The depth and width
of each MTZ are proportional to the energy used. The
use of high energy and low density seems to be more
appropriate for the treatment of acne scars in Asian
patients, as previously suggested (26,27).
In this study, patients’ perceived degrees of
improvement were 3.19 on average, which meant
‘more than significant improvement’. In procedures
aiming at aesthetic improvement, patient perception
of the treatment outcome appears to be most
important because it has a direct impact on patients’
body image and self-esteem (28), and clinicians tend
to underestimate the severity perceived by the
patients (29). Using the parameters described above,
even patients with icepick and deeper boxcar scars,
which were very resistant to conventional laser
treatments, began to notice visible improvement
after only one session. Moreover, many patients
mentioned they experienced a noteworthy improve-
ment in ‘skin quality’ and subsequently can wear
more natural makeup. These results are comparable
with those measured by physicians using the long-
pulsed Er:YAG laser, which revealed excellent
results in 36%, good results in 57%, and fair results
in 7% of patients (30). Since FP stimulates
epidermal thickening and leads to the significant
production and reorganization of collagen and
elastic fiber networks (31), the results are expected
to be long-lasting.
In conclusion, FP can be a safe and effective
option for the treatment of acne scars in Asian skin.
Optimal treatment parameters, treatment intervals,
and long-term clinical data for FP have yet to be
determined. In addition, combination treatment
with other available modalities might constitute a
synergistic approach for optimal outcomes.
Acknowledgement
Conflict of interest: No sources of funding were used
to assist in the preparation of this article. The
authors have no conflicts of interest that are directly
relevant to the content of this article.
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