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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 99-103

Comparative study between the efficacy of botulinum toxin type A versus carboxytherapy in the treatment of postacne scars


Department of Dermatology and Venereology, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt

Date of Submission02-Apr-2021
Date of Decision03-Apr-2021
Date of Acceptance04-Apr-2021
Date of Web Publication30-May-2021

Correspondence Address:
MBBCh Sara M Fikry
Alabbasia, Cairo, 11517
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_121_21

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  Abstract 


Background Acne scarring remains a challenge to treat. Both botulinum toxin type A (BTX-A) and carboxytherapy (CXT) are considered novel treatment modalities for acne scars.
Aim This study aimed to compare the efficacy and safety of BTX-A versus CXT in the treatment of postacne scars.
Patients and methods Forty patients aged 18–50 years, with mild to severe postacne scars, were enrolled in this study and were divided randomly and equally into two groups: group A included 20 patients who underwent three sessions of an intralesional injection into postacne scars by BTX-A at a 3-week interval and group B included 20 patients who underwent three sessions of CXT on postacne scars at a 3-week interval. Evaluation of the clinical response to treatment was performed every 3 weeks and 1 month after the last session by photos and the global scarring grading system and patient satisfaction was assessed.
Results There was a significant improvement in the degree of scar severity before and after treatment in both groups. There was no significant difference between improvements in both groups, indicating that both modalities of treatment yielded similar net results.
Conclusion Both BTX-A and CXT can be effective and safe therapeutic options for the treatment of postacne scars with no significant side effects.

Keywords: botulinum toxin type A, carboxytherapy, postacne scars


How to cite this article:
Fikry SM, Mahmoud WA, Elsebaey HK. Comparative study between the efficacy of botulinum toxin type A versus carboxytherapy in the treatment of postacne scars. Sci J Al-Azhar Med Fac Girls 2022;6:99-103

How to cite this URL:
Fikry SM, Mahmoud WA, Elsebaey HK. Comparative study between the efficacy of botulinum toxin type A versus carboxytherapy in the treatment of postacne scars. Sci J Al-Azhar Med Fac Girls [serial online] 2022 [cited 2023 Feb 7];6:99-103. Available from: http://www.sjamf.eg.net/text.asp?2022/6/1/99/346224




  Introduction Top


Acne vulgaris is a chronic inflammatory multifactorial disorder of the pilosebaceous follicles and one of the most prevalent skin disorders in the world that affects all ethnicities and age groups and is categorized by development of comedones, papules, pustules, cysts, nodules, and scars [1]. Acne is estimated to affect 9.4% of the global population, making it the eighth most prevalent disease worldwide [2]. Acne scarring can result from inflammatory damage to connective tissue of the skin affected by acne. Acne scarring has a significant negative effect on the quality of life of young adults. It may be associated with severe psychological distress [3]. Acne scars are classified into hypertrophic and atrophic. Atrophic acne scars are categorized into icepick, rolling, and boxcar types [4].

There are various therapeutic options for acne scars such as surgical techniques, resurfacing techniques, nonablative laser treatment, radiofrequency, autologous fat transfer and injection of dermal fillers [5]. The clinical utility of these treatments is limited due to complications such as incomplete scar removal, poor intraoperative visualization, scar worsening, tissue fibrosis, and permanent pigmentary alteration [6].

New techniques have been added to improve the outcome of treatment of acne scars and older techniques have been modified to improve risk–benefit profiles [7]. If there is scarring, particularly if this scarring is atrophic or mildly hypertrophic, normal muscle movement may have an exaggerated effect on normal aging skin. In addition to the well-known effect of botulinum toxin in reducing muscular activity, there also appears to be an inhibitory effect of botulinum toxin itself on fibroblasts [8].

