Skin booster non-animal stabilized hyaluronic acid and abobotulinumtoxinA in the management of acne scars and glabellar lines: A real-world case series of five patients

INTRODUCTION

Facial aging results from a combination of intrinsic and extrinsic factors, including genetics, environmental exposure, and lifestyle. Declining regenerative capacity and disrupted tissue remodeling lead to collagen loss, volume depletion, and progressive structural changes across all facial layers.^[1]

In addition to age-related changes, acne contributes substantially to long-term skin quality concerns, with scarring reported in up to 95% of affected individuals, most often involving the face.^[2] Surveys indicate that patients typically seek cosmetic procedures between the ages of 30 and 50 years, when age-related disharmonies become clinically apparent in the form of wrinkles and acne scars.^[3]

Conventional treatments for acne scars include resurfacing techniques, energy-based devices (EBD), and chemical peels; however, results are often variable, and patients frequently require multiple modalities to achieve optimal outcomes.^[4] In recent years, hyaluronic acid (HA) fillers have emerged as a valuable tool in acne scar management. Beyond their immediate volumizing effect, HA fillers stimulate neo-collagenesis and improve dermal elasticity, offering both short-term and long-term benefits. Skin booster non-animal stabilized HA (SB-NASHA) has shown particular promise in this regard. Based on small particles and high molecular weight HA, it is optimal for skin quality enhancement. The product is administered through microinjections using the SmartClick^™ system, which offers audible and tactile feedback for precise, controlled dosing in the concerned areas. SB-NASHA improves hydration and skin texture, making it especially effective in treating fine atrophic scars.^[2,5] Furthermore, the integration of SB-NASHA with adjunctive therapies such as EBDs provides a comprehensive and personalized approach to facial rejuvenation.^[6]

Parallel to the management of acne scars, neurotoxins play a pivotal role in addressing dynamic wrinkles such as glabellar lines. Botulinum toxin type A (BoNT-A) is widely utilized to temporarily relax hyperactive muscles, thereby softening expression lines and preventing their progression into deeper static wrinkles.^[7] In younger patients and those in their 30s, combining HA-based treatments with botulinum toxins has demonstrated synergistic effects.^[3]

In this case series, we present three patients treated with SBNASHA and EBD for acne scarring, and two patients treated with a combination of SB-NASHA and abobotulinumtoxinA (AboBoNT-A) for both acne scars and frown lines. Real-world data in the Indian population, particularly among individuals with darker skin types (Fitzpatrick V), remains limited, and this study helps address this gap.

CASE SERIES

This case series included five patients, one male and four females. All were classified as Fitzpatrick Skin Type V, commonly observed among individuals in Middle Eastern, Latin, light-skinned Black, or Indian populations with olive or dark skin tone, who are minimally sensitive to ultraviolet and very rarely burn but tan very easily.

All procedures were performed by a board-certified dermatologist with expertise in aesthetic treatments. Clinical records, procedural documentation, and standardized photographs were examined to obtain demographic data, treatment details, product selection, and follow-up outcomes, 2 weeks post-treatment. Informed consent was obtained from all participating patients.

All patients underwent sessions of SB-NASHA. Here, all patients were given SB-NASHA (20 mg/mL) with needle using Smartclick^™ technology. In some cases, treatment was complemented with neurotoxin injections or EBDs, based on clinical judgment and the concomitant complaint [Table 1]. No concurrent topical/systemic acne treatments during the study period were administered.

Primary outcomes were assessed using the global aesthetic improvement scale (GAIS), evaluating five domains including light reflectance/radiance, skin tone, elasticity/firmness, smoothness/texture, and scar appearance [Figure 1], in addition to the skin quality assessment scale (SQS) [Figure 2]. The Glabellar line severity score (GLSS) (0, no facial wrinkles; 1, mild facial wrinkles; 2, moderate facial wrinkles; 3, severe facial wrinkles) was used as an assessment tool for Glabellar lines in 2 Cases (Case 4 and 5) [Figure 3]. Secondary outcomes comprised the physician global evaluation scale and the patient global evaluation scale.

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Figure 1:

Global aesthetic improvement scale scores before and after treatment (2 weeks) across all 5 cases.

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Figure 2:

Comparison of before and after treatment (2 weeks) skin quality assessment scale scores in hydrolipid balance, discoloration, firmness, and texture showing the improvement in the SQS scores from 1 and 2 to 0, showing a +1 to +2 grade improvement.

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Figure 3:

Glabellar line severity scores before (2) and after treatment (0) (2 weeks) in Cases 4 and 5.

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At the end of the treatment, all the patients (Case 1, 2, 3, 4, 5) achieved a “Very Satisfactory” rating (Score 4) on both the physician and patient global evaluations scale.

DISCUSSION

This case series highlights Indian patients with Fitzpatrick Skin Type V, an underrepresented group in the literature. Treatment sequencing was individualized by presenting concern: pigmentation and scars (Cases 1-3) were managed with Q-switched lasers plus SB-NASHA, while frown lines (Cases 4-5) were treated with AboBoNT-A plus SB-NASHA. Primary outcomes demonstrated consistent improvements across GAIS domains – including radiance, skin tone, elasticity, texture, and scar appearance. All five cases showed a +1–+2 point gain in radiance and scar parameters, supporting the clinical relevance of these changes. These findings are consistent with prior studies reporting enhanced hydration, elasticity, and surface smoothness following HA microinjections.^[8] Importantly, scar appearance improved across all cases, corroborating published evidence that SBNASHA gels are safe and effective for patients with moderate-to-severe atrophic acne scars.^[9] Parallel improvements on the SQS, particularly in firmness, discoloration, texture, and oiliness [Figure 2], further reinforce the clinical benefits of SB-NASHA.^[5]

The concomitant use of these procedures within the same session may increase the risk of adverse events. It is therefore advisable to maintain an interval of approximately 2–3 weeks between treatments to allow adequate tissue recovery and healing. In this case series, Q-switch lasers were performed 2–3 weeks before each SB-NASHA session in Cases 1, 2, and 3 [Figure 4], resulting in marked improvements in skin texture and acne scar appearance. Using the laser first, followed by intradermal HA injections, allows pigmentary correction before deep skin hydration. This sequence-based approach aligns with evidence that recommends a 2-week interval between booster injections and EBD treatments – such as lasers or radiofrequency to minimize inflammation.^[10]

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Figure 4:

Pre and post (2 weeks) photograph documentation of Cases 1, 2, and 3. Case 1- Showed an improvement in the pores, lines, dullness, oiliness, dryness, laxity along with the other symptoms (circle). Case 2- Showed an improvement in the lines, scars, dullness, pigmentation, dryness, laxity along with the other symptoms (circle). Case 3- Showed an improvement in the redness, pores, pigmentation, dryness, along with the other symptoms (circle).

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AboBoNT-A is a safe and effective treatment for moderate-to-severe glabellar lines, offering a rapid onset and marked aesthetic improvements.^[7] A 2-grade improvement on the GLSS in both patients (Cases 4 and 5), demonstrated by baseline scores of 2 (moderate wrinkling), which improved to 0 (no visible lines) following treatment, indicated complete resolution of glabellar line severity [Figure 5]. Randomized controlled trials provide supportive evidence for the established efficacy and safety of AboBoNT-A, demonstrating ≥80–95% responder rates with ≥2-grade improvement in glabellar line severity at 4 weeks, with effects lasting a median of 3–5 months, while maintaining a well-tolerated safety profile.^[7,11]

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Figure 5:

Pre and post (2 weeks) photograph documentation of cases 4 and 5. Case 4- The arrow corresponds improvement in the frown lines after the treatment with the AboBoNT-A. The circle corresponds to the improvement in pores, scars, redness, oiliness, dryness, laxity. Case 5- The arrow corresponds improvement in the frown lines after the treatment with the AboBoNT-A. The circle corresponds to the improvement in pores, lines, scars, redness, oiliness, dryness, laxity.

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The present case series provides valuable real-world insights into the use of SB-NASHA, EBD, and AboBoNT-A in improving multiple dimensions of skin quality and glabellar line severity. However, this study has several limitations. The small sample size and retrospective study design limit the statistical power and restrict the generalizability of the findings. In addition, the use of heterogeneous treatment combinations makes it difficult to delineate the independent effects of each intervention. The absence of a control group and lack of blinded outcome assessment further introduce the potential for selection and observer bias. These limitations should be considered when interpreting the results, and future prospective, controlled studies with standardized treatment protocols and blinded assessments are warranted.

CONCLUSION

This retrospective case series highlights the clinical value of SB-NASHA and AboBoNT-A in enhancing skin quality and reducing glabellar line severity. The consistent improvements across multiple validated assessment scales suggest potential clinical utility in carefully selected patients. Findings are hypothesis-generating, and larger prospective, controlled studies with standardized protocols are warranted.