KNOWLEDGE CASE STUDY 21

SCAR issues Dr Patrick Treacy evaluates Radiesse as a treatment in

atrophic acne scarring

A
cne occurs in about 95% of 16-17
year-old boys and 84% of 16-17
year-old girls. Although the condi-
tion usually resolves by the mid
twenties; nevertheless, 1% of men
and 5% of women still bear signs of moderately
severe acne scarring at 40 years of age. Some
studies show scarring of some degree may affect
up to 95% of patients with acne.
Atrophic scarring often appears years later
and can cause great distress. Affected patients
report social inhibition, unhappiness, anxiety,
and even suicide because of their facial appear-
ance. For many years different treatment mo-
dalities have been used for the revision of acne
scarring with varying degrees of success.
Differing modalities for hypertrophic scarring
have included intralesional steroids, silicone
23-year-old patient during Radiesse treatment 23-year-old patient post Radiesse treatment
sheeting or vascular laser treatment. Laser skin
resurfacing is still the most popular thera-
peutic modality for the correction of atrophic teeth. The CaHA microspheres (2545mm) are
acne scars the more common type of defects suspended in an aqueous carboxymethylcellu-
encountered after inflammatory acne but it is lose carrier gel, composed of cellulose, glycerin,

not always effective in all types of lesions. Over
the past four years, numerous non-ablative laser
resurfacing and radiofrequency (RF) methods
have come to the forefront of technology and
been shown to create some improvement in the
appearance of these atrophic scars.
More recently, a number of autologous and
non-autologous techniques attempting dermal
and subcutaneous augmentation have been tried
to improve the facial aesthetic appearance. The
autologous methods have included dermal graft-
ing, fat transfer and more recently, implantation
of autologous fibroblasts, such as Isolagen.
There has also been interest in some forms of
non-autologous augmentation by way of injec-
tions of hyaluronic acid, polymethylmethacrylate
microspheres and calcium hydroxylapatite. This
study looked at the use of calcium hydroxylapa-
tite in the treatment of atrophic acne scarring.
Background of Calcium
Hydroxylapatite
Calcium hydroxylapatite (CaHA), the main
mineral component of Radiesse. Calcium is a
synthetic analogue of the inorganic salt found
in the human body as a constituent of bone and
and sterile water. None of these materials elicit
a chronic inflammatory, infectious or immune
response. Multiple clinical and histologic studies
have tended to document its safety, efficacy,
and longevity in tissue. At the present time, the
use of (CaHA) is approved by the US Food and
Drug Administration (FDA) for craniofacial
surgery, HIV related lipoatrophy and, more
For many years recently, for soft-tissue augmentation around the
different treatment nose and mouth. In view of the fact that many
studies have established the biocompatibility and
modalities have safety of CaHA in facial filling techniques, this
been used for filler is gaining popularity in the US and Europe.
It was for this reason that the author originally
the revision of considered the compound in the treatment of
acne scarring in 2004.
acne scarring with
varying degrees Methods
A series of 42 patients (22 male 20 female)
of success (skin phototypes I-IV) with varying degrees of
atrophic acne scarring were treated in a single-
centre, prospective, controlled trial over a one
year period. Patients were randomly selected on
the basis that they did not want to present for la-
ser resurfacing as a treatment for their problem.
This meant the patients were collected sporadi-