Injection of CO2 gas into the dermis by a needle with high pressure can cause fibrotic collagen breakage, producing the effects of subcision. CO2 gas is also known to stimulate collagen synthesis by increasing neovascularization and releasing more oxygen [9]. Carboxytherapy (CXT) has the same effect as needle subcision as it has the ability to improve blood flow, vascularization, and collagen synthesis. Moreover, CXT was found to improve skin elasticity and circulation, promote collagen repair, improve the appearance of fine lines and wrinkles and destroy localized fatty deposits [10].

The aim of this study was to compare the efficacy and safety of botulinum toxin type A (BTX-A) versus CXT in the treatment of postacne scars.


  Patients and methods Top


This interventional study was carried out on patients attending the Dermatology Outpatient Clinics of Al-Zahraa University Hospital, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt, during the period November 2019–September 2020. In total, 40 adult patients with atrophic postacne scars were enrolled. This study was approved by the Research Ethics Committee of the Faculty of Medicine for Girls, Al-Azhar University. Written informed consent was obtained from all participants. The inclusion criteria were as follows: patients of both sexes and age range 18–50 years, with no concurrent topical or systemic treatment for postacne scars during the last 3 months. The exclusion criteria were as follows: children younger than 18 years of age, individuals older than 50 years of age, pregnant and lactating women, patients with active inflammatory acne, active infection, premalignant or malignant lesions in the treatment area, patients with a history of chemical peeling or filler injection in the previous 6 months, patients with a history of bronchial asthma or any other systemic diseases and patients who received isotretinoin in the previous 6 months.

All participants underwent a full assessment of history and dermatological examination for the detection of site, size, number, and type of acne scars.

The baseline assessment of postacne scars was performed using digital camera photographs (Huawei Y9 16 mega pixels digital camera; JKM-LX1, China) of both sides of the face and by the global scarring grading system [11].

The 40 patients were divided randomly and equally into two groups: group A included 20 patients who underwent three sessions of an intralesional injection of postacne scars by BTX-A at a 3-week interval and group B included 20 patients who underwent three sessions of CXT on postacne scars at a 3-week interval.

First, a thick layer of topical anesthetic cream (Pridocaine cream − a mixture of lidocaine 2.5% and prilocaine 2.5%) was applied to the treated area under occlusion for 30 min before the procedures. Then, the whole face was cleaned using a mild cleanser.

Botulinum toxin type A

Patients in group A were administered an intralesional injection of BTX-A (Refinex 50 IU); this is a Chinese product. The dose was adjusted to 2.5 U/cm3 of the lesion, not exceeding 100 U/session.

Carboxytherapy

Patients in group B were subjected to a subcision that by an intradermal injection of 0.1–0.3 ml CO2 gas directly into the scars using a 30-G needle at 5-mm interval, 2-mm depth, and an angle of 15; the end point was plumbing of the scar by the gas and development of erythema.

Postprocedure care

Patients were instructed to avoid soap and topical creams on the first day. A topical antibiotic cream [Fucidin (fucidic acid) cream] was applied 1 day after the procedure for 3 days. Photo protection was advised with the use of 50+ sunscreen between and after sessions.

Assessment

Patients were assessed at the end of sessions and at the 1-month follow-up by digital camera photographs of the face with postacne scars using a Huawei Y9 16 mega pixels digital camera (JKM-LX1).

After the end of the treatment regimen, the photos of the scars were again assessed and graded by a blinded dermatologist 1 month after the last session and compared with that in the pretreatment period. Any change in the grading of scars was noted according to the Goodman and Baron [11] qualitative acne scarring grading system.

If the change was reduction by two grades, the improvement was considered excellent. If the change was reduction by one grade, the improvement was considered good and if there was no reduction in the grade of acne scarring, the improvement was considered poor [12].

Patient satisfaction was also evaluated for the degree of improvement. Finally, patients were also asked about any side effects such as pain and burning sensation experienced during every session and at 1 month after treatment.

