Combined acne-scar treatments beat single ones

Moderate-to-severe atrophic acne scars are treated with a bewildering range of options: ablative and non-ablative lasers, microneedling and radiofrequency microneedling, chemical reconstruction or peeling, subcision, fillers, and countless combinations of these with topical or injected adjuncts. Very few of these approaches have ever been compared directly with each other, so clinics tend to promote whatever they own. A network meta-analysis can link trials through their shared comparators to produce a ranking across interventions that were never tested head-to-head. This review set out to do exactly that for both effectiveness and tolerability.

The authors searched PubMed, Embase, the Cochrane Library and Web of Science for randomised controlled trials published between 1 January 2010 and 10 August 2025. Two reviewers independently screened studies, extracted data, assessed risk of bias and rated evidence certainty using GRADE. Outcomes were the ECCA score, the Goodman-Baron scar score, significant improvement rate, significant satisfaction rate, and pain on a visual analogue scale. A Bayesian network meta-analysis was run in R, with sensitivity analyses excluding small-sample and high-risk-of-bias studies. Fifty-six randomised controlled trials involving 1488 patients and 34 interventions were included, most from split-face or self-controlled designs.

In the primary SUCRA ranking, microneedling fractional radiofrequency plus bFGF ranked highest for ECCA score improvement, followed by CO2 laser plus ASCE and microneedling plus glycolic acid. CO2 laser plus subcision and CO2 laser plus platelet-rich plasma ranked highest for Goodman-Baron score improvement and for patient satisfaction. For significant improvement rate, the most favourable rankings went to CO2 laser plus topical insulin, CO2 laser plus PRP and microneedling plus PRP. On pain, microneedling plus PRP, MFR plus bFGF and YAG laser sat at the lower end. Sensitivity analyses broadly supported CO2 laser-based combinations, but ECCA and pain rankings shifted with network connectivity.

This consolidates a scattered literature into a single ranking and supports what many practitioners already suspected: layering mechanisms — resurfacing plus release of tethered scars, or resurfacing plus a biological adjunct — tends to beat any one modality alone. It also flags newer combinations such as CO2 laser with topical insulin and MFR with bFGF as promising but unvalidated. The open questions are substantial: 34 interventions across 56 trials means thin evidence per node, outcome measures are not standardised, and long-term durability is largely untested. Larger long-term randomised trials with standardised outcomes are explicitly called for.

If you are researching options for indented acne scarring, this is a reason to expect more from a considered combination than from a single device used alone, and to treat league-table positions of individual novel pairings with caution. The review's own framing is useful: scar type, Fitzpatrick skin phototype, downtime, pain and adverse-effect risk all belong in the decision alongside efficacy rankings. Pain differed meaningfully between approaches, so tolerability is a real trade-off rather than an afterthought. None of this substitutes for an assessment by a clinician who can see the scars in question.