Investigating the impact of added Profhilo mesogel to subcision versus subcision monotherapy in treating acne scars; a single‐blinded, split‐face randomized trial

Acne scar is an inflammatory condition, which commonly occurs in patients with acne vulgaris, especially in adults. Mesogels have been reported effective in improving atrophic acne scars.


| INTRODUC TI ON
Acne vulgaris is a prevalent inflammatory condition, especially among the young population.The global prevalence of acne occurrence is about 80%.Acne lesions tend to form scars as an inflammatory response in some patients.[3] The process of scarring is directly associated with acne severity and treatment retardation.Although the exact pathophysiology is vague, inflammatory mediators and the destruction of collagen fibers and connective and fat tissue can play a significant role in scarring. 1,2,4[7] Many techniques have been added to old methods of treating acne scars based on the challenges and difficulties encountered during treatment.These methods can be divided into two groups: 10] Different types of dermal fillers are an easy and non-surgical approach for acne scar treatment.Hyaluronic acid (HA) is one of the temporary dermal fillers used in acne scars.It is a glycosaminoglycan polysaccharide that tends to absorb water and is a component of normal connective tissue. 2,7ofhilo has recently been used as a therapeutic option for acne scars due to its bio-stimulatory effects.This high osmolality combination can influence tissue formation by absorbing water through lymphatic vessels and binding to cell receptors, promoting cellular uptake, and intracellular signaling.[12] High molecular weight HAs (H-HAs) lead to the aggregation and binding of fibrinogen and facilitate the access of polymorphonuclear leukocytes to the wound site.On the other hand, low molecular weight HAs (L-HAs, made from H-HA destruction) cause cytokine response and angiogenesis. 13 this single-blinded, split-face, randomized controlled trial, we investigated the effect of adding Profhilo to subcision compared to subcision monotherapy in acne scar treatment.We used a novel method to assess the outcomes using an exclusively made formula as the total score in addition to the Global Improvement Scale and Visual Analogue Scale (VAS for patient satisfaction).Written informed consent was obtained before initiating the procedure.Block randomization was performed (https:// www.seale denve lope.com/ ) to assign each side of the patient's face to a particular treatment.Inclusion criteria were patients aged 18-45 years, atrophic acne scars on both sides of the face, and candidates for subcison procedure.Exclusion criteria were any prior injection of fillers in the selected areas, prior surgical treatment for acne scars during the last 3 months, hereditary or acquired coagulation disorders, autoimmune disorders, infection in the treatment areas, history of allergy to HA, pregnancy or lactation, using isotretinoin during the past 6 months, and inability to attend follow-up sessions.

| Interventions
Both sides of the affected areas were sterilized, and the lesions were marked.One side was treated with subcision alone, while the other side was treated with subcision plus Profhilo injection in acne scars.
For the subcision side, anesthesia was performed with an injection of lidocaine 2%, and for the subcision plus Profhilo side, lidocaine 2% containing epinephrine (1/1000) was used; epinephrine was administered to prevent hematoma formation.Prior to Profhilo injection, a 29-gauge needle was used to move back and forth under the scars to release fibrous tissue.Afterward, the Profhilo was injected into the dermis under the scars using the same needle at a 30-45° angle and the total amount of injected Profhilo was 1 mL.
At the end of the injection, the final subcision of the lower parts of the dermis was performed cautiously with a 25-gauge cannula in a Conclusion: Despite no significant difference between the methods, Profhilo is more effective due to a higher satisfaction rate and better physiologic effects.