Statistical analysis

Data were analyzed using the Statistical Package for Social Science (IBM SPSS; IBM Corp., Armonk, New York, USA), version 23. The quantitative data were presented as mean, SDs, and ranges when their distribution was parametric and median with interquartile range (IQR) when nonparametric. Also, qualitative variables were presented as number and percentages. P value more than 0.05 was considered nonsignificant, P value less than 0.05 was considered significant and P value less than 0.01 was considered highly significant.


  Results Top


Forty patients with atrophic postacne scars were enrolled in the study and classified into two equal groups: group A (BTX-A) and group B (CXT).
  1. In group A: of the 20 patients, 18 (90%) were females and two (10%) were males; their ages ranged from 21 to 35 years (mean±SD: 27.00±3.97). Two (10%) patients had box car scars, four (20%) patients had ice picks scars, eight (40%) patients had rolling scars, and six (30%) patients had mixed types of atrophic acne scars. Their scar duration ranged from 2 to 13 years [median (IQR): 6 (4–8)]. Six (30%) patients had a negative family history of postacne scars and 14 (70%) patients had a positive family history of postacne scars ([Table 1]).
    Table 1 Comparison between group A and group B of qualitative Goodman and Baron grading systems before and after treatment

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  2. In group B: of the 20 patients, 14 (70%) were females and six (30%) were males; their ages ranged from 18 to 40 years (mean±SD: 25.10±7.09). Four (20%) patients had box car scars, four (20%) patients had ice picks scars, four (20%) patients had rolling scars and eight (40%) patients had mixed types of atrophic acne scars. Their scar duration ranged from 1 to 20 years [median (IQR): 4 (2–5)]. Eight (40%) patients had a negative family history of postacne scars and 12 (60%) patients had a positive family history of postacne scars ([Table 1]).


Assessment of the efficacy of treatment

According to the Goodman and Baron qualitative scaring grading system

At baseline, there was no statistically significant difference between the values of both groups (P=0.453) and by comparing the results of both groups after treatment, again, no statistically significant difference was found (P=0.306), indicating that both modalities of treatment yielded similar net results ([Table 1]).

At baseline, in group A, grade II was evident in five (25%) patients, grade III in 12 (60%) patients and grade IV in three (15%) patients. After an intralesional injection of BTX-A, good and poor responses were achieved in 14 (70%) and six (30%), respectively. Meanwhile, in group B, grade I was evident in two (10%) patients, grade II in 14 (70%) patients, grade III in two (10%) patients, and grade IV in three (10%) patients. After treatment by CXT, good and poor responses were observed in 15 (75%) patients and five (25%) patients, respectively, with no significant difference between the two groups (P>0.05) ([Table 2]).
Table 2 Comparison between group A and group B in scar improvement

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  Discussion Top


Atrophic postacne scar is one of the most unfavorable consequence after inflammatory acne. There are different treatment options for such scars; however, most of them showed minimal clinical efficacy or considerable morbidity and long downtime [12]. Therefore, other minimally invasive techniques are used for the treatment of acne scars to overcome these limitations [13].

Few studies have demonstrated the use of CXT for the treatment of postacne scars as CO2 gas is known to stimulate collagen synthesis by increasing neovascularization and releasing more oxygen [9]. However, BTX-A is considered an uncommon addition to the treatment modalities for acne scars. Botulinum toxin may act to improve the outcome of scars in a number of ways. Botulinum may have an inhibitory effect on scar formation [8]. Accordingly, this study aimed to compare the efficacy and safety of BTX-A versus CXT in the treatment of postacne scars.

In this study, no statistically significant difference was found between the two studied groups in the age of the patient, sex, family history of postacne scars, skin type, scar type and scar duration.

In the present study, according to the Goodman and Baron qualitative scaring grading system, at baseline, there was no significant statistically difference between the values of both groups and on comparing results of both groups after treatment, again, no significant statistically difference was found, indicating that both modalities of treatment yielded similar net results.

In terms of the efficacy of BTX-A according to qualitative improvements in the Goodman and Baron grading system, in group A, there was a highly statistically significant improvement before and after treatment. The improvement was good in 14 (70%) patients and poor in six (30%) patients.

