Treatment of acne scars using the plasma skin regeneration (psr) system
Lasers in Surgery and Medicine 40:124–127 (2008)
Treatment of Acne Scars Using the Plasma SkinRegeneration (PSR) System
MD,1 William H. Sturgill, MD,1 E. Victor Ross, MD,2 and Nathan S. Uebelhoer, DO
1Dermatology Department, Naval Medical Center San Diego, San Diego, California2Scripps Clinic, Division of Dermatology, Cosmetic Dermatology Center, San Diego, California
Background and Objectives: Acne scarring is a common
required to achieve satisfactory results, and each technique
and difficult to treat condition. The plasma skin regenera-
carries different risks and side effects.
tion (PSR) system is a novel device that causes delayed
The plasma skin regeneration system (PSR; Portrait,
ablation of the epidermis and controlled thermal modifica-
Rhytec, Inc., Waltham, MA) is a novel device that utilizes
tion to the underlying dermis. PSR has previously been
radiofrequency (RF) to convert nitrogen gas into a high-
shown to be a safe and effective treatment for facial
energy state of matter called plasma. The plasma
rhytides and benign skin lesions. In this study, we investi-
is directed onto the skin with the hand-piece of the device,
gated the safety and efficacy of single-treatment, high-
delivering thermal energy in a precise manner. The
energy, double-pass PSR for the treatment of acne scarring.
device causes part or all of the epidermis to become non-
Study Design/Materials and Methods: Ten patients
viable; however, with the epidermis intact, it acts as a
with acne scarring and Fitzpatrick skin types I–III were
biologic dressing until approximately 2–4 days after treat-
included in the study. All patients underwent a single PSR
ment when peeling begins. The PSR system has been
treatment with two high-energy passes (3.5–4.0 J). Treat-
advocated as an alternative to ablative and fractional
ments were performed in an outpatient clinic setting. Nine
resurfacing lasers, with the benefits of lower cost and a
patients completed 6 months of follow-up. Improvement
better safety profile [3,4]. An in vivo study showed that PSR
was determined by patient questionnaires and physician
could consistently achieve thermal injury into the papillary
evaluation of digital photographs taken prior to treatment
dermis resulting in collagen remodeling without per-
and at 3 and 6 months post-treatment.
manent pigmentary or textural irregularities . Follow-
Results: On average, patients reported 34% improvement
ing this, multiple sites demonstrated that facial rhytides
in their acne scarring at 3 months and 33% improvement
could be safely and effectively improved with this device
at 6 months. Blinded physician ratings of patient photos
[3,6]. Furthermore, PSR has been shown to remove benign
demonstrated 19% improvement at 3 months and 34% at
skin lesions with similar efficacy and low complication rate
6 months. Re-epithelialization was complete by 4–6 days
as the carbon dioxide (CO2) laser .
after treatment, and no serious adverse events were
Previous experience with efficacy of the PSR system in
treating acne scarring is limited. We hypothesized that the
Conclusion: PSR appears to provide a safe and effective
PSR system would be effective in improving acne scars,
single treatment, minimal downtime alternative for the
with minimal down-time and few side effects.
treatment of acne scarring. Additional studies are war-ranted to further demonstrate the safety and efficacy of
this device. Lasers Surg. Med. 40:124–127, 2008.
The study protocol was approved by our Institutional
Review Board and conformed to the guidelines of the 1975Declaration of Helsinki. Written informed consent was
Key words: plasma skin regeneration; acne scars; non-
obtained from all patients prior to treatment.
Patients were included in the study if they demonstrated
at least a mild degree of atrophic facial acne scarring, were
18 years of age or older, and their acne was either quiescent
Despite the widespread use of isotretinoin and other
or under adequate control with medications. Exclusion
therapies to aggressively treat acne, scarring from this
criteria included pregnancy and lactation, Fitzpatrick
condition remains a common problem presenting signi-
skin type IV or higher, history of collagen vascular disease
ficant therapeutic challenges. Several modalities havebeen advocated to treat acne scarring, including surgicaltechniques (punch grafts, punch excisions, subcision),
*Correspondence to: Dr. Nathan S. Uebelhoer, DO, Dermatol-
ogy Department, Naval Medical Center San Diego, Suite 300,
resurfacing techniques (dermabrasion, ablative laser treat-
34,520 Bob Wilson Drive, San Diego, CA 92134.
ment, chemical peels), non-ablative laser treatment,
autologous fat transfer, and injection of dermal fillers
Published online in Wiley InterScience(www.interscience.wiley.com).