K E Y W O R D S
acne scar, mesogel fillers, Profhilo, subcision localized area for better distribution of the mesogel.On the other side of the face, subcision was performed with a 29-gauge needle on the marked acne scars.The endpoint was the presence of ecchymosis in the scar areas.The same procedures were repeated at 1-month intervals for each patient.

| Assessment
Acne scars were initially divided into icepick, boxcar, and rolling subtypes based on a common classification system for acne scars. 14The primary assessments were performed by two blinded dermatologists using before and after photographs and skin ultrasound (DUB-USB; 22 MHz, TMP Company).The ultrasound was performed by a radiologist to determine the depth and type of scars at the baseline visit and 3 months after the last treatment session.Photography (Canon EoS 990D, 85 mm lens) was performed at baseline and 3 months after the final treatment session.The photos were taken in a fixed room with a lateral diffusing light source and at an arm's length distance.Based on ultrasound and photographs, blinded observers determined the lesion's type (icepick, rolling, and boxcar), numbers, and depth (superficial, medium, and deep).Then icepick, boxcar, and rolling scores were exclusively calculated using the following formula: (number of superficial lesions×1) + (number of medium-depth lesions×2) + (number of deep lesions×3).After calculating each side's score, the icepick, boxcar, and rolling scores were summed up to determine the total scores.Observers were also asked to qualitatively rate the improvement of each side based on before/after photographs according to the global scoring scale: no improvement (<25%), medium improvement (26%-50%), good improvement (51%-75%), and excellent improvement (>76%). 2 Patient satisfaction was measured by the VAS before the procedure and 3 months later.On a scale of 0-100, 0 represents "no satisfaction", and 100 represents "extreme satisfaction". 15

| Statistical analyses
Descriptive statistics were used to report quantitative variables, including mean, median, and standard deviation.Wilcoxon sign rank was used to report the correlation between the two treatment methods.To investigate the reliability of two blinded dermatologists, an interclass correlation coefficient was used; poor reliability:< 0.5, medium reliability: 0.5-0.75,good reliability: 0.75-0.9,and excellent reliability: >0.9.To analyze the main distinctions between criteria and compare the variations between two treatment values, the growth percentage criterion was employed using the following formula: starting value − end value starting value × 100.The Pearson correlation coefficient was also used to determine the co-efficiency between the main values.All analyses were performed using R Studio software version 4.1.1 at a significance level of <0.05.

