Laser, Microneedling, and Combination Therapies for Moderate to Severe Acne Atrophic Scars: A Systematic Review and...

To compare the efficacy and safety of laser therapies, microneedling/radiofrequency microneedling, chemical reconstruction or peeling, subcision, fillers, and combination treatments for moderate-to-severe atrophic acne scars using systematic review and Bayesian network meta-analysis.

PubMed, Embase, the Cochrane Library, and Web of Science were searched for randomized controlled trials published from January 1, 2010 to August 10, 2025. Two reviewers independently screened studies, extracted data, assessed risk of bias, and evaluated evidence certainty using GRADE. Outcomes included ECCA score, Goodman-Baron scar score, significant improvement rate, significant satisfaction rate, and pain visual analogue scale (VAS). Bayesian network meta-analysis was performed in R, and sensitivity analyses were conducted by excluding small-sample and high-risk-of-bias studies where applicable.

Fifty-six randomized controlled trials involving 1488 patients and 34 interventions were included. Most participants were enrolled in split-face or self-controlled studies. In the primary SUCRA analysis, MFR + bFGF ranked highest for ECCA score improvement, followed by CO₂ laser + ASCE and microneedling + glycolic acid. CO₂ laser + subcision and CO₂ laser + PRP ranked highest for Goodman-Baron score improvement and patient satisfaction. For significant improvement rate, CO₂ laser + topical insulin, CO₂ laser + PRP, and microneedling + PRP showed the most favorable rankings. For VAS, lower values indicated less pain; microneedling + PRP, MFR + bFGF, and YAG laser were associated with relatively lower pain rankings. Sensitivity analyses generally supported the robustness of CO₂ laser-based combination therapies, although ECCA and VAS rankings were more sensitive to network connectivity and limited evidence.

Combination therapies generally outperformed monotherapies for moderate-to-severe atrophic acne scars. Fractional CO₂ laser combined with subcision or PRP showed the most consistent benefits, whereas CO₂ laser + topical insulin and MFR + bFGF appeared promising but require further validation. Treatment selection should consider scar type, Fitzpatrick skin phototype, downtime, pain, adverse-effect risk, and patient preference. Larger long-term randomized trials with standardized outcomes are needed.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .