Treatment of Acne Scars Using Fractional Erbium:
Shakir J. Al-Saedy
, Maytham M. Al-Hilo
, Salah H. Al-Shami
MBChB, FICMS, DV, Consultant Dermatologist and Venereologist, Al-Kindy Teaching Hospital, Baghdad, Iraq
MBChB., Al-Kindy Teaching Hospital, Baghdad, Iraq
Background: Acne is a common disorder experienced by people between 11 and 30 years of age and to lesser
extent by older adults. Fractional resurfacing employs a unique mechanism of action that repairs a fraction of skin at a time.
The untreated healthy skin remains intact and actually aids the repair process, promoting rapid healing with only a day or two
of downtime. Objective: This study is designed to evaluate the safety and effectiveness of fractional photothermolysis
(fractionated Erbium: YAG laser) in treating moderate – severe atrophic acne scars. Methods: Thirty one females and 9 males
with moderate to severe atrophic acne scarring were enrolled in this study that attained Beirut Private Center for Laser
Treatments in Baghdad, Iraq during the period from March, 1
2011 to September, 1
2011. Fractional Erbium:YAG laser
2940 nm wavelength was delivered to the whole face with a single pass treatment and for the acne scar areas with two passes.
Therapeutic outcomes were assessed by standardized digital photography
Results: Ten patients (25%) reported excellent
patients (10%) mild improvement in the appearance of the acne scars. Conclusion: Erbium:YAG laser is an effective device
for skin resurfacing with faster recovery time and fewer side effects in comparison to other treatment modalities.
Acne, Atrophic acne scar, Fractional Er: YAG laser
Acne is a common disorder experienced by up to 80% of
people between 11 and 30 years of age and by up to 5% of
older adults . Several factors are incriminated in the
pathogenesis of acne including increased sebum production,
follicular abmormal keratinization, colonization with
Propionibacterium acnes, and a lymphocytic and
neutrophilic inflammatory response . The severe
inflammatory response to P acnes may results in permanent
disfiguring scars. Stigmata of severe acne scarring can lead
to social ostracism, withdrawal from society, and severe
psychological depression . Patients dislike the appearance
of acne, and prevention of acne scarring is often a key
motivation behind treatment.
Once scarring has occurred, patients and physicians are
left to struggle with the options available for improving the
appearance of the skin .
Acne scarring can be divided into 3 basic types: icepick
further subdivided into shallow or deep .
Other less common scars such as sinus tracts, hypertrophic
* Corresponding author:
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scars, and keloidal scars may occur after acne treatment .
Their treatment options include excision, cryosurgery,
pulsed dye laser treatment, compression with silicone
sheeting, and various other modalities .
Goodman proposed a qualitative global acne scarring
grading system (table 1) (Greg. J. Goodman and Jennifer A.
The concept of fractional photothermolysis revolutionized
cutaneous laser resurfacing when introduced by Manstein et
al in 2004. Using a nonablative, 1550-nm Er-doped fiber
laser, full-thickness columns of thermal injury (termed
microthermal treatment zones or MTZs) are created in a
pixelated pattern just below the level of the stratum corneum,
with the surrounding skin left intact.
Fractional resurfacing employs a unique mechanism of
action that repairs a fraction of skin at a time. The laser is
used to resurface the epidermis and, at the same time, to heat
the dermis to promote safely the formation of new collagen.
The untreated healthy skin remains intact and actually aids
the repair process, promoting rapid healing with only a day
or two of downtime . The primary target is both the
epidermis and dermis with the aim of creating small zones of
micro-damage separated by zones of non irradiated tissue
that assist with the rapid healing process. The aim of the
fractional approach is to obtain the best possible results with
the least possible damage, and the degree of thermal damage
delivered to the target skin depends on the dosage, the pulse
Shakir J. Al-Saedy et al.: Treatment of Acne Scars Using Fractional Erbium: YAG Laser
target area .
Er:YAG laser is a flashlamp-excited system that emits
is about 16 times better absorbed by tissue water than the
10,600 nm wavelength emitted by the CO2 laser. The
Er:YAG laser produces a pulse of 250-350 microseconds
that is less than the thermal relaxation time of the skin, which
is 1 msec. Also, the Er:YAG laser causes tissue ablation with
very little tissue vaporization and desiccation. The ablation
threshold of the Er:YAG laser for human skin has been
calculated at 1.6 J/cm
as compared with 5 J/cm
for high-energy, short-pulse CO2 laser systems. Because the
Er:YAG laser is so exquisitely absorbed
by water, it causes
damage. In contrast, the high-energy, short-pulse CO2 lasers
cause l00-120 μm of tissue damage, which is composed of
50-60 μm of apparent tissue desiccation (ablation or
coagulation) and an additional 50-75 μm of thermal damage.
The precise tissue ablation and small zone of residual
thermal damage results in faster reepithelialization and an
improved side effect profile. Apart from water being the
major chromophore of skin ablative lasers, the Er:YAG laser
wavelength is also absorbed by the collagen, further
supporting the ablation process within the deeper dermal
In 1997 the FDA approved Er:YAG laser for resurfacing
 and since then it gained more and more interest for the
purpose of resurfacing procedures, such as in acne scars or in
the rejuvenation of photoaged skin areas. In addition, many
other skin disorders formerly treated by dermabrasion or that
were indication for thermal laser coagulation or vaporization
can be removed by Er:YAG skin ablation (Table 2). They
comprise many superficial lesions derived from epidermal or
adnexal structures, but also various circumscribed
malformations and benign tumors located deeper within the
dermis. In addition, certain pigmented and melanocytic
lesions, as well as a variety of miscellaneous pathological
conditions can be removed [14-18].
This study, was designed to evaluate the safety and
effectiveness of fractional photothermolysis (fractionated
Erbium:YAG laser) in treating moderate – severe atrophic
2. Patients & Methods
This is an open therapeutic trial study performed at Beirut
Private Center for Laser Treatments in Baghdad, Iraq during
the period from March, 1
patients (31 females and 9 males) with moderate to severe
atrophic acne scarring according to Goodman’s qualitative
global scarring grading system were included in this study.
Their age ranges from 17-48 years with a mean ± SD of
28.075 ± 6.87 years. Their skin types were III – IV
(Fitzpatrick skin types). This study approved by the ethical
committee in Al-Kindy teaching hospital. Written informed
consent was obtained from each patient.
Exclusion criteria include known photosensitivity,
pregnancy or lactation, inflammatory skin disorders or active
herpes infection. Patients with hypertrophic or keloidal
scarring or history of hypertrophic or keloid were driven out
of the study. The use of anti-coagulants, isotretinoin or other
physical acne treatments over the past 6 months, patients
who had any medical illness (e.g. diabetes, chronic
infections, blood dyscrasias) that could influence the wound
healing process were also excluded. Patients were allowed to
continue previous acne medications during the study except
The whole procedure was fully explained and thoroughly
discussed with the patients about the mechanism of laser
treatment, the time required for the treatment, the behavior
after the laser treatment, and the prospects of successful
treatment and any unrealistic expectations of the end results
were strongly discouraged. The patients were informed
about all risks that may be caused by the laser treatment and
the pre- and post-operative care.
Prior to each treatment, the face was cleansed with a mild
non-abrasive detergent and gauzes soaked in 70% isopropyl
A topical anesthetic cream (EMLA, a eutectic mixture of
local anesthesia of 2.5% lidocaine and 2.5% prilocaine,
AstraZenica LP, Wilmington DE) was applied under an
occlusive dressing for 1 hour and subsequently washed off to
obtain completely dry skin surface. Eyes were protected with
opaque goggles. Systemic antiviral therapy (acyclovir 400
mg twice daily) prescribed for each patient the night before
operation as prophylaxis and for five days post operatively as
well as topical antibiotics and a moisturizing cream, the
patients were informed to apply a sunscreen for six weeks.
Three photos were taken before treatment for each patient
for both sides and the front of the face with a digital camera
visit post-treatment using identical camera settings, lighting,
and patient positioning.
Fractional Erbium:YAG laser (MCL30 Dermablate,
Asclepion Laser Technologies, Germany) 2940 nm
wavelength was delivered to the whole face with a single
pass treatment and with two passes for the acne scar areas
with total fluence of 108 J/cm
, interval of 0.5 second, and
169 microbeams with pulse energy on the treated site of 1.5 J.
The same parameters applied for all patients. Smoke
evacuator and a forced air cooling system (Zimmer
MedizinSystemme, Cryo version 6) accompanied the
procedure to improve patients comfort and compliance.
Patients were asked to return for medical assessment 1 week
after operation then followed up monthly for 3 months.
Therapeutic outcomes were assessed by standardized
digital photography by the patient himself and by two
blinded dermatologists. The dermatologists' evaluation and
self-assessment level of improvement of the patients were
evaluated using the following five-point scale:
0 = no change;
American Journal of Dermatology and Venereology 2014, 3(2): 43-49
2 = moderate improvement (26–50%);
3 = significant improvement (51–75%);
4 = excellent improvement (>75%).
The two assessors were blinded to the order of the
photographs. The evaluators were asked to perform two
actions. First, to identify the photograph that showed better
scar appearance. Second, to rate the difference in the severity
of the acne scars using the above mentioned scale.
In addition, the participants were asked to report any
cutaneous or systemic side effects associated with laser
treatment. In particular, a pain scale of 0–3 was used to
determine the level of discomfort during the procedures as
0 = no pain
1 = mild pain
2 = moderate pain
3 = severe pain
Statistical data were analyzed by Chi test using Software
Minitab V.16 and P value < 0.05 is considered statistically
significant descriptive data by frequency, percent, figure and
Figure 2. Patient no.2 pre- and 3 months post-operatively
Figure 3. Patient no.3 pre- and 3 months post-operatively
observer irrespective of distance
Erythematous, hyper- or hypo
–pigmented flat marks
of 50 cm or greater and may be covered adequately by makeup or the
normal shadow of shaved beard hair in males or normal body hair if
Mild rolling, small soft papular
distances of 50 cm or greater and is not covered easily by makeup the
normal shadow of shaved beard hair in males or body hair if extrafacial,
but is still able to be flattened by manual stretching of the skin
More significant rolling, shallow
‘‘box car ,’’ mild to moderate
hypertrophic or papular scars
distances of 50 cm or greater and is not covered easily by makeup or the
normal shadow of shaved beard hair in males or body hair (if extrafacial)
and is not able to be flattened by manual stretching of the skin
Punched out atrophic (deep
‘‘boxcar’’), ‘‘ice pick’’, bridges and
tunnels, gross atrophy, dystrophic
scars, significant hypertrophy or
Table 4. Response to treatment by Er:YAG laser for the level of improvement assessed by the patient
Forty patients (31 females and 9 males) were included in
the study. All patients completed the study, including the 3-
month follow-up period. All patients had mixed types of
atrophic acne scars, including ice pick, boxcar, and rolling
scars, although, some particular type predominates and
therefore is used to classify the patients accordingly (Table
results were escalating dramatically from 5% in 1
this group is not the major group who shows improvement.
Significant improvement group shows increase from 20%
after 1 week to 50% after 3 months, it gives us a strong
indicator of the overall results.
The improvement scale was so obvious from first week
(30% mild to 5% significant) through 4
– and 8
become more satisfactory (10% mild to 25%) after three
months of operation.
The final results after 3 months were as follows: Ten
patients (25%) reported excellent improvement, twenty one
patients (50%) significant improvement, six patients (15%)
moderate improvement, and four patients (10%) mild
improvement in the appearance of the acne scars. The results
were significant as indicated by the P value which was 0.002.
The patients self assessment of improvement was also
4). The results were almost comparable to the
dermatologists' assessment and were considered significant
as indicated by the P value which was 0.001.
Table (3) shows that the two factors (scores and weeks)
are not independent, in another words there is a relationship
between two factors (chi-square value 25.591 df=9 P=0.002).
Similar conclusion can be reported for Table (4) (chi-square
value 27.30 df=9 P=0.001)
The laser treatment was generally well tolerated. All
participants underwent treatment-related pain, but there was
no need for extra anesthesia (Table 5).
All participants reported mild erythema for approximately
2-3 days, and 80% of patients experienced edema for <24
hours following laser treatment. Peeling occurs from the
second day and completed in the fifth day in 90% of the
patients and in 10% last for 7 days. Social activity could
commence as early as 3 days after the laser treatment. Other
possible adverse events related to laser treatment in general,
such as pigmentary alterations (hyperpigmentation),
bleeding, vesiculation, crust, scarring, and infection were not
observed. (Table 6)
In this open therapeutic trial study, patients received
fractional Er:YAG laser in a single treatment session. The
final outcome was evaluated after three months period by
two blinded dermatologists and by the patient's
self-assessment using standardized digital photography. The
results were very satisfactory as more than 60% of patients
showed moderate to significant improvement. The patients'
self assessment is slightly lower than that of the
dermatologists; this might be attributed to the fact that the
patients usually use more subjective than objective scales,
and they show a higher level of expectations of end results
than the actual outcome. The results of both assessment
groups (the patients and the dermatologists) are significant as
indicated by the P values which were 0.001 and 0.002
According to best of our knowledge in fractional
photothermolysis, studies that investigate the role of
Erbium:YAG laser as a sole option in the treatment of
atrophic acne scars are lacking or very limited. There were
no controlled trials but few case series which reported the
effects of either the carbon dioxide or erbium:YAG laser. All
of the studies were of poor quality. The types and severity of
scarring were poorly described and there was no standard
scale used to measure scar improvement. There was no
reliable or validated measure of patient satisfaction; most
improvement was based on visual clinical judgment, in many
cases without blinded assessment . This might be
partially attributed to the fact that Er:YAG laser is
considered as a superficial laser and is usually not substantial
for the treatment of the relatively deep lesions of acne scars.
In a series of 78 patients, Weinstein  reported 70-90%
improvement of acne scarring in the majority of patients
treated with a modulated Er:YAG laser. He proposed that
pitted acne scars may require ancillary procedures, such as
subcision or punch excision, for optimal results. These
procedures can be performed either prior to or concomitant
with Er:YAG laser resurfacing.
The effect of fractional CO2 laser on skin resurfacing is
fully considered worldwide. However, there have been
limited studies comparing the clinical outcome and adverse
effects of these two lasers (CO2 vs. Er:YAG). In two studies,
one conducted in Iraq  and another one in Thailand [30),
investigating the efficacy of fractional CO2 laser for the
treatment of acne scars, 75% of the CO2 laser sites were
graded as having moderate to significant improvement of
scars. Their end-results were not significantly different from
our results after 3 months follow-up (65% showed moderate
to significant improvement) but taking in consideration the
duration of operation which was much shorter for Er:YAG
laser than the time needed to operate with CO2 laser (less
than 10 minutes for Er:YAG compared to 45 minutes for
CO2 laser). The post-operative pain, edema, erythema and
duration of peeling were less and more tolerable and
acceptable than that were associated with CO2 laser
treatment. In contrast to CO2 laser resurfacing, the narrower
zone of necrosis produced by the Er:YAG laser will allow
the skin to recover faster . Pigment alteration, which is a
common side effect of CO2 laser, was not reported with
Er:YAG laser in any of our patients even with those who
don't commit to strict sunscreen.
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, which can be obtained superbly by
the CO2 laser but when the Er:YAG laser is used for
resurfacing in the fractional mode, the results are noteworthy,
recovery time is considerably shortened and traditional
post-resurfacing sequelae are absent. Consequently this
allows the patients a rapid return to their social or work
Using the parameters mentioned earlier in this study, all
patients show different level of improvement ranging from
mild to excellent results after only one session of laser
treatment even in patients with icepick or deep boxcar scars
which are usually resistant to other conventional laser
treatment. Furthermore, many patients mentioned they
experienced a remarkable improvement in ‘skin quality’ and
subsequently can wear more natural makeup.
The final outcome of our treatment is best read after 3-6
months post-operatively. This time is usually needed for new
collagen remodeling  and it was the same time interval
we use to follow up our patients and read their end-results
which were significantly different from the results after one
Most types of acne scars will benefit to some degree by
laser resurfacing techniques. In acne scars the precision of
sculpturing with excellent visual control and minimal heat
damage can make Er:YAG laser ablation superior to CO2
laser. Moreover, thermal damage to follicles and sebaceous
glands can be avoided, so that acne flare ups, as reported
after CO2 laser is not reported .
In general, Erbium:YAG laser is an effective device for
skin resurfacing and has faster recovery time and fewer side
effects when compared to the CO2 laser resurfacing .
1. Fractional Erbium:YAG photothermolysis can be a safe
and effective option for the treatment of acne scars in Iraqi
patients by offering faster recovery time and fewer side
2. Fractional Erbium:YAG photothermolysis was
associated with substantial improvement in the appearance
of all types of acne scar, which includes the softening of scar
contours as well as the reduction of scar depth.
3. Most patients began to show a visible improvement
following only one session. According to visual assessments
of patients and dermatologists, patients' improvement
continues to occur even after 3 months of operation.
We need further studies with:
1. higher fluence and more passes.
2. more treatment sessions.
3. further follow up for 6-12 months.
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