| RE SULTS
Fourteen patients met the inclusion criteria, but two declined to participate due to concerns about the pandemic.A total of 12 patients, including three males (25%) and nine females (75%) were finally enrolled in this trial and each side of their face was randomly allocated to one of the interventions.The mean age of patients was 29.75 years (19-42 years).Fitzpatrick skin types of participants varied from II to IV.At baseline, 579 acne scars were found on both sides of all participants' faces, with the most common scar type being Boxcar (Table 1).
According to the formula mentioned, we calculated the total and clinical scores for each subtype before the treatment.The total and boxcar scores were significantly higher on the Profhilo + subcision sides than on the subcision sides (p-value = 0.027 and 0.020, respectively).There were no statistically significant differences in icepick and rolling scores between both sides before the treatment.
To adjust these differences before the treatment, the growth rate formula was used for each treatment method as follows: Growth rate = (after−before/before) × 100.
Regarding patient satisfaction self-scoring, the mean VAS scores before and after treatment were 26.58 and 69.25 on the Profhilo + subcision side and 39.83 and 63 on the subcision side, respectively.A significantly higher mean growth rate (VAS score) was observed on the Profhilo + subcision side (528.08%)compared to the subcision side (219.06%)(p-value = 0.021).Regarding sonographic depth, the mean depth before and after treatment was 284.42 and 179.92 μm on the Profhilo + subcision side and 351.5 and 204.42 μm on the subcision side, respectively.There was no statistically significant difference in the mean growth rate of sonographic depth between the two treatment methods.(p-value = 0.424).The mean total score before and after treatment was 53.79 and 37.79 on the Profhilo + subcision side and 40.33 and 28.75 on the subcision side, respectively.No significant significance was observed in the mean growth rate total score between the two treatment methods.(p-value = 0.424; Table 3).
Based on the Global Improvement Scale, there was no significant difference between both sides (p-value = 0.890; Table 3).
The rolling subtype on the subcision + Profhilo side significantly showed a better response to treatment than the icepick subtype regarding the clinical index (p-value = 0.04).On the subcision side, the rolling subtype showed more improvement than the icepick and boxcar subtypes regarding the clinical index (p-value = 0.016 and 0.002, respectively; Table 4).
In terms of the percentage reduction in clinical score, the boxcar subtype showed a significant decrease on the subcision side compared to the subcision + Profhilo side (p-value = 0.007).No significant difference was observed between the reduction percentage of clinical scores on both sides based on other subtypes (Table 5) The treatment progress is shown in Figure 1.No significant complaints were reported during the study and follow-up and the patients experienced mild and transient side effects (Table 6).
Acne scar is one of the most common cosmetic issues with a high incidence rate and significant importance due to its lasting disfigurement and remarkable psychological effects.Acne scarring is another consequence of healing acne inflammation and may even occur in mild to moderate cases with delayed treatment.Several therapeutic methods have been used to treat acne scarring. 8,16Subcision and dermal mesogels are two emerging methods with significant effects on atrophic acne scars.Subcision was first described by Orentreich and Orentreich in 1995 and is a surgical procedure primarily used to treat scars and wrinkles.For acne scars, this procedure is considered safe and uncomplicated.Furthermore, this method is applicable for concurrent use with other treatment modalities. 17,18e first use of dermal fillers in the treatment of atrophic acne scars was reported by Stegman et al. in 1980 using fillers and mesogels in combination with other modalities (such as subcision) has been effective for acne scars. 2,19,20rious fillers have been used in treating acne scars.The best type of filler is easy to inject, less painful and prompt, and has longlasting results and minimal side effects. 19HA is the most commonly used filler in aesthetic medicine for various purposes (e.g., augmentation), which is also known for its ability to repair and heal wounds. 13,21 was hypothesized that the addition of Profhilo to subcision is more effective than subcision monotherapy, based on a thesis that Profhilo promotes tissue healing in a non-inflammatory bed and replaces fibrosis with freshly synthesized collagen. 2,10mparing two clinical methods using self-scoring (VAS score) demonstrated that Profhilo was a significantly better treatment, with a mean score of 528 compared to 219 (p-value = 0.02).This difference can be attributed to the hydration impact of Profhilo and its physiology, which results in fewer morbidities.
The therapeutic effects of the two methods were compared using sonographic depth reduction, but no statistical significance was found between the methods.The calculated improvement mean value for the subcision side was 28.53% versus 29.21% for the subcision + Profhilo side (p-value = 0.4).However, the depth reduction of the Profhilo side was slightly better than that of the subcision side.There was no significant difference in the total score of image analysis and clinical scoring between the two methods.The growth percentage for the subsicion side was 22.27% versus 29.74% in the subcision + Profhilo side.A decrease in depth or total score might be statistically significant with a larger sample size.
A significant difference was observed in the boxcar subtype regarding the reduction in the clinical score on the subcision side (28.95 vs. 20.52,p-value = 0.007), which can be due to the effectiveness of hematoma replacement in the atrophic dermis.Icepick and rolling subtypes were also compared, and no significant statistical difference was observed (icepick subtype: 22.5 on the subcision side vs. 20 on the subcision + Profhilo, p-value = 0.73, rolling subtype: 49 on the subcision side vs. 36 on the subcision + Profhilo, p-value = 0.28).Without comparing the subtypes in treatment methods, the rolling subtype showed the best response to treatment in both the subcision and subcision + Profhilo sides (Figures 2 and 3).Profhilo side for this subtype.A larger sample size is required to establish its significance.

Although insignificant, more improvement was observed on the
Due to a strong correlation between the two analyzers, examining each lesion separately allows researchers to investigate with greater statistical confidence despite the small sample size.They make it possible to compare the therapeutic effect of each method separately in different types of scars.The use of more analysts is recommended to improve the p-value and obtain reproducible findings, which may lead to the use of this scoring method for future scientific research.
Despite satisfactory results on the Profhilo added side, the two methods were similar in depth reduction and total scoring.Moreover,  Profhilo is an innovative skin bio-remodeling HA, patented in 2015 by IBSA Pharmaceuticals based on the NAHYCO hybrid technology.This HA complex consists of 32 mg of H-HA (1100-1400 kDa) and 32 mg of L-HA (80-110 kDa).The combined HA will be stabilized during two steps of high high-temperature and low-temperature thermal process.The whole procedure results in a stable and cooperative hybrid HA complex with lower viscosity, higher HA concentration, less inflammatory response, better manageability, excellent tissue diffusion, minimal inflammatory response, and prolonged half-life compared to cross-linked HA. 13,22,23 Past in vitro studies have shown that hybrid cooperative complexes (HCC; such as Profhilo) improve keratinocytemediated wound healing in addition to increasing the expression of collagen types 1 and 3 and elastin.This complex causes the differentiation of fat and the proliferation of stem cells derived from fat, which leads to the recovery of local tissues affected by ischemia and scar remodeling and improves the potential of fat tissue renewal. 13,24,25e HCC method works in two ways: (1) Bio-regenerative impact on the epidermis via low-molecular weight and (2) remodeling performed by high-molecular weight.HCC does not involve any chemical changes or compounds except for hyaluronan molecules, composed of repetitive dimeric units. 24e mechanism of scar healing in subcision is the release of fibrotic cords under scars, the organization of blood in the stimulated area, and the formation of new connective tissue.Adding HA to this space helps delay the healing process and wound reconnection, ultimately leading to more formation of new connective tissue.The hybrid H-HA/L-HA creates high-quality collagen and decreases subcision sessions. 10e most important limitation of this study was the small sample size due to sampling during the epidemic, which led to moderate and weak correlation when investigating the scar subtypes and non-significant p-values.Moreover, a significant difference was seen F I G U R E 1 P1: Baseline photo, first session of treatment before initiating any procedure (male and female).P2: Follow-up photo, 3 months after the second treatment (male and female).
This single-blinded split-face, randomized controlled trial was done on 12 patients (three males and nine females) with Fitz Patrick skin type II-IV aged 18-45 years old from 2019 to 2020.The study was approved by the Ethics Committee of RAZI Hospital and Tehran University of Medical Sciences, Tehran, Iran, and also registered at the Iranian Registry of Clinical Trials (IRCT20201210049671N1).
the subcision + Profhilo side had higher numbers of stricter subtypes, such as boxcar, which might have influenced the final treatment results of this side.Mehrabi et al. assessed 30 patients who underwent random in-jections with Juvederm and Profhilo for the treatment of atrophic acne scars on each side of the face.The assessments were done at the first and third treatment sessions, and 6 months later.Although both fillers improved the lesions, the gradual impacts differed during follow-up.The effectiveness of Juvederm was rapid and mainly observed at the first and third visits, with minor changes during follow-up.While on the Profhilo side, most improvements occurred between the last treatment session and 6 months later.Similar results were obtained for skin elasticity, with Profhilo showing a delayed but significant effect.Therefore, it is assumed that Profhilo might have a delayed influence, and the duration of follow-up should be longer accordingly.11Artzi et al. showed improvement in acne scars after Profhilo injection, even though 6 months had passed after the last treatment session.In agreement with this study, the use of Profhilo in the treatment of acne scars may have beneficial effects in the healing of lesions.However, it was not compared with a single use of subcision, which was done in the current study.The Global Improvement Scale showed similar improvements in both arms, which were also consistent with the results reported by Artzi et al.2 Number and subtypes of acne scars.
TA B L E 1 TA B L E 2 Mean clinical score of acne scars.
Comparison of clinical index regarding treatment type.Patients' satisfaction (VAS score), sonographic depth, and the total score of acne scars before and after treatment and Global Improvement Scale after treatment of both sides (based on the growth rate formula).
TA B L E 5Comparison of clinical score reduction (%) regarding acne scar subtypes.TA B L E 3