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 22 KNOWLEDGE CASE STUDY
30 30
30
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16
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5 improvement while no subjects scored either
5 maximum or no improvement. At the three-
2
1
0 (40% of total) and to six patients (22% of total)
0 by completion of the year. At the 12-month
4w
ee
ks
Patient satisfaction with Radiesse in treatment of athrophic acne scarring over 12 month period
cally rather than all entering the trial at the same
time. The subjects ranged in age from 16-63 and
all acne scarring severity scores fell between four
and 30 on the Goodman system. Patients were
also evaluated using digital photography and an
improvement graduation scale [0= no improve-
ment, 1= 0-25% improvement, 2= 25-50%
improvement, 3= 50-75% improvement, 4=
75-100% improvement, 5=100% improvement]
at each subsequent treatment visit at one, three,
six, 12 and 24 months postprocedurally.
Subscision of each atrophic scar was
performed one week prior to injection with
CaHA to give a more uniform aesthetic effect.
Radiesse was injected through a 27-gauge
needle into the space left after subscision of the
acne scar in the region of the mid to deep der-
mis, although final placement also depended on
the presence of fibrous and cystic tissue in this
region of the skin.
The total volume of CaHA used, varied with
each patient, with the end point being agreed be-
tween subject and proceduralist. It was decided
not to record the amount of product used as this
n 25-50%
n 50-75%
n 75-100%
20
13
13
9
0 0
12 24 36
w w w
ee ee ee
ks ks ks
was felt to be not contributory to the final result.
Histologic evaluations of cutaneous biopsies
were not obtained before or during treatment,
although it was offered to at least one of the
patients who had a resultant adverse reaction.
Surgical procedure with Betadine cleansing
was used in most patients and Doxycycline
100mgs for two days was given as prophylaxis
in 11 patients who were felt to be at risk of
infection as they still appeared to have active
acne. One patient who had a previous photoal-
lergic problem with Doxycycline was prescribed
Augmentin Duo bd for two days.
Subjects were not excluded from the study
on the basis of bleeding disorders or whether
they were taking anticoagulants/anti-inflam-
matory agents as it was felt the bruising may be
unsightly but would probably improve overall
healing. Patients were excluded from the study if
they had received synthetic collagen, hyaluronic
acid, polymethylmethacrylate microspheres,
calcium hydroxylapatite or autologous fibroblast
injections to treated areas within six months of
the study.
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Clinical assessment scores were determined
at each treatment session and follow-up visit.
Patient satisfaction surveys and digital photog-
raphy were used where they were appropriate
to both parties, although both were considered
subjective with patients tending to focus on
the smallest detail and physicians photographi-
cally favoring the better results. All patients
were reviewed at two or four weeks post initial
treatment for a top up of Radiesse if required.
It was noted that 17 patients required a top
up of at least 0.15ml CaHA at one of the first
two visits. Smaller amounts (<0.1ml) were not
recorded as it was felt that the patient may have
seen some defects under deeper scrutiny that
were initially missed during the procedure.
Results
A total of 42 patients entered the one-year
trial. From the 42 patients who completed 12
months assessment, 30 patients (72% of total)
initially scored 4 (75-100% improvement) and
11 patients (27% of total) scored 3 (50-75%
improvement). One patient had score of 0-25%
month review the number showing score 4
(75-100% improvement) reduced to 24 patients
(58% of total), at six months to 20 patients
evaluation, nine patients (22% of total) showed
75% improvement, 20 patients (48% of total)
showed 50% improvement, and 14 patients
(30% of total) showed 25% improvement in
treated atrophic scars. Thirteen patients followed
over a 72-week period, showed some residual
benefit in 23% patient related to the compound
or neocollagenesis related to subscision. The au-
thor felt that monitoring the reduction of score
4 over the 12-month period largely related to the
efficacy of the compound in treating acne scars.
Side effects of treatment were mostly limited in
the group to mild transient erythema, bruising or
localised edema. Some patients required top up
or remodeling on initial review.
Conclusion
Most atrophic acne scars responded to treat-
ment. At 12-month evaluation, 22% of subjects
showed 75% improvement; while 48% showed
50% improvement. One patient had a score of
0-25% improvement while no subjects scored
either maximum or no improvement. The author
concludes that dermal fillers may provide a new
means of therapy in some patients being treated
for acne scarring. Newer injectable fillers are
becoming more biocompatible and safer and
are becoming a popular means of treating acne
scarring as an alternative in patients not opt-
ing for laser resurfacing. Despite the obvious
reservations in using long-term fillers in this type
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KNOWLEDGE CASE STUDY 23

The author considers
CaHA (Radiesse)
is a cost effective,
safe, and longer-
lasting dermal filler,
which can be used
for treatment of
facial atrophic acne
scarring

of procedure, CaHA may be considered a safe

method of treatment.
The author is aware of some recent reports
that CaHA is not without adverse events, as
described by Jansen et al 2006. The adverse
events reported, however, consisted of the
normal adverse events associated with all dermal
fillers. The exception herein may be the reported
27-year-old patient prior to Radiesse treatment occurrence of nodules, which typically formed
after injections of the lip mucosa. The author
found no side effects associated with CaHA, in
keeping with the fact it is the only filler for which
no confirmed granulomas have been reported to
date. In conclusion, the author considers CaHA
(Radiesse) is a cost effective, safe, and longer-
lasting dermal filler, which can be used for treat-
ment of facial atrophic acne scarring.

[References]
(1) Cotterill JA, Cunliffe WJ. Suicide in
dermatological patients. Br J Dermatol
1997; 137: 246-250
(2) Layton AM, Henderson CA, Cunliffe WJ.
A clinical evaluation of acne scarring and
its incidence. Clin Exp Dermatol 1994; 19:
303-308
(3) Seaton ED, Mouser PE, Charakida A, Alam
S, Seldon PE and Chu AC. (2006) Investiga-
tion of the mechanism of action of non-ab-
lative pulsed-dye laser therapy in photo-re-
juvenation and inflammatory acne vulgaris.
British Journal of Dermatology155:4,
748-755
(4) Jansen DA, Graivier MH. Evaluation of a
calcium hydroxylapatite-based implant
(Radiesse) for facial soft tissue aug-
mentation. Plast Reconstr Surg 2006;118
(Suppl):22S-30S
(5) Treacy P, Goldberg D. Use of a BioPolymer
Filler for Facial Lipodystrophy in HIV-posi-
tive patients undergoing treatment with Anti
Retro Viral Drugs. Journal of Dermatologi-
27-year-old patient after Radiesse treatment cal Surgery Volume 32,Number 6, June
2006, pp. 804-808(5)

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