[1,2]. A combination of different modalities is typically
or keloids, history of dermal fillers or dermabrasion, oralretinoids in the previous 12 months, topical retinoids in theprevious 2 months, and inability to avoid significant sunexposure during the follow-up period. A total of 10 patientswere enrolled and treated.
Prior to treatment, facial photographs were taken.
Patients were given cephalexin 500 mg BID and acyclovir400 mg TID for bacterial and viral prophylaxis, res-pectively. Pre-operative medications included 75 mg IMmeperidine, 50 mg IM hydroxyzine, 1–2 mg PO lorazepam,and topical 4% lidocaine cream applied 30–45 minutesbefore treatment.
Following a 1 hour training session under the guidance of
the principal investigator (NSU), a dermatology resident(MJG) with no prior experience with plasma technologyperformed one treatment on each subject. A single pass ofhigh-energy plasma (3.5–4.0 J) was delivered to theforehead, mouth and cheeks, followed by a second passat 4.0 J over only the acne scarred areas. A thick coat ofpetrolatum was applied to the face after treatment. After24 hours, patients were instructed to wash the face with amild cleanser and to apply dilute white vinegar soaksthree times a day for 1 week following treatment.
Patient questionnaires were completed and photographs
were taken on the day of treatment and at 1 week, 2 weeks,1 month, 3 months, and 6 months after treatment. Side-lighting was used to accentuate acne scars at the pre-operative, 3-, and 6-month visits (Fig. 1).
Nine out of 10 patients completed the study and were
included in the final analysis. One treated subject thatmissed the 3-month visit was lost to follow-up.
Immediately after treatment, patients were asked to rate
their pain level on a scale from 0 to 8. The average painreported was 4.6, corresponding to a level of moderate tosevere based on the scale used (range 3–7). All patientsreported that any discomfort associated with the procedureresolved by the next day.
Desquamation typically began on the third day after
treatment, and was complete by the 7-day follow-up visit. Patients commonly reported that the peeling was completeby 1 or 2 days prior to their 1 week visit (5–6 days post-op). Pruritus was a common complaint in the first 2 weeks aftertreatment and was controlled with oral antihistamines. Allfacial erythema returned to baseline by the 1 month post-treatment visit. No new textural scarring occurred as aresult of the procedure.
Patients were asked to rate the percentage improvement
in their acne scars at 3 and 6 months using a scaledivided into 10 percentage-point increments. Patientsrated the forehead, right cheek, left cheek, and mouth/chin separately, and those numbers were averaged in theanalysis. At 3 months, average patient-rated improvementwas 34.2% (range 5–70%). At 6 months, average improve-ment was 33% (range 2.5–90%).
Fig. 1. A–C: Pre-treatment photographs (left) compared to
Seven out of 10 patients followed up for facial photo-
6 months following a single PSR treatment (right) demonstrat-
graphy at 3 months, and 9 out of 10 had photography taken
ing modest improvement in three separate patients with mild
at 6 months. Follow-up photographs were compared with
scars (A), moderate acne scarring (B) and severe scarring (C).
pre-treatment views and percentage improvement was
in an office setting, avoiding the risks and costs associated
rated by a blinded assessor (WHS). The following 6-point
with conscious sedation or general anesthesia that may be
grading scale was used to rate the before and after photos:
necessary with other treatments. Finally, since the PSR is
0 for no improvement, 1 for up to 10% improvement, 2 for up
an RF-induced nitrogen plasma device there are no special
to 30% improvement, 3 for up to 50% improvement, 4 for up
safety measures, such as protective eyewear, required.
to 70% improvement, and 5 for up to 90% improvement.
Although the pain associated with each treatment during
The 6 month photos were divided into right-sided and left-
the study required significant use of analgesics and
sided images and each side was evaluated separately. The
anxiolytics, we have since found that the pain can be well
3-month average improvement was rated by the blinded
controlled with the adjunctive use of a forced cool air
assessor was 19% (n ¼ 7; range 0–50%). At 6 months,
chiller. Since the completion of the study, we routinely use
the blinded average improvement was 34.4% (n ¼ 9; range
forced cool air (Zimmer MedizinSystems, Irvine, CA) in all
5–70%). The highest rated side for each patient resulted in
treatments with the PSR alleviating the need for systemic
an average of 41.1% improvement overall.
Minor adverse events encountered included hyper-
One of the biggest issues with CO2 ablative resurfacing
pigmentation in two patients and a recurrence of herpes
is the delayed-onset hypopigmentation, which can develop
labialis in 1 patient. The hyperpigmentation was first seen
18–24 months post-treatment. To our knowledge, there
at the 1-month follow-up in both patients and consisted of a
have been no reports of delayed hypopigmentation occur-
bronze discoloration in the treated areas of the face. One
ring with the PSR system. Indeed, even a study investigat-
patient had skin type II, was treated with sunscreen, and
ing CO2 laser resurfacing to treat acne scars that involved
experienced resolution of the hyperpigmentation by the
a cohort of 60 patients with skin types I–V and a follow-
6-month follow-up. The other patient was skin type III, was
up time of 18 months showed no occurrences of delayed
treated with sunscreen and Tri-Luma, and experienced
hypopigmentation . It is possible that acne scarring
resolution by 3 months. The herpes labialis occurred in a
patients are less likely to experience hypopigmentation
patient with a history of recurrent cold sores, despite
after resurfacing, compared with the photoaged population
complete re-epithelialization and adequate prophylaxis.
in whom this adverse effect has been reported in the past.
Symptoms were reported at day 13, the patient was
One limitation to our study is the fact that patients were
given a second course of oral acyclovir, and the symptoms
only followed for 6 months, which would not be enough
resolved within 2 days. No patients reported drainage or
follow-up time to capture cases of delayed hypopigmenta-
weeping from the treated sites and all erythema had
tion, even though we believe this to be an extremely
completely resolved by 1 month following the treatment.
No serious adverse events occurred during the follow-up
Our study, similar to others that have evaluated modest
textural changes of facial skin over time, is also limited bythe use of pre- and post-treatment photography. Although
all of our photos were performed by professional photo-
We report a blinded average of up to 41% improvement in
graphers in the same studio using the same equipment and
facial acne scars 6 months after a single high-fluence
lighting techniques, variations in exposure and slight
treatment with the PSR system. While the magnitude
angle differences are noticeable. Despite this, the ratings
of improvement that we observed in this study is not as
of improvement noted by the blinded evaluator and those of
dramatic as that seen with multipass ablative CO2 laser
the patients themselves were fairly consistent. In addition,
treatment , PSR offers several advantages.
our study was limited by the number of patients enrolled.
First, the PSR is less operator dependent than traditional
To have converted the trends seen in this study to statistical
resurfacing. Most of the desired and adverse effects of CO2
significance would have required a much larger cohort.
and Er:YAG ablative resurfacing are due to the depth ofthermal injury directly related to the operator’s choice of
fluence and number of passes. The ability to recognize the
In this pilot study, the Portrait PSR appeared to be a
level of ablation necessary to achieve dramatic results
safe and effective device for treating facial acne scars. It
with ablative lasers without causing permanent scarring
represents an operator independent single-treatment tool
or hypopigmentation requires significant experience and
with a relatively tolerable down time. Future studies are
skill. Our study demonstrates that, even at high energy,
needed to explore the potential of repeat treatments to
double pass, the PSR requires minimal operator training to
further enhance the textural benefits seen in this study,
achieve predictable and safe effects with modest improve-
and to further demonstrate the safety and efficacy of the
In contrast to aggressive ablative techniques, plasma
regeneration maintains the integrity of the epidermisleading to less downtime, in terms of persistent erythema
and wound care. Most patients are able to return to their
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