On reviewing the literature, there were no studies using BTX-A for the treatment of atrophic acne scars.

In group B, according to the Goodman and Baron qualitative grading system for acne scars, there was a highly statistically significant improvement before and after treatment. The improvement was good in 15 (75%) patients and poor in five (25%) patients.

Our findings were in agreement with the study of Moftah et al. [13], who compared the efficacy and safety of the CXT and skin microneedling for the treatment of atrophic postacne scars; 32 patients with atrophic postacne scars were treated in a split-face manner with microneedling on the right side and CXT on the left side. The left side of the face showed excellent, good, and poor responses in 43.75, 43.75, and 12.50% of the patients, respectively.

Our findings were also in agreement with the study of Nassar et al. [14], who compared the efficacy and safety of the platelet-rich plasma vs CXT in the treatment of atrophic scars: 40 patients with atrophic scars were divided into two groups: group A included 20 patients who received a PRP injection and group B included 20 patients who received a CO2 injection. All the patients in the CXT group showed improvements in the scar appearance. Also, there was a significant difference between both the CXT and PRP groups in the treatment of atrophic scars; the percentage of improvement was higher in the CXT group than in the PRP group.

In the present study, there was no significant correlation between percentages of improvement after CXT with the age of patients. This was in agreement with Koutna [15], who stated that age is misleading as excellent results could be achieved in 60-year-old patients and small or average effects in 38-year-old patients, and not in agreement with Nassar et al. [14], whose study indicated that there was a significant negative correlation between percentages of improvement after CXT with the age of patients, which indicated that the younger the patient, the higher the response to treatment.

All patients of both groups in this study reported additional cosmetic benefits besides improvement of acne scars.

In group A, these benefits include narrowing of the wide pores and decrease in sebum secretion. These results were reported also by Ahmed El Attar and Nofal [16], in their study, in which 35 patients with wide facial pores received a single session of microbotox. After a single treatment session, the total average improvement in wide facial pores was 87.2% and there was also an improvement in skin texture and sheen.

In group B, these benefits included skin rejuvenation and improvement of facial fine lines and wrinkles. These results were also reported by Paolo et al. [17], in their study, in which 90 patients with moderate to severe periorbital wrinkles and/or dark circles received subcutaneous injections of CO2 once a week for 7 weeks. At the end of the study period, patients reported a reduction in facial fine lines and wrinkles.

After each BTX-A session, erythema and edema occurred, which resolved within 3–4 h after the session. Meanwhile, patients reported transient erythema, warmness, and swelling of the area injected after each CXT session, resolving within 10 min to 1 h later. During injection of BTX-A and CXT, there was mild tolerable pain, which subsided shortly after the session in all patients. At 2 months after the last session of BTX-A or CXT, no side effects were detected.


  Conclusions Top


Both BTX-A and CXT are equally effective, tolerable, safe, and noninvasive treatment modalities of atrophic acne scars.

Recommendations

Further studies with increasing number of sessions and follow-up period are recommended to obtain more satisfactory results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Lee SJ, Suh DH, Chang KY, Kim HJ, Kim TI, Jeong KH, Song KY. The efficacy and safety of subcision using CO2 gas combined with fractional laser for acne scars. Clinical and microscopic evaluation. J Cosmet Laser Ther 2016; 18:417–420.  Back to cited text no. 9
    
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Moftah NH, El Khayyat MA, Ragai MH, Alaa H. Carboxytherapy versus skin microneedling in treatment of atrophic postacne scars: a comparative clinical, histopathological, and histometrical study. Dermatol Surg 2018; 44:1332–1341.  Back to cited text no. 13
    
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Nassar SO, Eltatawy RA, Hassan GF. Safety and efficacy of platelet‐rich plasma vs carboxytherapy in the treatment of atrophic scars: a comparative clinical and histopathological study. Dermatol Ther 2020; 33:e13942.‏  Back to cited text no. 14
    
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